Early cognitive behavioral therapy for depression after cardiac surgery

Effectiveness of non-pharmacological interventions in improving sleep quality after cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Sleep disturbance is highly prevalent among post-operative cardiac patients, with negative impacts on surgical recovery and rehabilitation. Post-operative pain and anxiety commonly seen in cardiac surgery patients are associated with poor sleep. Sleep medications commonly used are not ideal with prolonged usage, and non-pharmacological interventions can be good alternatives or complements.

AIM

To examine effectiveness of non-pharmacological interventions in post-operative cardiac settings on sleep quality, pain intensity and anxiety.

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, CENTRAL, Embase, CINAHL, Scopus, CNKI and ProQuest Dissertations and Theses were searched on 12 October 2022. Randomised controlled trials of non-pharmacological interventions examining sleep quality for adult post-operative cardiac patients were included. Included studies were appraised using Cochrane Risk of Bias tool version 1. Meta-analysis was conducted using RevMan version 5.4.1, and heterogeneity was assessed using I2 statistics and Cochran Q's test.

RESULTS

Eighteen studies involving 1701 participants were identified. Coronary artery bypass graft was most common. Non-pharmacological interventions varied in types and duration. All intervention groups were compared to usual care, placebo, no interventions or active comparators. Statistically significant improvement in sleep quality (SMD = -.91, 95% CI = -1.17 to -.65) was found among intervention groups that explored cognitive behavioural therapy, relaxation techniques, exercise, massage, acupressure, aromatherapy, music, eye mask and earplugs. Pain intensity was reduced (SMD = -.63, 95% CI = -1.05 to -.20) with cognitive behavioural therapy, relaxation techniques, massage, music and eye mask. Anxiety was improved (SMD = -.21, 95% CI = -.38 to -.04) with exercise and music.

CONCLUSION

The overall use of non-pharmacological interventions can optimise sleep after cardiac surgery. Further research with greater methodological rigour is needed to investigate different intervention-related characteristics while considering potential confounders.

RELEVANCE TO CLINICAL PRACTICE

Post-operative cardiac settings can consider incorporating non-pharmacological interventions. Patients and healthcare providers can be better informed about the use of such interventions to improve sleep.

REGISTRATION

PROSPERO CRD42022384991.

Cognitive behavioral therapies for depression and anxiety in people with chronic disease: A systematic review and meta-analysis

OBJECTIVE

Anxiety and depression in chronic disease are common and burdensome co-morbidities. There has been growing interest in cognitive and behavioral therapies (CBTs) for anxiety and depression in chronic disease, however their efficacy has not been well-established. This study examined the efficacy of CBTs for depression and/or anxiety symptoms within chronic disease and explored the moderating role of clinical and methodological characteristics.

METHODS

Following prospective registration, electronic databases were searched up to 2023 for randomized controlled trials (RCTs) examining CBTs for depression and/or anxiety in any adult chronic disease population.

RESULTS

We included 56 RCTs. The overall effect of CBTs was g = 0.61 (95% CI, 0.49, 0.72) for depression and g = 0.56 (95% CI, 0.42, 0.70) for anxiety. A range of methodological features significantly moderated the effect sizes obtained, including type of control group and the outcome measure used. Risk of Bias ratings indicated some concerns regarding RCT conduct and reporting.

CONCLUSIONS

CBTs lead to moderate improvements in both depression and anxiety symptoms among people with chronic disease. However, the efficacy of CBT should be interpreted considering certain study and sample characteristics. It is recommended that future studies make improvements to study methodology and reporting.

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.

Efficacy of Cognitive Behavior Therapy in Reducing Depression among Patients with Coronary Heart Disease: An Updated Systematic Review and Meta-Analysis of RCTs

PURPOSE

The aim of this review is to identify the efficacy of cognitive behavior therapy (CBT) and the characteristics of CBT therapy that effectively improve depression among patients with coronary heart disease (CHD).

METHODS

Studies that assessed CBT efficacy in decreasing depression among CHD patients with randomized controlled trials (RCTs) were searched through PsycINFO, PubMed, CINAHL, Academic Search Complete, Scopus, and Google Scholar. Two reviewers independently screened and critically appraised them using the Cochrane risk-of-bias tool. The fixed- and random-effect models were applied to pool standardized mean differences.

RESULTS

Fourteen RCTs were included in the quantitative analysis. Depression was significantly lower in the CBT group (SMD -0.37; 95% CI: -0.44 to -0.31; p < 0.00001; I² = 46%). Depression in the CBT group was significantly lower in the short-term follow-up (SMD -0.46; 95% CI: -0.69 to -0.23; p < 0.0001; I² = 52%). Moreover, the subsequent therapy approaches were effective in reducing depression, including face-to-face and remote CBT, CBT alone or combination therapy (individual or mixed with a group), and frequent meetings.

