A randomized controlled trial of secondary prevention of anxiety and distress in a German sample of patients with an implantable cardioverter defibrillator

Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation

BACKGROUND

Depression and anxiety occur frequently (with reported prevalence rates of around 40%) in individuals with coronary heart disease (CHD), heart failure (HF) or atrial fibrillation (AF) and are associated with a poor prognosis, such as decreased health-related quality of life (HRQoL), and increased morbidity and mortality. Psychological interventions are developed and delivered by psychologists or specifically trained healthcare workers and commonly include cognitive behavioural therapies and mindfulness-based stress reduction. They have been shown to reduce depression and anxiety in the general population, though the exact mechanism of action is not well understood. Further, their effects on psychological and clinical outcomes in patients with CHD, HF or AF are unclear.

OBJECTIVES

To assess the effects of psychological interventions (alone, or with cardiac rehabilitation or pharmacotherapy, or both) in adults who have a diagnosis of CHD, HF or AF, compared to no psychological intervention, on psychological and clinical outcomes.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2009 to July 2022. We also searched three clinical trials registers in September 2020, and checked the reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing psychological interventions with no psychological intervention for a minimum of six months follow-up in adults aged over 18 years with a clinical diagnosis of CHD, HF or AF, with or without depression or anxiety. Studies had to report on either depression or anxiety or both.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were depression and anxiety, and our secondary outcomes of interest were HRQoL mental and physical components, all-cause mortality and major adverse cardiovascular events (MACE). We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

Twenty-one studies (2591 participants) met our inclusion criteria. Sixteen studies included people with CHD, five with HF and none with AF. Study sample sizes ranged from 29 to 430. Twenty and 17 studies reported the primary outcomes of depression and anxiety, respectively. Despite the high heterogeneity and variation, we decided to pool the studies using a random-effects model, recognising that the model does not eliminate heterogeneity and findings should be interpreted cautiously. We found that psychological interventions probably have a moderate effect on reducing depression (standardised mean difference (SMD) -0.36, 95% confidence interval (CI) -0.65 to -0.06; 20 studies, 2531 participants; moderate-certainty evidence) and anxiety (SMD -0.57, 95% CI -0.96 to -0.18; 17 studies, 2235 participants; moderate-certainty evidence), compared to no psychological intervention. Psychological interventions may have little to no effect on HRQoL physical component summary scores (PCS) (SMD 0.48, 95% CI -0.02 to 0.98; 12 studies, 1454 participants; low-certainty evidence), but may have a moderate effect on improving HRQoL mental component summary scores (MCS) (SMD 0.63, 95% CI 0.01 to 1.26; 12 studies, 1454 participants; low-certainty evidence), compared to no psychological intervention. Psychological interventions probably have little to no effect on all-cause mortality (risk ratio (RR) 0.81, 95% CI 0.39 to 1.69; 3 studies, 615 participants; moderate-certainty evidence) and may have little to no effect on MACE (RR 1.22, 95% CI 0.77 to 1.92; 4 studies, 450 participants; low-certainty evidence), compared to no psychological intervention.

AUTHORS' CONCLUSIONS

Current evidence suggests that psychological interventions for depression and anxiety probably result in a moderate reduction in depression and anxiety and may result in a moderate improvement in HRQoL MCS, compared to no intervention. However, they may have little to no effect on HRQoL PCS and MACE, and probably do not reduce mortality (all-cause) in adults who have a diagnosis of CHD or HF, compared with no psychological intervention. There was moderate to substantial heterogeneity identified across studies. Thus, evidence of treatment effects on these outcomes warrants careful interpretation. As there were no studies of psychological interventions for patients with AF included in our review, this is a gap that needs to be addressed in future studies, particularly in view of the rapid growth of research on management of AF. Studies investigating cost-effectiveness, return to work and cardiovascular morbidity (revascularisation) are also needed to better understand the benefits of psychological interventions in populations with heart disease.

Defibrillator exchange in the elderly

Background

Implantable cardioverter-defibrillator (ICD) therapy in elderly patients is controversial because survival benefits might be attenuated by nonarrhythmic causes of death.

Objective

The purpose of this study was to investigate the outcome of septuagenarians and octogenarians after ICD generator exchange (GE).

Methods

A total of 506 patients undergoing elective GE were analyzed to determine the incidence of ICD shocks and/or survival after GE. Patients were divided into a septuagenarian group (age 70-79 years) and an octogenarian group (age ≥80 years). The primary endpoint was death from any cause. Secondary endpoints were survival after appropriate ICD shock and death without experiencing ICD shocks after GE ("prior death").

Results

The association of the ICD with all-cause mortality and arrhythmic death was determined for septuagenarians and octogenarians. Comparing both groups, similar left ventricular ejection fraction (35.6% ± 11.2% vs 32.4% ± 8.9%) and baseline prevalence of New York Heart Association functional class III or IV heart failure (17.1% vs 14.7%) were found. During the entire follow-up period of the study, 42.5% of patients in the septuagenarian group died compared to 79% in the octogenarian group (P <.01). Prior death was significantly more frequent in both age groups than were appropriate ICD shocks. Predictors of mortality were common in both groups and included advanced heart failure, peripheral arterial disease, and renal failure.

Conclusion

In clinical practice, decision-making for ICD GE among the elderly should be considered carefully for individual patients.

