High Blood Pressure, Cardiovascular Disease and Mental Health | What's the Connection?

Hey there, everybody, and welcome to this counselor education presentation on mental health issues associated with high blood pressure and cardiovascular disease. I'm your host, Dr. Donnelly Snipes. Over the past few weeks, we've been talking about a lot of physiological issues that can either occur as a result of mental health issues or be a risk factor for mental health issues, or both. And I think it's important as mental health clinicians and social workers that we are aware of this reciprocal interaction so we can screen for physiological health issues and make referrals so the person has a better chance at early intervention. And we can also be aware of and educate the person about, if as appropriate, about how their mental health condition may put them at higher risk for certain physical conditions. So they can be aware and they can make sure that, that they're being screened for them. In this video, we're going to define and examine the prevalence of high blood pressure and cardiovascular disease, learn how mental health issues can be risk factors for cardiovascular disease, explore the impact of high blood pressure and cardiovascular disease on mental health. So it's a reciprocal interaction. It can. Mental health can actually cause or contribute to the development of cardiovascular diseases, and cardiovascular diseases can cause or worsen mental health issues. And then we'll finish up by identifying strategies to improve wellness while living with high blood pressure or cardiovascular disease. I say this a lot in this series. We are not medical doctors. We are not going to make prescriptions for exercise, for nutrition, for, for anything that falls outside of our scope of practice. We can make referrals if the person needs. If we think the person may need to adjust their, their eating or their exercise levels or whatever, we can ensure that we work with those other providers to know the treatment plan, and we can help maintain the person's motivation for implementing that treatment plan. We can educate people about the importance of good nutrition and exercise and that sort of stuff in maintaining their health. But we're not going to prescribe, we're not going to create plans for them to change their nutrition or change their exercise. That is between them and their medical providers. So let's start out with some simple definitions and prevalence. Why do we really care? High blood pressure is defined as a systolic blood pressure of over 130 or a diastolic blood pressure of over 80. And high blood pressure impacts 45% of adults. Let that sink in. Nearly one out of every two adults will develop high blood pressure. That is a staggering number, just absolutely staggering. And as I always say, the data that we have right now is out of date. Data that we are working with now almost always has a two or three year lag time between when it's collected and when it's released to the public. So the data that we're dealing with in 2023 is data that they collected back in 2019 or the very, very be 2020. And we know what happened in 2020. Cardiovascular diseases are a group of disorders of the heart and blood vessels and include coronary heart disease, cerebrovascular disease, rheumatic heart disease and other conditions. We're not again medical doctors. So unless we have a person who is has a specific diagnosis, in which case we're going to learn about it, knowing all these different types of diseases is less important. What's important is to know that the impact of cardiovascular disease in general, 4 of 5 cardiovascular disease related deaths are due to heart attack or stroke and about 655,000Americans die from heart disease annually. Just let that sink in. That is a really big number. What are some mental health risk factors for cardiovascular disease? Yes, I said that correctly. Mental health conditions that are associated with the development of cardiovascular disease. A much higher risk of developing cardiovascular disease. Now the first one some people are going to argue about, and the research is inconclusive about what heavy drinking means, but in some people who are heavy chronic drinkers, they have found that alcohol use, because of its impact on blood pressure, may contribute to the development of cardiovascular disease. And as always, well, not as always, as recently. The references for this will be linked from the show notes. If you want to look at some of these references. If you are not taking this for CEUs, if you're taking this for CEUs, the PowerPoint will be in the classroom@allce.com and you'll be able to click on the links as you like to nicotine was also found to be a risk factor for developing cardiovascular disease in both cigarette smokers and E cig users. So it's not just cigarettes, it's not just cigars, it is also E cig users because it's the nicotine that is one of the factors that contributes to the risk of cardiovascular disease. They found that people who use cannabis, and I know there's going to be more people who argue with me on this one too, but people who use cannabis, especially heavy users and long term users, not your, you know, intermittent recreational users, tend to be at a much higher risk for developing cardiovascular disease. My speculation, and this was not articulated in the article, but my speculation would be that those who use cannabis, this is not cbd. This is actual cannabis. Those who use cannabis that have high levels of thc, which we know is has stimulatory effects, people who are using those that type of cannabis may be at a greater risk. People who are using more milder types may not be as at risk. But we don't know. We just don't know. This is such a new area. Opioids. People who use