CONCLUSIONS

CBT therapy effectively reduces depression, particularly in short-term follow-up. The application of CBT therapy in CHD patients should consider these findings to increase the efficacy and efficiency of therapy. Future research is needed to address generalizability.

Feasibility, Acceptability, and Preliminary Efficacy of a Positive Psychology Intervention in Patients With Coronary Heart Disease: A Randomized Controlled Trial

BACKGROUND

Both positive (e.g., optimism, well-being) and negative (e.g., stress, depressive symptoms) psychological constructs are associated with cardiovascular health. Positive psychology interventions (PPIs), which involve the cultivation of well-being through systematic activities, have the potential to enhance positive constructs and reduce negative ones; however, there has been limited study of PPIs in individuals with coronary heart disease.

OBJECTIVE AND METHODS

This 3-arm, randomized controlled pilot trial investigated the feasibility, acceptability, and preliminary efficacy of an 8-week, group-based PPI, compared with group-based cognitive-behavioral therapy and treatment as usual, in patients with coronary heart disease. Assessments were completed at baseline, 9 weeks postintervention, and 15-week follow-up, and outcomes included C-reactive protein, happiness, optimism, psychological distress, and depressive symptoms.

RESULTS

Eighty-four patients with coronary heart disease were included (mean age = 57.6 ± 8.3; 13.1% female). Participants in the PPI group completed 6.8 (standard deviation 1.3) of 8 sessions (85%), and the majority of PPI (96%) participants completed ≥5 out of the 8 sessions. PPI exercises were rated as easy to complete and subjectively useful, and PPI participants reported a high likelihood of continuing them after the intervention. In preliminary efficacy analyses, there were no consistent treatment effects of the PPI on C-reactive protein levels compared with treatment as usual and cognitive-behavioral therapy. Finally, the PPI was associated with nonsignificant, small- to medium-sized greater improvements in psychological outcomes compared with treatment as usual and cognitive-behavioral therapy at 9 and 15 weeks.

CONCLUSIONS

Among individuals with coronary heart disease, a group-based PPI was feasible, well-accepted, and associated with preliminary, nonsignificant, small- to medium-sized improvements in mental health compared with treatment as usual and cognitive-behavioral therapy.

Depression interventions for individuals with coronary artery disease - Cost-effectiveness calculations from an Irish perspective

BACKGROUND

A substantial proportion of individuals with coronary artery disease experience moderate or severe acute depression that requires treatment. We assessed the cost-effectiveness of four interventions for depression in individuals with coronary artery disease.

METHODS

We assessed effectiveness of pharmacotherapy, psychotherapy, collaborative care and exercise as remission rate after 8 and 26 weeks using estimates from a recent network meta-analysis. The cost assessment included standard doses of antidepressants, contact frequency, and staff time per contact. Unit costs were calculated as health services' purchase price for pharmaceuticals and mid-point staff salaries obtained from the Irish Health Service Executive and validated by clinical staff. Incremental cost-effectiveness ratios were calculated as the incremental costs over incremental remissions compared to usual care. High- and low-cost scenarios and sensitivity analysis were performed with changed contact frequencies, and assuming individual vs. group psychotherapy or exercise.

RESULTS

After 8 weeks, the estimated incremental cost-effectiveness ratio was lowest for group exercise (€526 per remission), followed by pharmacotherapy (€589), individual psychotherapy (€3117) and collaborative care (€4964). After 26 weeks, pharmacotherapy was more cost-effective (€591) than collaborative care (€7203) and individual psychotherapy (€9387); no 26-week assessment for exercise was possible. Sensitivity analysis showed that group psychotherapy could be most cost-effective after 8 weeks (€519) and cost-effective after 26 weeks (€1565); however no group psychotherapy trials were available investigating its effectiveness.

DISCUSSION

Large variation in incremental cost-effectiveness ratios was seen. With the current assumptions, the most cost-effective depression intervention for individuals with coronary artery disease after 8 weeks was group exercise.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions.

SELECTION CRITERIA

We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes.

MAIN RESULTS

Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I² = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I² = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I² = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I² = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I² = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I² = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention.

AUTHORS' CONCLUSIONS

In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.

The association between advanced practice nursing roles and outcomes in adults following cardiac surgery: A systematic review of randomized controlled trials

BACKGROUND

Empirical findings have shown significant and non-significant effects of advanced practice nursing roles within postoperative cardiac settings. The inconsistencies of the current literature preclude the identification of a significant effect of advanced practice nursing roles on patient and organizational outcomes.