The use of SCL-k-9 to measure general psychopathology in women and men with skin conditions

Objectives

To measure general psychopathology in dermatologic outpatients using the Symptom-Checklist-K-9 (SCL-K-9); to investigate whether the SCL-K-9 is able to categorize patients with and without significant non-psychotic disorders; and to perform a single-item analysis of the SCL-K-9, with a focus on gender differences.

Methods

Cross-sectional study on consecutive dermatological patients. We used two self-administered questionnaires to assess general psychopathology symptoms: General Health Questionnaire-12 (GHQ-12) and SCL-K-9. Sociodemographic information was collected with standardized forms. The performance of the SCL-K-9 in classifying patients according to their current emotional distress severity was assessed using a ROC procedure. Finally, we measured differences in scores obtained among women and men in SCL-K-9 single items.

Results

A total of 292 patients were studied (71.2% women). We observed statistically significant differences in SCL-K-9 total mean scores and in most single items among genders. We found that it would be more appropriate to use gender-specific cut-offs when using SCL-K-9 to screen dermatological patients for general psychopathology.

Conclusion

The SCL-K-9, with its compact format could provide, in a short time, a wide range of information related to critical areas that challenge the mental health of patients with skin diseases.

Device nurse intervention facilitates the patients' adaptation to cardiac shock devices in the remote monitoring era

BACKGROUND

A substantial number of patients with shock devices (implantable cardioverter defibrillators [ICDs] or ICDs with resynchronization [CRTDs]) experience psychological distress.

OBJECTIVE

We investigated the device nurse telephone intervention's effect on improving the patient's adaptation to shock devices, quality of life (QOL), and anxiety in the remote monitoring era.

METHODS

The patient's adaptation to the device, health-related QOL, and anxiety were investigated by the modified Implanted Devices Adjustment-Japan score (IDAS), Short Form-36, and State-Trait Anxiety Inventory (STAI) before and 1-year after the device nurse telephone intervention, performed every 3 months. A total of 95 patients (median age 69 years and 25 females) participated. Sixty patients had ICDs and 35 CRTDs. Structural heart disease was observed in 72 patients, and idiopathic ventricular arrhythmias in the others. The mean left ventricular ejection fraction was 46% ± 15%. The median duration since the device implantation was 5.2 years.

RESULTS

The total IDAS score significantly improved from 28.42 ± 7.11 at baseline to 26.77 ± 7.68 (p = 0.0076) at 1 year. Both the state and trait anxiety significantly improved (from 38.9 ± 9.6 to 35.3 ± 9.0 [<0.0001] and 38.8 ± 10.3 to 36.2±9.8 [p = 0.0044], respectively). The prevalence of patients with a state and trait anxiety of more than 40 decreased from 44 (46%) and 38 (40%) patients before the study to 27 (28 %) and 32 (34 %) at 1 year. The SF-36 mental component summary score significantly increased (50.8 ± 8.3 at baseline to 53.1 ± 7.7 at 1 year, p = 0.0031).

CONCLUSIONS

The device nurse intervention facilitated the patient's adaptation to the shock device, increased the health-related QOL, and reduced the patient's anxiety.

Intervention mediating effects of self-efficacy on patient physical and psychological health following ICD implantation

This study examined mechanisms by which social cognitive theory (SCT) interventions influence health outcomes and the importance of involving partners in recovery following the patients' receipt of an initial implantable cardioverter defibrillator (ICD). We compared direct and indirect intervention effects on patient health outcomes with data from a randomized clinical trial involving two telephone-based interventions delivered during the first 3 months post-ICD implant by experienced trained nurses: P-only conducted only with patients, and P + P conducted with patients and their intimate partners. Each intervention included the patient-focused component. P + P also included a partner-focused intervention component. ICD-specific SCT-derived mediators included self-efficacy expectations, outcome expectations, self-management behavior, and ICD knowledge. Outcomes were assessed at discharge, 3- and 12-months post ICD implant. Patients (N = 301) were primarily Caucasian, male, 64 (± 11.9) years of age with a mean ejection fraction of 34.08 (± 14.3). Intervention effects, mediated through ICD-specific self-efficacy and outcome expectations, were stronger for P + P compared to P-only for physical function (β = 0.04, p = 0.04; β = 0.02, p = 0.04, respectively) and for psychological adjustment (β = 0.06, p = 0.04; β = 0.03, p = 0.04, respectively). SCT interventions show promise for improving ICD patient physical and psychological health outcomes through self-efficacy and outcome expectations. Including partners in post-ICD interventions may potentiate positive outcomes for patients.Trial registration number (TRN): NCT01252615 (Registration date: 12/02/2010).

Efficacy of a web-based intervention for improving psychosocial well-being in patients with implantable cardioverter-defibrillators: the randomized controlled ICD-FORUM trial

Aims

Anxiety, depression, and reduced quality of life (QoL) are common in patients with implantable cardioverter-defibrillators (ICDs). Treatment options are limited and insufficiently defined. We evaluated the efficacy of a web-based intervention (WBI) vs. usual care (UC) for improving psychosocial well-being in ICD patients with elevated psychosocial distress.

