Perioperative and Long-Term Development of Anxiety and Depression in CABG Patients

The pathophysiology and management of depression in cardiac surgery patients

Background

Depression is common in the cardiac surgery population. This contemporary narrative review aims to explore the main pathophysiological disturbances underpinning depression specifically within the cardiac surgery population. The common non-pharmacological and pharmacological management strategies used to manage depression within the cardiac surgery patient population are also explored.

Methods

A total of 1291 articles were identified through Ovid Medline and Embase. The findings from 39 studies were included for qualitative analysis in this narrative review.

Results

Depression is associated with several pathophysiological and behavioral factors which increase the likelihood of developing coronary heart disease which may ultimately require surgical intervention. The main pathophysiological factors contributing to depression are well characterized and include autonomic nervous system dysregulation, excessive inflammation and disruption of the hypothalamic-pituitary-adrenal axis. There are also several behavioral factors in depressed patients associated with the development of coronary heart disease including poor diet, insufficient exercise, poor compliance with medications and reduced adherence to cardiac rehabilitation. The common preventative and management modalities used for depression following cardiac surgery include preoperative and peri-operative education, cardiac rehabilitation, cognitive behavioral therapy, religion/prayer/spirituality, biobehavioral feedback, anti-depressant medications, and statins.

Conclusion

This contemporary review explores the pathophysiological mechanisms leading to depression following cardiac surgery and the current management modalities. Further studies on the preventative and management strategies for postoperative depression in the cardiac surgery patient population are warranted.

Does Mental Distress Predict Cardiac Surgical Outcome?

BACKGROUND

 Mental distress is suspected to influence the morbidity of cardiac patients. Evaluating mental distress in cardiac patients is rare and the impact on surgical outcome is still not certified.

METHODS

 In 94 cardiac surgical patients, mental distress was assessed by the Patient Health Questionnaire-4 (PHQ-4). We defined length of stay in hospital and on intensive care unit as well as time of mechanical ventilation as outcomes on surgery. Age, physical activity, diabetes, overweight, PHQ-4, and an inflammation marker were tested for their predictive value on outcomes.

RESULTS

 Reportedly prevalence of generalized anxiety was 16.0% and depression rate was 13.8%. Length of stay in hospital was 13 ± 8 days, time of mechanical ventilation was 10 (0-1,207) hours, and length of stay on intensive care unit was 3 ± 6 days. Length of stay in hospital was significantly predicted by age (p = 0.048), low physical activity (p = 0.029), and high C-reactive protein (CRP; p = 0.031). Furthermore, CRP was the only significant predictor of time of mechanical ventilation and length of stay on intensive care unit.

CONCLUSION

 Outcome was not predicted by mental distress. However, inflammation marker CRP was predictive for outcome, potentially caused by higher cardiovascular risk profile. Additionally, depression was referred to be associated with inflammation. Probably, the small sample and the timing of assessment were responsible for the missing relation between mental distress and outcome. We presume a relation with low physical activity and depression. Nevertheless, further randomized studies are needed to pay more attention on patients' distress to intervene preoperatively to improve postoperative outcome.

Risk of depression after coronary artery bypass grafting: a SWEDEHEART population-based cohort study

Aims

A diagnosis of depression in patients with coronary heart disease is associated with worse outcomes. This study examined the long-term risk for new onset of depression after coronary artery bypass grafting (CABG) compared to an age- and sex-matched control group from the general population.

Methods and results

In total, 125 418 primary isolated CABG patients and 495 371 matched controls were included from 1992 to 2017. The SWEDEHEART registry and three other national registers were used to acquire information about baseline characteristics and depression. The adjusted risk of depression was estimated by using Cox regression models adjusted for patient characteristics, and socioeconomic variables, described by hazard ratios (HR) and 95% confidence intervals (CI). In total, 6202 (4.9%) CABG patients and 17 854 (3.6%) controls developed depression. The cumulative incidence of depression was higher in CABG patients than in the control population [6.1%, 95% CI 6.0–6.3 vs. 4.7% (4.7–4.8), P < 0.0001]. Overall, the CABG group had a marginally increased adjusted risk of depression compared to controls [adjusted HR (aHR): 1.05 (1.01–1.09), P = 0.0091]. In age-specific analyses, the increased risk compared to controls was only present in patients <65 years [aHR: 1.19 (1.11–1.27), P <0.0001] and was only evident during the first 5 years after surgery.

