Womenʼs Hearts—Stress Management for Women With Ischemic Heart Disease

Psychological interventions for coronary heart disease

BACKGROUND

Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures.

OBJECTIVES

Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac-related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study-level predictors of the impact of these interventions.

SEARCH STRATEGY

The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review.

SELECTION CRITERIA

Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow-up of six months. Adults with specific diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information.

MAIN RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non-fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): -0.21 (95% CI -0.35, -0.08) and anxiety, SMD: -0.25 (95% CI -0.48 to -0.03). Results for mortality indicated some evidence of small-study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type-A behaviours (ß = -0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (ß = 0.23, p = 0.03), (3) included client-led discussion and emotional support as core therapeutic components (ß = 0.31, p < 0.01), or (4) included family members in the treatment process (ß = 0.26, p < 0.01) were significantly less effective.

AUTHORS' CONCLUSIONS

Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Psychological and social factors in coronary heart disease

More than six decades of empirical research have shown that psychosocial risk factors like low socio-economic status, lack of social support, stress at work and family life, depression, anxiety, and hostility contribute both to the risk of developing coronary heart disease (CHD) and the worsening of clinical course and prognosis in patients with CHD. These factors may act as barriers to treatment adherence and efforts to improve life-style in patients and populations. In addition, distinct psychobiological mechanisms have been identified, which are directly involved into the pathogenesis of CHD. In clinical practice, psychosocial risk factors should be assessed by clinical interview or standardized questionnaires, and relevance with respect to quality of life and medical outcome should be discussed with the patient. In case of elevated risk, multimodal, behavioural intervention, integrating counselling for psychosocial risk factors and coping with illness, should be prescribed. In case of clinically significant symptoms of depression and anxiety, patients should be referred for psychotherapy, and/or medication according to established standards (especially selective serotonin reuptake inhibitors (SSRIs)) should be prescribed. Psychotherapy and SSRIs appear to be safe and effective with respect to emotional disturbances; however, a definite beneficial effect on cardiac end-points has not been documented.

Cognitive-behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials

BACKGROUND

Meta-analyses on psychological treatment for depression in individuals with a somatic disease are limited to specific underlying somatic diseases, thereby neglecting the generalisability of the interventions.

AIMS

To examine the effectiveness of cognitive-behavioural therapy (CBT) for depression in people with a diversity of somatic diseases.

METHOD

Meta-analysis of randomised controlled trials evaluating CBT for depression in people with a somatic disease. Severity of depressive symptoms was pooled using the standardised mean difference (SMD).

RESULTS

Twenty-nine papers met inclusion criteria. Cognitive-behavioural therapy was superior to control conditions with larger effects in studies restricted to participants with depressive disorder (SMD = -0.83, 95% CI -1.36 to -0.31, P<0.001) than in studies of participants with depressive symptoms (SMD = -0.16, 95% CI -0.27 to -0.06, P = 0.001). Subgroup analyses showed that CBT was not superior to other psychotherapies.

CONCLUSIONS

Cognitive-behavioural therapy significantly reduces depressive symptoms in people with a somatic disease, especially in those who meet the criteria for a depressive disorder.

Effects of examination stress on psychological responses, sleep and allergic symptoms in atopic and non-atopic students

BACKGROUND

Recent findings indicate that atopics may be more vulnerable to stress than non-atopics. However, the roles of psychological well-being and sleep in this presumed increased sensitivity are not known.

PURPOSE

To investigate the effects of a brief naturalistic stressor on psychological responses, sleep, and allergic symptoms and to compare those responses between atopic and non-atopic individuals.

METHODS

We assessed atopic and non-atopic students during a period without and during a period with examinations.

RESULTS

For both atopic and non-atopic students, tension, anxiety, and depression deteriorated in response to examination, as did sleep latency and sleep quality. Overall, atopics were more tense, had more anxiety, longer sleep latencies, and were less well rested than non-atopics. Non-atopic students rose from bed later during the examination period. In response to examination, atopic students reported increased frequency of stress behaviors (e.g., eating fast), while decreased stress behaviors were reported by non-atopic students. Allergic symptoms were not affected.

CONCLUSION

Atopic students were worse off in aspects of psychological well-being and sleep, but displayed only partly stronger responses to a stressor compared to non-atopic students. In spite of a broad negative response to examination, allergic symptoms were not affected.

Does stress reduction change the levels of cortisol secretion in patients with coronary artery disease?

PURPOSE

It has been shown that behavioral therapy has effects on stress behavior in patients with coronary artery disease. Salivary cortisol measurements are widely used to assess psychological stress, stress reactivity, or both. The aim of this study was to investigate whether improved stress behavior in type A patients with coronary artery disease involved changes in cortisol secretion pattern.

METHODS

Twenty-four male patients were identified as type A individuals and completed a 12-month cognitive-behavioral stress management program. Stress behavior was evaluated by using a validated questionnaire. Morning and evening salivary cortisol levels were measured over 3 consecutive days at baseline and after 12 months.