Methods and results

This multicentre, randomized controlled trial (RCT) enrolled 118 ICD patients with increased anxiety or depression [≥6 points on either subscale of the Hospital Anxiety and Depression Scale (HADS)] or reduced QoL [≤16 points on the Satisfaction with Life Scale (SWLS)] from seven German sites (mean age 58.8 ± 11.3 years, 22% women). The primary outcome was a composite assessing change in heart-focused fear, depression, and mental QoL 6 weeks after randomization to WBI or UC, stratified for age, gender, and indication for ICD placement. Web-based intervention consisted of 6 weeks’ access to a structured interactive web-based programme (group format) including self-help interventions based on cognitive behaviour therapy, a virtual self-help group, and on-demand support from a trained psychologist. Linear mixed-effects models analyses showed that the primary outcome was similar between groups (η  _p  ² = 0.001). Web-based intervention was superior to UC in change from pre-intervention to 6 weeks (overprotective support; P = 0.004, η  _p  ² = 0.036), pre-intervention to 1 year (depression, P = 0.004, η  _p  ² = 0.032; self-management, P = 0.03, η  _p  ² = 0.015; overprotective support; P = 0.02, η  _p  ² = 0.031), and 6 weeks to 1 year (depression, P = 0.02, η  _p  ² = 0.026; anxiety, P = 0.03, η  _p  ² = 0.022; mobilization of social support, P = 0.047, η  _p  ² = 0.018).

Conclusion

Although the primary outcome was neutral, this is the first RCT showing that WBI can improve psychosocial well-being in ICD patients.

Social cognitive intervention following an initial implantable cardioverter defibrillator: Better treatment response for secondary versus primary prevention

BACKGROUND

The patient + partner (P+P) is a patient/partner-focused social cognitive intervention with demonstrated efficacy to improve outcomes following an initial implantable cardioverter defibrillator (ICD). Little is known about how the patient response may differ by ICD implant indication. The aim of this study was to examine the response to intervention for patients with an initial ICD by reasons for primary versus secondary ICD indication.

METHOD

A longitudinal secondary analysis of data from a randomized clinical trial testing the P+P intervention examined patient health outcomes over 12 months, stratified by the indication for the ICD: primary prevention without cardiac resynchronization therapy (CRT) (1o No CRT, n = 100), primary prevention with CRT (1o CRT, n = 78), secondary prevention after cardiac arrest (2° Cardiac Arrest, n = 66), and secondary prevention for other arrhythmias (2o Other, n = 57). Outcomes included physical and mental health status (Short-Form-36 Physical Component Summary and Mental Component Summary), physical symptoms (Patient Concerns Assessment), depression (Patient-Health-Questionniare-9), and anxiety (State-Trait Anxiety Inventory).

RESULTS

Participants (n = 301) were on average 64 years old, primarily male (73.7%) and Caucasian (91%) with reduced ejection fraction (34%). There were no baseline differences between ICD groups for all outcomes (P > .05). Patients in the 2° Cardiac Arrest group showed greater improvement from baseline to 3 months in physical and mental health outcomes. The 2° Cardiac Arrest group had better physical (F = 11.48, P = .004) and mental health (F = 4.34, P = .038) and less severe physical (z = 2.24, P = 0.013) and depressive symptoms (z = 2.71, P = .003) at 12 months compared to the 1o No CRT group.

CONCLUSION

The P+P intervention was more effective for promoting physical and psychological health outcomes for individuals receiving an ICD for 2o prevention after cardiac arrest.

The Effects of Positive Psychological Interventions on Medical Patients' Anxiety: A Meta-analysis

OBJECTIVE

Positive psychology interventions, which involve systematic completion of activities designed to promote well-being, are being increasingly studied in medically ill patients. However, the extent to which these interventions ameliorate patient anxiety remains unclear. Therefore, the aim of the study was to conduct a meta-analysis to determine the efficacy of positive psychology interventions in reducing anxiety in medical patients.

METHODS

Electronic databases Medline, PsycINFO, SciELO, Cochrane (Central), and ClinicalTrials.gov were searched from inception to June 18, 2018, to identify studies of positive psychology interventions that included a validated measure of anxiety as an outcome measure.

RESULTS

The search generated a total of 1024 studies. Twelve randomized controlled trials (n = 1131) delivered to medical patients were included in the review, and a further 11 nonrandomized trials (n = 300) were included in a secondary analysis. Positive psychology interventions were effective at reducing patient anxiety relative to a control with a small to medium effect size (g = -0.34, 95% confidence interval = -0.50 to -0.18), and results were maintained at a mean of 8-week follow-up (g = -0.31, 95% confidence interval = -0.54 to -0.08). Clinician-led interventions seemed to be more effective than self-administered interventions, and longer interventions were more effective than shorter interventions. Secondary analysis of nonrandomized trials also found that positive psychology interventions are associated with reduced anxiety.

CONCLUSIONS

Positive psychology interventions seem to be effective at reducing medical patient anxiety. Future research is needed to determine optimal intervention characteristics, including dose and intervention content, that maximize the observed treatment effects.

Web-Based Intervention to Improve Implantable Cardioverter Defibrillator Patients’ Shock-Related Anxiety and Quality of Life: A Randomized Controlled Trial

In spite of its effectiveness, implantable cardioverter defibrillator (ICD) patients face psychological problems such as shock-related anxiety due to device shocks. The aim of this study was to evaluate whether a web-based intervention program for ICD patients would reduce shock-related anxiety and improve quality of life compared with usual care. This was a randomized controlled trial study including a total of 76 patients. Data were collected using Turkish versions of the Florida Shock Anxiety Scale and Short Form Health Survey (SF-36) at 0 (baseline), 3, and 6 months. Following intervention, there was a significant decrease in shock anxiety levels of patients and a statistically significant increase in social functioning, role-physical, mental health, vitality, and bodily pain subdimensions of SF-36. While no statistically significant difference was found between groups in terms of summary scores of SF-36, our results suggest that web-based interventions can be useful for ICD patients.

