Return to work after a heart attack

Return to work after a heart attack

Journal of Psychosomatic RETURN Research, Vol. 17, pp. 231 to 243. Pergamon TO WORK AFTER Press. 1973. Printed in Great Britain A HEART ATTAC...

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Journal of Psychosomatic

RETURN

Research,

Vol.

17, pp. 231 to 243. Pergamon

TO WORK

AFTER

Press. 1973. Printed in Great Britain

A HEART

ATTACK*.!

ELIZABETH L. CAY, N. VETTER, A. PHILIP and PAT DUGARD (Received 28 November 1972)

THE QUALITY of life after a heart attack depends on “the physiological and medical limitations imposed by the myocardial infarction itself; and on the psychological problems of accommodating to a serious illness and holding it in perspective in subsequent life” [l]. For the great majority of men with acute ischaemic heart disease successful rehabilitation implies return to work without loss of status and earnings, and recent studies by Wynn [2] and Nagle [3] have suggested that failure to achieve this may not always be due to organic cardiac disease but may result frequently from psychological disability. In the present study independent assessments of physical and psychological status during immediate convalescence were made in an unselected group of 203 male patients who had received initial treatment in the Coronary Care Unit, Royal Infirmary of Edinburgh. The patients were recalled to the hospital four months and one year later; work status, physical residual symptoms, emotional adjustment following their illness and social problems encountered since discharge were reviewed. The aim of the study was to examine those factors which are relevant to the individual’s ability to return to work after a heart attack. THE STUDY GROUP The group comprised 203 consecutive male patients who were admitted to the CCU and who survived long enough to be transferred to one of the six general medical wards of the hospital. Their ages ranged from 16 to 79 yr with a mean of 55 yr. One hundred and fifty-four patients (76 per cent) were working on admission, 14 (7 per cent) were unemployed and the remaining 35 patients (17 per cent) had already retired. The patients were divided into social classes according to the Registrar General’s Classification by occupation, or in the case of those unemployed or retired accord&g to their last occupation. In Class I there were 9 patients; in II, 42; in III, 63; in IV, 51; in V, 38. One hundred and thirty-one had a detinite myocardial infarction (MI), 101 (50 per cent) being seen during their first major attack and 30 (15 per cent) during a second or subsequent MI. Of the remaining patients without MI, 45 (22 per cent) had no history of a previous MI and 27 (13 per cent) had such a history. Although the most frequent.diagnosis made in these patients was myocardial ischaemia, some were admitted with other cardiac disease (pacemaker failure, chronic complete heart block, arrhythmais requiring monitoring, valvular disease).

METHOD Assessment during convalescence The patients were seen by a psychiatrist at intervals during their stay in the ward. They were aware that the interviews were for research purposes, and that the psychiatrist formed no part of their treatment situation. No patient refused to co-operate in the study. Their medical state was independently assessed by a physician. Work record. This was assessed by the psychiatrist after the patients had been in the ward for 8-10 days. This particular time was chosen because the majority of patients had recovered from their acute symptoms and could be regarded as having entered the convalescent stage of the illness. It was *From the Coronary Care Unit, Royal Infirmary of Edinburgh, Department of Psychological Medicine and the MRC Unit for Epidemiological Studies in Psychiatry, University of Edinburgh. TThis study was supported by a grant from the Scottish Hospital Endowments Research Trust. 231