opioids and you're scratching your head going, but opioids are depressants. They make most people tired. Well, yeah, but they also slow respiration and they lower blood pressure, sometimes to the point when people overdose of stopping their breathing. And this changes. When people are chronically using opioids, this changes their vasculature. The body adapts to this lowered threshold to this lower blood pressure and stuff. And then when they don't have the opioids in the system, it's sort of like a tsunami. People with anxiety are at great risk for cardiovascular disease, mainly because people with anxiety tend to have a very active HPA axis and tend to develop high blood pressure. People who, I mean, when you think about people with high blood pressure, you think about people who have a poor diet and who worry a lot. They're high stress people. And you know, I think of my father in law and when he gets upset, my mother in law saying, you got to think about your pressure. And it's true. Anxiety, stress, anger really contributes to people's risk of developing high blood pressure, which is one of the greatest risk factors for cardiovascular disease. And then we have depression. Approximately 15 to 20% of patients with cardiovascular disease have depression and approximately two thirds of patients who have a heart attack develop depression. So this article was really looking at what happens to people who have cardiovascular disease, but it also may reflect pre existing depression that may have been less effectively treated that contributed to the development of cardiovascular disease. They also found that people with depression, people with major depressive disorder, have a higher risk of developing cardiovascular disease in the future. So that is really interesting and shows us the strong connection between the mind and the body. It also shows us that there may be things, and we're going to talk about some of those in a minute, that we may be missing that are contributing or causing the depressive symptoms that have less to do with serotonin and more to do with cardiovascular or microvascular microvasculature issues. People who have dementia are at an increased risk for cardiovascular disease. People who have dementia and people who have schizophrenia, we'll talk about in just a second, may engage in less proactive Health related behaviors which can put them at risk. Grief is another mental health risk factor for cardiovascular disease. People who are grieving, particularly widows in one study that I looked at, were at a much greater risk of starting to have high blood pressure and the onset of cardiovascular disease symptoms in the first 18 months after their significant other passed. Now, it doesn't mean that cardiovascular disease can't develop five years later, but it's important to look at the early onset, look at things that may be happening during that time. And there's the whole issue of broken heart syndrome, which we're not going to go into here, that some studies have indicated that when people are severely grieving, the heart actually changes shape a little bit. So there are cardiovascular consequences of grief. People with PTSD or cptsd, remember, that's complex. PTSD are at a higher risk of developing high blood pressure and then cardiovascular disease. They're often under chronic stress, they, they're hypervigilant, their HPA axis is more active, their HPA axis is disregulated. And that can contribute to problems with blood pressure regulation, with blood sugar regulation and a whole host of other things. And schizophrenia. Individuals with schizophrenia have a reduced life expectancy, interestingly, largely due to an increased risk of cardiovascular disease. Schizophrenia involves a systemic dysregulation of the body with detrimental effects on the heart. Now, this study was very clinical in nature, but the take home message is people with schizophrenia are at a much higher risk of cardiovascular disease. Working in community mental health and working in supported living for a while, I know that there's a proportion of people with schizophrenia who have difficulty with activities of daily living, with engaging in healthful behaviors with smoking and the antipsychotic medication they're on also reduces their dopamine, reduces their motivation, reduces their energy to engage in some of those activities. So we do need to recognize that it's not just as simple as there's something going wrong in the body. There are things that we can look at as clinicians and go, okay, when you're on this medication, this is what happens. What can we do to increase motivation and help you have a higher quality of life? So there is a lot that we can do. Other risk factors for cardiovascular disease and mental health issues. So these are risk factors for developing one or the other or both. Altered gut microbiota. You didn't think you were going to hear about that today. Well, you are. They found that altered gut microbiota contributes to hypertension and ather, atherosclerosis. When we trigger that HPA Axis that fight orf flight response. That stress response, we know, alters the gut microbiome. And when somebody is under chronic stress, gut microbiomes altered in order to support the stress response. And that ongoing stress response contributes to hypertension. Circadian rhythm dysfunction, including irregular sleep duration and timing, may be a risk factor for cardiovascular disease in addition to traditional cardiovascular risk factors and sleep quantity and or quality. This was a really interesting study because they found that people who were getting adequate sleep quantity and pretty good sleep quality still were at greater risk of developing cardiovascular disease if their sleep schedule was all over the place. Now, think about your