Conclusion

Patients who underwent CABG had a higher risk of new onset of depression compared to sex- and age-matched controls in the general population. The risk of depression was especially pronounced in younger patients during the first 5 years after surgery.

The effect of the family presence on anxiety and agitation of patients under mechanical ventilation after open heart surgery: a randomized clinical trial

Background

Family-centered care has been considered as a philosophy of care. Family presence in intensive care units (ICUs), especially in the acute phase of the disease is controversial. This study has been carried out in order to determine the effect of the family presence on anxiety and agitation in patients undergoing coronary artery bypass grafting (CABG).

Materials and methods

In a clinical trial, 70 patients were randomly allocated into groups of experimental and control. In the experimental group, during the weaning process from the mechanical ventilation, a family member was present at the bedside. The degree of anxiety and Richmond’s Agitation and Sedation Scale (RASS) were compared in seven consecutive time stages, including the time of entry into the ICU, the first respiratory drive, the family entrance, 20 min and 1 h after the presence of the family member, the time of extubation, and 1 h after extubation.

Results

There was a significant difference between the two groups in the mean scores of the anxiety scale in the first (P =0.008), second (P=0.002), and third stages (P =0.005). This difference was not significant in the fourth to seventh stages (P>0.05). As the baseline anxiety levels were different, a covariate adjustment was used for comparisons between treatments, adjusting the main analyses for baseline anxiety levels. Analysis showed that groups were not different. Also, there was no significant difference in the mean scores of RASS between the two experimental and control groups at any of the seven stages (P> 0.05).

Conclusion

According to the findings of the present study, the presence of a family member does not reduce the level of anxiety and agitation of patients undergoing cardiac surgery. However, it can be concluded that this intervention is feasible in acute and complex situations after open heart surgeries.

Trial registration

This study has been registered in the Iranian Registry of Clinical Trials with the code IRCT201609014299N4.

Patient-reported outcomes in coronary artery disease: the relationship between the standard, disease-specific set by the International Consortium for Health Outcomes Measurement (ICHOM) and the generic health-related quality of life instrument 15D

BACKGROUND

Patient-reported outcome (PRO) instruments measure health gains, including changes in health-related quality of life (HRQoL). Previous studies have assessed the reliability and relationship of multiple HRQoL instruments in search of the optimal instrument for feasible measurement of PROs. Although the 15D instrument was shown to have the best sensitivity and construct validity among cardiac patients, it is unknown how well it captures relevant disease-specific information scores compared to instruments included in the International Consortium for Health Outcomes Measurement (ICHOM) standard set. The aim of this study was to investigate whether the disease-specific PRO instruments and a generic HRQoL instrument capture disease related symptoms in coronary artery disease (CAD) patients.

METHODS

Health status and HRQoL were assessed with the instruments included in the ICHOM standard set: Seattle Angina Questionnaire short-form (SAQ-7), Rose Dyspnea Scale (RDS), two-item Patient Health Questionnaire (PHQ-2), and with the 15D HRQoL instrument at baseline and 1 year from the treatment in a university hospital setting. Spearman correlation and explanatory factor analysis were used to assess the relationship of baseline scores and 1-year change in scores of 297 patients.

RESULTS

At baseline, the overall 15D score and SAQ-physical limitation (SAQ-PL), 15D "breathing" and SAQ-PL, as well as "breathing" and RDS showed moderately strong correlations. The factor interpreted to reflect "Breathing-related physical activity", based on high loadings of "breathing", RDS, SAQ-PL, "mobility", "vitality", and "usual activities", explained 19.2% of the total variance. Correlations between 1-year changes in scores were fair. The factor of "Breathing-related physical activity", with significant loading of RDS, SAQ-PL, "breathing, "usual activities", "vitality", "sexual activity", "mobility", and disease-specific quality of life explained 20.5% of the total variance in 1-year change in scores. The correlation of angina frequency measured by SAQ-7 and the 15D instrument was poor.