232

ELIZABETHL. CAY, N. VE~ER, A. PHILIP and PAT DUGARD

noted whether the patient was working on admission, and his occupation was recorded. A detailed history of his work record was taken which included the number of jobs throughout his working life, periods of unemployment and reasons for change in jobs. Following this the patients were graded on a five point scale according to their work records; l=excellent; 2=good; 3=fair; 4=poor; 5=bad. Psvchologica/ slate. This was assessed by the psychiatrist by means of a semi-structured interview which was carried out at the same time as the assessment of the patient’s work record. On the basis of this information the presence or absence of symptoms of emotional upset was noted, and such symptoms were classified using broad diagnostic categories, e.g. anxiety, depression. No attempt was made to estimate the severity of upset. A clinical grading of the patient’s previous personality was also made. The patients were rated on a three point scale as showing no evidence of personality disorder, with personality disorder likely to be present, or as showing evidence of definite personality disorder. At the end of the interview a short test of psychiatric symptoms was administered using the Persona1 Disturbance Scale of the Symptom Sign Inventory or SSI [4]. The SSI provides an objective index of current pathology and in the present study acted as a check on the clinical diagnosis. It also affords a method of grading the severity of upset as the patients are categorised on a three point scale according to their test scores; N=normal, no upset; B= borderline, mildly upset; P=psychiatric, severely upset. Severity of the heart attack. A grading of physical severity of the attack was made on transfer from the CCU by the physician. While it is realised that no prognostic index is wholly satisfactory [5], the Peel Index [6] gives a good indication of severity and was used in the study. Problems at work. On the day before discharge the psychiatrist recorded for each patient who had not retired before admission whether he anticipated any difficulty in returning to work after his heart attack. Such difficulties included inability to return to work for any reason, loss of job while in hospital, or a known prejudice of his previous employer against employing patients after a heart attack. The patients were graded as having no problems, with some problems or with serious problems. Assessment four months and one year after discharge The patients were reviewed at a follow-up clinic at the hospital four months and one year after discharge. Work. The work status of the patient at the time of interview was noted. Time of return, change in job and any adjustments, with reasons for these, which had been made in a previous job were recorded for those who were working. Following this an assessment, to take into account occupational changes and any adjustment in a previous job, was made on each patient who had been working on admission to hospital. These patients were graded as: l=fully active in pre-admission job or comparable job; 2= not fully active in pre-admission job or comparable job; 3 = working in less demanding job; 4=retired since admission but not due to age; 5=not yet working. Problems encountered by the patient in his efforts to return to work after his heart attack were noted and were graded in the same way as had been done just before discharge from hospital. Psychological assessment. The presence of psychological disturbance was estimated by the psychiatrist in the same way as in the hospital interview, and following this the Personal Disturbance Scale of the SSI was administered again. Without taking any history of physical symptoms, the psychiatrist asked the patients whether they considered that they suffered from any physical disability following their heart attack. On the basis of their replies each patient was graded on a three point scale as having no disability, with some disability or with serious disability. Medical assessment. This was carried out by the physician quite independently of the psychological assessment. He recorded the physical residual symptoms suffered by the patients following their heart attack, and then graded each patient for severity of angina and breathlessness on a three point scale; l=no symptoms; 2=mild symptoms; 3=severe symptoms. The criteria used for grading the patients for severity of these symptoms were those recommended by WHO [7]. RESULTS Assessment four months after discharge Of the 203 patients in the study group, 12 patients died in the ward, 10 with complications of MI (ventricular aneurysm, ruptured ventricle, uncontrollable arrhythmia, congestive cardiac failure) and in the remaining 2 patients, who had not had an MI on this admission, the cause of death was congestive cardiac failure. At the end of four months a further 11 patients had died, 10 of these deaths being classified as due to cardiovascular disease. Each of the patients who died after discharge had a history of MI, in 7 cases within the preceding four months.

Return to work after a heart attack

233

Information on return to work, medical and psychological state was obtained for 166 (92 per cent) of the 180 survivors. Failure to see the patients occurred for several reasons; they had left the district, were too ill to attend the hospital or they did not come, despite repeated requests, for follow-up. Work status

Ninety-four (52 per cent) were working four months after their heart attack, 43 (25 per cent) were unemployed and 28 (16 per cent) were retired. In 15 cases (7 per cent) their work status was not known. Of the 154 patients who were working on admission, 66 per cent of those with a first Ml had returned to work; 76 per cent of those after a second MI; 69 per cent of those who had never had an Ml; and 77 per cent of those who did not have an MI on this admission but who had a history of a previous MI. Eighty-five of the 94 patients who were working had returned to their previous jobs, though considerable adjustments to lighten their work load had been made in 33 cases. This occurred whether or not the patient had had a confirmed MI four months previously. Since their heart attack 60 patients had changed their occupational status (retired, not yet working or change to a lighterjob). In 43 cases this was directly due to their illness, in 5 it was unrelated and in 12 cases the reasons for change were not known. Of the 48 patients where the reasons for the change were known, in 39 instances the change had been instigated by the patient himself or his medical advisors and in the remaining 9 cases by the employer against the wishes of the patient. The grading of their activity at work four months after their heart attack in the 154 patients who were working on admission is shown in Table 1. There was a considerable decrease in working efficiency; only one third after a first MI were working as hard as before their illness and about half of those after a subsequent MI. Outcome was similar in the proportion of the group who did not have an MI on this admission; 52 per cent of those who never had an Ml were working as well as before and 38 per cent of those with a history of a previous Ml. The small number of premature retirals occurred in the infarct groups and these patients were much older than the others. Patients who changed to a less demanding job were younger than the other members of the group, but otherwise the age of the patient did not appear to influence return to work. More patients with professional and managerial posts were working by this time than were skilled and unskilled workers; only 5 per cent of those in social classes 1 and II had not yet gone back to work and 32-39 per cent of those in the other social classes. There were no differences in the proportion of patients in each social class who were back to full activity but considerable discrepancy in those who were working less hard. This is most likely a reflection of the greater capacity for adjusting the work load in professional and managerial posts. Physical