An Evidence-Based Review of Early Intervention and Prevention of Posttraumatic Stress Disorder

We present an evidence-based review of post-trauma interventions used to prevent posttraumatic stress disorder (PTSD). Literature search of PubMed from 1988 to March 2016 using keywords "Early Intervention AND Prevention of PTSD" yielded 142 articles, of which 52 intervention studies and 6 meta-analyses were included in our review. Trauma-focused cognitive behavioral therapy and modified prolonged exposure delivered within weeks of a potentially traumatic event for people showing signs of distress have the most evidence in the treatment of acute stress and early PTSD symptoms, and the prevention of PTSD. Even though several pharmacological agents have been tried, only hydrocortisone prior to high-risk surgery, severe traumatic injury, or during acute sepsis has adequate evidence for effectiveness in the reduction of acute stress symptoms and prevention of PTSD. There is an urgent need to determine the best targets for interventions after trauma to accelerate recovery and prevent PTSD.

Effect of psycho-educational interventions on quality of life in patients with implantable cardioverter defibrillators: a meta-analysis of randomized controlled trials

Background

Implantable cardioverter defibrillators (ICD) were developed for primary and secondary prevention of sudden cardiac death. However, ICD recipients’ mortality is significantly predicted by their quality of life (QOL). The aim of this meta-analysis was to evaluate the effects of psycho-educational interventions on QOL in patients with ICDs.

Methods

We systematically searched PubMed, Medline, Cochrane Library, and CINAHL through April 2015 and references of relevant articles. Studies were reviewed if they met following criteria: (1) randomized controlled trial, (2) participants were adults with an ICD, and (3) data were sufficient to evaluate the effect of psychological or educational interventions on QOL measured by the SF-36 or SF-12. Studies were independently selected and their data were extracted by two reviewers. Study quality was evaluated using a modified Jadad scale. The meta-analysis was conducted using the Cochrane Collaboration’s Review Manager Software Package (RevMan 5). Study heterogeneity was assessed by Q statistics and I² statistic. Depending on heterogeneity, data were pooled across trials using fixed-effect or random-effect modeling.

Results

Seven randomized controlled trials fulfilled the inclusion and exclusion criteria, and included 1017 participants. The psycho-educational interventions improved physical component summary (PCS) scores in the intervention groups more than in control groups (mean difference 2.08, 95 % CI 0.86 to 3.29, p < 0.001), but did not significantly affect mental component summary (MCS) scores (mean difference 0.84, 95 % CI -1.68 to 3.35, p = 0.52).

Conclusion

Our meta-analysis demonstrates that psycho-educational interventions improved the physical component, but not the mental component of QOL in patients with ICDs.

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

INTRODUCTION

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

METHODS/DESIGN

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

DISCUSSION

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

Heart-focused anxiety in patients with chronic heart failure before implantation of an implantable cardioverter defibrillator: baseline findings of the Anxiety-CHF Study

AIMS

We analysed heart-focused anxiety (HFA) and its predictors in patients with heart failure before implantation of an implantable cardioverter defibrillator (ICD). Herein, we report the baseline data of the Anxiety-CHF Study which investigates HFA before and after ICD implantation.

METHODS AND RESULTS

HFA, general anxiety and depression, perceived quality of life (QoL) and type D personality were measured with validated psychological instruments. Clinical parameters such as severity of heart failure measured by NYHA class and left ventricular ejection fraction (EF) were determined. One hundred and ten patients were interrogated before ICD implantation (70 % male, mean age = 60.5 ± 14.9 years, mean EF = 31 % ± 9 %, 91 % NYHA II-III, 92 % primary prevention). HFA was present in 53 patients (48.6 %); 37 participants (33.9 %) showed increased levels of general anxiety and 33 patients (30.3 %) showed increased levels of depression with clinical significant levels in 16 subjects (14.7 %) for general anxiety and 13 subjects (11.9 %) for depression. Poor QoL was reported in 30 patients (27.5 %). HFA was correlated with QoL, general anxiety, depression, type D personality, myocardial infarction (MI), and systolic blood pressure. QoL, general anxiety and former MI were significant predictors of HFA (R (2) = 0.453).

CONCLUSION

Heart-focused anxiety is highly prevalent in heart failure patients prior to ICD implantation. Measures of disease severity such as EF or NYHA class do not predict HFA, neither does Type D personality. HFA is predicted by a history of MI and psychological parameters such as general anxiety and impaired QoL. CLINICALTRIALS.

GOV IDENTIFIER

NCT02226770.

Phone-delivered mindfulness training for patients with implantable cardioverter defibrillators: results of a pilot randomized controlled trial

BACKGROUND

The reduction in adrenergic activity and anxiety associated with meditation may be beneficial for patients with implantable cardioverter defibrillators.

PURPOSE

This study aims to determine the feasibility of a phone-delivered mindfulness intervention in patients with defibrillators and to obtain preliminary indications of efficacy on mindfulness and anxiety.

METHODS

Clinically stable outpatients were randomized to a mindfulness intervention (eight weekly individual phone sessions) or to a scripted follow-up phone call. We used the Hospital Anxiety and Depression Scale and the Five Facets of Mindfulness to measure anxiety and mindfulness, and multivariate linear regression to estimate the intervention effect on pre-post-intervention changes in these variables.

RESULTS

We enrolled 45 patients (23 mindfulness and 22 control; age, 43-83; 30 % women). Retention was 93 %; attendance was 94 %. Mindfulness (beta = 3.31; p = 0.04) and anxiety (beta = -1.15; p = 0.059) improved in the mindfulness group.

