The effects of self-hypnosis on quality of life following coronary artery bypass surgery: preliminary results of a prospective, randomized trial

The Role of Hypnotherapy in Postoperative Cardiac Surgical Patients, A Scoping Review of Current Literature

OBJECTIVE

Hypnotherapy has been proposed as an emerging tool that can be implemented in management of different aspects of postoperative cardiac surgical care. This technique involves hypnotic induction to redirect focus and attention away from post-surgical pain. Emerging literature has shown that hypnosis significantly improves emotional distress immediately preceding surgical procedures and these effects have been demonstrated to extend into the postoperative period. The purpose of this scoping review is to summarize current literature on the role of hypnotherapy in the management of perioperative pain, anxiety, and depression in patients undergoing cardiac surgery.

METHODS

A database search was conducted using PubMed, Embase, and Google Scholar. We included all comparative studies (randomized and non-randomized) that examined the effect of hypnotherapy on pain, anxiety, and depression in patients undergoing cardiac surgery. Included articles were restricted to adult patients and English language only.

RESULTS

Literature search yielded a total of 64 articles, of which, 14 duplicates were removed. After title and abstract screening, only 18 articles were included for full-text review. Six studies (with a total number of 420 patients) were included in the final analysis. Of these, five were randomized control trials and one was a cohort study.

CONCLUSION

Our findings suggest that there may be a potential role for the use of hypnotherapy in the management of pain, anxiety, and depressive symptoms in the perioperative period of cardiac surgery. However, more robust evidence is required to justify its incorporation in the routine perioperative management pathways in this group of patients.

Exploring Non-pharmacological Methods for Pre-operative Pain Management

The management of pain is an essential aspect of surgical care, and pain levels in post-operative patients vary case by case. Treating postoperative pain is crucial as it leads to better outcomes and reduces risk of long term pain. While post-operative analgesics has been the mainstay of treatment, this mini-review explores an emerging concept which is preoperative pain management, with promising potential. Such interventions include educating patients on the expected pain outcomes and available pain medications. Non-pharmacological methods such as relaxation exercises have also proven to be effective after abdominal surgery, and educating patients on the existence of such methods pre-operatively encourages them to make use of available therapies. A major area of importance is the pre-operative psychological and emotional wellbeing of patients, as it is a strong predictor of pain and pain prognosis. Cognitive Behavioral Therapy can be effectively used to tackle preoperative anxiety and reduce pain levels. Hypnosis is another developing modality for decreasing stress. Lastly, long term pre-operative opioid use has been linked with higher pain scores and longer pain duration. This provides the basis on which pre-operative opioid weaning can lead to favorable post-operative pain outcomes.

While many of these methods have not been experimented on recipients of abdominal surgery in specific, it still paves the path for newer pain control strategies that can eventually be adopted for visceral surgery patients. This review points the reader and researchers to new and developing areas that hold the potential to revolutionize current established pain management guidelines.

Virtual reality and hypnosis for anxiety and pain management in intensive care units: A prospective randomised trial among cardiac surgery patients

BACKGROUND

Virtual reality and hypnosis are little studied in complex contexts, such as intensive care, where patients need significant physical and psychological assistance.

OBJECTIVES

To compare and combine hypnosis and virtual reality benefits on anxiety and pain on patients before and after cardiac surgery.

DESIGN

Prospective randomised controlled clinical trial.

SETTING

The study was conducted in the University Hospital of Liege (Belgium) from October 2018 to January 2020.

PATIENTS

One hundred patients (66 ± 11.5 years; 24 women, 76 men) were included. Participants were adults undergoing cardiac surgery. Exclusion criteria: psychiatric diseases, claustrophobia, acrophobia, hearing loss, visual impairment, extreme fatigue, confusion surgery cancelled.

INTERVENTIONS

Patients were randomly assigned to four arms (control; hypnosis; virtual reality; virtual reality hypnosis) and had 20 min of one of the techniques the day before and the day after surgery.

MAIN OUTCOMES MEASURES

Anxiety, pain, fatigue, relaxation, physiological parameters, and opioid use were evaluated before and after each session.