shift workers there. Think about, well, shift workers especially. Why is this? Well, they suspect that because so many of your bodily systems are connected to your circadian rhythms. If you're not sleeping at the same and waking at roughly the same times each day, if you're all over the map, then the circadian cycles for everything get thrown out of whack, which contribute to the development of cardiovascular disease, Obstructive sleep apnea, obesity, hypoventilation syndrome, and chronic obstructive pulmonary disease. All of these keep the body from getting enough oxygen. And lack of sufficient oxygen contributes to hypertension, hpa, axis dysregulation, and cardiovascular disease and mental health issues. Among healthy older adults, social isolation and low social support may be more important than loneliness as a cardiovascular risk factor. Although all three isolation, low social support, and loneliness are associated with depression, this is another area where as clinicians, we can intervene. We can help people address those issues of social isolation, low social support, and, you know, process what's going on that's contributing to their loneliness, the impact of high blood pressure and cardiovascular disease. So we've talked about how mental health diseases or mental health issues can lead to cardiovascular disease. We've talked about other factors that can contribute to both of them. Now let's look at how high blood pressure and cardiovascular disease contribute to mental health issues. The physical consequences of cardiovascular disease may contribute to the development of mental health issues and vice versa. When people have a heart attack or a stroke that is very traumatic for the person as well as for their loved ones. So we're dealing with that. When people have a heart attack or a stroke, they may be depressed about the fact that they can't do some of the things they used to do. They may feel very overwhelmed at the prospect of recovery. They may be very anxious that it's going to happen again. So we need to recognize all of these. They need to potentially grieve the fact that they are not as 10 foot tall and bulletproof as they thought they were, it can contribute to kidney disease. And this is another one of those. Kidney disease is nothing to take lightly. So it can be very intimidating for someone who gets a diagnosis of kidney disease to figure out, okay, now how am I going to deal with this and what's the progression? There's a lot of anxiety that surrounds that, A lot of depression that goes with developing or being diagnosed with a chronic disease. Sexual dysfunction, including erectile dysfunction and reduced libido, are also physical consequences of high blood pressure or cardiovascular disease. And for a lot of people, their sex life is an important part of their life. And if they can't perform or if they have no interest in sex, they feel inadequate, they feel depressed, they feel less connected. And it goes more than just cognitive to physiological. We know that sex contributes to the release of dopamine, the release of oxytocin. And so people who start developing sexual dysfunction may feel very anxious, depressed, self conscious, worthless. We need to help people process this and feel empowered. And hopefully peripheral artery disease can also develop, leading to pain and excessive fatigue. Now, when we think about depression, we think about people who have a lot of fatigue. When you're in chronic pain, it's exhausting. That HPA axis is constantly on because it says, hey, there's a problem somewhere. We need to figure out how to fix it to make the pain stop. So the pain is one thing, but the fatigue is something else. Their quality of life often goes down, at least initially, until they figure out how, how to deal with it. Because that excessive fatigue, they don't have the energy to walk the dog, to go to their kids ball games, to get up and clean the house. They may start feeling bad about themselves, they may start feeling guilty or depressed. And then we see increases in LDL or bad cholesterol accumulations. And decades, we have been programmed with the knowledge that high LDL is very, very dangerous. And that can cause a lot of anxiety in people because it's not something that they can see. So if they have high, high cholesterol, it's hard to know if what they're doing is working to bring down their cholesterol. And they can't go. It's not like when you're trying to lose weight and you can weigh yourself once a week. You can't really do that with cholesterol. So there is a certain amount of anxiety and trepidation, Especially if they have a loved one who had cardiovascular disease or worse yet died as a result of complications. From cardiovascular disease. Now we move on, as I mentioned earlier, but when we talked about the connection between mental health and cardiovascular issues. Cerebral, small vessel disease, cerebral. We're not talking cardiac, we're talking cerebral. So the small vessels in the head is a chronic progressive disorder of the arterials, capillaries and small veins supplying the brain. So these are all the faucets, if you will, that bring oxygen to the brain, that bring nutrients to the brain. CSVD is associated commonly known risk factors for vascular diseases, including hypertension, diabetes, smoking, obstructive sleep apnea and depression. These are all things that we can screen for, that we can make referrals for to help people with early intervention. CSVD can contribute to the cognitive impairment in the elderly and is noted in about 20% of strokes and 45% of dementias. Management is mainly based on combating known risk factors for cardiovascular disease. So if we want to keep the brain healthy, we need to keep the heart healthy, we need to keep the vasculature