Psychological assessments for cardiac rehabilitation patients

Feasibility and Outcomes in a Pilot Randomized Controlled Trial of a Psychosocial Intervention for Adults With Congenital Heart Disease

BACKGROUND

North American adults with congenital heart disease (CHD) are known to be at elevated risk of mood and anxiety disorders. This was the first trial of a group psychosocial intervention targeting this patient population.

METHODS

Within this feasibility study, we conducted a 2-arm pilot randomized controlled trial (RCT) in which patients were randomized to Usual Care or an 8-session group psychosocial intervention (Adult Congenital Heart Disease-Coping and Resilience [ACHD-CARE]). Here, we report feasibility outcomes in accordance with published recommendations: (1) process, (2) resources, (3) management, (4) acceptability of the intervention, and (5) scientific outcomes (for which the primary outcome measures were anxiety and depression symptoms).

RESULTS

Forty-two patients were randomized in the pilot RCT. The study was executable within a realistic timeline and revealed no significant human and data-management problems. The intervention was determined to be acceptable and highly valued by participants who participated in the ACHD-CARE program. The main challenges were practical barriers (eg, transportation, scheduling group sessions in-person given competing schedules) and retention. With regard to scientific outcomes, there were no adverse outcomes, and treatment fidelity was confirmed. Although not powered to test efficacy, there was a medium effect size (in favour of the intervention group) for depression symptoms.

CONCLUSIONS

We determined it would be feasible to conduct a full-scale trial of a psychosocial intervention targeting adults with CHD, although with modifications to address practical barriers to participation. Should this intervention prove effective, a manualized intervention could be made be available.

Adult Congenital Heart Disease-Coping And REsilience (ACHD-CARE): Rationale and methodology of a pilot randomized controlled trial

INTRODUCTION

One-third of North American adults with congenital heart disease (CHD) have diagnosable mood or anxiety disorders and most do not receive mental health treatment. There are no published interventions targeting the psychosocial needs of patients with CHD of any age. We describe the development of a group psychosocial intervention aimed at improving the psychosocial functioning, quality of life, and resilience of adults with CHD and the design of a study protocol to determine the feasibility of a potential full-scale randomized controlled trial (RCT).

METHODS/DESIGN

Drawing upon our quantitative and qualitative research, we developed the Adult CHD-Coping And REsilience (ACHD-CARE) intervention and designed a feasibility study that included a 2-parallel arm non-blinded pilot RCT. Eligible participants (CHD, age ≥ 18 years, no planned surgery, symptoms suggestive of a mood and/or anxiety disorder) were randomized to the ACHD-CARE intervention or Usual Care (1:1 allocation ratio). The group intervention was delivered during eight 90-minute weekly sessions. Feasibility will be assessed in the following domains: (i) process (e.g. recruitment and retention), (ii) resources, (iii) management, (iv) scientific outcomes, and (v) intervention acceptability.

DISCUSSION

This study underscores the importance of carefully developing and testing the feasibility of psychosocial interventions in medical populations before moving to full-scale clinical trials. At study conclusion, we will be poised to make one of three determinations for a full-scale RCT: (1) feasible, (2) feasible with modifications, or (3) not feasible. This study will guide the future evaluation and provision of psychosocial treatment for adults with CHD.

Factors that influence obesity, functional capacity, anxiety and depression outcomes following a Phase III cardiac rehabilitation programme

AIMS AND OBJECTIVES

To examine changes in functional capacity, anxiety, depression and BMI in patients who completed a cardiac rehabilitation programme and to determine the influencing factors.

BACKGROUND

While the effectiveness of cardiac rehabilitation is long established, more studies are needed to examine the combined effectiveness of this multicomponent intervention and the factors that influence this in the changed profile of patients currently attending cardiac rehabilitation.

DESIGN

The study was a longitudinal retrospective study of patients following a six- or eight-week Phase III cardiac rehabilitation programme.

METHODS

The study recruited 154 patients. Functional capacity, anxiety, depression, weight, waist circumference and BMI were assessed at the beginning and end of cardiac rehabilitation. t-tests were used to assess changes over time, and multivariate regression analysis was used to determine the influence of factors on these changes.

RESULTS

Significant improvements were seen in functional capacity, waist circumference, weight and BMI, but not in depression and anxiety. Multivariate analysis revealed that being younger and less fit was associated with greater improvements in functional capacity while reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Models testing the influence of the factors on BMI, anxiety and depression were not significant.

CONCLUSION

Cardiac rehabilitation is still an effective method to instigate changes in cardiac risk factors despite the changes in patients profile attending programmes.

