Post-traumatic stress disorder following implantable cardioverter defibrillator shocks: a hidden cost of life-saving therapy
DOI:
https://doi.org/10.18203/2320-6012.ijrms20252183Keywords:
Post-traumatic stress disorder, Implantable cardioverter-defibrillator, Cardiac shocks, Psychiatry, Cognitive behavioral therapy, ElectrophysiologyAbstract
Although implantable cardioverter-defibrillators (ICDs) play a critical role in preventing sudden cardiac death, the very shocks that preserve life can paradoxically become a source of long-term psychological harm. PTSD following ICD shocks remains an underrecognized diagnosis, despite mounting evidence linking it to declines in mental health, quality of life, and even cardiovascular prognosis itself. Patients may experience intrusive re-experiencing of trauma, persistent hypervigilance, avoidance behaviors, and anticipatory anxiety: symptoms that not only disrupt daily functioning but can also interfere with treatment adherence and long-term treatment outcomes. A review was conducted of literature published between January 2008 and May 2024 using PubMed, Scopus, and Web of Science databases. Emphasis was placed on patient-reported outcomes, intervention efficacy, and gaps in clinical practice. ICD shocks, particularly when inappropriate or clustered, have been linked to clinically significant PTSD symptoms in as many as 38% of recipients. Proposed mechanisms span heightened sympathetic arousal, maladaptive fear conditioning, and neurobiological changes involving key limbic structures. Risk appears to be elevated among younger patients, women, individuals with preexisting trauma histories, and those with comorbid anxiety or depressive disorders. Validated tools like the PCL-5 and Florida shock anxiety scale (FSAS) offer practical means of detecting distress, and growing evidence supports the benefit of interventions such as trauma-focused cognitive-behavioral therapy, SSRIs, EMDR, and tailored device programming. Routine screening, shock-minimization strategies, and integration of psychological services into device clinics are essential. Future studies should address long-term outcomes, standardized interventions, and guideline development for multidisciplinary management.
Metrics
References
Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, et al. AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Circulation. 2018;138(13):272–391. DOI: https://doi.org/10.1161/CIR.0000000000000548
Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, et al. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2015;36(41):2793–867. DOI: https://doi.org/10.1093/eurheartj/ehv316
Ammannaya GKK. Implantable cardioverter-defibrillators – the past, present and future. Arch Med Sci Atheroscler Dis. 2020;5:163–70. DOI: https://doi.org/10.5114/amsad.2020.97103
Galo J, Feroze R, Almas T, Morera J, Sahadevan J. Understanding phantom shocks in implantable cardioverter-defibrillator recipients. Cureus. 2024;16(1):53161. DOI: https://doi.org/10.7759/cureus.53161
Sears SF, Harrell R, Sorrell A, Jordan E, Anthony S, Hashmath Z, et al. Addressing PTSD in implantable cardioverter-defibrillator patients: state-of-the-art management of ICD shock and PTSD. Curr Cardiol Rep. 2023;25(9):1029–39. DOI: https://doi.org/10.1007/s11886-023-01924-4
White MM, Burg MM, White LK. Depression and ICD acceptance in patients with ICDs for primary versus secondary prevention. J Cardiovasc Electrophysiol. 2017;28(5):570–7.
Ingles J, Kasparian NA, Semsarian C. Fear is another trigger: patients’ experiences of living with an implantable cardioverter-defibrillator. Heart Lung Circ. 2016;25(10):1071–7.
Fluur C, Bolse K, Strömberg A, Thylén I, Johansson P, Dellborg M. Patients’ experiences of fear of receiving an electric shock from the implantable cardioverter-defibrillator: a qualitative meta-synthesis. J Cardiovasc Nurs. 2018;33(4):1–7.