RESULTS

The main results did not show any significant differences between the groups. In all groups, anxiety decreased and pain increased from baseline to the postoperative day. Relaxation increased in all groups in the pre-operative (P < 0.0001) and postoperative period (P = 0.03). There were no significant differences for fatigue, physiological measures, or opioid use.

CONCLUSION

As there were no significant differences between groups for the measured variables, we cannot affirm that one technique is better than another. Additional studies are required to compare and evaluate the cost-effectiveness of these techniques for critical care patients and caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03820700. https://clinicaltrials.gov/ct2/show/NCT03820700. Retrospectively registered on 29 January 2019.

Hypnotic communication for periprocedural analgesia during transcatheter ablation of atrial fibrillation

INTRODUCTION

Hypnosis is a therapeutic strategy for pain control. We aimed at investigating the use of this technique in a large population undergoing atrial fibrillation (AF) ablation.

METHODS

70 consecutive AF patients referred for transcatheter ablation, underwent hypnotic communication for periprocedural analgesia (Group A), were compared with 70 patients undergoing conventional analgesia (Group B). Procedural data, anxiety, perceived pain, perceived procedural duration and the dosages of administered analgesic drugs were compared using validated score scales.

RESULTS

Hypnotic communication (Group A) resulted in a significant procedural-related anxiety reduction (Pre procedural 4.7 ± 2.9 Vs Intra Procedural 0.8 ± 1.2, P < 0.001) and perceived procedural duration (Real length 108 ± 33 min Vs Perceived Length 77 ± 39 min, P < 0.001). Group A patients reported a painless procedure in 78% (Pain scale ≤2). Regarding analgesic drug, Group A used only Fentanyl and Paracetamol. The Fentanyl dosage was similar in Group A and B (mean 0.142 Vs 0.146 mg, P = 0.65) while higher Paracetamol dosage was reported in Group A (mean 853 Vs 337 mg, P < 0.001). Group B also used Midazolam (mean 1.8 mg), Propofol (mean 43.8 mg) and narcosis was required in 2 patients. Total radiofrequency (RF) delivered time did not differ between the two groups (mean 28.9 Vs 27.6 min, P = 0.623) as well as mean RF power (mean 35.3 Vs 35.5 W, P = 0.424). No complications occurred.

CONCLUSION

Hypnotic communication during AF ablation was related to a significant reduction of intra-procedural anxiety, perceived pain, procedural analgesic drugs dosage and perceived procedural duration without affecting total RF delivered time and procedural safety.

Interest and Attitudes about Hypnosis in a Large Community Sample

Despite the available empirical evidence supporting the efficacy of hypnosis for alleviating symptoms and side effects across a variety of clinical contexts, hypnosis has failed to disseminate widely. One way to try to better understand the lack of hypnosis dissemination is to apply a marketing theory approach, focusing on attitudes and beliefs about a product (hypnosis) held by consumers. Better understanding of such factors can lead to strategies to promote the product among consumers, and in this case, encourage dissemination. The goal of the study was to investigate relationships between interest in hypnosis use and: 1) attitudes about hypnosis; 2) beliefs about the effectiveness of hypnosis (i.e., hypnosis credibility, and hypnosis effectiveness expectancies); 3) past experience with hypnosis; and 4) the perceived hedonic value and utility of hypnosis. The study also explored participants' preferences for hypnosis delivery method (i.e., live or recorded), as well as preferences for hypnosis labeling (i.e., how hypnosis is defined). Participants (N = 509) were recruited through Amazon Mechanical Turk and completed an anonymous online survey. The results revealed that participants' attitudes about hypnosis, their expectancies for the effectiveness of hypnosis, and the perceived hedonic value of hypnosis accounted for unique variance in participants' interest in hypnosis, ps < .05. Together, these variables accounted for 73% of the variance in participants' interest in hypnosis use. Based on these findings, we recommend that these key variables should be considered when planning for greater dissemination and uptake of empirically supported hypnosis interventions.

The effect of guided imagery on physiological and psychological outcomes of adult ICU patients: A systematic literature review and methodological implications

OBJECTIVES

Guided imagery (GI) is a relaxation technique that is being increasingly explored in various patients' populations. We systematically reviewed evidence on the effects of GI on physiological and psychological outcomes of adult critically ill patients and extracted implications for future research.

