Telemedicine interventions for ICD recipients with psychological distress: an important piece of a complex puzzle

This invited commentary refers to ‘Effectiveness of telemedicine interventions on anxiety, depression, and health-related quality of life in adults with implantable cardioverter defibrillators: A systematic review and meta-analysis of randomized controlled trials’ by B.K.Y. Ho et al., https://doi.org/10.1093/eurjcn/zvaf225. The use of implantable cardioverter defibrillators (ICDs) has become commonplace for the prevention of sudden cardiac death, with approximately 200 000 implanted worldwide annually.1 However, while ICDs are life-saving for many people, they can also come with psychological implications.2 Given the high prevalence of anxiety, depression, and post-traumatic stress disorder,2 the search has been on for effective interventions to treat these problems. A recent systematic review published in the European Journal of Cardiovascular Nursing by Ho et al. investigated the effectiveness of telemedicine interventions on anxiety, depression, and health-related quality of life for adults with ICDs.3 They found no difference between telemedicine and standard care; this is an interesting result given the rapid integration of digital and telehealth approaches into contemporary cardiovascular and psychological care. Understanding how delivery models influence outcomes is essential, yet interpreting null effects is challenging. The ICD population is heterogeneous, the post-implantation journey may vary considerably, and the outcomes chosen to represent ‘success’ need to capture the psychological reality of living with a device. These factors are important to consider when interpreting current research findings and designing future studies. People have ICDs implanted for a range of primary and secondary prevention indications, and these groups can differ in their needs. A cardiac arrest survivor may be suffering from psychological trauma from their arrest4 or cognitive deficits due to a hypoxic brain injury,5 in addition to receiving their ICD. This complexity might explain why a 2020 study found that a social-cognitive intervention was more effective for individuals receiving an ICD for secondary prevention after cardiac arrest than those receiving it for primary prevention, despite no baseline differences between the groups.6 The intervention may have addressed the additional psychological and cognitive challenges faced by cardiac arrest survivors, highlighting the importance of considering indication-specific needs when designing post-ICD interventions. The trajectory of symptoms post-implantation should also be considered. Distress often peaks around implantation and may naturally decline without the need for formal therapy.2 So trials that enrol everyone may show no effect irrespective of the intervention, as those with the most improvement are lost in the larger population. The improving trajectory may also be disrupted if device shocks or dysfunction occur,2,7 re-elevating distress during the ‘intervention’ period. Driving restrictions may also play a part for some recipients; for example, in the UK, recipients may be unable to drive for 6 months, with further restrictions possible after device shocks (depending on the reason for the shock). This can undermine recipients’ natural coping mechanisms, as they are unable to access work and social networks.8 Interventions may need to be designed with re-entry points or on-demand support (open door/self-referral) rather than offered at specific time points post-implantation or blocks of 6–8 weeks, for example. Hence, time-sensitive evaluation might be helpful, for example, pre-shock vs. post-shock or during driving restrictions vs. after. As the authors note, the present systematic review includes only anxiety, depression, and health-related quality of life, perhaps missing some relevant ICD-related outcomes such as distress, trauma symptoms, fear of shocks, or fear-avoidance/kinesiophobia. There are also positive behaviours or mindsets that many psychologically focused interventions aim to enhance, such as activity resumption, coping self-efficacy, or acceptance of the device. This could be seen as a ‘seesaw’ with ‘perceived challenges’ on one side (shocks, device complications, driving restrictions) with coping resources (information, social network, behaviour change) tipping the balance on the other. This has parallels with the ‘Transactional model of stress and coping’, which posits that individuals make several key appraisals in the face of adverse events. First, appraising if something is a threat, then assessing the availability and efficacy of the resource to manage the threat. Where there is a perceived deficit in resource further stress/distress is likely. Capturing outcomes from both sides of the ‘seesaw’ may reveal intervention effects that are not apparent when examining broader measures such as health-related quality of life.9 Identifying outcome measures used for screening ICD recipients may also help tailor interventions to specific subgroups within the ICD population. Individuals with lower-intensity symptoms may benefit most from information, reassurance, and brief low-intensity support, while those with moderate difficulties might require short (perhaps tele-delivered) interventions. While a smaller, more complex minority will continue to need individual psychological care. Delivering this stepped approach, however, depends on there being processes for screening, triage, and referral—and on deciding when screening should occur: at implantation, when distress is often highest, or later, as people resume everyday activities and new challenges emerge. One pragmatic solution is to offer universal low-intensity support alongside a self-referral pathway, enabling recipients to access further assessment and higher-level interventions whenever their needs change. Telemedicine may have a role here too, beyond intervention delivery, with the potential for continuous monitoring of physical and mental health outcomes, which can then trigger referrals for further support. Furthermore, telemedicine offers meaningful advantages for the complex challenges described above. Interventions can be asynchronous, ready to view and use at a time convenient for the ICD recipient. Particularly those who work or have caring responsibilities. Self-referral and contact with therapy teams via video and telephone might be quicker and simpler than arranging in-person follow-up appointments.10 However, well-recognized disadvantages remain: telemedicine risks excluding those who lack access to or confidence in using it.11 Ultimately, what is needed may be a flexible approach that combines telemedicine and in-person options tailored to individual needs, resources, and stage of recovery. VJ and BI conceived the invited commentary, VJ wrote the first draft, BI reviewed and edited. Vicky L Joshi (Ph.D (Conceptualization [lead]; Writing—original draft [lead])), and Bruce Irvine (PhD (Conceptualization [equal]; Writing—review & editing [supporting])) No funding was involved in this publication. This commentary does not contain new data.