Mental Health Issues Associated with High Blood Pressure and Cardiovascular Disease

Foreign. I'd like to welcome everybody to today's presentation on mental health issues associated with high blood pressure and cardiovascular disease. I'm your host, Dr. Donnelly Snipes. We're going to define and examine the prevalence of high blood pressure and cardiovascular disease. And it's a lot more prevalent than even I thought. Will explore the impact of high blood pressure and cardiovascular disease on mental health and identify strategies to improve wellness while living with high blood pressure and cardiovascular disease. And that's really where we, as counselors and social workers and pastors come in, is helping people in enhance their health education, enhance their health knowledge, so hopefully they can prevent it. But if they do develop high blood pressure or cardiovascular disease, helping them figure out strategies to help them live their highest quality of life. High blood pressure is defined as a systolic blood pressure, the top number over 130, or a diastolic blood pressure of over 80. So the bottom number is over 80 or the top number is over 130. The prevalence of hypertension in the US is almost half. 45% of adults. That's a staggering number. 45% of adults in the US have hypertension. And hypertension contributes to a whole host of problems. So what are the risk factors for hypertension? People who are obese. 78% of men with high blood pressure are obese and 65% of women with high blood pressure are obese. So there is a significant correlation. Why is this? Well, when people are obese over fat, that's not the same as overweight, where people have a lot of muscle. But over fat, it results in altered hemodynamics. It results in alterations of the blood profile, impaired sodium balancing or homeostasis. So the person be may become more sensitive to sodium renal dysfunction, which is the kidneys. So the kidneys which are responsible for filtering out a lot of the toxins aren't working quite as well. And as a result, toxins may build up, which can contribute to systemic inflammation and high blood pressure. Autonomic nervous system imbalance so you remember your autonomic nervous system is the automatic one, the one you don't have to think about. It's responsible for your respiration and your heart rate and keeping things going even when you're sleeping. Endocrine alterations and we've talked about this one before when we've talked about obesity, that estrogen tends to be increased in people, both genders, when they are over fat, when they are obese. So there are alterations in gonadal hormones which impact, if you remember, if you were in that class, when we talked about the hypothalamic gonadal axis, the hypothalamus, pituitary gonadal axis, the endocrine system, your gonadal hormones interact with serotonin, with dopamine, with norepinephrine, with your HPA axis, they are inextricably linked to one another. So if there are alterations in that, then it's going to likely lead to alterations in neurotransmitters as a result of renal dysfunction and autonomic nervous system imbalance. There's also an increase, as I said, in oxidative stress, you know, buildup of toxins in the body and inflammation, which can result in vascular injury. All of that is a problem. You know, inflammation we know, is directly associated with the development of mood disorders. We also know that vascular injury, problems in the cardiovascular system, getting oxygenated blood to the brain, can also cause cognitive problems, can cause the development of a lot of different mood issues, etc. People who eat a lot of excess sodium may be at risk for high blood pressure. Interestingly, in the articles that I read, there are some people who are not sensitive to salt, so they eat it and, you know, it is what it is. But there are people, especially people who are obese, who may be more salt sensitive. So when they eat salt, it disproportionately increases their blood pressure. And the same thing can be seen to a certain extent for them, for a lot of them with stimulants, which is why a lot of your cold medicines have a high blood pressure friendly version of the cold medicines, because they may have an exaggerated response to the stimulants in cold medicines, which we can extrapolate to, Meaning they also may have an exaggerated response to caffeine, insufficient omega 3s, which are anti inflammatory in nature, potassium, calcium and magnesium. So a crappy diet is also associated with high blood pressure. Now, imbalances in omega 3s lead to dysfunction in your endocannabinoid system, which is going to impact your mood. Imbalances in potassium, calcium and magnesium also impact the body's ability to make and effectively use the neurotransmitters. So we need to remember that these are essential building blocks that our body needs. Low physical activity often is correlated with obesity, but low physical activity in itself is a risk for high blood pressure. Sleep apnea is also a high risk factor for developing high blood pressure. Now, a lot of our clients, if they are depressed or even anxious, and they may be so anxious they just don't have the energy to work out. So they may have low physical activity. They may be eating a crappy diet because they're eating ingesting foods that are comfort foods more than nutrient foods. A lot of those comfort foods are also high in sodium. A lot of people, not all, but there. There is a strong correlation between mood disorders and sleep apnea, as well as cognitive dysfunction and sleep apnea. So