REVIEW METHOD USED

Systematic literature review of published studies based on the Cochrane Guidelines.

DATA SOURCES

Studies were located through literature searches of CINAHL, PubMed, Embase, Cochrane Database of Systematic Reviews and Psych-Info.

REVIEW METHODS

We explored effects of GI in critically illness. The outcome measures included pain, anxiety, hemodynamic measurements, stress neuropeptides, length of stay, sleep quality, inflammatory markers, patient satisfaction and cost of care. The Cochrane Collaboration's tool for assessing risk of bias was employed. Extracted data included pathophysiological framework, sample, diagnoses of participants, specifics of intervention, design, experimental groups, analyses and main outcomes.

RESULTS

Based on the selection criteria, 10 studies were identified, involving N=1391 critically ill patients. The main limitations include incomplete outcome data and selective reporting, incomplete blinding and lack of experimental group allocation concealment. Due to heterogeneity and incomplete reporting, a meta-analysis was not feasible. Our findings included: (a) favourable effects of the intervention with regard to decrease of pain, anxiety and LOS; (b) many studies employing randomised controlled trial designs; (c) a predominant focus on patients with cardiac surgery; (d) large heterogeneity in measurement of outcomes. Moreover, the evidence suggests that improvements in sleep quality, patient satisfaction and cost of care merit further investigation. Methodological implications include the need to clarify the underlying physiological framework, the use of repeated measure designs and the adjustment for confounders.

CONCLUSIONS

On the basis of these results, and of the absence of reported side-effects, we conclude that GI is a promising patient-centered approach for the improvement of a number of patients' outcomes that merits further investigation in critical care.

Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia

BACKGROUND

In a review and meta-analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion-focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect.

OBJECTIVES

To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review.

SELECTION CRITERIA

We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion-focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post-surgery.

DATA COLLECTION AND ANALYSIS

One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion.Where possible we used random-effects meta-analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta-analysis we performed a narrative review.

MAIN RESULTS

Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty-one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta-analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD -0.20, 95% confidence interval (CI) -0.35 to -0.06), length of stay (mean difference -0.52 days, 95% CI -0.82 to -0.22) and negative affect (SMD -0.35, 95% CI -0.54 to -0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached.Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as 'low' because of the high level of heterogeneity in meta-analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta-analysis, so we rated the quality of evidence as `very low'.

AUTHORS' CONCLUSIONS

The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well-conducted and clearly reported research.

Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures

OBJECTIVES

A large body of research has demonstrated that patient factors are strong predictors of recovery from surgery. Mind-body therapies are increasingly targeted at pre-operative psychological factors. The objective of this paper was to evaluate the efficacy of pre-operative mind-body based interventions on post-operative outcome measures amongst elective surgical patients.

METHODS

A systematic review of the published literature was conducted using the electronic databases MEDLINE, CINAHL and PsychINFO. Randomised controlled trials (RCTs) with a prospective before-after surgery design were included.

RESULTS

Twenty studies involving 1297 patients were included. Mind-body therapies were categorised into relaxation, guided imagery and hypnotic interventions. The majority of studies did not adequately account for the risk of bias thus undermining the quality of the evidence. Relaxation was assessed in eight studies, with partial support for improvements in psychological well-being measures, and a lack of evidence for beneficial effects for analgesic intake and length of hospital stay. Guided imagery was examined in eight studies, with strong evidence for improvements in psychological well-being measures and moderate support for the efficacy of reducing analgesic intake. Hypnosis was investigated in four studies, with partial support for improvements in psychological well-being measures. Evidence for the effect of mind-body therapies on physiological indices was limited, with minimal effects on vital signs, and inconsistent changes in endocrine measures reported.

CONCLUSIONS

This review demonstrated that the quality of evidence for the efficacy of mind-body therapies for improving post-surgical outcomes is limited. Recommendations have been made for future RCTs.

Bypass surgery with psychological and spiritual support (the BY.PASS Study): results of a pragmatic trial based on patients' preference

BACKGROUND

Some general hospitals within the German health system provide supportive interventions, psychological as well as spiritual, to their patients. It remains to be proven if these interventions are effective when used in routine clinical practice.