RESULTS

Although the patients showed a significant improvement in psychosocial well-being after 12 months, their basal cortisol levels or diurnal rhythm of cortisol did not change. There was no correlation between stress score and cortisol levels.

CONCLUSIONS

The value of salivary cortisol as both a stress marker and a new cardiovascular risk factor has been discussed but the data from this small pilot study raise the question of its utility as a stress marker in cardiac rehabilitation.

Cognitively oriented behavioral rehabilitation in combination with Qigong for patients on long-term sick leave because of burnout: REST--a randomized clinical trial

BACKGROUND

Despite an increase in the occurrence of burnout, there is no agreement on what kind of rehabilitation these patients should be offered.

PURPOSE

Primary aim of this study was to evaluate effects on psychological variables and sick leave rates by two different group rehabilitation programs for patients on long-term sick leave because of burnout. Rehabilitation program A (Cognitively oriented Behavioral Rehabilitation (CBR) and Qigong) was compared with rehabilitation program B (Qigong only).

METHOD

In a randomized clinical trial, 96 women and 40 men with a mean age of 41.6 +/- 7.4 years were allocated to one of the two rehabilitation programs.

RESULTS

A per-protocol analysis showed no significant difference in treatment efficacy between the groups. Both groups improved significantly over time with reduced levels of burnout, self-rated stress behavior, fatigue, depression, anxiety, obsessive-compulsive symptoms, and sick leave rates. In an intention-to-treat analysis, patients in program A had fewer obsessive-compulsive symptoms and larger effect sizes in self-rated stress behavior and obsessive-compulsive symptoms compared to patients in program B.

CONCLUSION

This study showed no differences in effect between CBR and Qigong compared with Qigong only in a per-protocol analysis. Both rehabilitation programs showed positive effect for patients with burnout.

Vital exhaustion in coronary heart disease: the impact of socioeconomic status

BACKGROUND

Vital exhaustion has been shown to be a significant risk factor contributing to coronary heart disease, as well as a predictor of a worse prognosis among coronary patients. Socioeconomic differences in vital exhaustion may be part of the causal mechanism in the health and mortality inequalities connected with socioeconomic disadvantage. Our aim was to explore socioeconomic inequalities in vital exhaustion among coronary patients.

METHODS

We included 362 patients (32% women, mean age 56+/-7.3 years) who were referred for coronary angiography. The Maastricht interview for vital exhaustion was conducted with each patient. Level of income and education were used as indicators of socioeconomic status. Functional status was assessed with the NYHA (dyspnoe symptoms) and CCS (chest pain) scales.

RESULTS

Logistic regression showed significant socioeconomic inequalities in vital exhaustion among patients. Participants with low and middle income and education had a higher probability of being exhausted in comparison with patients with high income and education [odds ratio (95% confidence interval): 13.31 (4.67-37.94) and 2.10 (1.19-3.64), respectively]. Associations remained statistically significant after controlling for the effect of functional status and seriousness of disease. Socioeconomic differences were more salient among men than among women.

CONCLUSION

Low education and income seem to be strongly associated with higher vital exhaustion among patients; a significant factor contributing to worse prognosis and lower quality of life among patients with coronary heart disease.

Financial strain predicts recurrent events among women with coronary artery disease

BACKGROUND

Although a number of epidemiological studies have found an association between socioeconomic status (SES) indices such as income and education and coronary morbidity and mortality, few have looked at health consequences arising from actually experiencing financial shortcomings. The objective of the present study was to examine whether financial strain predicts recurrent coronary artery disease (CAD) events among women with established CAD.

METHODS

Two hundred two women (mean age 62+/-9 years) hospitalized for an acute coronary event were followed over a period of 3.5 years. Demographic, socioeconomic, lifestyle-related, psychosocial and biological characteristics were obtained by means of questionnaires and clinical examination. Data on recurrent cardiac events were collected from the Swedish discharge and death registers.

RESULTS

Women experiencing financial strain over the past year had an increased risk for recurrent events, i.e. the combination of all-cause mortality, new acute myocardial infarction and unstable angina pectoris during the follow-up with an unadjusted hazard ratio (HR) of 3.2 (95% CI 1.6-6.6), and a HR of 2.76 (95% CI 1.02-7.50) after controlling for education, household income, age, cohabiting status, inclusion diagnosis and rehabilitation therapy. Adjustment for potential mediators, i.e. psychosocial factors, lipids, diabetes mellitus, smoking, body-mass index, blood pressure, physical activity, alcohol consumption, participation in other cardiac rehabilitation programs did not alter the results significantly.

CONCLUSIONS

Financial strain was a predictor for recurrent events among women with CAD, independently of commonly used SES indicators such as education and household income. Future studies will have to explore the mechanism behind this association.