OBJECTIVE

1) identify patient and organizational outcomes of advanced practice nursing roles in postoperative cardiac surgery and 2) synthesize the evidence of current roles of advanced practice nurses in postoperative cardiac surgery to provide the best quality of care for patients.

METHOD

A systematic review of randomized controlled trials was conducted in six electronic databases, including Medline, CINHAL, Embase, Cochrane Database, Joanna Briggs Database and Web of Science, and the grey literature. Randomized controlled trials published after 1999 were included if they examined advanced practice nursing roles and recruited patients who underwent cardiac surgery. The study selection was performed by two independent reviewers, and consensus was achieved with a third reviewer. Data extraction was conducted by one reviewer and revised by a second reviewer. The methodological quality of the included studies was assessed with the Evidence Project risk of bias tool by two independent reviewers and revised by a third reviewer. A narrative synthesis of the available evidence was completed. No meta-analysis technique was attempted because of the high heterogeneity of the included studies.

RESULTS

Among 4,448 retrieved papers, ten randomized controlled trials and three secondary analyses were included in this review. The methodological quality of the included studies was moderate. All studies included a comparison group and the majority of the studies collected data using a blinded researcher. However, all studies were based on small sample sizes and failed to randomly recruit participants. Five studies implemented nurse practitioner roles and five studies implemented clinical nurse specialist roles. The advanced practice nursing care included health condition management, lifestyle promotion and coping strategies with patients. A total of 22 outcomes were identified, including 13 patient outcomes (e.g., depressive symptoms) and nine organizational outcomes (e.g., rehospitalization after discharge). Each outcome was examined in one to five studies. All of the included outcomes were associated with inconsistent findings.

CONCLUSION

The findings from existing literature remain inconsistent. The high risk of bias and the small sample sizes could potentially explain the non-significant findings. Avenues for future research should focus on the development of methodologically high-quality studies with larger sample sizes to enhance our understanding of the effectiveness of advanced practice nursing roles.

The effect of sociodemographic factors on anxiety, depression, and perceived social support in patients with internal medicine and surgical problems

PURPOSE

This study aimed to determine the effect of sociodemographic factors on anxiety, depression, and perceived social support in patients with internal medicine and surgical problems.

DESIGN AND METHODS

The study comprised 522 patients who were hospitalized at the internal medicine and surgical clinics of the training and research hospital of a university.

FINDINGS

Of all the patients, 27% were at the risk of anxiety and 51.7% at the risk of depression. Sociodemographic characteristics, health-related issues, and disease characteristics, besides hospitalization-related matters, affected anxiety, depression, and social support levels of patients.

PRACTICE IMPLICATIONS

It was determined that more than half of the patients were at the risk of depression. Perceived social support is essential to reduce the risk of anxiety and depression.

Effectiveness of Cognitive Behavioral Therapy for Depression and Anxiety in Patients With Cardiovascular Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Depression and anxiety are highly prevalent in patients with cardiovascular disease (CVD) and influence their mental well-being and CVD prognosis. The primary objective was to assess the effectiveness of cognitive behavioral therapy (CBT) for depression and anxiety in patients with CVD. Secondary objectives were to assess the impact of CBT on cardiovascular mortality, cardiovascular events, patient satisfaction, and quality of life.

METHODS

MEDLINE, PsycINFO, CINAHL, CENTRAL, and alternative sources were searched for randomized controlled trials and observational studies with a control. Studies were required to assess CBT in coronary heart disease, acute coronary syndrome, atrial fibrillation, or postmyocardial infarction patients, with anxiety and/or depression. Studies were independently screened by two reviewers and critically appraised using the Cochrane Risk of Bias tool. The random-effects model was used to pool standardized mean differences (SMD).

RESULTS

Twelve randomized controlled trials were included. At follow-up, depression (SMD = -0.35, 95% confidence interval [CI] = -0.52 to -0.17, p < .001, I = 59%) and anxiety (SMD = -0.34, 95% CI = -0.65 to -0.03, p = .03, I = 71%) scores were significantly lower in CBT patients compared with controls. Change in mental health quality of life (SF-12) was also significantly greater for CBT patients, compared with controls (mean difference = 3.62, 95% CI = 0.22 to 7.02, p = .04, I = 0%). No differences in patient satisfaction or cardiovascular events were evident between CBT and control groups. Among the study reports included in this meta-analysis, data specific to cardiovascular mortality were not reported.

CONCLUSIONS

Cognitive behavioral therapy seems to be an effective treatment for reducing depression and anxiety in patients with CVD and should be considered in standard clinical care.