CONCLUSIONS

Mindfulness training can be effectively phone-delivered and may improve mindfulness and anxiety in cardiac defibrillator outpatients.

Position paper on the importance of psychosocial factors in cardiology: Update 2013

Background: The rapid progress of psychosomatic research in cardiology and also the increasing impact of psychosocial issues in the clinical daily routine have prompted the Clinical Commission of the German Heart Society (DGK) to agree to an update of the first state of the art paper on this issue which was originally released in 2008.

Methods: The circle of experts was increased, general aspects were implemented and the state of the art was updated. Particular emphasis was dedicated to coronary heart diseases (CHD), heart rhythm diseases and heart failure because to date the evidence-based clinical knowledge is most advanced in these particular areas. Differences between men and women and over the life span were considered in the recommendations as were influences of cognitive capability and the interactive and synergistic impact of classical somatic risk factors on the affective comorbidity in heart disease patients.

Results: A IA recommendation (recommendation grade I and evidence grade A) was given for the need to consider psychosocial risk factors in the estimation of coronary risks as etiological and prognostic risk factors. Furthermore, for the recommendation to routinely integrate psychosocial patient management into the care of heart surgery patients because in these patients, comorbid affective disorders (e.g. depression, anxiety and post-traumatic stress disorder) are highly prevalent and often have a malignant prognosis. A IB recommendation was given for the treatment of psychosocial risk factors aiming to prevent the onset of CHD, particularly if the psychosocial risk factor is harmful in itself (e.g. depression) or constrains the treatment of the somatic risk factors. Patients with acute and chronic CHD should be offered anti-depressive medication if these patients suffer from medium to severe states of depression and in this case medication with selective reuptake inhibitors should be given. In the long-term course of treatment with implanted cardioverter defibrillators (ICDs) a subjective health technology assessment is warranted. In particular, the likelihood of affective comorbidities and the onset of psychological crises should be carefully considered.

Conclusions: The present state of the art paper presents an update of current empirical evidence in psychocardiology. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiological practice and highlights areas of high priority. The evidence for estimating the efficiency for psychotherapeutic and psychopharmacological interventions has increased substantially since the first release of the policy document but is, however, still weak. There remains an urgent need to establish curricula for physician competence in psychodiagnosis, communication and referral to ensure that current psychocardiac knowledge is translated into the daily routine.

The effect of cardiac genetic testing on psychological well-being and illness perceptions

OBJECTIVE

To assess the effects of positive cardiac genetic diagnoses, ICD discharges, and arrhythmias on measures of psychological well-being.

METHODS

Fifty-eight adults with prior cardiac genetic testing were enrolled. Patient well-being was determined using the SF-36 (QoL), HADS-A and HADS-D (anxiety/depression), and IPQ-R (patients' perceptions of illness). Patients with positive and negative cardiac genetic test results were compared using non-parametric statistics.

RESULTS

Genetic testing yielded 76% with a positive diagnosis and 29% reported an ICD shock. QoL assessments (n = 33) were within normal ranges (mean of 50) with the exceptions of general health (44.1 ± 12.2, p < 0.01) and bodily pain (55.1 ± 9.1, p < 0.01) domains, but only the bodily pain domain showed differences between those with positive and negative cardiac genetic test results. Subjects with ICD discharges had higher scores than those without shocks in consequential and emotional IPQR subscales as well as greater perceived risks of experiencing a serious cardiac event, developing additional symptoms, or limitations in daily activities.

CONCLUSION

Positive genetic results did not negatively impact patient well-being with the exception of the bodily pain domain of the SF-36.

Comprehensive cardiac rehabilitation improves outcome for patients with implantable cardioverter defibrillator. Findings from the COPE-ICD randomised clinical trial

AIMS

The aim of this randomised clinical trial was to assess a comprehensive cardiac rehabilitation intervention including exercise training and psycho-education vs 'treatment as usual' in patients treated with an implantable cardioverter defibrillator (ICD).

METHODS

In this study 196 patients with first time ICD implantation (mean age 57.2 (standard deviation (SD)=13.2); 79% men) were randomised (1:1) to comprehensive cardiac rehabilitation vs 'treatment as usual'. Altogether 144 participants completed the 12 month follow-up. The intervention consisted of twelve weeks of exercise training and one year of psycho-educational follow-up focusing on modifiable factors associated with poor outcomes. Two primary outcomes, general health score (Short Form-36 (SF-36)) and peak oxygen uptake (VO₂), were used. Post-hoc analyses included SF-36 and ICD therapy history.

RESULTS

Comprehensive cardiac rehabilitation significantly increased VO2 uptake after exercise training to 23.0 (95% confidence interval (CI) 20.9-22.7) vs 20.8 (95% CI 18.9-22.7) ml/min/kg in the control group (p=0.004 (multiplicity p=0.015)). Comprehensive cardiac rehabilitation significantly increased general health; at three months (mean 62.8 (95% CI 58.1-67.5) vs 64.4 (95% CI: 59.6-69.2)) points; at six months (mean 66.7 (95% CI 61.5-72.0) vs 61.9 (95% CI 56.1-67.7) points); and 12 months (mean 63.5 (95% CI 57.7-69.3) vs 62.1 (95% CI 56.2-68.0)) points (p <0.05). Explorative analyses showed a significant difference between groups in favour of the intervention group. No significant difference was seen in ICD therapy history.