CONCLUSIONS

The 15D detects dyspnea and depression similarly to RDS and PHQ-2 but not angina similarly to the SAQ-7. This may call for supplementing the 15D instrument with a disease-specific instrument when studying CAD patients.

A randomized clinical trial of an eHealth intervention on anxiety in patients undergoing abdominal aortic aneurysm surgery

BACKGROUND

The potential benefit of eHealth interventions in patients with abdominal aortic aneurysm (AAA) is uncertain. The primary aim of this study was to investigate the effect of an eHealth intervention on anxiety in patients with AAA undergoing surgery.

METHODS

A single-centre randomized clinical trial of patients with AAA scheduled for surgical repair was undertaken. The intervention group received an eHealth tool and psychosocial support besides standard care. The control group received standard care. The analysis of treatment effects was performed as intention-to-treat and per protocol analysis. The primary outcome measure was anxiety mean score (Hospital Anxiety and Depression Scale Anxiety (HADS)-A). Secondary outcomes measures were HADS Depression and short-form 12-item health survey mean scores.

RESULTS

Some 120 participants were randomized. No effect on anxiety mean scores was found in the intention-to-treat analysis (-1.21 versus -0.54, P = 0.330). Among those randomized to the intervention, only 30 of 60 participants used the eHealth tool (application (app) users). The app users were younger and had a higher educational level. A decrease in anxiety mean scores was noted in those who used the app in the per protocol analysis (-2.00 versus -0.54, P = 0.028). The intervention group stated a lower physical-component health-related quality of life (HRQoL) (-4.32 versus -1.16, P = 0.042) but mental-component HRQoL and depressive symptoms were unchanged.

CONCLUSIONS

Delivery of an eHealth intervention in this RCT did not result in an improvement in anxiety scores in patients awaiting AAA surgery. Uptake of the eHealth tool was low, although it resulted in lower anxiety scores in those participants who actually used it.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03157973 (http://www.clinicaltrials.gov).

Impact of cognitive behavioral therapy on depression symptoms after transcatheter aortic valve replacement: A randomized controlled trial

BACKGROUND

Depression is a significant concern after cardiac surgery and has not been studied in patients undergoing transcatheter aortic valve replacement (TAVR). We sought to examine the prevalence of pre-procedure depression and anxiety symptoms and explore whether brief bedside cognitive behavioral therapy (CBT) could prevent post-TAVR psychological distress.

METHODS

We prospectively recruited consecutive TAVR patients and randomized them to receive brief CBT or treatment as usual (TAU) during their hospitalization. Multi-level regression techniques were used to evaluate changes by treatment arm in depression, anxiety, and quality of life from baseline to 1 month post-TAVR adjusted for sex, race, DM, CHF, MMSE, and STS score.

RESULTS

One hundred and forty six participants were randomized. The mean age was 82 years, and 43% were female. Self-reported depression and anxiety scores meeting cutoffs for clinical level distress were 24.6% and 23.2% respectively. Both TAU and CBT groups had comparable improvements in depressive symptoms at 1-month (31% reduction for TAU and 35% reduction for CBT, p = .83). Similarly, both TAU and CBT groups had comparable improvements in anxiety symptoms at 1-month (8% reduction for TAU and 11% reduction for CBT, p = .1). Quality of life scores also improved and were not significantly different between the two groups.

CONCLUSIONS

Pre-procedure depression and anxiety may be common among patients undergoing TAVR. However, TAVR patients show spontaneous improvement in depression and anxiety scores at 1-month follow up, regardless of brief CBT. Further research is needed to determine whether more tailored CBT interventions may improve psychological and medical outcomes.

Predicting poor postoperative acute pain outcome in adults: an international, multicentre database analysis of risk factors in 50,005 patients

Supplemental Digital Content is Available in the Text.