healthy, and then we have the side effects of medication. Medications are generally not without side effects. Balance and coordination difficulties, fatigue, headache, are some of the more common side effects of a lot of the medications for high blood pressure and cardiovascular disease. We need to help people figure out how to have their highest quality of life and, and remain treatment compliant. We need to have people figure out how to live their highest quality of life and have fatigue. We can talk with them about how these side effects are impacting their life. We can talk with them about tips and tools that their doctor has shared with them for how to manage those side effects and what to do. Now, if their headache, for example, is chronic, if it's ongoing, we need to refer them back to their doctor and say, hey, you need to go to talk to your physician about this. And because that is what one of my physicians one time referred to as unacceptable side effect, that is a side effect of a medication that is going to likely contribute to treatment discontinuation because it's just screwing up your quality of life. We're not telling people to change their dose. We are not telling people whether they're on the right or the wrong medication. We're saying, hey, if you're having this problem, you really need to talk to your doctor about it. There's an increased risk of sleep apnea in patients who are taking antidepressants, SSRIs, benzodiazepines, or your anti anxiety medication and hypertensives. So if they're taking SSRIs and anti hypertensives, or benzos and anti hypertensives or heaven forbid all three, they are at a much greater risk of sleep apnea. That's important. Why? Because we know that sleep apnea is a risk factor for the development of cardiovascular disease, but we also know that it is a risk factor for the development of depression. When the brain is not getting enough oxygen, it is not able to do everything it needs to do to help you feel happy and healthy. Just to be overly simplistic now, one area that I did find really interesting, one area of research was that statins or your cholesterol lowering medications have been found to interact with antidepressants, improving the mood response. So people who are on statins and anti cholesterol medications and SSRIs may actually have an enhanced response to their medication. Affective and cognitive consequences of high blood pressure and cardiovascular disease what we need to look at is identifying what's going on with the person and whether it was a pre existing condition, they were already angry or grieving or depressed before this developed. In which case what caused that, Whether or whether it's a consequence of their diagnosis of a chronic disease. Okay, we can deal with that. Or if it's what we'll call a side effect of their disease, they are because they've developed sleep apnea or the side effect of their medication or whatever. But we need to figure out what, what is causing these feelings. Think about if you were diagnosed with a chronic condition that could be life threatening. Wow, that would increase a little bit of health anxiety in most people. That may induce grief, that may induce depression, that may have a lot of effects on people. So let's talk about some of these affective and cognitive consequences. I put anger, grief and depression all in one. Because remember, grief is denial, anger, bargaining, depression and acceptance. So there's a grieving process that we go through when our life changes that is inevitable. Some people may have ongoing anger or ongoing depression. That is their stuck point in resolving that grief. Or they may have anger, grief and depression about something totally different. So we need to recognize that. But the consequences in terms of high blood pressure and cardiovascular disease, we need to ask ourselves, why would this person be angry about this? I think the answers are pretty obvious. Why would this person feel depressed or hopeless and helpless about this? Think you know, again, those are pretty obvious answers that we can answer for ourselves. We want to know what their thoughts are, but we can see how this would happen. We also need to recognize that hypertension, high blood pressure causes low grade chronic inflammation which can negatively affect mental Health interfering with mood regulating chemicals. So hypertension itself could actually be contributing to the depression, anxiety. Yeah. You get that diagnosis, you may be a little bit anxious, not only about the progression of the diagnosis or, you know, if you're going to die, but also about how's your family going to respond. What impact is this going to have? Are you going to be around to see your kids graduate and get married? So there's a lot of fear and panic that may flood people's brains when they get this diagnosis, but then when they have it, especially health anxiety and maybe abandonment anxiety in some people tend to be more, more prominent down the road because when they start having a flare up or when they start getting a weird pain or there's a change, they may become ex, extremely concerned that it's a result of the hypertension or cardiovascular disease. Fatigue. Fatigue can come from high blood pressure, from cardiovascular disease, from not getting enough oxygen throughout the body. That's true. Fatigue can also come from being worried about what's going to happen. Fatigue can also come from being angry about what's going on. Fatigue can also come from depression. And fatigue can also just happen. So we need to look at what's going on, what might be causing this person's fatigue in this particular situation. And a lot of people, especially early on in their diagnoses, may not sleep well because they're worried that something's going to happen when