residual symptoms

A considerable number of the group had angina following their heart attack, 45 patients being classified as having mild angina and 33 as having severe symptoms, and it occurred more often in those who had a confirmed MI four months previously; 48 per cent of those after a first MI had angina, 60 per cent after a subsequent MI and 34 per cent of the other patients. Severe angina was not very frequent after a first MI (12 per cent) or in those who had never had a confirmed MI (11 per cent) but was seen more often in patients who had had more than one MI (44 per cent) and in those who had a history of a previous infarction but who were presumed to have myocardial ischaemia on this admission (27 per cent). Ninety-nine patients complained of breathlessness, 81 being classified as having mild symptoms and 18 as being severely incapacitated. Mild symptoms were distributed very evenly throughout the diagnostic groups (42-50 per cent) but severe breathlessness was largely confined to patients with more than one MI (24 per cent) and to those who had had an MI before their last admission (23 per cent). The individual’s ability to work within four months of a heart attack was related to the physical residual symptoms suffered by him (Table I). More patients with angina had not yet started working compared with those without this symptom and, of those who were back to work, fewer patients with angina were working as hard as before. On the other hand, if anything, patients with severe angina were doing better than those with mild angina. This was reflected in their length of convalescence; patients without angina returned to work 59.6 days after discharge from hospital, those with mild symptoms after 80.7 days, while those with severe symptoms returned in 69.2 days. Severe breathlessness was also a factor in the patient’s failure to return to work within four months, though a mild degree of this symptom did not appear to incapacitate the patients. It is interesting to note that, though fewer were working, just as many of the group with severe breathlessness who had returned were working as hard as before as were the other patients. They had, however, taken longer to return. Patients without breathlessness started work 55.5 days after discharge, those with mild symptoms in 68.4 days and those with severe symptoms in 100 days.

44

40

42

28

36

27 19 24 3 8 4 3 6 0 20 39 36 MI, previous MI.

41

41

26 29 6 5 6 0 18 25

44 0 0 0 57

43

assessment

Emotional upset present Psychiatric diagnosis in upset patientsAnxiety Depression SSI data-Borderline Psychiatric

Emotional upset present Psychiatric diagnosis in upset patientsAnxiety Depression SSI data-Borderline Psychiatric

Time of assessment

During immediate convalescence in the ward

Four months after discharge

63 37 58 21 42

61 55 37 43 30

48 42 58 32 24

51 40 50 28 22



Subsequent MI (%)

19 2 6 17

56

First MI (%)

TABLE2.-EMOTIONAL DISTURBAWEAFTERA HEARTATTACK

Anx.-anxiety.

56 41 21 13 47 27 4 64 80 2 52 5 32 39 no previous MI, D-No

52

20

55 71 75 21 24

52 52 44 25 57

26 63 38 48

3 25 28 0 8 9 9 3 0 14 28 43

36

65 23 49 43

21 6 0 29

14

No MI, previous MI (%) 70

34 8 0 42

29 7 0 36

38

No MI, no previous MI (%) 69

16

28

TABLE1.-RETURN TO WORKWITHINFOURMONTHSOF A HEARTATTACK Social Class (%) Physical status at four Psychological status at four months Age months I III IV Diagnosis SSI data Angina (%) Breathlessness Symptoms (yr) & & (%) (%) (%) (%) V NtiP II NMS Dep. _’ Anx. NtiS Abs. -‘-’Pres.

Fully active in nreadmission job or comparable job 36 41 52 38 Not fully active in preadmission job or comparable job 23 29 17 31 Less demanding job 7 0 0 8 Retired (not due to age) 5 6 0 0 Not working 29 17 31 23 A-First MI, B-Subsequent MI, C-No MI, N-none, M-mild, S-severe. Abs.-absent, Pres.-present, Dep.-depression, N-none, B-borderline, P-psychiatric.