Eight risk factors were identified in a large international database. Patients with 3 or more risk factors are at higher risk for poor pain outcome.

Background:

The aim of this study was to determine simple risk factors for severe pain intensity (≥7 points on a numeric rating scale [NRS]), to analyse their relation to other patient-reported outcome measures and to develop a simple prediction model.

Methods:

We used data from 50,005 patients from the PAIN-OUT project. Within a first data set (n = 33,667), relevant risk factors were identified by logistic binary regression analysis, assessed for additional patient-reported outcome measures beyond pain intensity and summed up for developing a simple risk score. Finally, sum of factors was plotted against postoperative pain outcomes within a validation data set (n = 16,338).

Results:

Odds ratios (OR) for the following risk factors were identified: younger age (<54 years, OR: 1.277), preoperative chronic pain at the site of surgery (OR: 1.195), female sex (OR: 1.433), duration of surgery (>90 minutes, OR: 1.308), preoperative opioid intake (OR: 1.250), feeling anxious (OR: 1.239) and feeling helpless due to pain (OR: 1.198), and the country of the recruiting centre (OR: 1.919). Patients with ≥3 risk factors had more severe pain intensity scores, spent a longer time in severe pain, and wished to have received more pain treatment (P < 0.001). A simple risk score was created with 4 risk factors showing a moderate prediction level.

Conclusions:

Patients with ≥3 risk factors are at higher risk for poor postoperative acute pain outcome after surgery. Future studies using this score might show that preventive strategies might decrease pain intensity, pain-related postoperative dysfunction, and the development of chronic pain.

Surgery, stomas, and anxiety and depression in inflammatory bowel disease: a retrospective cohort analysis of privately insured patients

AIM

Patients with inflammatory bowel disease (IBD) are diagnosed with anxiety/depression at higher rates than the general population. We aimed to determine the frequency of anxiety/depression among IBD patients and the temporal association with abdominal surgery and stoma formation.

METHOD

We conducted a retrospective cohort study in adult patients with IBD using difference-in-difference methodology and a large commercial claims database (2003-2016). Outcomes were anxiety/depression diagnoses before and after major abdominal surgery or stoma formation.

RESULTS

We identified 10 481 IBD patients who underwent major abdominal surgery, 18.8% of whom underwent stoma formation, and 41 924 nonsurgical age- and sex-matched IBD controls who were assigned random index dates. Rates of anxiety and depression increased among all cohorts (P < 0.001). Surgical patients had higher odds of anxiety [one surgery, adjusted OR 6.90 (95% CI 6.11-7.79), P < 0.001; two or more surgeries, 7.53 (5.99-9.46), P < 0.001] and depression [one surgery, 6.15 (5.57-6.80), P < 0.001; two or more surgeries, 6.88 (5.66-8.36), P < 0.001] than nonsurgical controls. Undergoing multiple surgeries was associated with a significant increase in depression from 'pre' to 'post' time periods [1.43 (1.18-1.73), P < 0.001]. Amongst surgical patients, stoma formation was independently associated with anxiety [1.40 (1.17-1.68), P < 0.001] and depression [1.23 (1.05-1.45), P = 0.01]. New ostomates experienced a greater increase in postoperative anxiety [1.24 (1.05-1.47), P = 0.01] and depression [1.19 (1.03-1.45), P = 0.01] than other surgical patients.

CONCLUSION

IBD patients who undergo surgery have higher rates of anxiety and depression than nonsurgical patients. Rates of anxiety and depression increase following surgery. Stoma formation represents an additional risk factor. These findings suggest the need for perioperative psychosocial support services.

Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis

Coronary artery bypass graft surgery (CABG) might adversely affect the health status of the patients, producing cognitive deterioration, with depression being the most common symptom. The aim of this study is to analyse the prevalence of depression in patients before and after coronary artery bypass surgery. A systematic review and meta-analysis was carried out, involving a study of the past 10 years of the following databases: CINAHL, LILACS, MEDLINE, PsycINFO, SciELO, Scopus, and Web of Science. The total sample comprised n = 16,501 patients. The total number of items was n = 65, with n = 29 included in the meta-analysis. Based on the different measurement tools used, the prevalence of depression pre-CABG ranges from 19-37%, and post-CABG from 15-33%. There is a considerable presence of depression in this type of patient, but this varies according to the measurement tool used and the quality of the study. Systematically detecting depression prior to cardiac surgery could identify patients at potential risk.