Efficacy of a social support and problem-solving intervention on heart failure self-care: A pilot study

OBJECTIVE

The purpose of this study was to examine the preliminary effects of a coping partnership intervention comprised of social support and problem-solving on HF self-care maintenance, management, and confidence.

METHODS

A 3-group randomized controlled pilot study was conducted. The intervention group received 1 home visit, weekly (month 1), and biweekly (months 2 and 3) telephone calls. The attention group received telephone calls starting at week 2, following a similar pattern. The control group received usual care only. The Self-care of Heart Failure Index, was administered at baseline, 5, 9, and 13 weeks. Linear mixed modeling examined intervention effect on study outcomes.

RESULTS

A total of 66 participants completed the study. The participants were mean age 61 years; 54.2% male; 56% Non-Caucasian; and 43.9% New York Heart Association HF Class II. Significant treatment-by-time interaction effects were noted for self-care maintenance (F=4.813; p=0.010) and self-care confidence (F=4.469; p=0.014). There was no significant treatment-by-time interaction effect on self-care management.

CONCLUSIONS

Coping partnership interventions that strengthen support and social problem- solving may improve self-care maintenance and confidence in individuals with HF.

PRACTICE IMPLICATIONS

Clinicians should consider including these components in HF patient education and clinical follow-up.

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 in depressed cardiac surgery patients: role of ejection fraction

AIMS

The aim of this study was to evaluate the relationship of ejection fraction (EF) and depressive symptoms in cardiac surgery patients assigned to nurse-guided cognitive behavioral therapy (CBT) or usual care (UC).

METHODS

Depressive symptoms were assessed using the Beck Depression Inventory (BDI). Seventy-seven patients (31% women; mean [SD] age, 63.6 [9.8] years) received 8 weeks of either CBT or UC. Using repeated-measures analysis of variance, changes in depressive symptoms over time were evaluated.

RESULTS

There was a significant interaction among time, treatment group, and EF status (p = 0.019). In the patients with preserved EF (≥40%), mean BDI scores in the UC group worsened by 1.9%, whereas those in the CBT group improved by 31.0%. In the patients with low EF (<40%), mean BDI scores worsened by 26.8% and improved by 75.3% in the UC and CBT groups, respectively.

CONCLUSIONS

Nurse-guided CBT is effective in reducing depressive symptoms after cardiac surgery, particularly in patients with low EF.

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.

Depression, anxiety and major adverse cardiovascular and cerebrovascular events in patients following coronary artery bypass graft surgery: a five year longitudinal cohort study

BACKGROUND

Although depression and anxiety have been implicated in risk for major adverse cardiovascular and cerebrovascular events (MACCE), a theoretical approach to identifying such putative links is lacking. The objective of this study was to examine the association between theoretical conceptualisations of depression and anxiety with MACCE at the diagnostic and symptom dimension level.

METHODS

Before coronary artery bypass graft (CABG) surgery, patients (N = 158; 20.9 % female) underwent a structured clinical interview to determine caseness for depression and anxiety disorders. Depression and anxiety disorders were arranged into the distress cluster (major depression, dysthymia, generalized anxiety disorder, post-traumatic stress disorder) and fear cluster (panic disorder, agoraphobia, social phobia). Patients also completed the self-report Mood and Anxiety Symptom Questionnaire, measuring anhedonia, anxious arousal and general distress/negative affect symptom dimensions. Incident MACCE was defined as fatal or non-fatal; myocardial infarction, unstable angina pectoris, repeat revascularization, heart failure, sustained arrhythmia, stroke or cerebrovascular accident, left ventricular failure and mortality due to cardiac causes. Time-to-MACCE was determined by hazard modelling after adjustment for EuroSCORE, smoking, body mass index, hypertension, heart failure and peripheral vascular disease.

RESULTS

In the total sample, there were 698 cumulative person years of survival for analysis with a median follow-up of 4.6 years (interquartile range 4.2 to 5.2 years) and 37 MACCE (23.4 % of total). After covariate adjustment, generalized anxiety disorder was associated with MACCE (hazard ratio [HR] = 2.79, 95 % confidence interval [CI] 1.00-7.80, p = 0.049). The distress disorders were not significantly associated with MACCE risk (HR = 2.14; 95 % CI .92-4.95, p = 0.077) and neither were the fear-disorders (HR = 0.24, 95 % CI .05-1.20, p = 0.083). None of the symptom dimensions were significantly associated with MACCE.