ABCD

Diagnosis (%)

Return to work after a heart attack Emotional

23.5

disturbance

The results of the psychological assessment of the 203 patients during immediate convalescence and four months after discharge are summarised in Table 2. Immediately after their heart attack 131 patients (65 per cent) were assessed clinically as showing evidence of emotional upset and this occurred whether or not the admission diagnosis of myocardial infarction was confirmed. The results of the SSI bore out the clinical assessment and, using this measure as the estimate of emotional disturbance, it appeared that 30 per cent after a first Ml were quite severely upset and almost half the patients in the other diagnostic groups. Four months later the group was more stable emotionally, 92 patients (51 per cent) having symptoms of disturbance and the proportion of those severely upset had dropped to 22-24 per cent. The only exception occurred in the patients who had never had an MI; 57 per cent of these patients were severely upset four months after discharge. The kind of emotional reaction found at this time had altered a little compared with that found in the immediate convalescent phase, as the patients who were observed to be disturbed were likely to have symptoms of depression rather than anxiety. Work after a heart attack was related to the individual’s emotional adjustment (Table 1): 64 per cent of those who were disturbed at four months had started work and 77 per cent of the other patients, and of the upset patients who had returned only 28 per cent were working as hard as before their illness compared with 56 per cent of the others. They had also had a more prolonged convalescence, returning to work 71.4 days after discharge from hospital while those without upset had returned in 58.5 days. The small number of patients who changed to a less demanding job included more disturbed than stable individuals. These findings were present throughout the diagnostic groups. Also, severity of upset and the type of emotional reaction at four months were relevant to outcome. Using the SSI data to estimate upset, there was a decrease in the numbers working when the patients who were severely upset were compared with those who were mildly disturbed, and of those in the former group who had returned only 20 per cent were working as hard as before. A particularly vulnerable group were those who were depressed four months after their heart attack; 42 per cent had not returned and only I6 per cent were working as well as before their illness. Problems

in returning

to work

Of the 154 patients who were working on admission, 83 (56 per cent) encountered no problems in returning to work or in finding a new job after their heart attack and 45 (30 per cent) had difTiculty, the majority of these (36 patients) having serious work problems. In the remaining 26 cases (14 per cent) some were dead and the others did not attend the follow-up clinic. Patients with a confirmed MI on this admission found less difficulty in working again than did those who were presumed to have myocardial ischaemia; serious work problems occurred in 21 per cent of the infarct group and in 4.5 per cent of the others. As might be expected, patients without angina encountered fewer difficulties than those with angina (p 0.05). But severe breathlessness did prevent the patient from working; 78 per cent of the patients severely handicapped in this way had serious difficulty compared with 21 per cent ot those without this symptom or who were mildly incapacitated by it. As occurred with angina, the infarct patients appeared to cope better with residual symptoms than the patients with ischaemia. Following their infarction only 12 per cent of those with mild symptoms complained of work problems compared with 44 per cent of those similarly handicapped following their presumed ischaemic attack. Problems in returning to work after a heart attack were also related to the patient’s emotional state (Table 3). Patients who were emotionally disturbed at four months, whether or not they had had a confirmed MI on this admission, were more likely to have encountered difficulties than those who were not upset (pi ONll). Forty-three per cent of the upset patients complained of serious problems connected with return to work and only 8 per cent of those who were not upset. The kind of emotional reaction observed at four months was not related to these difficulties; 31 per cent of the anxious patients had serious problems and 28 per cent of the depressed patients. Serious difficulty in return to work was likely to be associated with quite severe emotional upset as 53 per cent of those who were

TO WORK

52 9 39

Angina (%) Mild 45

46 15 39

33

Severe

IN

74 12 14

63 63 4 33

81 22 78

18 88 4 8

64 48 9 43

92

Psychiatric symptoms (%) Absent Present

First MI (%)

77

69 19 12

Number of patients

No disability Some disability Serious disability

62 17 21

24

Subsequent MI (%)

57 24 19

pre?ous MI (%) 39

No MI,

Diagnosis

50 22 28

18

No MI, previous MI (%)

72 16 12

84

None 54 24 22

45

Mild

Angina (%)

50 28 22

33

Severe

78 12 10

63

None

58 27 15

81

Mild

Breathlessness

Physical assessment

21 21 58

18

Severe

(%)