people may be coming to see us, and we may be addressing their cognitions and, you know, their lifestyle factors and things like that. But we also need to remember to start asking about sleep apnea, because there is a very strong correlation between sleep apnea, systemic inflammation, and mood disorders. So, you know, for. For people to reach their highest level of care, we need to address that. Also, sleep apnea increases the risk of hypertension. Immune reactivity can cause hypertension in people with autoimmune diseases. So a lot of our clients may also have autoimmune issues. We need to recognize that that puts them at greater risk for hypertension. Now, the information out there was surprising to me about caffeine. And a lot of the research indicated that under 600 milligrams per day, and I'm not recommending this, I'm just telling you the research under 600 milligrams per day often does not have a significant impact on heart rate or blood pressure unless somebody has a sensitivity. Now, obviously, generally they were looking at 600 milligrams across a day, not in an hour. That there's a very big difference there, but that's still a lot. Your average cup of coffee has about 80 milligrams of caffeine. So that would be drinking, what, eight, seven, eight cups of coffee in a day. And, you know, I can tell you I've been there, done that, but I don't think I've generally exceeded that when I was drinking caffeine. And mental stress is also a risk factor for hypertension. When people are under stress, it kicks off that HPA axis. It increases cortisol, it increases adrenaline, it increases norepinephrine. It increases blood pressure in order to help the person fight or flee. The whole goal is to keep the blood circulating so they can do what they need to do. So mental stress itself can be a target for counselors to work with people to help them reduce their risk of developing high blood pressure or manage their high blood pressure. It's also important, and I don't know that I mentioned it anytime in this presentation, but I will just kind of point out that blood pressure medications can interact with other medications. And blood pressure medications often need to be adjusted based on age and weight. My grandmother was on blood pressure medication, as are many people that are over 65. And when her blood pressure medications would get too high, she would have problems with dizziness and falling and, and other things. So we want to recognize that blood pressure can play a role in symptoms that we might attribute to cognitive dysfunction or something else. Okay, so cardiovascular disease. Cardiovascular disease is a group of disorders of the heart and blood vessels, including coronary artery disease, cerebrovascular disease, rheumatic heart disease, and other conditions. Now what we want to focus on with this is not the specifics, but the fact that it's cardio the heart and vascular the veins and arteries. So there's a problem with the blood oxygen transport system. Basically four out of five cardiovascular deaths are due to heart attacks and strokes. Now, the prevalence, I just kind of want you to wrap your head around this so you can recognize how prevalent it is. About 655,000Americans die from heart disease each year in 2021. So this year a little over 600,000 people will die of cancer. 528,603Americans die of, died of coronavirus in a year. So we want to recognize and not minimize the impact of and the prevalence of heart disease and cancer. We want to rank it up with coronavirus. You know, let's start taking it just as seriously. But risk factors for cardiovascular disease include high blood pressure, high LDL cholesterol, that's your bad cholesterol, Obesity, unhealthy diet, smoking, and heavy alcohol use. Now, alcohol use was not as much of a risk factor according to the research I did for blood pressure. But for vascular disease it does become an issue. And they define heavy alcohol use is approximately 5 ounces of wine or 12 ounces of beer more than eight times a week. So the clients that we work with that minimize their, their alcohol consumption because they're only drinking wine or only drinking beer, we do want to point out to them that there could be side effects from that. Aside from the fact that alcohol does alter your neurotransmitters and your mood and your, it impacts your HPA axis, It also is a risk factor for cardiovascular disease. Physical consequences of high blood pressure and cardiovascular disease. Heart attacks. Well, when somebody has a heart attack that is a life threatening event, it can be extremely traumatic. It is not uncommon for people who develop heart attacks to develop health related anxiety, to develop PTSD related to the heart attack episode, or, and, or to have to grieve because they may lose functioning in certain aspects of their life or they can't do things like they used to. After they have a heart attack, they may be angry that they've got to go through rehabilitation. So we do want to recognize that there is a significant emotional and cognitive component to recovery and living with high blood pressure or cardiovascular disease. Strokes are another common problem associated with high blood pressure and cardiovascular disease. When the brain doesn't get enough oxygen, people can have a stroke and this can lead to dementia and physical dysfunction. We, we all know of people who've had strokes that have lost functioning in part of their body or lost the ability to speak again. For the individual as well as for their family. There is a certain amount of trauma