AIM

To evaluate the effectiveness of psychological and spiritual interventions on improving recovery following bypass surgery.

METHODS

The BY.PASS study is a pragmatic, patient preference trial (ISRCTN 07297983). Adult patients scheduled for elective coronary bypass surgery were enrolled. Patients were assigned to study conditions according to their personal preference: preference for psychological interventions, for spiritual interventions or for no intervention. Patients who were open for any kind of intervention were randomly assigned either to psychological or spiritual interventions. During a control period, patients were asked about their preference, but did not receive any interventions. Primary outcomes of the study were in-hospital morbidity and early mortality. Psychological measures served as secondary outcomes.

RESULTS

A total of 847 patients were enrolled. Patients of the control (n = 260) and the intervention group (n = 269) who explicitly wanted to have interventions were compared. No significant treatment effects either for morbidity (d = 0.08, 95% CI -0.09 to 0.25), or for mortality (OR = 1.81; 95% CI 0.50-6.57) could be found. A reduction of negative mood resulted from both interventions.

CONCLUSIONS

Although the effects observed were small, the study can serve as a basis to discuss methodological as well as theoretical aspects of a pragmatic trial, based upon patients' preferences.

Patient-reported outcomes in studies of complementary and alternative medicine: problems, solutions, and future directions

Patient-reported outcome (PRO) measures are frequently used to assess therapeutic efficacy and effectiveness of complementary and alternative medicine (CAM). Although CAM investigators are increasingly making use of valid, self-report instruments to assess patient-relevant outcomes, the sheer number of available instruments poses challenges. Two of the more pressing issues are discussed: the lack of guidance for selecting measures and the limited attention paid to the clinical meaningfulness of PRO results. Solutions are offered that may support selection and standardization of outcome measures for future CAM studies. This includes testing of tools from the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS). Increased standardization of outcome measurement in CAM studies will allow for more cross-study comparisons and facilitate the statistical pooling of results, ultimately leading to a more informative evidence base.

Physical conditioning and mental stress reduction--a randomised trial in patients undergoing cardiac surgery

BACKGROUND

Preoperative anxiety and physical unfitness have been shown to have adverse effects on recovery from cardiac surgery. This study involving cardiac surgery patients was primarily aimed at assessing the feasibility of delivering physical conditioning and stress reduction programs within the public hospital setting. Secondary aims were to evaluate the effect of these programs on quality of life (QOL), rates of postoperative atrial fibrillation (AF) and length of stay (LOS) in hospital.

METHODS

Elective patients scheduled for coronary artery bypass graft and/or valve surgery at a public hospital in Melbourne, Australia were enrolled. Patients were randomized to receive either holistic therapy (HT) or usual care (UC). HT consisted of a series of light physical exercise sessions together with a mental stress reduction program administered in an outpatient setting for the first two weeks after placement on the waiting list for surgery. A self-administered SF-36 questionnaire was used to measure QOL and hospital records to collect data on LOS and rate of postoperative AF.

RESULTS

The study population comprised 117 patients of whom 60 received HT and 57 received UC. Both programs were able to be delivered within the hospital setting but ongoing therapy beyond the two week duration of the program was not carried out due to long waiting periods and insufficient resources. HT, as delivered in this study, compared to UC did not result in significant changes in QOL, LOS or AF incidence.

CONCLUSIONS

Preoperative holistic therapy can be delivered in the hospital setting, although two weeks is insufficient to provide benefits beyond usual care on QOL, LOS or postoperative AF. Further research is now required to determine whether a similar program of longer duration, or targeted to high risk patients can provide measurable benefits.

TRIAL REGISTRATION

This trial was conducted as part of a larger study and according to the principles contained in the CONSORT statement 2001.