Anxiety, depression and stress among employees of a public higher education institution in São Paulo, Brazil

BACKGROUND

Occupational health is increasing in visibility within the scientific community and has become a field of international research and discussions in which occupational stress is described as a possible stressor.

OBJECTIVE

To analyze the relationship between anxiety and depression symptoms and socioeconomic level among technical-administrative employees of a public university in the state of São Paulo, Brazil.

METHODS

The sample comprised 89 participants. Data were obtained through Lipp's Inventory of Stress Symptoms for adults to identify levels of stress and the Hospital Anxiety and Depression scale. An additional questionnaire was administered to gather information on educational and socioeconomic levels.

RESULTS

About 45% of the participants exhibited symptoms of anxiety and 39% of depression, however, without direct relationship with their socioeconomic level. Among the participants with depression 50% were professors, and among those with depression 38.4% were administrative employees. Stress was more frequent among the participants who had attended higher education (29.6%) and graduate studies (33.3%).

CONCLUSION

The study results indicate a high prevalence of anxiety and depression regardless of the socioeconomic level of the participants. Stress was more frequent among the participants with higher educational level.

Impact of Preoperative Functional Status on Quality of Life after Cardiac Surgery

BACKGROUND

 With increasing importance, health-related quality of life (HRQoL) has become a crucial outcome measure of cardiac surgery. The aim of this study was to assess the dynamics of HRQoL change within 12 months after surgery and to identify predictors of deterioration in physical and mental health.

METHODS

 The cohort of this prospective study included 164 consecutive patients who underwent elective surgery. HRQoL was assessed on the basis of the Short-Form 36 questionnaire at three different times: upon admission and at 3 and 12 months after surgery. The minimal clinically important difference (MCID) was used to determine whether the surgery resulted in deterioration of HRQoL.

RESULTS

 In general, physical and mental health status improved within the first year after cardiac surgery. However, after 12 months, 7.9 and 21.2% of patients had clinically significant poorer physical (PCS) and mental component summary (MCS) scores, based on the MCID approach. The results of multivariate analysis identified preoperative health status, age < 70 years, coronary artery bypass grafting, and a previous neurological event as predictors of deterioration in postoperative HRQoL. The greatest risks for deterioration were higher preoperative PCS and MCS scores.

CONCLUSION

 Although we were able to demonstrate a general improvement in the HRQoL following cardiac surgery, in one-fifth of patients, there was no recovery of mental health status even after 1 year. As this effect is mainly determined by preoperative functional status, HRQoL should be an integral part of medical consultation, especially in younger patients with a positive perception of quality of life.

Anxiety and depression after burn, not as bad as we think-A nationwide study

OBJECTIVE

A history of psychiatric disorders is more common among patients who have had burns than in the general population. To try and find out the scale of the problem we have assessed self-reported symptoms of anxiety and depression after a burn.

METHODS

Consecutive patients with burns measuring more than 10% total body surface area or duration of stay in hospital of seven days or more were included. Personal and clinical details about the patients were extracted from the database at each center. Data were collected from the Hospital Anxiety and Depression Scale, as well as Health-Related Quality of Life (HRQoL; Short Form-36, SF-36) and questionnaires about socioeconomic factors. All results were obtained 12 and 24 months after the burn, and compared with those from a reference group.

RESULTS

A total of 156 patients responded to the questionnaires. Mean (SD) age and TBSA (%) were 46 (16.4) years and 23.6 (19.2) %, respectively. There were no differences in incidence between the burn and reference groups in anxiety or depression either 12 or 24 months after the burn. Those who reported higher anxiety and depression scores also had consistently poorer HRQoL as assessed by the SF-36.