that's associated with one of these life altering events and anxiety. There also may be a grieving process as people adjust to their new normal Post incident. Kidney disease can be a consequence of high blood pressure and cardiovascular disease. And if it develops to the point where the person has to be on dialysis, that can be more of a problem. There are potentially pain associated with kidney disease and there's a lot of other side effects like fatigue and other things that need to be managed. So when people develop high blood pressure or cardiovascular disease, they are at greater risk for significant health events that can impair their activities as they know them. Sexual dysfunction is another impact of high blood pressure. It is important to put this out there because that can be a motivating factor for people. But also clients that we're seeing that have erectile dysfunction or reduced libido, we want to examine have they had their blood pressure checked? That's one of those easy things to figure out. And if they do have high blood pressure or low blood pressure, make sure that they're getting that evaluated. Because sexual dysfunction can have a significant impact on mood and self esteem. Peripheral artery disease is another consequence of high blood pressure or cardiovascular disease. And it can lead to. Excuse me, sorry. It can lead to pain and excessive fatigue. When your arteries peripheral means, you know, not in your trunk but in your arms and legs and things when they're, when they are diseased, they are not going to be carrying the oxygenated blood as effectively, which can contribute to pain, swelling and excessive fatigue. When you're not getting blood oxygenated, it's not running through that oxygenation system quickly enough. You know, it starts to become, you think, stagnant. You know, that's not exactly what happens. But when you have high blood pressure or cardiovascular disease because the arteries are diseased, it often contributes to Accumulations of those ldl, of that LDL cholesterol, of those plaques in the arteries, which further makes the arteries diseased. Now, if that wasn't enough, you know, the diseases themselves or the conditions themselves have some significant potential side effects that we need to help people be aware of, learn how to cope with, prevent when possible. But the medications people take for cardiovascular disease and high blood pressure also have side effects. Balance and coordination difficulties are one of them. As I mentioned, when my grandmother's blood pressure medication would be too high, she would start having a lot of difficulty with balance and coordination and falls. But this can happen to younger people who are on high blood pressure medication too, which can make them put them at risk for injury. It can make them more prone to fall in stores, have more fatigue and difficulty shopping and doing their activities of daily living. That can be extremely frustrating for people, and they may start feeling hopeless, helpless, depressed, because they just can't do what they used to do. Headache is another symptom of these medication side effects and increased risk of sleep apnea with if somebody's taking antidepressants or benzodiazepines and antihypertensives, there is an increased risk of sleep apnea. We want to be aware of that, because sleep apnea, as we said earlier, is a risk for high blood pressure, so it may worsen high blood pressure. But again, sleep apnea can also contribute to cognitive decline and mood disorders. So that's one thing we certainly want to rule out, especially if the person's mood markedly changed or their cognitive abilities markedly changed after starting their antihypertensive medication. Statins, interestingly enough, are designed to lower cholesterol and have been found to interact with antidepressants, improving the mood response. So they suspect that statins reduce inflammation and that reduction in inflammation works in tandem with the antidepressants to improve improve mood response in some people, which again underscores the importance for our clients who are depressed or anxious. And I throw anxious in there too. Because a lot of SSRIs treat anxiety, it's important to make sure that their blood pressure is within normal limits because that can be a significant confounding factor to their adequate recovery. Can taking antihypertensives and an SNRI that increases norepinephrine be unhealthy because of the neurotransmitters going in both directions? That is a great question, and I don't know the answer, but I will look it up after class or at the end of class. So just bear with me on that one. Over 10,000 people come to BetterHelp every day looking for a counselor. BetterHelp makes it easy for you to move your practice online and focus on what you love most, helping others. Better Help's easy to use platform, takes care of referrals and billing and provides a secured platform to communicate with your clients. Join more than 18000 therapists at Better Help Helping to improve people's mental health and lives. Affective Cognitive consequences Now these are the ones that we can dig our teeth into pre existing consequences of diagnosis or the clinical event. So prior to somebody learning they've got hypertension, they may be angry, struggling with grief or depression, anxiety, fatigue or ptsd. So this may be a pre existing issue that exacerbates and promotes the development in some ways of high blood pressure and or cardiovascular disease or and it can also be a consequence once somebody gets a diagnosis. So