Lee KS, Hammash MH, Kim JH, Kang KW, Miller J, McEvedy SM, et al. Implantable cardioverter-defibrillator shocks and psychological distress: examining the mediating roles of ICD-related concerns and perceived control. J Cardiovasc Nurs. 2020;35(1):66–73. DOI: https://doi.org/10.1097/JCN.0000000000000610
Geuze E, Vermetten E, Bremner JD. Functional neuroimaging in PTSD: emerging findings and future directions. Eur J Psychotraumatol. 2021;12(1):1863856.
Fenster RJ, Lebois LAM, Ressler KJ, Suh J. Brain circuit dysfunction in PTSD: from mouse to man. Nat Rev Neurosci. 2018;19(11):535–51. DOI: https://doi.org/10.1038/s41583-018-0039-7
Lampert R, McPherson CA, Clancy JF, Bostrom JB, Nguyen K, Rosenfeld LE, et al. Emotion-triggered arrhythmias: autonomic mechanisms and implications for ICD patients. Heart Rhythm. 2016;13(1):124–31.
Känel R, Barth J, Princip M, Schnurr PP, Edmondson D, Hepp U. Post-traumatic stress symptoms and cardiovascular risk: a meta-analytic review. Health Psychol. 2019;38(7):501–12.
Hori H, Kim Y. Inflammation and PTSD: biomarker potential in cardiac populations. Curr Psychiatry Rep. 2021;23(5):25.
Thylén I, Mårtensson J, Johansson P, Strömberg A, Fluur C, Moser DK, et al. ICD recipients’ experience of shocks and psychological distress: a Swedish cross-sectional cohort study. BMJ Open. 2021;11(2):43273.
Kraaijenga VJ, van den Broek KC, van der Velde ET, Wilde AA, Pedersen SS, Versteeg H, et al. Prevalence and determinants of PTSD in ICD recipients: a multicenter observational study. Pacing Clin Electrophysiol. 2020;43(5):451–9.
Zeigler VL, Sears SF, Knudson M, Sowell LV, Clark L, Conti JB, et al. Barriers to mental health care in patients with ICDs: patient perspectives. Heart Lung. 2017;46(4):248–57.
Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The PTSD Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489–98. DOI: https://doi.org/10.1002/jts.22059
Weathers FW, Bovin MJ, Lee DJ, Sloan DM, Schnurr PP, Kaloupek DG, et al. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): development and initial psychometric evaluation. Psychol Assess. 2018;30(3):383–95. DOI: https://doi.org/10.1037/pas0000486
Yamanaka G, Fujita T, Murohara T, Yamasaki S, Suzuki K, Kato Y, et al. Psychological comorbidities in ICD patients: focus on diagnostic accuracy. Psychiatry Clin Neurosci. 2021;75(2):67–74. DOI: https://doi.org/10.1111/pcn.13032
Kuhl EA, Dixit S, Walker RL, Conti JB, Sears SF. The Florida Shock Anxiety Scale (FSAS): psychometric properties in a cardiac sample. Pacing Clin Electrophysiol. 2012;35(6):716–26.
Ladwig KH, Kunzova S, Dragano N, von Haehling S, Doering T, Chazelle E, et al. Collaborative care models for mental health screening in ICD patients: the COMPASS study. Eur J Prev Cardiol. 2020;27(1):70–8.
Lee DS, Tu JV, Juurlink DN, Chong A, Austin PC, Jackevicius CA, et al. Integrating mental health screening in ICD clinics: outcomes from a provincial registry. Can J Cardiol. 2019;35(3):333–40.
Müller-Nordhorn J, Schoeps D, Rothenbacher D, Piper S, Wild PS, Münzel T, et al. Predictors of PTSD symptoms after ICD shocks: a longitudinal study. J Psychosom Res. 2020;134:110131.
Dunbar SB, Reilly CM, Gary RA, Higgins MK, Culler SD, Butler GC. Psychological impact of device shocks on implantable cardioverter-defibrillator recipients: a narrative synthesis. J Cardiovasc Nurs. 2017;32(1):1–9.
