On Monday night, Bob Huggins, the coach of the West Virginia University basketball team, fell to his knees next to the court. The 63-year-old told media outlets that it was because his implanted defibrillator went off. He said it felt like someone slammed him in the back. After doctors looked him over, they determined he was fine to keep coaching the game.
More patients with life-threatening heart conditions like Huggins' are getting this devide implanted to fix the problem, and it's saving their lives. But it's also coming with a surprising side effect—about one in five patients develops post-traumatic stress disorder (PTSD).
A ventricular arrhythmia can cause the heart to beat irregularly, sometimes as the result of previous damage (like a heart attack or heavy alcohol or drug use) and sometimes from a genetic quirk. It's an electrical problem, distinct from the "plumbing problems" remedied by bypass surgeries. At their most mild, arrhythmias can feel like mini-heart attacks, a fluttering sensation in the chest combined with pain or fainting. At worst, an arrhythmia can result in cardiac arrest, which frequently causes death.
In the 1970s, doctors developed a device that could put a stop to that, called an Implantable Cardioverter Defibrillator (ICD). About the size of a pager and implanted under the skin near the collarbone, the ICD is connected with wires to the inside and surface of the heart. The ICD can detect when the heartbeat gets out of whack and shocks it to put it back in rhythm (this is reportedly unsettling but not painful). ICDs have gained popularity over the past 20 years—today, somewhere around 800,000 Americans are living with ICDs.
There's no doubt that ICDs do more good than harm. "The ICD represents a fantastic medical advance. The identification and treatment of arrhythmia by implantable device is the stuff of science fiction," says Samuel Sears, the director of health psychology at East Carolina University. "The challenge for us comes back to the human factors."
Sears has been studying ICDs and their relationship to trauma for nearly 20 years. He's published more than 100 articles and a book on the subject. Sears is intensely focused on collecting data about the lives of ICD patients in order to make their lives measurably better. He calls this his "life's work."
There can be a few different events that can cause someone to develop PTSD. Sometimes witnessing the cardiac death of a loved one can be enough. For others, the process of being diagnosed with a cardiac condition, getting the ICD—and sometimes having a cardiac arrest themselves—can lead to trauma. But the surprising shocks from the ICD can be some of the biggest triggers, especially if they happen frequently and lead to many more medical procedures.
It's not just the shock itself that's traumatizing, Sears says—it's the meaning of it. "Often patients don't know anything is happening [in their hearts,] and then they receive a shock—the ICD detects the problem before the patient perceives it," Sears says. "It works great, but they also realize they were in danger and didn't even know it. Our patients they realize they are in fact marked with risk." After the shock, they might realize they almost died. That gives trauma a starting point, he says.
Together, these factors can combine to create anxiety disorders (found in 13 to 38 percent of ICD patients), depression (30 percent of patients), and PTSD (found in between 20 and 40 percent of ICD patients, depending on the study, and increasing over time after implantation). Psychological distress has a profound effect on the body, too—patients with PTSD are 3.2 times more likely to die within five years of receiving their ICDs, according to a 2008 study.
Not everyone will develop PTSD, of course. There's not a lot of data on what makes a person at higher risk, Sears says, but it's generally understood that PTSD happens more in women (who tend to be likely to acknowledge stress), in younger patients, in people with previous psychological disorders, or are socially isolated.
Doctors typically don't discuss the risk of PTSD with patients who are candidates to receive ICDs, Sears says—it's very much a secondary concern. Keeping them alive is always more important; they can look at treatments for PTSD if and when they need to. "We want to protect the patient first, prevent premature death. The second part is to make patients feel safe."
Indeed, Sears and others in the field have developed versions of cognitive behavioral therapy, one of the primary treatments for PTSD, tailored to ICD patients. They also have a list of recommendations for patients who need help coping with stressful events; active approaches to coping work best. Sears is now working on collecting accelerometer data as an indicator of psychological wellness—patients who aren't moving after their surgery are not engaged with the world, which could indicate a psychiatric disorder like PTSD. And cardiologists are constantly working to improve the ICDs themselves so that shocks happen only when they need to.
"This is new stuff—no generation of people has ever tried to live with heart disease before," Sears says. Stigmatizing mental illness gets in the way; the body and mind are one and the same, he adds. Ultimately, to Sears, treating PTSD is a welcome challenge. It means cardiologists are keeping people alive.