CONCLUSION

Comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves VO₂-uptake and general health. Furthermore, mental health seems improved. No significant difference was found in the number of ICD shocks or anti-tachycardia pacing therapy.

Age-related differences in the effect of psychological distress on mortality: Type D personality in younger versus older patients with cardiac arrhythmias

Background. Mixed findings in biobehavioral research on heart disease may partly be attributed to age-related differences in the prognostic value of psychological distress. This study sought to test the hypothesis that Type D (distressed) personality contributes to an increased mortality risk following implantable cardioverter defibrillator (ICD) treatment in younger patients but not in older patients. Methods. The Type D Scale (DS14) was used to assess general psychological distress in 455 younger (≤70 y, m = 59.1) and 134 older (>70 y, m = 74.3) ICD patients. End points were all-cause mortality and cardiac death after a median follow-up of 3.2 years. Results. Older patients had more advanced heart failure and a higher mortality rate (n = 34/25%) than younger patients (n = 60/13%), P = 0.001. Cardiac resynchronization therapy (CRT), but not Type D personality, was associated with increased mortality in older patients. Among younger patients, however, Type D personality was associated with an adjusted hazard ratio = 1.91 (95% CI 1.09–3.34) and 2.26 (95% CI 1.16–4.41) for all-cause and cardiac mortality; other predictors were increasing age, CRT, appropriate shocks, ACE-inhibitors, and smoking. Conclusion. Type D personality was independently associated with all-cause and cardiac mortality in younger ICD patients but not in older patients. Cardiovascular research needs to further explore age-related differences in psychosocial risk.

Cognitive-affective symptoms of depression after myocardial infarction: different prognostic importance across age groups

OBJECTIVE

Cognitive-affective symptoms of depression may not be as strongly related to prognosis after myocardial infarction (MI) as somatic depressive symptoms. Because it is not known whether this pattern of results is influenced by the age at which patients are diagnosed as having MI, we examined whether the importance of these symptoms is age dependent in the Enhancing Recovery in Coronary Heart Disease study.

METHODS

Patients with depression after MI (n = 1823) in the Enhancing Recovery in Coronary Heart Disease study were stratified into the following age groups: younger than 70 years (mean [standard deviation] = 55 [9.0] years) and 70 years or older (mean [standard deviation] = 76 [4.9] years). Measurements included demographic and clinical data and the Beck Depression Inventory. The end point was a composite of recurrent MI and mortality during a mean follow-up of 2.1 years.

RESULTS

Patients 70 years or older had more severe manifestations of cardiac disease and somatic comorbidities than did patients younger than 70 years (p < .001). During follow-up, 456 patients died or had a recurrent MI. In patients 70 years or older, increasing age, disease severity, and comorbidities--but not depressive symptoms--independently predicted prognosis. In contrast, cognitive-affective symptoms of depression predicted death/MI in patients younger than 70 years (hazard ratio = 1.03, 95% confidence interval = 1.01-1.04, p = .011), after adjustment for disease severity and comorbidities. Somatic symptoms largely explained the link between cognitive-affective symptoms and adverse events, with the exception of hopelessness (hazard ratio = 1.47, 95% confidence interval = 1.11-1.95, p = .007), suggesting that somatic depressive symptoms accurately reflect the depressed mood state in this age group.

CONCLUSIONS

Somatic symptoms and hopelessness independently predicted death/MI in MI patients younger than 70 years. Research needs to reexamine the modulating effect of age in studies on somatic and cognitive-affective symptoms of post-MI depression.

Depression, psychological distress, and quality of life in patients with cardioverter defibrillator with or without cardiac resynchronization therapy

Congestive heart failure is frequent and leads to reduced exercise capacity, reduced quality of life (QoL), and depression in many patients. Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICD) offer therapeutic options and may have an impact on QoL and depression. This study was performed to evaluate physical and mental health in patients undergoing ICD or combined CRT/ICD-implantation (CRT-D). Echocardiography, spiroergometry, and psychometric questionnaires [Beck Depression Inventory, General World Health Organization Five Well-being Index (WHO-5), Brief Symptom Inventory and 36-item Short Form (SF-36)] were obtained in 39 patients (ICD: 17, CRT-D: 22) at baseline and 6-month follow-up (FU) after device implantation. CRT-D patients had a higher NYHA class and broader left bundle branch block than ICD patients at baseline. At FU, ejection fraction (EF), peak oxygen uptake, and NYHA class improved significantly in CRT-D patients but remained unchanged in ICD patients. Patients with CRT-D implantation showed higher levels of depressive symptoms, psychological distress, and impairment in QoL at baseline and FU compared to ICD patients. These impairments remained mostly unchanged in all patients after 6 months. Overall, these findings imply that there is a need for careful assessment and treatment of psychological distress and depression in ICD and CRT-D patients in the course of device implantation as psychological burden seems to persist irrespective of physical improvement.

Behavioral interventions in patients with an implantable cardioverter defibrillator: lessons learned and where to go from here?

BACKGROUND

The implantable cardioverter defibrillator (ICD) is the first-line treatment for primary and secondary prevention of sudden cardiac death. A subgroup of patients experience psychological distress postimplant, and no clear evidence base exists regarding how best to address patients' needs. The aim of this critical review is to provide an overview of behavioral interventions in ICD patients to date, and to delineate directions for future research using lessons learned from the ongoing RISTA and WEBCARE trials.

METHODS

We searched the PubMed and PsycInfo databases to identify reports of behavioral trials targeting distress and related factors in ICD patients published between 1980 and April 2012.