we want to recognize that there are a lot of issues going on. A lot of the post diagnosis or post incident issues have to do with trauma surrounding the issue. Grief over not being as healthy as they thought they were, over fear of a for. For shortened future, over not being able to do some of the activities that they used to do. There's a lot of things that may need to be addressed post incident or post diagnosis. Even for some people if they're told that they've got a really significantly reduced salt that may lead to a lot of anger at the situation and you know, part of that grieving process, denial, anger, bargaining, depression, acceptance. We need to help them figure out a way to work through that. So motivational enhancement techniques can be really helpful here for increasing their motivation to comply with the doctor's treatment recommendations as well. And the dietitians as well as encouraging them to embrace the dialectics or as Hayes would say in acceptance and commitment therapy encourage them to live in the and I can have high blood pressure and still live a rich and meaningful life. I may have to make some modifications but I can have both of these things concurrently. We want to address anxiety and, and all of these things like I said could also occur beforehand that because of trauma, because of stressful environments, because of whatever that increased their HPA axis dysregulation that contributed to the development of these things through you know, through excess stress, keeping their blood pressure up and or through self medication of the of that stress with alcohol or nicotine products. So we do want to recognize that people who develop these conditions probably had some stressors going into it and the more we can help them address those stressors, the more we can help them re regulate their HPA axis and potentially eliminate this confound to their condition. Fatigue is one that is challenging for a lot of people. And you know, we already talked about the fact that fatigue happens when the cardiovascular system isn't working as effectively, so all that oxygen isn't getting where it needs to be. And that can be an extremely debilitating and frustrating symptom. So we do want to help people learn how to set goals and to pace themselves so they can do the things that they want to do within reason. Even with the diagnosis, my stepfather and it wasn't his wasn't cardiovascular disease. But as he got older, you know, once he got into his mid-80s, his fatigue that he would get tired a lot easier. And his fatigue kept him from being able to walk the golf course 18 holes and that just drove him batty. But you know, he, he compromised by agreeing to use one of the little golf carts instead of trying to walk the course. Was it the ideal solution? No, he's, you know, he was still angry that he couldn't walk, walk the course, but he did still find a way to keep that activity which was crucial, critical to his the definition of a rich and meaningful life. And then vascular dementia occurs when the oxygen level to the brain drops for a period of time. And it can occur in people with severe sleep apnea because there's repeated instances where the oxygen is, is stopped to the brain. But it also occurs after a stroke and, and other cardiovascular instance incidents. Now this dementia is a result of brain damage. So the individual as well as their caregivers or their family may have to learn different ways of being in the moment, different ways of planning and, and alter their interactions with one another. Because the, depending on the severity of the dementia, obviously the person may need more help than, than they use than they needed prior to the event. In terms of interpersonal consequences of high blood pressure and cardiovascular disease in both the individual as well as their loved ones, especially immediate family, there's often an increase in anxiety and depression which may abate over time, especially with health education and treatment compliance. So getting a diagnosis of heart disease is terrifying. I remember when my grandmother, grandfather got that diagnosis, I was like, okay, what does that mean? And understanding, helping people understand in common terms what that means, what the prognosis is, you know, what the next five, 10, 20 years is going to look like, that's important. Helping them identify and learn the strategies they can use to maximize their quality of life and minimize or slow the progression, whenever possible, can be extremely helpful too, because you're empowering them. You're saying, here are all the things that you can do. And instead of feeling like you are a prisoner to your own body, there are active steps you can take. So you're empowering them. Now the challenge comes when the patient is not treatment compliant and the patient may be treatment resistant. You know, I hate that word. Because they are afraid that whatever they do is not going to do any good. So why should they, you know, be miserable? They may be afraid that or, or angry that they have to give it up. There's a lot of reasons why they may be resistant to, to giving it up or, or complying with treatment in whatever way that the person or the doctor wants them to. So we need to evaluate treatment resistance as communication and really dig into that motivational enhancement approach and help them identify the benefits and drawbacks to complying with treatment or the parts of treatment that they don't really like, and then identifying the benefits and drawbacks to non compliance. And it's