CONCLUSION

Seen as a group, people who have had burns report anxiety and depression the same range as a reference group. Some patients, however, express more anxiety and depression, and concomitantly poorer HRQoL. These patients should be identified, and offered additional support.

New Insights Into the Comorbidity of Coronary Heart Disease and Depression

Coronary heart disease (CHD) and depression are common disorders that markedly impair quality of life and impose a great financial burden on society. They are also frequently comorbid, exacerbating patient condition, and worsening prognosis. This comorbidity strongly suggests shared pathologic mechanisms. This review focuses on the incidence of depression in patients with CHD, deleterious effects of depression on CHD symptoms, and the potential mechanisms underlying comorbidity. In addition to the existing frequent mechanisms that are well known for decades, this review summarized interesting and original potential mechanisms to underlie the comorbidity, such as endocrine substances, gut microbiome, and microRNA. Finally, there are several treatment strategies for the comorbidity, involving drugs and psychotherapy, which may provide a theoretical basis for further basic research and clinical investigations on improved therapeutic interventions.

Effect of cardiac rehabilitation programme following elective percutaneous coronary angiography on depressive symptoms: A cohort study

Background

Depression is a common condition in cardiac patients. We investigated the effect of cardiac rehabilitation on depressive symptoms as detected by Beck depression inventory II score (BDI) in patients who underwent percutaneous coronary intervention (PCI).

Methods

In this cohort, 95 patients met our criteria. Patients were then studied in two groups based on their participation in the rehabilitation program to rehabilitation (exposure) and the control (non-exposure) groups. The control group consisted of those who only participated in the introductory session and decided not to continue the program. Finally, demographic and clinical parameters as well as the BDI scores were compared between the study groups.

Results

Data of 35 patients who completed rehabilitation program was compared with 60 patients who did not. There was no significant difference between the study groups regarding the demographic and clinical variables, except for a higher frequency of family history for CAD in the control group (p < 0.001). The frequency of the patients with no or mild depression was significantly higher in the rehabilitation group than the controls (p = 0.02). There was also a significant increase in the BDI score of the control group and a significant decrease in the rehabilitation group (p < 0.001). After adjustment for confounders (family history and severity of CAD), not attending the rehabilitation program was a strong risk factor for depression (OR = 10.8, 95% CI: 1.3, 88.5; P = 0.027).

Conclusion

Overall, this study showed that not attending cardiac rehabilitation program following elective PCI was a risk factor for depression.

Psychological interventions for acute pain after open heart surgery

BACKGROUND

This is an update of a Cochrane review previously published in 2014. Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is associated with a risk of negative consequences. Several trials investigated the effects of psychological interventions to reduce acute postoperative pain and improve the course of physical and psychological recovery of participants undergoing open heart surgery.

OBJECTIVES

To compare the efficacy of psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention control in adults undergoing open heart surgery for pain, pain medication, psychological distress, mobility, and time to extubation.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and PsycINFO for eligible studies up to February 2017. We used the 'related articles' and 'cited by' options of eligible studies to identify additional relevant studies. We checked lists of references of relevant articles and previous reviews. We searched the ProQuest Dissertations and Theses Full Text Database, ClinicalTrials and the WHO International Clinical Trials Registry Platform to identify any unpublished material or ongoing trials. We also contacted the authors of primary studies to identify any unpublished material. In addition, we wrote to all leading heart centres in Germany, Switzerland, and Austria to check whether they were aware of any ongoing trials.

SELECTION CRITERIA

Randomised controlled trials comparing psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery.

DATA COLLECTION AND ANALYSIS

Two review authors (SZ and SK) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We calculated effect sizes for each comparison (Hedges' g) and meta-analysed data using a random-effects model. We assessed the evidence using GRADE and created 'Summary of findings' tables.