81 3 16

43

Normal

RELATION TO PHYSICALANDPSYCHOLOGICAL STATUS

Breathlessness (%) None Mild Severe

AFTER A HEART ATTACK

TABLE~.--PATIENT'SOPINIONOFHISPHYSICALDISABILITYFOURMONTHSAFTERAHEARTATTACK

78 3 19

None 84

Patient’s opinion of disability

No difficulty Some difficulty Serious difficulty

Number of patients

Work situation

TABLE3.-PaoaLEMs rH RETURN

39 8 53

43

Psychiatric

86 8 6

64

47 29 24

92

Psychological assessment Symptoms Symptoms absent present (%) (%)

74 10 16

48

SSI Data (%) Borderline

AT FOUR MONTHS

237

Return to work after a heart attack markedly disturbed had great difficulty in finding employment per cent of those who were not upset or only mildly so.

after their heart attack and only 16

Attitudes towards physical disability At interview four months after discharge from hospital 98 patients of the group (54 per cent) felt they suffered no physical disability following their heart attack, 32 (18 per cent) considered they had some disability and 28 (15 per cent) rated themselves as severely handicapped. In 22 cases (13 per cent) the reaction of the patient was not known. On the whole, the definitive physical diagnosis made four months previously did not influence the patients (Table 4) though slightly more of the infarct group regarded themselves as free of any residual disability than did the ischaemic patients. The patient’s perception of his disability was certainly related to physical residual symptoms as more patients without angina rated themselves as physically tit compared with those with angina (~~0.025). But those with the most severe angina were not always those who thought they were the most disabled; there was practically no difference in patients graded by the physician as having mild or severe angina in their assessment of physical disability and half the patients who had severe angina did not regard themselves as suffering from any physical handicap. Severe breathlessness was much more accurately regarded as a real disability, but even in these patients 21 per cent did not think that they were disabled at all. A complicating factor was the presence of emotional upset (Table 4) as disturbed patients were much more likely to regard themselves as physically handicapped than were those who had no clinical evidence of emotional disturbance (p
Outcome

Number of patients Alive Working Working on admissionReturned to work Angina-Mild -Severe Breathlessness-Mild -Severe Emotional unset uresent

First MI (%)

Subsequent Ml (%)

No MI, no previous MI (%) 45

No MI, previous MI (%) 27

101 -_ 81 65

30 17

58

93 62

70 55

77 40 8 38 13 56

81 32 41 50 14 56

74 22 10 54 10 52

71 28 28 50 28 61

ELIZABETH L. CAY, N. VETTER, A. PHILIP and PAT DUGARD

238

evenly irrespective of the physical diagnosis, while emotional upset occurred in just over half the patients whether or not an MI had been confirmed one year before.

Outcome

at

fourmonths and otte year compared

There had been surprisingly little change in outcome in the group when the assessment made at four months were compared with those at the later review (Table 6). TABLE 6.-OUTCOME

AT FOUK MONTHSAND ONE YEAR AFTERA HEARTATIACK

OLltcome

Number of Patients Alive Angina

-None -Mild -Severe Breathlessness -None -Mild -Severe Emotional upset present Activity at work _ Fully active Not fully active Less demanding job Retired since admission (not due to age) Not working since admission Retired due to age Problems in None working after a Some heart attack Serious Patient’s opinion None of physical Some disability following Serious his heart attack

Review at four months

(%) 203

Review at one year (%) 203

88 52 28 20 39 50 II 51 42 23 4

82 52 33 15 40 46 14 46 45 18 14

4 27 65 7 28

5 16 2 66 6 28

63 20 17

54 17 29

Residual physical disability, as assessed by the physician, was practically unchanged apart from a small decrease in the number of patients rated as having severe angina, and the psychiatrist’s estimate of the extent of emotional upset was virtually the same as at the earlier review. A few more patients had returned to work; 69 per cent of those working before admission were working by four months and 77 per cent had returned by one year; but there was no increase in the proportion of patients who were working as hard as before their illness. The average length of convalescence in the group was 86 days. Those patients who had had a prolonged convalescence of more than four months, when they did start working again, changed to a less demanding job, resuming work 140 days after discharge. Work problems in the group were just as frequent as they had been eight months earlier. Though the physician’s estimate of residual disability suggested that the patients’ physical state had not deteriorated, the patients themselves tended to think that they were more handicapped now than they had been earlier.