really, really important to give credence, to give validation to the fact that, yeah, I can see why there are reasons you may not want to start exercising or give up sodium or whatever the case is. You know, I, I hear that and, and validate that there are benefits to non compliance, but do they outweigh the risks? So helping them use that decisional balance activity can be super helpful. And Pat's very true. Our point is very true. When you give information, when we are increasing people's health education, we want to do it gradually. You don't want to dump a hour long presentation on them when they're in crisis. They just found out about the diagnosis or found out about it a couple of days ago, and they're still kind of reeling from this idea that they or their loved one has a chronic condition. So we don't want to overload them. We want to make sure that it is something that is either preferably written down and if possible, that there are videos that you link to. For certain conditions, like the Mayo Clinic has videos, you don't necessarily need to make your own. There's a lot on YouTube. YouTube. You just need to watch them and make sure they're accurate and reliable. But when people are in crisis, it's important to recognize that they are not going to remember near as much as they would when they weren't in crisis. And they may need to go back and watch those videos a couple of times in order to get everything. So it is Important to pace yourself when providing information, but to provide information in a way that is empowering and motivating to the individual. Create win wins whenever possible. You know, if you take this medication and we can get you stabilized on it, get you at the right dose, then you know, what are the benefits to you? Changes in leisure activities and family responsibilities may also result in a grieving process for the individual as well as the whole family. There is going to be potentially a readjustment. Maybe dad has high blood pressure or had a heart attack and you know, he really shouldn't be out push mowing the lawn in the 90 degree heat anymore so somebody else has to pick up that chore. Or medications that the person is taking contribute to their fatigue and may make it difficult to walk those 18 holes of golf. That's a lot of walking and that can be frustrating for the individual and they may feel disempowered. I guess maybe the word I'm looking for. My, my stepfather was very, very against driving in a golf cart because he wanted to prove that he was strong enough, gosh darn it, and he didn't have to be toted around, as he put it. But it's important to help people examine their cognitions and then gradually start trying to introduce cognitive restructuring. How is it that you can still do this thing that is super important, super meaningful to you and in a way that's not going to harm you in terms of push mowing the lawn? You know, maybe there's a rebalancing of who does what activities or, or what have you, but it is a adjustment for everyone in the household potentially. And, and it's important to recognize that, you know, if somebody has to spend more time doing chores now because dad can't do them anymore, can't do certain ones anymore, that Junior may feel resentful for the moment. And it's important to work through that with Junior so it doesn't start creating antagonism. And it is important to, as Pat also points out, to maintain motivation. When people first get a diagnosis, they may be gung ho to learn about how to prevent it. But then, just like your New Year's resolutions, after about a month, it's just like, eh, you know, I'm gonna give a little here, forget to do this. So it is important for the caseworker, the counselor whome to regularly engage in motiv motivational enhancement interventions to make sure the person remembers why it's important. And when I do motivation, I'll go off on a little side, side tangent right now, motivation has multiple, multiple dimensions. So you want to engage as many of those dimensions as possible. How is it going to make them feel physically better if they do this? How is it going to prove their energy, help them sleep better, lose weight, whatever it is they want to do? How is it going to help them feel effectively better? How is it going to make them happier or enjoy life more? How is it going to make them cognitively feel better? How is it going to clear up that foggy headedness or help them change their attitude if they get their blood pressure under control, how is it going to impact their relationships if they are, if they get their condition under control? You know, yes, it may not be fun to have to start exercising and eat a healthier diet and all that stuff, but if you get this cardiovascular disease under control, then you may have the energy, you may be able to reduce some of your meds some and have more energy to do the things that you want to do. And it's likely that it will help you live longer so you can enjoy more activities with your family. So engage physical, affective, cognitive and interpersonal aspects of motivation whenever possible. The foundation for a healthy blood pressure, according to the experts, consists of a healthy diet, adequate exercise, and mental and environmental stress reduction. So not only cognitive stress, but we also want to reduce environmental stress. And that can include, you know, noisy environments, heat stress, anything that may increase blood pressure. We want to try to make sure that we're, we're addressing. Trait mindfulness may have protective effects on blood