Connected Hearts & Minds: Applying Psychology to Enhance Digital Tools for CHF Management

With the ageing population, obesity, and stress levels on the rise Congestive Heart Failure (CHF) is spreading like an epidemic. In the US alone there are 6.9 million people suffering from CHF, while projections for 2030 estimate the numbers will reach 8.5 million¹. Aside from the huge financial strain of CHF management, the human impact is even more worrisome. CHF is a high mortality condition, and without treatment and accompanying lifestyle changes little can be done to control it. CHF is not only a physical condition but also a psychological one, with the connection between the two deepening as the condition progresses. 

Stress, lifestyle choices, genetic predisposition, and various other factors significantly contribute to the development of congestive heart failure (CHF). It's evident that these elements are closely intertwined with diminished mental well-being.

Poor mental well-being can be signaled by demotivation, which, in turn, leads to lower treatment adherence, resulting in disease progression. In fact, it is a vicious cycle. After being diagnosed with CHF, the stress of its incurability, along with the additional stress induced by necessary lifestyle changes, further contributes to the disease's progression. 

However, the effects of CHF can indeed be mitigated and a big part of it is a complete change of lifestyle. This requires giving up long-standing habits, which is a challenging task for everyone, but especially for those that are 65 and older, the largest CHF population, which is naturally inclined towards conservation over flexibility and openness. Failure to embrace change leads to condition progression, impacting both physical and psychological health, thus highlighting the inseparable link between physical and mental well-being. 

Even though the cure for CHF is not currently within the reach, ongoing advancements in medical technology offer valuable tools for both patients and healthcare professionals to effectively manage heart failure. For instance, digital tools can now measure body fluid levels, monitor vitals, track movement, diet, and even monitor medication adherence. Some tools on the market can even effectively predict the occurrence of a heart failure episode, suggesting that prevention is possible. However, despite these efforts, persistently high hospitalization rates underscore the need for continued research and innovation to enhance patient outcomes. 

The following text will discuss how psychology can be utilized to advance CHF management, with the special implications for digital tools. 

Patient Adherence 

CHF is classified as a chronic disease, which means it is a long-term condition that demands ongoing treatment. The permanent lifestyle change, and treatment requires continuous patient adherence. Since this is a high-risk medical condition, even the slightest failure to comply can have significant consequences. Solution makers and healthcare professionals should prioritize fostering adherence just as much as creating medically effective solutions.  

This is where psychology can play a crucial role.  

Decrease in patient adherence is often linked to motivational issues², negative chronic condition sentiment, perceived lack of control, social isolation, doubtful meaning of life, and overall perceived low quality of life³. Even hospitalizations can negatively impact patients, by signaling heart failure progression, reduced capacity, severe symptoms, and mortality, subsequently impacting overall subjective well-being⁴. This results in even lower patient adherence due to lower perceived self-efficacy⁵. 

Managing chronic condition requires patients to be active agents in their disease management. This means the patient needs to be continuously motivated to engage in such a role. The challenge with communicating CHF management lies in its profound severity, and according to the threat appeal theory, this extreme severity can result in avoidance. Many CHF patients may avoid behavior change triggers instilled with fear, such as instructions from doctors or family members. Thus, reminding the patient of its condition is no longer serving anyone, instead, solutions should focus on fostering intrinsic motivation to sustain long-term adherence. This can be achieved with the help of digital tools that promote self-care. 

Finding Motivation  

Various creative ways exist to facilitate intrinsic motivation, with Self-Determination Theory (SDT)⁶ serving as a guiding tool. The essence of SDT lies in promoting autonomy, enhancing competence, and fostering relatedness, therefore setting the foundation for transforming outcomes. Embracing these intrinsic motivational factors represents an opportunity for solution makers to influence patient adherence within the realm of chronic condition management. In accordance with SDT, the cultivation of intrinsic motivation emerges as a critical element for patients to adhere to recommended strategies for mitigating their condition.  