Workitlg at one year

Physical and psychiatric morbidity in the 31 patients who had not returned to work one year after their heart attack was compared with that of the 102 patients who were working (Table 7). There was no difference in angina in the two groups and indeed as many of the patients who were not working were free of this symptom as were those who were working. Breathlessness was related to ability to work after a heart attack as significantly fewer of the patients who had this symptom were working compared with those who had no residual breathlessness. On the other hand, emotional disturbance was also closely related to return to work, as the upset patients were much less likely to be working than those who were not upset. These findings occurred whether or not an MI had been confirmed one year previously.

239

Return to work after a heart attack A HEART

TABLE 7.-FACTORSDETERMININGRETURNTOWORKAFTER

Patients working one year later

-(%) Number of patients Angina Breathlessness Emotional

upset

Patient’s opinion of physical disability

-(%)

102

31 53 33 14 19 62 19 10 90 29 19 52

56 32 12

-None -Mild -Severe -None -Mild -Severe -Absent -Present None Some Serious

ATTACK

Patients not working one year later

41

46 I 52 48 68 18 14

N.S. p-Co.02 p
p
Also, residual angina did not determine whether or not those who were working returned to full activity; 42 per cent of those who were working as hard as before had angina, 46 per cent of those who were not fully active and 50 per cent of those who had changed to a less demanding job. Performance at work depended more on breathlessness as 45 per cent of those who had returned to full activity had breathlessness, 64 per cent of those who were working less hard and 61 per cent of those who had changed to an easier job. In addition, the emotional reaction of the patient was related to his level of activity at work: 62 per cent of those who had returned to their previous performance level had adjusted well, having no evidence of emotional upset. Of those who were working less well only 27 per cent were without symptoms of anxiety or depression and 50 per cent of those who had changed to an easier job. Practical problems and difficulties in relation to work were still present in 44 cases one year after their heart attack. Of these patients 13 were working in unsatisfactory conditions, e.g. under threat of redundancy, in jobs where the patient resented obvious demotion, and the other 31 were unemployed. As occurred at the earlier review such difficulties were not always the result of physical disability (Table 8) and psychiatric morbidity was very high in these patients.

TABLES.-PROBLEMS IN RELATIONTO WOKK Physical and psychological assessments Number of Patients -None -Mild -Severe -None Breathlessness -Mild -Severe Emotional upset -Absent -Present Angina

ONE

YEAR AFTER

Patients without work problems (%) 87

Patients with minor work problems (%) 8

57 33 10 49 44 7 60 40

50 25 25 25 7.5 12 88

A HEARTATTACK Patients with serious work problems (%) 36 45 36 19 23 58 19 6 94

N.S.

p < 0.02 p < OGOl

The patient’s own opinion of his physical handicap following his illness was an important factor in failure to return to work (Table 7); 71 per cent of those who were not working one year later regarded themselves as handicapped to some extent and only 32 per cent of those who were working. This attitude towards disability depended not only on residual physical symptomatology but also on the individual’s emotional adjustment after his illness (Table 9). While patients with angina or breathlessness were likely to consider that they were disabled, there was a wide variation in estimated disability for the same degree of severity of the physical symptoms. Patients who were anxious or depressed one year after their heart attack were likely to regard themselves as severely physically disabled.

ELIZABETH L. CAY, N. VETTEK, A. PHILIP

240 TABLE 9.-FAC-roRs Patient’s

and

PAT DUGARD

DETERMINING THE PATIENT’S OWN OPINION OF HIS HANDICAP ONE YEAK AFTER A HEART ATTACK

opinion

Angina

(%)

Breathlessness

(%)

of his disability Number of patients No disability Some disability Serious disability