MAIN RESULTS

We added six studies to this update. Overall, we included 23 studies (2669 participants).For the majority of outcomes (two-thirds), we could not perform a meta-analysis since outcomes were not measured, or data were provided by one trial only.No study reported data on the number of participants with pain intensity reduction of at least 50% from baseline. Only one study reported data on the number of participants below 30/100 mm on the Visual Analogue Scale (VAS) in pain intensity (very low-quality evidence). Psychological interventions did not reduce pain intensity in the short-term interval (g 0.39, 95% CI -0.18 to 0.96, 2 studies, 104 participants, low-quality evidence), medium-term interval (g -0.02, 95% CI -0.24 to 0.20, 4 studies, 413 participants, moderate-quality evidence) or in the long-term interval (g 0.05, 95% CI -0.20 to 0.30, 2 studies, 200 participants, moderate-quality evidence).No study reported data on median time to re-medication or on number of participants re-medicated. Only two studies provided data on postoperative analgesic use in the short-term interval, showing that psychological interventions did not reduce the use of analgesic medication (g 1.18, 95% CI -2.03 to 4.39, 2 studies, 104 participants, low-quality evidence). Studies revealed that psychological interventions reduced mental distress in the medium-term (g 0.37, 95% CI 0.13 to 0.60, 13 studies, 1388 participants, moderate-quality evidence) and likewise in the long-term interval (g 0.32, 95% CI 0.10 to 0.53, 14 studies, 1586 participants, moderate-quality evidence). Psychological interventions did not improve mobility in the medium-term interval (g 0.23, 95% CI -0.22 to 0.67, 3 studies, 444 participants, low-quality evidence), nor in the long-term interval (g 0.09, 95% CI -0.10 to 0.28, 4 studies, 458 participants, moderate-quality evidence). Only two studies reported data on time to extubation, indicating that psychological interventions reduced the time to extubation (g 0.56, 95% CI 0.08 to 1.03, 2 studies, 154 participants, low-quality evidence).Overall, the very low to moderate quality of the body of evidence on the efficacy of psychological interventions for acute pain after open heart surgery cannot be regarded as sufficient to draw robust conclusions.Most 'Risk of bias' assessments were low or unclear. We judged selection bias (random sequence generation) and attrition bias to be mostly low risk for included studies. However, we judged the risk of selection bias (allocation concealment), performance bias, detection bias and reporting bias to be mostly unclear.

AUTHORS' CONCLUSIONS

In line with the conclusions of our previous review, there is a lack of evidence to support or refute psychological interventions in order to reduce postoperative pain in participants undergoing open heart surgery. We found moderate-quality evidence that psychological interventions reduced mental distress in participants undergoing open heart surgery. Given the small numbers of studies, it is not possible to draw robust conclusions on the efficacy of psychological interventions on outcomes such as analgesic use, mobility, and time to extubation respectively on adverse events or harms of psychological interventions.

Cognitive behavioral therapy for depression improves pain and perceived control in cardiac surgery patients

BACKGROUND

Depression after cardiac surgery (CS) is associated with increased pain and decreased sleep quality. While cognitive behavioral therapy (CBT) aimed at depression is effective in relieving depressive symptoms after cardiac surgery, little is known about its ability to ameliorate other common postoperative problems that affect recovery and quality of life.

AIMS

The purpose of this study was to evaluate the effects of CBT for depression on pain severity, pain interference, sleep, and perceived control in patients recovering from CS.

METHODS

Depressed patients recovering from CS were randomized to receive either eight weeks of CBT or usual care. At baseline and post-intervention, patients completed questionnaires for depressive symptoms, pain, sleep, and perceived control. Group comparisons were conducted using t-tests or chi square analysis. Repeated measures analysis was used to assess the effect of the intervention in changes over time.

RESULTS

The sample (n=53) included 16.9% women and had a mean age of 67.8±9.2 years. CBT for depression increased perceived control (p<0.001) and decreased pain interference (p=0.02) and pain severity (p=0.03). Group effects remained significant (p<0.05) for perceived control and pain interference and a trend was observed for pain severity (p<0.10) after controlling for variables that differed at baseline. There were no group differences in sleep disturbance over time.

CONCLUSIONS

A depression-focused CBT intervention yields benefits in other common postoperative problems, specifically improved perceived control and decreased pain in depressed cardiac surgery patients.