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.