RELEVANCE TO CLINICAL PRACTICE

Continued encouragement of the historically less typical patients to participate in cardiac rehabilitation is needed as reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Despite psychosocial components within the programme, no significant improvements were observed over cardiac rehabilitation in depression or anxiety. While effectiveness was observed, there is room for further optimisation of practice and research by employing and documenting clearly the use of behavioural techniques.

Psychological Correlates of Outcome after Coronary Artery Bypass Graft

BACKGROUND

Psychological effects of Coronary Artery Bypass graft (CABG) have been of interest all over the world but there is a paucity of Indian work.

METHODS

30 patients undergoing CABG at a service hospital were included. All patients filled a specially designed proforma. Mini Mental Status Examination, Hospital anxiety and depression scale, Coronary scale, Seattle angina questionnaire and Euro-QOL 5D were performed before and seven days after CABG.

RESULTS

43.3% had significant anxiety and 30% had significant depression before CABG. Following CABG, 36.67% of the patients had significant anxiety while 40% had significant depression. On the Seattle angina questionnaire, physical limitation reduced from 71.6 ± 7.9 to 53.1 ± 14.6. There was significant improvement in treatment satisfaction from 37.8 ± 6.1 to 59.4 ± 4.2 following CABG. On th euro quality of life scale (EQ5D) health status improved from 38.17 ± 9.51 before CABG to 68.5 ± 5.28 after CABG.

CONCLUSION

There is a significant incidence of anxiety and depression in patients undergoing CABG, both before and after surgery.

Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles

OBJECTIVE

To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease.

DESIGN

A critical review of the literature (1994-2009).

FINDINGS

The prevalence of depression and anxiety is high in both chronic obstructive pulmonary disease (8-80% depression; 6-74% anxiety) and chronic heart failure (10-60% depression; 11-45% anxiety). However, methodological weaknesses and the use of a wide range of diagnostic tools make it difficult to reach a consensus on rates of prevalence. Co-morbid depression and anxiety are associated with increased mortality and healthcare utilisation and impact upon functional disability and quality of life. Despite these negative consequences, the identification and management of co-morbid depression and anxiety in these two diseases is inadequate. There is some evidence for the positive role of pulmonary/cardiac rehabilitation and psychotherapy in the management of co-morbid depression and anxiety, however, this is insufficient to guide recommendations.

CONCLUSIONS

The high prevalence and associated increase in morbidity and mortality justifies future research regarding the management of anxiety and depression in both chronic heart failure and chronic obstructive pulmonary disease. Current evidence suggests that multi-faceted interventions such as pulmonary and cardiac rehabilitation may offer the best hope for improving outcomes for depression and anxiety.

Cardiac rehabilitation for the treatment of women with chest pain and normal coronary arteries

OBJECTIVE

To explore cardiac rehabilitation (CR) as a treatment for psychological and physiological morbidity in women with chest pain and normal coronary arteries (cardiac syndrome X).

DESIGN

Sixty-four women aged 57.3+/-8.6 years (mean +/- SD) with cardiac syndrome X were randomly assigned to an 8-week phase III CR exercise program or symptom monitoring control. All women completed the Hospital Anxiety and Depression Scale, Health Anxiety Questionnaire, and Short Form-36 before and after intervention and at the 8-week follow-up. CR patients underwent physical assessment before and after CR.

RESULTS

After CR, patients demonstrated improved symptom severity (2.0+/-0.8 vs 1.26+/-1.1, P=0.009), Hospital Anxiety and Depression Scale depression score (8.0+/-3.4 vs 6.4+/-3.1, P=0.04), total Health Anxiety Questionnaire score (12.0+/-5.5 vs 9.5+/-6.0, P=0.008), health worry (4.5+/-3.1 vs 3.52+/-2.4, P=0.025) and interference (2.4+/-1.8 vs 1.6+/-1.8, P=0.004), SF-36 physical functioning (53.1+/-20.4 vs 62.3+/-23.9, P = 0.006), energy (36.3+/-20.7 vs 49.8+/-19.1, P<0.001), pain (49.9+/-20.7 vs 58.1+/-22.9, P=0.028), and general health (48.8+/-17.9 vs 57.6+/-17.0, P=0.01) not found among the control women. Improvements were maintained at follow-up. CR patients showed significant improvements in Shuttle Walk Test performance (326.8+/-111.0 vs 423.6+/-133.2 m, P<0.001), diastolic blood pressure (84.7+/-9.4 vs 79.7+/-7.3 mm Hg, P=0.007), and body mass index (29.1+/-6.0 vs 28.4+/-6.17 kg/m2, P=0.003).

CONCLUSIONS

An 8-week phase III CR program improves exercise tolerance, quality of life, psychological morbidity, symptom severity, and cardiovascular risk factors in women with cardiac syndrome X.