Discussion
This case series showed that three cases referred for mental healthcare as part of a HFSMP depression and anxiety screening initiative were incidentally found to meet criteria for HD. None of the HF patients with HD had any psychiatric diagnoses recorded in their medical histories despite comorbid major depressive disorder and generalized anxiety disorder, and the importance of depression to HF prognosis [20]. This finding highlights the importance of multi-modal evidence-based psychological assessment and the importance of a multi-disciplinary team approach for patients who are being treated for HF.
Across the three cases, one patient declined treatment, while the other two experienced modest improvements in HD symptoms. This finding is consistent with the wider literature where dropout rates can range from 13% [21] to 30% [22], and even after best-practice CBT treatment many patients with HD remain symptomatic despite reducing their symptoms significantly [8]. Reflecting this, multiple new directions for research are being investigated to enhance the efficacy of CBT for HD including adding a contingency management approach to treatment [23] and between-session internet-based clinician support [24] and such strategies may enhance outcomes in patients who have HD and comorbid HF or other cardiovascular diseases.
The case study highlights the importance of considering patient comorbidities and making case-informed modifications to best-practice treatment when working with individuals with HD, and how these modifications can support clients to engage in best-practice treatment for HD. Physical fitness and adherence to HF self-management [25] likely determines a patient’s capability for participation in sorting/discarding tasks that are critical in CBT for HD. Consequently, HF patients require pacing of sorting/discarding tasks to reduce fatigue, or other modifications. This parallels the practical assistance for patients with physical impairments in a previous geriatric sample undergoing CBT for hoarding [26]. Indeed, modifications to standard CBT interventions in HF and other cardiovascular patients are poorly reported in the literature [27, 28], with most anxiety treatments designed for non-cardiac patients [29]. The paucity of anxiety disorder interventions in cardiovascular populations underscores the importance of further research and case-studies in this nascent field. Parallel research has shown that modifications to cognitive components of CBT in sub-samples with intellectual disability [30] and cognitive impairment [26] improve hoarding disorder treatment efficacy. Future research in this field is particularly important in HD, given the significant medical and psychiatric comorbidity seen in this population [4, 31].
In conclusion, CBT for HD appears moderately effective in the treatment of individuals with comorbid HF. However, the treatment necessitates several modifications to reduce risk for dizziness, syncope, and falls that clinicians should familiarize themselves with. The findings from this study may generalize to other cardiovascular conditions characterized by high fatigability or geriatric populations with postural hypotension and hypoperfusion. Future research in this field using larger samples is warranted.