None 82 68 14 18

Mild Severe 52 24 46 29 21 13 33 58 JJ
None 67 77 12 11

Mild Severe 12 22 47 18 20 14 33 68 P
Emotional

upset

(%) Absent Present 70 90 83 32 13 19 4 49 p
DISCUSSION

Modern thinking in cardiac rehabilitation is that return to work after a heart attack should not be unduly delayed; Freiberg in the latest edition of his textbook, and recent publications by WHO have recommended that in the uncomplicated case the aim should be ten weeks after the onset of the acute illness [8-lo]. There is no evidence that prolonged convalescence improves the patient’s physical state or his prognosis, and psychologically definite harm may be done as the longer the patient regards himself or is treated by his family as an invalid the harder it is for him to return to an active life. Many studies have been carried out to determine how many patients go back to work after a heart attack and to find out which factors prevent or delay the patient’s return. The proportion of those who resume employment has been variously stated as less than 50 per cent [ll] to more than 80 per cent [12, 131 and a growing body of evidence suggests that the adverse psychological effects of a heart attack, if not recognised, may be as important in failure to return as physical disability [3, 141 though Nagle noted recently that few studies have attempted to examine physical and psychological factors simultaneously in the same group of patients. In the present study, two-thirds of the patients after a first infarction were working again by four months. It appears, however, that merely estimating the proportion of such a group who are working results in an over-optimistic assessment of work after a heart attack, as less than half were working as well as before their illness. The majority of the others gave as their reasons for not doing so fear of precipitating another heart attack, weakness and lassitude and a general feeling that after a heart attack it was not worth striving any more. These findings were not specific to the infarct groups but occurred just as frequently in the other patients. When the group was examined four months after their heart attack it appeared that physical residual symptoms such as angina and breathlessness, especially if the latter was severe, were certainly important in prolonging convalescence and increasing the difficulties encountered by some of the patients when they attempted to return to their previous jobs or to find new employment. But severely disabling symptoms occurred with only moderate frequency (19 per cent of the group had severe angina and 11 per cent had severe breathlessness) and, even in the cases estimated by the physician as severely disabled, 64 per cent with severe angina and 43 per cent with severe breathlessness were working again within four months of discharge from hospital. The complicating factor appeared to be the attitude of the patient to his symptoms as half of those with severe angina and 21 per cent with severe breathlessness would not admit that they were in any way disabled. In the

Return to work after a heart attack

241

same way, the attitude towards disability of those with mild residual symptoms influenced outcome. The evidence from this study suggests that the physical consequences of a heart attack do not by themselves determine success of failure of rehabilitation. Only half the patients who had no angina or breathlessness following their heart attack were working as efficiently four months later, and emotional upset, especially if severe, appeared to exert a powerful influence in delaying or preventing patients from returning to work. Patients who were depressed or anxious following their heart attack were likely to consider any physical symptoms as sufficiently severe to stop them working or to place insurmountable difficulties in their way when they contemplated the prospect of returning to employment. The same factors operated whether or not the patients had a confirmed infarction on this admission and, if anything, appeared to exert more influence on those who had not had an infarction. These patients suffered less physical residual disability than the infarct group but they did not return to work more readily, probably because psychological upset was more prominent in these patients who consequently did not feel that they were less disabled. It is reasonable to expect that one year after their heart attack the physical state of the majority of patients and their emotional reaction to the acute episode would be stabilised. The similarity of the findings of the medical, psychological and social assessments at four months and one year suggest that this occurs much earlier. Also, the factors which were important in prolonging the patient’s convalescence beyond four months were the same as those which prevented him from working one year later. The presence of angina after a heart attack was the exception to this; while this symptom was related to failure to return by the earlier review it did not differentiate between those who were working or not eight months later. The finding that morale was higher in those who were working within four months of their heart attack, especially if they were able to work as efficiently as before their illness, justifies the search for all factors which may be relevant to achieving this. The results of this study suggest that comprehensive rehabilitation embracing medical, psychological and social aspects is necessary in many patients. There is no point in delaying such rehabilitation as there was very little improvement in outcome when the results of the later review were compared with those at four months. Education of the patient during his convalescence in hospital about his disease and reassurance that it is possible for the majority of patients after a heart attack to go back to work should go far to reduce anxiety and allay uncertainty about the future. Since emotional upset was common during convalescence, drugs to promote sleep and to reduce anxiety should not be withheld and supportive psychotherapy may be necessary in the more disturbed patients. It would appear that those who are depressed following a heart attack are particularly liable to have difficulties in rehabilitation. At the same time orientation of the patient towards work forms an important part of his psychological management and the help of a social worker to examine the problems which he may have in returning to work or in finding a new job should be sought. This may necessitate contact with the patient’s previous employer, and in this particular group it appeared that many of the employers were indeed willing to take them back and to make adjustments to lighten their work load. In patients who for various reasons cannot return to their previous employment efforts to find them new jobs