pressure. When caregivers and individuals with the disease face high levels of stress and getting a diagnosis is one of them. But even after their diagnosis or before it, they may, anyone is prone to experience periods of high levels of stress. So helping people develop trait mindfulness, helping them develop this ability to be aware of how they're feeling and what they're needing and identify their emotions before they're out of control and figure out how to regulate them more effectively. All of that is super helpful. Hardiness and resilience both decrease the effect of stressful life events, mediating the development of illness symptoms. So even if somebody has cardiovascular disease or even if they've had a heart attack, developing hardiness and resilience within that person has been shown to reduce the development of further illness symptoms, reduce their risk of further heart attack, et cetera. Now, hardiness was proposed back in the late 70s, early 80s by Kabasa and is compo comprised of commitment, control and challenge. People who have a hardiness trait tend to be committed to Multiple aspects in their life, they can recognize that, okay, this one over here might be going crappy. You know, I had a heart attack, not the thing I really wanted, but all of these other things in my life are actually going decent or important to me, and I'm committed to all of them. So commitment helps people see the bigger picture, not just focus in on the one thing that is distressful. Control helps them identify the aspects of all of the things in their life, including whatever's going bad. Helps them identify which aspects they can control. What can they do to mediate the situation or eliminate the situation. And then people who view all of these things as a challenge instead of a chore or a barrier also tend to have much greater outcomes. If they get a report back that they've got high blood pressure and they're like, all right, gosh darn it, I am going to get that blood pressure down. I am not going to end up on blood pressure medication. If they're at that stage, then they may see it as a challenge to figure out how to get their body to do what they want it to do. So viewing things as challenges or learning opportunities can help promote hardiness, resilience and optimism. You can use techniques like in dialectical behavior therapy such as distress tolerance and dialectics, helping people embrace the and living in the and as we've already talked about, or in cognitive behavioral therapy, I abbreviated fcp. I don't know, you know, however you want to abbreviate it. But help them evaluate, you know, when they start feeling anxious or depressed, identify their thoughts, evaluate the facts for and against their beliefs. Once they figure out what is fact based, then identifying what aspects of the situation they have control over and finally looking at the probability if based on the facts in this current situation, if I do the things that I can to control the situation, what is the probability that I can have a positive outcome? So facts, control and probability. Maintaining hope and positivity versus managing worries, fears and anxieties is also predominant. And that is another one of those sort of semantic twists. But we've talked about it some. In acceptance and commitment therapy, using energy to move toward a goal instead of trying to eliminate a problem can be very liberating. So using energy to maintain hope and positivity and optimism when you're having, when you're emphasizing those, there tends to be less worry, fear and anxiety. Yoga and meditation were also found to be very helpful in helping people develop auto autonomic cardiovascular control. They start to be able to practice breathing in deeply and exhaling and they learn how to slow their heart rate. For example, they can learn how to trigger that rest and digest, which can help lower blood pressure. So since autonomic cardiovascular control is impaired in people with hypertension, it leads to an increase in sympathetic influences to the heart and peripheral vessels, which is a gobbledygook way of saying when people get stressed out, their HPA axis is activated and it causes a dump of a bunch of adrenaline and the heart rate starts speeding up. And a lot of physiological responses. But people can learn to identify those physiological responses as at least moderately controllable and develop strategies for downregulation. Improvement in family relationships and reductions in interpersonal stress are also important when we're talking about cardiovascular disease and high blood pressure. Anything that causes that heart to start speeding up causes the blood pressure to go up, like triggering the HPA axis trick. Triggering the threat response system is probably going to aggravate the condition. So we want to help people identify what are their triggers for anxiety and anger and irritation particularly, and how can we help them moderate those as much as possible? We want to help them reduce environmental stress triggers and vulnerabilities. So let's start with triggers. If they have a bunch of dogs and solid surface floors, when, when the dog starts barking furiously, it may startle them and it may trigger an anxiety response. But there can be other environmental stressors, such as, you know, living in unsafe housing that increases people's underlying sense of stress and unsafeness. So their HPA axis is always somewhat activated. So we want to look, have them look in their environment and identify what in your environment is stressful. Noises, smells, sights, those