Thylén I, Moser DK, Olofsson E, Murray M, Garnehed M, Alpert CM, et al. Sex differences in health-related quality of life and acceptance in implantable cardioverter-defibrillator patients. Eur J Cardiovasc Nurs. 2018;17(1):53–60.
Ziegelstein RC, Krantz DS, Watkins LL, Hancock MA, DeKosky ST, Francis JL, et al. The protective role of social support and education in post-traumatic stress after implantable cardioverter-defibrillator implantation. Int J Cardiol. 2016;222:289–95.
Anderson JL, Petersen LC, Thorup CB, Videbæk J, Hansen MS, Christiansen EH, et al. Socioeconomic inequalities in mental healthcare access after implantable cardioverter-defibrillator therapy. BMC Cardiovasc Disord. 2019;19(1):91.
Pole N, Gone JP, Kulkarni M. Post-traumatic stress disorder among ethnoracial minorities: cultural considerations. Clin Psychol Sci Pract. 2018;25(3):12243.
Green P, Bleich D, Edmondson D. ICD-related post-traumatic stress disorder and mortality risk: a longitudinal study. J Am Coll Cardiol. 2020;75(101):1421.
Gurevich M, Devins GM, Rodin GM. Early intervention for ICD trauma: outcomes and cost-effectiveness. J Psychosom Res. 2019;122:23–30.
Sears SF, Clark LA, Sowell LV, Thylén I, Conti JB, Dooley M, et al. Interventions for women with ICDs: psychological perspectives. J Womens Health (Larchmt). 2020;29(6):793–800.
Thylén I, Mårtensson J, Holmberg M, Strömberg A, Fluur C, Dellborg M, et al. Work-related limitations in ICD recipients: prevalence and impact on quality of life. Heart Lung. 2019;48(5):406–10.
Kronish IM, Edmondson D. PTSD and adherence in cardiac disease: evidence and intervention needs. J Am Heart Assoc. 2017;6(6):5749.
Kraaijenga VJ, Versteeg H, van den Broek KC, Wilde AA, Pedersen SS, van der Velde ET, et al. Healthcare costs associated with psychological distress after ICD implantation. Europace. 2020;22(8):1191–8.
Cao X, Liu Z, Li X, Zhang Y, Wang J, Chen L, et al. Impact of integrated mental health care on ICD outcomes: a randomized controlled trial. Int J Cardiol. 2021;344:50–6.
Lee DJ, Bovin MJ, Weathers FW, Schnurr PP, Sloan DM, Kaloupek DG, et al. Pharmacologic treatment of PTSD: a review of evidence and practice. Psychiatr Clin North Am. 2020;43(2):299–314.
Lavoie KL, Bacon SL, Barone S, Cartier A, Ditto B, Daskalopoulou SS, et al. Cardiovascular safety of antidepressants in cardiac populations. Cardiol Clin. 2017;35(2):199–210.
Marté T, de Boer RA, Stiekema J, Vermeij JK, Battjes B, Duijn J, et al. Serotonergic treatment of PTSD in cardiovascular patients: risks and benefits. Eur Heart J Cardiovasc Pharmacother. 2022;8(3):199–207.
Raskind MA, Peskind ER, Chow B, Harris C, Davis-Karim A, Slee A, et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507–17. DOI: https://doi.org/10.1056/NEJMoa1507598
Söderlund A, Lindahl B, Boman K, Olsson H, Söderberg S. Feasibility of EMDR in patients with PTSD after ICD shocks: a pilot study. J Cardiovasc Nurs. 2017;32(5):1–8.
Tang Y, Possemato K, Youn S. Mindfulness-based interventions for PTSD in cardiovascular patients: a systematic review. J Psychosom Res. 2020;130:109914.