CONCLUSIONS

Generalized anxiety disorder was significantly associated with MACCE at follow-up after CABG surgery. The findings encourage further research pertaining to generalized anxiety disorder, and theoretical conceptualizations of depression, general distress and anxiety in persons undergoing CABG surgery.

Changes in language use mediate expressive writing's benefits on health-related quality of life following myocardial infarction

The present study assessed linguistic mediators on the effects of expressive writing on health-related quality of life (HRQOL), depression and anxiety following myocardial infarction (MI). One hundred and twenty-one cardiac patients were randomised (expressive writing = 61; control = 60), 98 (expressive writing = 47; control = 51) provided pre- and post-data, with 89 (expressive writing = 43; control = 46) completing the three-month follow-up. The expressive writing group wrote (20 mins/day for three consecutive days) about their thoughts and feelings regarding their MI, and the control group wrote (20 mins/day for three consecutive days) about daily events that occurred during the year prior to the MI. The outcome measures of depression, anxiety and HRQOL were completed pre-randomisation, post-intervention and three months post-intervention; the mediating variables assessed were changes in (a) positive emotion words, (b) negative emotion words and (c) cognitive-processing words. Three months post-intervention, the expressive writing group had significantly higher HRQOL. The positive effects of expressive writing were significantly associated with increases in both positive emotion words and cognitive-processing words across the three days of expressive writing. Expressive writing is a beneficial intervention that may enhance HRQOL among cardiac patients.

Feasibility of a nursing intervention to prepare frail older patients for cardiac surgery: a mixed-methods study

BACKGROUND

Given the growing number of vulnerable, older cardiac surgery patients, the preadmission PREvention Decline in Older Cardiac Surgery patients (PREDOCS) programme was developed to reduce the incidence of postoperative complications. Before the clinical effects of such a complex multicomponent intervention can be evaluated, the feasibility needs to be determined to detect possible problems with the acceptability, compliance and delivery.

AIM

The purpose of this study was to test the PREDOCS programme on its feasibility and estimate theoretical cost savings.

METHODS

In a mixed-methods multicentre study, the Medical Research Council (MRC) guidelines concerning testing feasibility were followed, and theoretical cost savings were calculated. We used data from interviews and the continuous data registry at three hospitals. The results were reported following the criteria for reporting the feasibility of complex interventions (CReDECI).

RESULTS

Twenty-one females and 49 males out of 114 eligible patients completed the intervention and provided full data. Patients were equally satisfied with the usual care and the PREDOCS programme (satisfaction rate respectively standard deviation (SD): 7.5 (95% confidence interval (CI): 6.4-8.7) and 7.6 (6.6-8.6)). The involved nurses were satisfied with the tools for guiding patients to reduce their risk of postoperative complications and considered the PREDOCS programme as complementary to usual care. Integrating PREDOCS into current hospital structures appeared to be difficult. Both patients and nurses indicated that the additional consult was tiresome for the patient. The PREDOCS programme will be cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients.

CONCLUSIONS

The PREDOCS programme is acceptable for patients and nurses but should be built into the hospital's cardiac surgery pathway or applied in home care.

The effectiveness of non-pharmacological interventions in improving psychological outcomes for heart transplant recipients: a systematic review

BACKGROUND

Post-heart transplant psychological distress may directly hinder physiological health as well as indirectly impact on clinical outcomes by increasing unhealthy behaviors, such as immunosuppression non-adherence. Reducing psychological distress for heart transplant recipients is therefore vitally important in order to improve not only patients' overall health and well-being but also clinical outcomes, such as morbidity and mortality. Evidence from other populations suggests that non-pharmacological interventions may be an effective strategy.

AIM

The purpose of this study was to appraise the efficacy of non-pharmacological interventions on psychological outcomes after heart transplant.

METHOD

A systematic review was conducted using the Joanna Briggs Institute methodology. Experimental and quasi-experimental studies that involved any non-pharmacological intervention for heart transplant recipients were included, provided that data on psychological outcomes were reported. Multiple electronic databases were searched for published and unpublished studies and reference lists of retrieved studies were scrutinized for further primary research. Data were extracted using a standardized data extraction tool. Included studies were assessed by two independent reviewers using standardized critical appraisal instruments.

RESULTS

Three studies fulfilled the inclusion and exclusion criteria, which involved only 125 heart transplant recipients. Two studies reported on exercise programs. One study reported a web-based psychosocial intervention. While psychological outcomes significantly improved from baseline to follow-up for the recipients who received the interventions, between-group comparisons were not reported. The methodological quality of the studies was judged to be poor.

CONCLUSIONS

Further research is required, as we found there is insufficient evidence available to draw conclusions for or against the use of non-pharmacological interventions after heart transplant.