Effects of an expanded cardiac rehabilitation programme in patients treated for an acute myocardial infarction or a coronary artery by-pass graft operation

Objective: To investigate the effects of expanded cardiac rehabilitation with multifactorial interventions on metabolic and inflammatory markers, exercise performance and on established cardiovascular risk factors.

Design: Single-centre prospective randomized controlled trial.

Setting: A university hospital.

Subjects: Two hundred and twenty-four patients with an acute myocardial infarction or patients undergoing coronary artery by-pass grafting.

Intervention: Patients were randomized to expanded cardiac rehabilitation including stress management, increased physical training, staying at a 'patient hotel' and cooking sessions, or to usual cardiac rehabilitation

Main measures: Biochemical risk markers and exercise performance; follow-up was one year.

Results: There were no significant differences between the two treatment groups in the changes of biochemical risk markers or in exercise performance. Thus, low-density lipoprotein (LDL)-cholesterol levels decreased from 3.00 (0.97) to 2.54 (0.66) mmol/L in the intervention group and from 3.20 (0.85) to 2.54 (0.63) mmol/L in the control group, fibrinogen levels decreased from 5.30 (2.00) to 4.25 (1.01) g/L in the intervention group and from 5.29 (1.89) to 4.33 (0.83) g/L in the control group and C-reactive protein (CRP) levels decreased from 3.04 (2.79) to 2.09 (2.13) mg/L in the intervention group and from 4.01 (3.49) to 2.39 (2.49) mg/L in the control group. Total workload (W) improved from 118 (35) to 136 (34) in the intervention group and from 117 (36) to 133 (39) in the control group.

Conclusion: There was no further significant benefit in biochemical risk markers or in exercise performance among patients undergoing the expanded rehabilitation as compared to the control group which received usual cardiac rehabilitation.

Work and marital status in relation to depressive symptoms and social support among women with coronary artery disease

BACKGROUND

Work and marital status have been shown to be associated with health outcome in women. However, the effect of employment and marriage on psychosocial functioning has been studied predominantly in healthy subjects. We investigated whether work and marital status are associated with depressive symptoms, social support, and daily stress behavior in women with coronary artery disease (CAD).

METHODS

Data of 105 women with CAD and of working age were analyzed. General linear models were used to determine the association between work and marital status and depressive symptoms, social support, and daily stress behavior.

RESULTS

Women who were working at the time of measurement had lower levels of depressive symptoms (7.0 +/- 1.2 vs. 12.1 +/- 0.9, p < 0.01) and higher levels of social support (21.6 +/- 1.0 vs. 18.9 +/- 0.7, p = 0.03) than the nonworking women, whereas marital status was not related to any of the outcome variables. Results were similar after adjusting for potential confounders, that is, age, education, self-reported health, and risk factors for CAD. There was no significant interaction between marital status and working status on depressive symptoms, social support, or daily stress behavior.

CONCLUSIONS

In women with CAD, all <65 years of age, after a cardiac event, patients working had lower levels of depressive symptoms and a better social integration than those not working, regardless of reason for being nonemployed. Daily stress behavior, depression, and social support did not differ between cohabiting and not cohabiting women. Future interventions should take into consideration that women with CAD who are unemployed may have a higher risk for depression and social isolation and, therefore, poor clinical outcomes.

Cognitive-behavioural stress management does not improve biological cardiovascular risk indicators in women with ischaemic heart disease: a randomized-controlled trial

OBJECTIVES

Psychosocial factors, such as stress and vital exhaustion, are associated with an increased risk of cardiovascular events, and women report more psychosocial ill-being after an acute myocardial infarction than men. We have earlier shown that a cognitive-behavioural intervention in women with ischaemic heart disease (IHD) improved psychosocial well-being. In the present study, we tested the hypothesis that the improvement in psychosocial well-being is associated with an improvement in biochemical indicators of cardiovascular risk.

DESIGN

Randomized-controlled trial in northern Sweden.

SETTING

Outpatient care.

SUBJECTS

Women with IHD were randomized to either a 1-year cognitive-behavioural stress management programme or usual care. Of the 159 women who completed the study, 77 were in the intervention group, and 82 in the control group.

INTERVENTIONS

A 1-year cognitive-behavioural stress management programme versus conventional care.

RESULTS

Group assignment was not found to be a determinant of waist circumference, high sensitive C-reactive protein (hs-CRP), fibrinogen, von Willebrand factor (vWF), plasminogen activator inhibitor type 1 (PAI-1) activity, tissue plasminogen activator (tPA) activity, tPA antigen, tPA-PAI-1 complex, leptin, or HOMA2 insulin resistance index (HOMA2-IR) at follow up. Changes in psychosocial variables were not associated with changes in any of the biological risk indicators.

CONCLUSIONS

Even if our cognitive-behavioural stress management programme had effects on proximal targets, such as stress behaviour and vital exhaustion, we found no improvement in intermediate biochemical targets related to the metabolic syndrome and IHD. Our results challenge the proposition that the relationship between psychological well-being and biological cardiovascular risk indicators is a direct cause-effect phenomenon.