they go to sleep. So there's a lot of different causes for fatigue, ptsd. And I have here primary and secondary. The person who experiences a cardiovascular event, whether it be a stroke or a heart attack, may develop ptsd. They may not, but they may likewise their loved ones. If they had a heart attack and fell out in the middle of Christmas dinner, it's likely going to have a traumatic impact on those who were present and maybe even not present because their loved one suddenly was, you know, in critical condition. We do want to recognize that impact. We also want to recognize the impact of PTSD and hypervigilance on maintaining or worsening the high blood pressure and cardiovascular disease and then vascular dementia. And I know this kind of physical. But it's important to recognize that when the vascular system quits working as well, when the brain quits getting enough oxygen and nutrients, people start developing dementia. That's overly simplified again, but you get my point. And when people develop dementia, their cognition becomes impaired. Risk factors for cognitive impairment and dementia after a stroke are multifactorial, including depressive illness. So not everybody has a stroke will necessarily develop dementia. But we do need to recognize that it's a possibility. Relational consequences of high blood pressure and cardiovascular disease. As I mentioned, there's an initial increase in anxiety and depression in the patient who had this cardiovascular incident or got this diagnosis, as well as the significant others, which may abate over time, especially with health education, treatment compliance, and symptom improvement. Now, I will mention here that again that if the person, the patient or their loved ones has had a family member or somebody that they cared about deeply die or have severe consequences from high blood pressure or cardiovascular disease, then it basically may reopen that o old wound. It may bring that trauma to light again. So we need to recognize if somebody seems to be having a much stronger reaction than we would expect to their particular diagnosis. We need to get curious about why. And likely, again, it has to do either with lack of information or. Or they may have a prior experience that makes them believe that this is essentially a death sentence. Changes in leisure activities and family responsibilities result in a grieving process and possibly an alteration of relationships. If dad has a heart attack and he really shouldn't push mow the lawn anymore, if that's something he loved doing, then he may be depressed about that. If it is something that he did as a part of, as his contribution to the family's house chores, then he may feel inadequate when he's not able to do that. There are a lot of reasons that people may experience relational consequences. The family may recognize that dad can't push mow the lawn anymore intellectually, but emotionally, occasionally they may also get frustrated when they have to do things that he used to do. And it's important to encourage mindfulness, encourage people to be aware of where their feelings or their thoughts are coming from so they can address them. And people with cardiovascular disease may be on medications that cause fatigue, making it difficult for them to do those things that they love doing or they feel they need to do, which can cause grief. And I have the example here of the fatigue and the difficulty with balance making it difficult to walk 18 holes of golf. Okay, well, maybe they can get a cart now and ride. But some people, part of the game, part of the. Whatever it is, part of playing golf is walking the course and appreciating the course. So to them, riding in a. Riding in a cart, just. It. It isn't quite the same. Interventions we need to help people control vascular risk factors in order to reduce the incidence of dementia in both healthy and cognitively impaired people. Vascular risk factors. Well, the foundation for a healthy blood pressure consists of a healthy Diet, adequate exercise and regulation of mental stress, keeping that HPA axis healthy or getting it healthy and environmental stress. So we need to really recognize the impact of the environment, Noise, excessive light, you know, stressful environments for the person. You know, that's one aspect. But we also need to help them become aware of what triggers their HPA axis and heal it. If they have had a history of trauma and their HPA axis is dysregulated. Trait mindfulness may have protective effects on blood pressure in the face of high levels of stress. So this is basically good old fashioned mindfulness. Being present in the moment, recognizing when you're starting to feel stressed and doing something about it, either accepting it is what it is, or figuring out how to improve the next moment or whatever strategy the person uses. But that mindfulness keeps them from just continuing to push through until their blood pressure is, is through the roof. Hardiness and resilience is one are one tool that you can use to decrease the effect of stressful life events and mediate the development of illness symptoms. Now in hardiness, the key is commitment, control and challenge. Recognizing what's important in their rich and meaningful life. What are they committed to doing? What are they committed to? Using their energy on what's important. What can they control in their life? They're committed to staying as healthy as they can. Okay, that's great. They can't control the fact that they have cardiovascular disease now, but they can control their treatment compliance. So commitment, recognizing what deserves their energy, controlling the things they can and viewing changes they have to make or viewing obstacles that pop up as challenges instead of barriers, instead of something that