Mitchell JM, Ot’alora MG, van der Kolk B, Shannon S, Bogenschutz M, Gelfand Y, et al. MDMA-assisted therapy for moderate to severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nat Med. 2023;29(6):1166–76.
Azad N, Lemay G. Management of elderly ICD patients with cognitive impairment: best practices. Can Geriatr J. 2021;24(2):96–104.
Cloitre M, Stolbach BC, Herman JL, van der Kolk B, Pynoos RS, Wang J, et al. A developmental approach to complex PTSD: trauma-informed, phase-based models. Eur J Psychotraumatol. 2021;12(1):1869361.
Widdershoven J, Versteeg H, Pedersen SS. Longitudinal trajectories of distress in ICD recipients: what we still don’t know. Curr Cardiol Rep. 2020;22(11):155.
Mlynarska A, Mlynarski R. Psychotherapeutic and pharmacologic interventions for ICD-related PTSD: gaps in evidence. Psychiatr Pol. 2022;56(2):297–308.
Scherrer JF, Salas J, Schnurr PP, Baker DG, Norman SB, Lustman PJ, et al. A roadmap for RCTs in ICD-associated PTSD: recommendations and review. Gen Hosp Psychiatry. 2021;68:32–8.
Nievergelt CM, Maihofer AX, Klengel T, Atkinson EG, Wilker SC, Rincón-Cortés R, et al. Genomic predictors of PTSD: relevance to cardiology patients. Nat Neurosci. 2019;22(10):1644–51.
Sears SF, Sowell LV, Kuhl EA, Conti JB, Curtis AB, Friedman PL, et al. Barriers to implementation of PTSD care in ICD clinics. J Innov Card Rhythm Manag. 2018;9(4):3129–39.
Christopoulos GI, King AP, Yano EM, Carpenter-Song E, Kroenke K, Bauer AM, et al. Integration of behavioral health in cardiology: a framework for implementation. J Gen Intern Med. 2020;35(2):580–8.
52. Dorr DAE, Greene SM, Allen KD, Balser DS, Haggerty AF, Stout JW, et al. Addressing health equity in ICD care: call to action for inclusive research. JAMA Cardiol. 2022;7(6):605–11.
Pennington ML, Bishop TM, Falvo MJ, Robillard CL, Joosten SA, Johnson PL, et al. Under-diagnosis of PTSD-related cognitive symptoms in older cardiac patients. Aging Ment Health. 2020;24(10):1670–7.
Edmondson D, Shaffer JA, Falzon L, Burg MM, Davidson KW. Meta-analysis of cognitive-behavioural therapy for PTSD in patients with cardiovascular disease. Am J Cardiol. 2013;112(10):1549–56.
Wilkoff BL, Williamson BD, Stern RS, Moore SL, Lu F, Lee SW, et al. Strategic programming of detection and therapy parameters in implantable cardioverter-defibrillators reduces shocks in primary-prevention patients: results from the PREPARE study. J Am Coll Cardiol. 2008;52(7):541–7. DOI: https://doi.org/10.1016/j.jacc.2008.05.011
Zaman S, Taylor JK, Myles RC, Betts TR, Lambiase PD, Whinnett ZI, et al. Safety and efficacy of extended detection intervals for ICDs in real-world practice. JACC Clin Electrophysiol. 2015;1(5):405–14. DOI: https://doi.org/10.1155/2015/389360
Briere J, Scott C. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. 2nd ed. Thousand Oaks (CA): SAGE. 2014.
58. Pflaumer C, Attenhofer Jost CH, Connolly HM, Ruzieh M, Friedman PA, Asirvatham SJ, et al. ICDs in paediatric patients: psychological outcomes and quality of life. Heart Rhythm. 2020;1(3):127–34.
Crosson J, Urakami L, Dasgupta R, Lee H, Broxterman A, Batra V, et al. Paediatric ICDs and PTSD: integrative strategies for young patients. J Pediatr Health Care. 2022;36(1):85–92.