Bypass surgery with psychological and spiritual support (the By.pass study): study design and research methods

Effects of psychological as well as spiritual interventions on outcome in cardiac surgery have mostly been studied with a focus on presurgical interventions. Systematically controlled analyses of the effects of psychological and spiritual interventions depending on the patients' preference have not been performed so far, although these studies would help to assign patients to an adequate support. The By.pass study is a bi-center, controlled trial of patients undergoing coronary bypass surgery and coronary bypass surgery combined with valve replacement surgery in 2 different German hospitals. Patients are assigned to 1 of 5 conditions, mainly according to their personal therapeutic preference: preference for psychological interventions (group 1), preference for spiritual interventions (group 2), or preference for no intervention (group 5). Patients who are open for any kind of intervention are randomly assigned either to psychological (group 3) or spiritual interventions (group 4). Six months before the start and 6 months after the end of the treatment phase, patients were assigned to the control groups. These were asked about their subjective preference (psychological, spiritual, no intervention, or no specific preference) as well but received no interventions. Patients will be enrolled from October 2006 to December 2009. The 6-month follow-up will be completed in July 2010.

HYPNOSIS TO MANAGE DISTRESS RELATED TO MEDICAL PROCEDURES: A META-ANALYSIS

This meta-analysis evaluates the effect of hypnosis in reducing emotional distress associated with medical procedures. PsycINFO and PubMed were searched from their inception through February 2008. Randomized controlled trials of hypnosis interventions, administered in the context of clinical medical procedures, with a distress outcome, were included in the meta-analysis (26 of 61 papers initially reviewed). Information on sample size, study methodology, participant age and outcomes were abstracted independently by 2 authors using a standardized form. Disagreements were resolved by consensus. Effects from the 26 trials were based on 2342 participants. Results indicated an overall large effect size (ES) of 0.88 (95% CI = 0.57-1.19) in favour of hypnosis. Effect sizes differed significantly (p < 0.01) according to age (children benefitted to a greater extent than adults) and method of hypnosis delivery, but did not differ based on the control condition used (standard care vs. attention control).

Pilot validation of a self-report outcome measure of complementary and alternative medicine

BACKGROUND

We previously developed a multidomain, self-report outcome measure relevant to a wide range of complementary and alternative medical (CAM) therapies. We report the results of a pilot study to validate the measure.

METHODS

Fifty-two patients (60% female, mean age, 53 years) seeking services from CAM providers completed a battery of measures prior to a scheduled visit. The battery included the Positive and Negative Affect Schedule, items from the Brief Pain and Fatigue Inventories, ratings of global quality of life (QOL) and change in physical health, and our pilot measure consisting of six hypothesized subscales (pain, fatigue, physical/functional ability, personal control, existential issues, and general QOL). Internal reliability, item convergence and discrimination, construct, and concurrent validity were assessed.

RESULTS

Pilot measure domains appeared to be internally reliable with five of six alpha coefficients exceeding 0.70. Multitrait scaling analyses demonstrated that most items converged on the domains that they were hypothesized to represent, although item discrimination was demonstrated for the pain domain only. Correlations with standardized assessments of pain, fatigue, and global QOL showed evidence of construct validity. All domain scores differentiated patients classified high versus low in global QOL (P < .01) and four (pain, fatigue, physical/functional ability, and general QOL) differentiated patients who perceived recent changes in their physical health (improvement vs decline; P < .05).

CONCLUSION

These results provide preliminary psychometric data for a pilot measure of CAM outcomes, though further testing is warranted.

Hypnosis to manage anxiety and pain associated with colonoscopy for colorectal cancer screening: Case studies and possible benefits

This study explored using hypnosis for pain and anxiety management in 6 colonoscopy patients (5 men, 1 woman), who received a hypnotic induction and instruction in self-hypnosis on the day of their colonoscopy. Patients' levels of anxiety were obtained before and after the hypnotic induction using Visual Analogue Scales (VAS). Following colonoscopy, VASs were used to assess anxiety and pain during colonoscopy, perceived effectiveness of hypnosis, and patient satisfaction with medical care. Hypnotizability was assessed at a separate appointment. The authors also obtained data (time for procedure, number of vasovagal events, and recovery time) for 10 consecutive patients who received standard care. Results suggest that hypnosis appears to be a feasible method to manage anxiety and pain associated with colonoscopy, reduces the need for sedation, and may have other benefits such as reduced vasovagal events and recovery time.

Psychological interventions for coronary heart disease

BACKGROUND

Psychological interventions can form part of comprehensive cardiac rehabilitation programmes (CCR). These interventions may include stress management interventions, which aim to reduce stress, either as an end in itself or to reduce risk for further cardiac events in patients with heart disease.