RESULTS

We identified 17 trials for the review. Generally, compared to usual care, behavioral interventions were associated with reduced anxiety and depression and improved physical functioning, with effect sizes ranging from small to moderate-large (0.10-1.79 for anxiety; 0.23-1.20 for depression). Important limitations were small sample sizes and potential selection bias, hampering generalizability of the results. In addition to a need for larger trials, experiences from the RISTA and WEBCARE trials suggest that intervention trials tailored to the individual patient may be the way forward.

CONCLUSIONS

Behavioral interventions show promise with respect to reducing distress in ICD patients. Large-scale intervention trials targeted to the individual needs and preferences of patients are warranted, as a "one size fits all" approach is unlikely to work for all ICD patients.

Anxiety and risk of ventricular arrhythmias or mortality in patients with an implantable cardioverter defibrillator

OBJECTIVE

A subgroup of patients with an implantable cardioverter defibrillator (ICD) experiences anxiety after device implantation. The purpose of the present study was to evaluate whether anxiety is predictive of ventricular arrhythmias and all-cause mortality 1 year post ICD implantation.

METHODS

A total of 1012 patients completed the state version of the State-Trait Anxiety Inventory at baseline. The end points were ventricular arrhythmias and mortality the first year after ICD implantation.

RESULTS

Within the first year after ICD implantation, 19% of patients experienced a ventricular arrhythmia, and 4% died. Anxiety was associated with an increased risk of ventricular arrhythmias (hazard ratio [HR] = 1.017; 95% confidence interval [CI] = 1.005-1.028; p = .005) and mortality (HR = 1.038; 95% CI = 1.014-1.063; p = .002) in adjusted analysis. Patients with anxiety (highest tertile) had a 1.9 increased risk for ventricular arrhythmias (95% CI = 1.329-2.753; p =.001) and a 2.9 increased risk for mortality (95% CI = 1.269-6.677; p = .01) compared with patients with low anxiety (lowest tertile). Among 257 patients with cardiac resynchronization therapy, anxiety was associated with mortality (HR = 5.381; 95% CI = 1.254-23.092; p = .02) after adjusting for demographic and clinical covariates.

CONCLUSIONS

Anxiety was associated with an increased risk of ventricular arrhythmias and mortality 1 year after ICD implantation, independent of demographic and clinical covariates. Monitoring and treatment of anxiety may be warranted in a selected subgroup of high-risk patients with an ICD.

Anxiety and depression in patients with an implantable cardioverter defibrillator and their partners: a longitudinal study

BACKGROUND

Little is known about the relation between emotional distress of patients with an implantable cardioverter defibrillator (ICD) and distress of their partners. This longitudinal study aimed to determine the association between patient and partner distress, and to explain distress in patients and partners using demographic, clinical, and psychological characteristics of patients and partners.

METHODS

In total, 343 patients (84% male, mean age = 63.2 ± 9.2 years) and partners (18% male, mean age = 60.3 ± 9.4 years) completed self-report measures on anxiety and depressive symptoms at the time of implantation and at 2, 12, and 18 months follow-up. Type D personality (DS14; nonexpression of negative emotions) was assessed at baseline. Clinical information was gathered from medical records. Multilevel modeling was applied.

RESULTS

The correlations between distress in patients and partners were positive (range r = 0.19-0.43; all P's < 0.001). Generally, partners experienced more anxiety and patients more depression. Patient and partner characteristics explained about half of the variance of distress of patients and partners. As expected, psychological characteristics had the strongest effect on distress. Patient anxiety was associated with patient depression and Type D, and to the corresponding distress variable of the partner (anxiety). Similar results were found for patient depression, partner anxiety, and partner depression.

CONCLUSION

Distress of ICD patients is associated with distress of their partners. Future studies need to investigate mechanisms of these patient-partner dynamics, such as communication and behavioral issues. It may be timely to not only focus emotional support on patients, but also on their partners.

[Internet therapy for ICD-patients]

Implantable cardioverter-defibrillators (ICD) are increasingly used for the prevention of potentially lethal cardiac arrhythmias due to their confirmed superior medical efficiency. Nevertheless, ICD-patients often suffer from psychosocial problems, e.g., anxiety and depression. These issues are rarely addressed in routine medical follow-up care. Due to the limited mobility of many ICD-patients, Internet-based care may be ideal for delivering psychosocial care to patients in their homes. Our pilot study and case studies illustrate prospects and challenges of this approach. We developed icd-forum.de, a 6-week internet-based prevention program that provides a platform for information, a virtual self-help group, and a professionally moderated chat room in order to help decrease anxiety and to improve quality of life. A critical evaluation in the context of other published studies on the subject allows recommendations for the implementation of future internet-based psychosocial programs for ICD-patients to be deduced. It is the authors' opinion that such programs offer advantages specifically for heart failure patients and they recommend their broader use. Prior to this, conclusive evaluation studies are needed.

The prevalence of anxiety and depression in adults with implantable cardioverter defibrillators: a systematic review

OBJECTIVE

The implantable cardioverter defibrillator (ICD) is used to treat life-threatening ventricular arrhythmias and in the prevention of sudden cardiac death. A significant proportion of ICD patients experience psychological symptoms including anxiety, depression or both, which in turn can impact adjustment to the device. The objective of this systematic review was to assess the prevalence of anxiety and depression or symptoms of anxiety and depression among adults with ICDs.

METHODS

Search of MEDLINE®, CINAHL®, PsycINFO®, EMBASE® and Cochrane® for English-language articles published through 2009 that used validated diagnostic interviews to diagnose anxiety or depression or self-report questionnaires to assess symptoms of anxiety or depression in adults with an ICD.