Autonomy is manifested in encouraging self-monitoring, choosing among treatment options, sustaining positive preventative behaviors one understands, and by fostering a collaborative approach between healthcare providers and patients. Often, there is a disconnect between the patient and doctor, which leads to the patient dissociating from his/her condition management. Patients might adopt the false belief that doctors must “fix” their condition, or be treated at the hospital, which often results in a cycle of damaging habits. On the other hand, doctors can feel as if no matter what they do, once a patient goes home, he/she undoes every effort done at the hospital, which subsequently leads to physician burnout.  

Part of this issue can be attributed to the patient’s lack of knowledge, but part of it can be explained by the perceived lack of control over one’s health outcomes. Negative narrative over chronic condition disheartens patients from the start. Upon diagnosis patients are inclined to think that little or nothing can be done, this belief is further fueled with patient-doctor dynamics, followed by the harsh reality of challenges and limitations of everyday functioning. Little in this process is naturally set to foster a positive attitude and nurture of self-efficacy, which is why digital tools can account for what the system is lacking. 

That is why the next step in the process is to promote competence. Competence is demonstrated through the celebration of small steps aimed at successful and healthy behavioral changes. Digital solutions can play a huge role in the nurture of competence, by providing patient-centric tools and incorporating features that remind the patients of the importance of small steps. Digital tools can also be triggers of action and guiding agents of change, something neither the doctors nor family members can do all the time for the patients.  

Lastly, relatedness emphasizes the importance of social connectedness with family, caregivers, and most of all other CHF patients. This can be achieved by creating community among CHF patients through support groups, mentorship programs, and promoting digital communication channels exclusively for CHF patients. Immediate caregivers can provide encouraging messages instead of frightening signals to further reinforce beneficial behavior as oppose avoidance. Lastly, healthcare professionals can share the necessary knowledge digitally, without having to repeat themselves multiple times. 

The proposed system requires multiple stakeholders' action. Psychologists should work on crafting creative solutions to engage patients; solution makers should think of psychology just as much as the medicine; providers ought to create nurturing environments and access to knowledge for patients, while payors should incentivize action to change. Only through an integrated system we can make a significant difference.  

Reference List

1. Urbich, M., Globe, G., Pantiri, K., Heisen, M., Bennison, C., Wirtz, H. S., & Di Tanna, G. L. (2020). A systematic review of medical costs associated with heart failure in the USA (2014–2020). Pharmacoeconomics, 38, 1219-1236. https://doi.org/10.1007/s40273-020-00952-0
2. Celano, C. M., Villegas, A. C., Albanese, A. M., Gaggin, H. K., & Huffman, J. C. (2018). Depression and anxiety in heart failure: a review. Harvard Review of Psychiatry, 26(4), 175. https://doi.org/10.1097/HRP.0000000000000162
3. Kovacs, A. H., Brouillette, J., Ibeziako, P., Jackson, J. L., Kasparian, N. A., Kim, Y. Y., ... & American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Stroke Council. (2022). Psychological outcomes and interventions for individuals with congenital heart disease: a scientific statement from the American Heart Association. Circulation: Cardiovascular Quality and Outcomes, 15(8), e000110. https://doi.org/10.1161/HCQ.0000000000000110
4. Allen, L. A., Gheorghiade, M., Reid, K. J., Dunlay, S. M., Chan, P. S., Hauptman, P. J., ... & Spertus, J. A. (2011). Identifying patients hospitalized with heart failure at risk for unfavorable future quality of life. Circulation: Cardiovascular Quality and Outcomes, 4(4), 389-398. https://doi.org/10.1161/CIRCOUTCOMES.110.958009 
5. Buck, H. G., Dickson, V. V., Fida, R., Riegel, B., D’Agostino, F., Alvaro, R., & Vellone, E. (2015). Predictors of hospitalization and quality of life in heart failure: A model of comorbidity, self-efficacy and self-care. International Journal of Nursing Studies, 52(11), 1714-1722. https://doi.org/10.1016/j.ijnurstu.2015.06.018
6. Deci, E. L., & Ryan, R. M. (2008). Self-determination theory: A macrotheory of human motivation, development, and health. Psychologie Canadienne, 49(3), 182–185. https://doi.org/10.1037/a0012801