242

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should begin while they are still in hospital. Thus all patients after their heart attack could leave hospital as free from worry and anxiety as possible, optimistic of their prospects of return to work and with concrete evidence that arrangements to enable them to do so are already under way. SUMMARY The

work status of the survivors of a group of 203 consecutive male patients with ischaemic heart disease who had received initial treatment in the Coronary Care Unit. Royal Infirmary of Edinburgh. was reviewed four months and one year after discharge from hospital. Ai the same time independent assessments were made of their physical and psychological state. Psychological testing included a symptom measure of emotional upset (SSI). Of the 154 patients who were working on admission, 94 (69 per cent) returned to work within 4 months and 102 (77 per cent) were working at 1 yr, and it was noted that the physical diagnosis of the acute attack (myocardial infarction or ischaemia) made little difference to outcome. Efficiency at work had decreased considerably as less than half the patients reported that they were working as hard as before their illness. The individual’s ability to work within 4 months and the activity at work of those who had returned were related to residual physical symptomatology, angina and severe breathlessness, though the patients with severe angina tended to do better than those with mild symptoms. After a year the presence of angina did not differentiate between those who were working or not, nor was this symptom related to the patient’s ability to attain his previous level of performance. By this stage residual breathlessness was more important in determining the patient’s capability to earn his living. There was considerable emotional disturbance in this group of patients after their heart attack; about half the patients had clinical evidence of anxiety of depression and, using SSI data, about one-quarter were quite severely disturbed. Emotional upset, especially if severe, contributed to failure to return to work within 4 months and at 1 yr 90 per cent of those who were not working were depressed or anxious. Activity at work in those who had returned was also related to emotional disturbance; 62 per cent of those who had returned to their previous level of performance had no psychological symptoms and only 27 per cent of those who were working less well. The patient’s own opinion of the extent of his physical handicap following his illness was important in determining return to work. While this was related to angina and breathlessness, there was a wide variation in estimated disability for the same degree of severity of the physical symptom, and half of these with severe angina and 21 per cent with severe breathlessness would not admit they wcrc disabled. The patient’s opinion of his handicap was coloured by his emotional state; patients who were depressed or anxious following their heart attack were likely to regard themselves as severely physically handicapped. Ackllowlerlgenlerrrs-The authors would like to thank Professor K. W. Donald, Dr. M. F. Oliver and Dr. D. G. Julian, physicians in administrative charge of the Coronary Care Unit, Royal Infirmary of Edinburgh, for much helpful advice and criticism during the study. We acknowledge the support of Professor G. M. Carstairs and Dr. J. R. Smythies, Department of Psychological Medicine, University of Edinburgh, while we were carrying o& the’study. We are grateful to the physicians of the Royal Infirmary for permission to study their patients. REFERENCES 1. Psychological Hazards of Convalescence after Mycoardial Infarction. Lancet 1, 1055 (1971). 2. WYNN A. Unwarranted emotional distress in men with ischaemic heart disease. Med. .I. Aust 2, 847 (1967). 3. NAGLE R., GANGOLA R. and PICTON-ROBINSONI. Factors influencing return to work after myocardial infarction. Lancet 2, 454 (1971). 4. FOULDS G. A. and HOPE K. Manual of the Symptom Sign Inventory (SSZ), University of London Press, London (1968). 5. KURIEN V. A. and OLIVER M. F. Assessment of the immediate prognosis during acute myocardial infarction. A/II. Heart J. 78, 718 (1969). 6. PE~I. A. A. F.. SEMPLET.. WANG I.. LANCASTERW. M. and DALL J. L. G. A coronary _. prognostic index for grading the severity of infarction. Br. Heart J. 24, 745 (1962). 7. ROSE G. A. and BLACKRURN H. Cardiovascular Populatiorl Studies: Methods, WHO, Gene-*a (1966). 8. FRIEDBERGC. K. Diseases of the Heart, W. B. Saunders, Philadelphia (1966).

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9. The Rehabilitation of Patients with Cardiovascular Diseases, Regional Office for Europe, WHO, Copenhagen (1967). 10. A Programme for the Physical Rehabilitation of Patients wifh Acute Myocardial Infarction, Regional Office for Europe, WHO, Copenhagen (1969). 11. PELL S. and D’ALONSOC. A. Immediate mortality and five-year survival of employed men with a first myocardial infarction. New Eng. J. Med. 270, 915 (1964). 12. GRODENB. M. Return to work after myocardial infarction. Scot. Med. J. 12, 297 (1967). 13. HAY D. R. and TURBOTTS. Rehabilitation after myocardial infarction and acute coronary insufficiency. N.Z. Med. J. 71, 267 (1970). 14. GOBLEA. J., ADEY G. M. and BULLENJ. F. Rehabilitation of the cardiac patient. Aled. J. Aust. 2, 975 (1963).