RESULTS

Forty-five studies that assessed over 5000 patients were included. Between 11% and 28% of patients had a depressive disorder and 11-26% had an anxiety disorder in 3 small studies (Ns=35-90) that used validated diagnostic interviews. Rates of elevated symptoms of anxiety (8-63%) and depression (5-41%) based on self-report questionnaires ranged widely across studies and times of assessment. Evidence was inconsistent on rates pre- versus post-implantation, rates over time, rates for primary versus secondary prevention, and for shocked versus non-shocked patients.

CONCLUSION

Larger studies utilizing structured interviews are needed to determine the prevalence of anxiety and depression among ICD patients and factors that may influence rates of anxiety and depressive disorders. Based on existing data, it may be appropriate to assume a 20% prevalence rate for both depressive and anxiety disorders post-ICD implant, a rate similar to that in other cardiac populations.

COPE-ICD: a randomised clinical trial studying the effects and meaning of a comprehensive rehabilitation programme for ICD recipients -design, intervention and population

Background

Growing evidence exists that living with an ICD can lead to fear and avoidance behaviour including the avoidance of physical activity. It has been suggested that psychological stress can increase the risk of shock and predict death. Small studies have indicated a beneficial effect arising from exercise training and psychological intervention, therefore a large-scale rehabilitation programme was set up.

Methods/Design

A mixed methods embedded experimental design was chosen to include both quantitative and qualitative measures. A randomised clinical trial is its primary component. 196 patients (power-calculated) were block randomised to either a control group or intervention group at a single centre. The intervention consists of a 1-year psycho-educational component provided by two nurses and a 12-week exercise training component provided by two physiotherapists. Our hypothesis is that the COPE-ICD programme will reduce avoidance behaviour, sexual dysfunction and increase quality of life, increase physical capability, reduce the number of treatment-demanding arrhythmias, reduce mortality and acute re-hospitalisation, reduce sickness leading to absence from work and be cost-effective. A blinded investigator will perform all physical tests and data collection.

Discussion

Most participants are men (79%) with a mean age of 58 (range 20-85). Most ICD implantations are on primary prophylactic indication (66%). 44% is NYHA II. Mean walk capacity (6MWT) is 417 m. Mean perception of General Health (SF-36) is PCS 42.6 and MCS 47.1.

A large-scale ICD rehabilitation trial including psycho-educational intervention and exercise training has been initiated and will report findings starting in 2011.

Trial Registration

ClinicalTrials.gov: NCT00569478

A randomized controlled trial of cognitive behavior therapy tailored to psychological adaptation to an implantable cardioverter defibrillator

OBJECTIVES

To evaluate a eight-session cognitive behavior therapy (CBT) intervention tailored to adaptation in implantable cardioverter defibrillator (ICD) patients; and to test for treatment group by gender interaction effects.

METHODS

Patients receiving their first ICD implant were randomized to CBT or usual cardiac care. Primary outcomes measured at baseline, 6-month, and 12-month follow-ups were symptoms of anxiety and depression (Hospital Anxiety and Depression Scale), posttraumatic stress disorder symptoms (Impact of Events Scale-Revised), and phobic anxiety (Crown-Crisp Experiential Index). Secondary outcomes were quality of life (Short Form-36 Physical Component Summary and Short Form-36 Mental Component Summary) and ICD shocks or antitachycardia pacing therapies.

RESULTS

Of 292 eligible patients, 193 consented and were randomized to CBT (n = 96) or usual cardiac care (n = 97). Eighty percent were male; mean age was 64.4 years (standard deviation = 14.3); and 70% received an ICD for secondary prevention. No baseline differences were observed between the treatment conditions; however, women scored worse than men on all psychological and quality of life variables (p < .05). Eighty-three percent completed follow-up. Repeated-measures analyses of covariance revealed significantly greater improvement with CBT on posttraumatic stress disorder total and avoidance symptoms for men and women combined (p < .05) and significantly greater improvement in depressive symptoms and Short Form-36 Mental Component Summary only in women (p < .01). No differences were observed between treatment conditions on ICD therapies over follow-up.

CONCLUSION

A CBT intervention to assist adaptation to an ICD enhanced psychological functioning over the first year post implant.

Gender disparities in psychological distress and quality of life among patients with an implantable cardioverter defibrillator

A subset of patients with an implantable cardioverter defibrillator (ICD) reports psychological distress and poor quality of life (QoL). Gender is one of the factors that has been proposed to explain individual differences in these outcomes. In this viewpoint, we (1) review the evidence for gender disparities in psychological distress and QoL in ICD patients by means of a systematic review, and (2) provide recommendations for future research and clinical implications. A systematic search of the literature identified 18 studies with a sample size ≥ 100 that examined gender disparities in anxiety/depression and QoL in ICD patients (mean prevalence of women = 21%; mean age = 62 years). Our review shows that there is insufficient evidence to conclude that gender per se is a major autonomous predictor for disparities in psychological distress and QoL in ICD patients. Women had a higher prevalence of anxiety and poorer QoL in some studies, but there was no statistically significant gender effect in relation to 80% (26/32) of the outcomes reported in the 18 studies. Studies are warranted that are designed a priori and sufficiently powered to examine gender disparities in distress and QoL outcomes in order to establish the exact gender-specific effect. Due to a need to explore the complexity of this issue further, at this time, caution is warranted with respect to the clinical implications.