says, nope, you can't have this life saying, okay, well maybe I can't do it the way I thought I was going to do it. How can I get around this obstacle? DBT Dialectical Behavior Therapy Using distress tolerance and dialectics can be extremely helpful to people to recognize that they can tolerate distress and jumping down to acceptance and commitment therapy. DBT tools as well as ACT tools can be helpful at keeping people from getting into what we call dirty discomfort. And that means being angry about being depressed or being angry about being anxious about being depressed. You know, feeling bad about feeling bad, that's just compounding the illness that's struggling in quicksand. So distress tolerance helps people say, all right, this sucks. It is. They're not saying, I shouldn't feel this way or I should. It's just, I am unhappy right now. I am. This is going on and it's unpleasant. Dialectics helps people embrace the good with the bad, which kind of goes along with living in the and in acceptance and commitment therapy. I can have a rich and meaningful life and also have cardiovascular disease. Is it what I would choose? Maybe not, probably not. But I can have both of them. And cognitive behavioral therapy. Facts, control and probability. I'm afraid that I've got a death sentence. I'm afraid that I'm going to die. What are the facts in this situation? And facts, control and probability can be very helpful for health anxiety when people start having symptoms or twinges. What are the facts in this situation? What do I have control of? And if I do, what's within my control, what is the probability that I'm going to end up in intensive care or worse? So facts, control and probability can help people address some of their anxiety. But first they've got to use those distress tolerance tools to get out of their emotional mind and into their wise mind. Away from reacting in fight or flee to acting proactive steps in their wise mind. We can help people maintain hope and positivity versus managing worries, fears and anxieties. And it's important to acknowledge we don't want to use toxic positivity. We, we need to acknowledge and allow, allow people goodness. Imagine that, Allow them to have their own feelings, to acknowledge their worries, their fears and their anxieties. Yes, that exists. We're not ignoring that. We're not saying it doesn't exist. However, it's also important to balance that out and recognize what they do have control over, what they do have hope for and what they do feel positive about. Otherwise they just get stuck in this negative fear loop. Yoga and meditation, partly because of their impact on the vagus nerve, has also been found to be very helpful in regulating blood pressure and even helping people with cardiovascular disease. They found that autonomic cardiovascular control is impaired in hypertension, so that vagal tone is crappy, leading to an increase in the sympathetic influences to the heart and peripheral vessels. So when a person gets stressed, they don't have the balance of the calming. The, the, the, the stress chemicals just kind of take over. Vagus nerve stimulation has been used to address cardiovascular disorders like arrhythmias, heart failure and arterial hypertension. Now this isn't just any old random vagus nerve stimulation. However, they have found other study. There are other studies that have shown that as a tool for someone to use to help them deal with anger and anxiety, diaphragmatic vagus nerve stimulation, that slow deep breathing can help trigger that vagus nerve and reduce blood pressure in the moment. We also need to help people improve their family relationships and reduce interpersonal stress. For a lot of people who develop cardiovascular disease, especially those who had high blood pressure, that were stressed out people, type A people, we need to encourage them to examine where that anxiety was coming from to address the abandonment anxiety, to address the prior traumas and adverse childhood experiences that may be continuing to impact them in the present. To strengthen current family relationships so they feel safe, loved, secure and supported. We want to help them reduce environmental triggers and vulnerabilities. As I mentioned earlier, noises or getting awakened multiple times in the middle of the night by the noisy neighbors or even by being too hot. I know we had a warm front come in last night and all of a sudden the overnight temperature went from being 42 to 68 and I didn't plan for that, so I woke up in the middle of the night just absolutely burning up. It's important for them to recognize their environmental stressors, an adjustment and motivational enhancement for new eating and activity patterns. This again, we're not prescribing it, we are taking someone else's treatment plan and increasing motivation for treatment compliance. Hypertension and cardiovascular disease can both be aggravated by and cause depression, anxiety, anger, grief and even ptsd, especially if there's a life threatening episode. High blood pressure and cardiovascular disease are largely preventable and or treatable. As clinicians, counselors, social workers, case managers, we need to help people address grief and health anxiety in themselves as well as their significant others. Provide tools such as hardiness, mindfulness, meditation, yoga, tragic optimism and cognitive restructuring. Improve their health literacy about the disease as well as about the interventions, what they can do in order to best remain treatment compliant and motivations for treatment compliance. And finally, we can encourage self advocacy regarding medication or treatment side effects. If something is just not working for that person, we need to encourage them to talk with their doctor or dietitian or whatever provider it is.