OBJECTIVES

To determine the effectiveness of psychological interventions, in particular stress management interventions, on mortality and morbidity, psychological measures, quality of life, and modifiable cardiac risk factors, in patients with coronary heart disease (CHD).

SEARCH STRATEGY

We searched CCTR to December 2001 (Issue 4, 2001), MEDLINE 1999 to December 2001 and EMBASE 1998 to the end of 2001, PsychINFO and CINAHL to December 2001. In addition, searches of reference lists of papers were made and expert advice was sought.

SELECTION CRITERIA

RCTs of non-pharmacological psychological interventions, administered by trained staff, either single modality interventions or a part of CCR with minimum follow up of 6 months. Adults of all ages with CHD (prior myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, angina pectoris or coronary artery disease defined by angiography). Stress management (SM) trials were identified and reported in combination with other psychological interventions and separately.

DATA COLLECTION AND ANALYSIS

Studies were selected, and data were abstracted, independently by two reviewers. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

Thirty six trials with 12,841 patients were included. Of these, 18 (5242 patients) were SM trials. Quality of many trials was poor with the majority not reporting adequate concealment of allocation, and only 6 blinded outcome assessors. Combining the results of all trials showed no strong evidence of effect on total or cardiac mortality, or revascularisation. There was a reduction in the number of non-fatal reinfarctions in the intervention group (OR 0.78 (0.67, 0.90), but the two largest trials (with 4809 patients randomized) were null for this outcome, and there was statistical evidence of publication bias. Similar results were seen for the SM subgroup of trials. Provision of any psychological intervention or SM intervention caused small reductions in anxiety and depression. Few trials reported modifiable cardiac risk factors or quality of life.

REVIEWERS' CONCLUSIONS

Overall psychological interventions showed no evidence of effect on total or cardiac mortality, but did show small reductions in anxiety and depression in patients with CHD. Similar results were seen for SM interventions when considered separately. However, the poor quality of trials, considerable heterogeneity observed between trials and evidence of significant publication bias make the pooled finding of a reduction in non-fatal myocardial infarction insecure.

Systematic review and meta-analysis of interventions for postoperative fatigue

BACKGROUND

Postoperative fatigue is common, even after uncomplicated operations. Various theories have been presented regarding its aetiology, each suggesting different possible interventions. The purpose of this review was to identify all studies that have assessed interventions for postoperative fatigue and to evaluate these interventions using meta-analytical techniques.

METHODS

Randomized controlled trials of interventions, identified from a systematic search of relevant databases, were evaluated according to standardized criteria and categorized according to intervention modality. Data relating to the efficacy of each intervention at four different postoperative time-points were collated and data synthesis by meta-analysis was performed.

RESULTS

Analgesia is effective in reducing fatigue immediately after operation. Perioperative administration of human growth hormone reduces fatigue between 8 and 30 days after abdominal surgery. Weaker evidence was found to suggest an influence of glucocorticoid administration and of surgical technique on fatigue in the first week after operation. No evidence was found to support the theory that psychosocial or nutritional interventions affect the symptom.

CONCLUSION

While the results demonstrate that improved analgesia can attenuate immediate postoperative fatigue in most patient groups, further research is needed to determine whether the efficacy of human growth hormone and glucocorticoids extends beyond abdominal surgery. The paucity of research into cognitive-behavioural, sleep and activity-based interventions also needs to be addressed.

Brief presurgery hypnosis reduces distress and pain in excisional breast biopsy patients

Each year, hundreds of thousands of women undergo excisional breast biopsies for definitive diagnosis. Not only do these patients experience pain associated with the procedure, but they also endure distress associated with the threat of cancer. Hypnosis has been demonstrated as effective for controlling patients' pain in other surgical settings, but breast surgery patients have received little attention. To determine the impact of brief presurgical hypnosis on these patients' postsurgery pain and distress and to explore possible mediating mechanisms of these effects, 20 excisional breast biopsy patients were randomly assigned to a hypnosis or control group (standard care). Hypnosis reduced postsurgery pain and distress. Initial evidence suggested that the effects of hypnosis were mediated by presurgery expectations.