are the big ones. And sounds, I guess that goes with noises. You know, if they live next to a railroad track and the train comes by every quarter hour, that could potentially be an environmental stress trigger in terms of vulnerabilities. We want to eliminate anything that keeps people from getting adequate quality sleep. Getting there's setting their circadian rhythms. So being able to get out, get sunlight, get bright light. You know, if they're in a cave like atmosphere all day long, that's going to contribute to excess stress and circadian rhythm dysfunction. So noise that keeps them from sleeping if they are doing shift work. Shift work tends to be really hard on the cardiovascular system because it throws the circadian rhythms completely out of whack. So that might be another intervention that they need to look at for, you know, going to day shift or, or if they insist on staying night on night shift, then staying on night shift, even on their days off and adjustment and motivational enhancement for new eating and activity patterns, helping people figure out how to not only implement the requirements, but maintain them. So the doctor says you've got to start walking 30 minutes a day and that's just completely overwhelming. Okay. So ideally, you know, work with the rest of the multidisciplinary team, but for some people, they may need to break it up and do 10 or three 10 minute episodes at first throughout the day, and then eventually work up to doing a solid 30 minutes. So it's important to work with people to figure out, okay, what is it that you can and are willing to do? Right now our goal is over here, you're here. What is it that you can do to start moving towards that goal, even if a little bit. Hypertension and cardiovascular disease can both be aggravated by and cause the development of depression, anxiety, anger, grief and even ptsd if there is a life threatening episode. High blood pressure and cardiovascular disease are largely preventable and or treatable. So it's important to help people recognize that, you know, this isn't, this is likely something that you can work with. This is likely something that you can slow the progression of if it is a progressive illness. In terms of the roles of the counselor or social worker, we need to address grief and health anxiety in both the patient and the family, providing them with tools such as hardiness, mindfulness, meditation, activities, yoga, optimism and cognitive restructuring. Now, I say yoga, and that's kind of one of those general terms that, that's there. But Tai Chi has also been found to be very helpful when we're talking about meditation. It doesn't have to be traditional sitting in one place meditation. It can be open awareness meditation. I have a couple of videos on different meditation styles or approaches on the YouTube channel if you want to look at different types of meditation. Because like for example, my father, I know he never would have done what you consider traditional yogic meditation, but he would go out and sit on the porch and listen to the birds and be present in the moment. So that by virtue of being present in the moment would help him decrease his HPA axis responsiveness. We want to help people improve their health literacy and motivation for treatment compliance. Remembering that behavior is communication. So if people are not doing what is prescribed, we need to explore why. Are they afraid of something? Do they not have the skills? Do they not understand how to do it? What is it that's preventing them from being treatment compliant? If it is a grief anger issue, they don't want to give something up or then we, we can help them address those cognitions and figure out ways to hopefully create a compromise where they can still have it to some extent. Finally, we want to encourage self advocacy regarding medication and treatment side effects. A lot of people with hypertension and high cholesterol are medication non compliant because of either the cost of the medication or the side effects. It is really important that we encourage people to be open and adamant with their providers. If the side effects of the medications that they're being prescribed are unacceptable, if they're contributing to non compliance, then it's important for the person to be forthright so the treatment provider can work with them to try to develop something that, something that will work. It's also important if they can't afford their medication. There are a lot of medication formularies like at grocery stores or Walmart or you know those places where you can get certain prescriptions for like $4 a month. There are, there's good Rx, I know that's one that is online now where people can get significant discounts on their medication. If neither one of those pans out. You can also go to the pharmaceutical company's website. So if it's made by Eli Lilly, go to Lily's website and find the page or section entitled Patient Assistance Program. It's almost universally entitled Patient Assistance Program and a lot of times that is a one page sheet that the doctor fills out and faxes into the pharmaceutical company that can help them use, can help them get medication that is free or low cost. In terms of who can use patient assistance, anybody can apply for patient assistance. Every pharmaceutical company has different rules for who they will approve for patient assistance. So you just, it depends on the pharmaceutical company and sometimes the drug, whether the pharmaceutical pharmaceutical company will grant a fee waiver for it.