Efficacy of functional relaxation and patient education in the treatment of somatoform heart disorders: a randomized, controlled clinical investigation

[Embodiment - Connecting Body and Mind]

Body and mind are often considered as separate entities, also in medicine. However, new neuroscientific research indicates that body and mind are much more connected than previously thought. This scientific contribution will look at the importance of "embodiment" for medicine.

Prevalence, characteristics and measurement of somatic symptoms related to mental health in medical students: a scoping review

INTRODUCTION

Somatic symptoms related to mental health in medical students are under-researched, with nothing on the topic being published in the United States in over three decades. This scoping review is the first of its kind to explore the prevalence, type and severity of somatic symptoms induced by stress, anxiety, depression and burnout amongst medical students, with the objective of describing the significance and breadth of this issue.

METHODS

PRISMA-ScR guidelines were used to guide this review. A comprehensive search was performed of 22 databases, followed by bibliographic and hand searching. Inclusion criteria were published, peer-reviewed articles with a sample of medical students and at least one measure of somatic symptoms related to mental health, in English or with an English-language translation. Excluded were review, companion and editorial articles. Coding was done by an experienced coder trained in systematic review techniques. Two authors reviewed each article.

RESULTS

Twenty-nine articles met inclusion criteria, representing 16 countries, 31 schools/teaching hospitals and 9,887 medical students. The prevalence of somatic symptoms ranged from 5.7 to 80.1%, and somatic symptoms were overwhelmingly found to be significantly correlated with mental ill-health. Somatic symptoms included back pain, neck pain, headaches, sleep disturbances and functional gastrointestinal disorders. Eleven different outcome measures were used, with varying degrees of validity and reliability, which were compared and assessed.

CONCLUSIONS

Somatic symptoms appear strongly correlated with mental ill-health in medical students, and are likely highly prevalent. This review highlights the need for further research on somatic symptoms of mental ill-health in medical students, particularly in the United States, and the addition of larger, multi-institutional cohorts to expand our understanding of prevalence, incidence and inciting factors of somatic symptoms. Longitudinal studies tracking somatic symptoms' effect on career trajectory and professional burnout levels are also needed. Finally, future research should explore interventions for reducing physical symptom burden in medical students.

Effect of functional relaxation on the quality of life in patients with periprosthetic joint infection: Protocol for a randomised controlled trial

INTRODUCTION

Periprosthetic joint infection (PJI) is a devastating complication in orthopaedic and trauma surgery, which puts a high burden on the patients involving recurrent hospitalisation, prolonged courses of antibiotic medication, severe pain and long periods of immobility as well as high levels of psychological distress. Thus, this multicentre study aims at implementing body-oriented psychotherapy in clinical practice and evaluating its therapeutic effect on the quality of life.

METHODS AND ANALYSIS

A prospective, parallel two-armed randomised controlled trial with approximately n=270 patients with verified PJI treated surgically with a one-staged exchange, or a two-staged exchange will be conducted. Functional relaxation (FR) therapy will be implemented as a group therapy. FR originally belongs to the psychodynamically based body-oriented psychotherapy. Intervention techniques consist of minute movements of small joints, which are performed during relaxed expiration accompanied by an exploration of differences of body feelings. A group will include 3-8 patients, led by a specialist physiotherapist certified in FR once a week. The participants are consecutively admitted to the class and participate in 12 sessions. The control group will consist of patients receiving an unspecific 'placebo relaxation' intervention for the same duration. The primary efficacy endpoint is the mental component summary and physical component summary of quality of life assessed by the 36-Item Short Form Health Survey (SF-36) after 6 months. Secondary outcomes include SF-36 scores after 12 months, consumption of pain medication, mobility measured by the Parker mobility score and the physical activity measured by daily steps with an accelerometer (actibelt).

ETHICS AND DISSEMINATION

Approval from the Ethical Committee of the University Hospital Regensburg was received (file number: 21-2226-101). Written, informed consent to participate will be obtained from all participants. Results will be made available in the form of peer-reviewed publications and presentation in congresses.

TRIAL REGISTRATION NUMBER

DRKS00028881; German Clinical Trials Register.

[Development and Evaluation of a Manualized Body-Psychotherapeutic Group Intervention with Functional Relaxation for Patients with Cancer "Calm with Body and Soul"]

OBJECTIVE

A feasibility study to determine whether oncology patients in the acute phase of their disease can participate in and benefit from a functional relaxation (FR) program.

METHODS

A group intervention (N=14) over 10 sessions following the FR functional relaxation stress manual; measurement of psychological distress by a pre-post questionnaire survey.

RESULTS

The intervention appears well suited to help psychologically distressed patients process their symptoms and cope with stressors. There was some indication that general well-being increased and hyperarousal decreased.Overall well-being increased; hyperarousal decreased.

DISCUSSION

The intervention was well accepted, but regular participation was not always possible due to the disease. The body therapy approach and group setting seemed particularly helpful. Due to the heavy physical strain on the patients, the structure of the groups as well as individual exercises were adapted individually.

CONCLUSION

The body-based interventions made unconscious elements accessible and thus to work with therapeutically to a limited extent. Further research is needed to show the effectiveness of this functional relaxation group intervention.

Effectiveness of Body Psychotherapy. A Systematic Review and Meta-Analysis

Despite the growing relevance and applicability of elements based on and derived from the embodied mind paradigm, body psychotherapy (BPT) appears not to be a well-established treatment option. This might be due to a lack of proof for its efficacy. We searched electronic databases (Pubmed MEDLINE, PsycInfo, and PSYNDEX) for randomized controlled trials (RCTs) examining predefined BPT interventions. A total of 2,180 references were screened, of which 113 studies were scrutinized in detail and 18 RCTs finally included. The observed effect size (ES) demonstrated medium effects of BPT on primary outcomes psychopathology and psychological distress. In case of significant statistical heterogeneity, exploratory subgroup analyses revealed diagnosis and the degree of control group activity as noteworthy moderators. For secondary outcomes, evidence was scarce, and an improvement could be demonstrated only for coping abilities. The identified evidence indicates that BPT is beneficial for a wide spectrum of psychic suffering. There is a strong need for high-quality studies with bigger samples and for well-defined diagnostic entities to underpin its effectiveness.

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

Stress Reduction Techniques for Health Care Providers Dealing With Severe Coronavirus Infections (SARS, MERS, and COVID-19): A Rapid Review

OBJECTIVE

A rapid review was conducted to identify the most effective stress reduction techniques for health care providers dealing with patients infected with severe coronavirus (SARS, MERS, and COVID-19).

METHODS

PubMed, PsychInfo, Embase, and CINAHL databases were searched to identify relevant studies. Searches were restricted by date (2000 until present). All empirical quantitative and qualitative studies in which relaxation techniques of various types implemented on health care providers caring for patients during severe coronavirus pandemics and articles that consider the implementation of mental health care services considered to be pertinent, such as commentaries, were included.

RESULTS

Fourteen studies met the selection criteria, most of which were recommendations. Only one study described a digital intervention, and user satisfaction was measured. In the recommendations, both organizational and individual self-care interventions were suggested.

CONCLUSIONS

Further research is necessary to establish tailor-made effective stress reduction interventions for this population, during these challenging and particular times.

[Pilot Data from the Evaluation of an Integrative Body Psychotherapy Program for Patients with Psychogenic Non-Epileptic Seizures]

Psychogenic non-epileptic seizures (PNES) occur in the context of various diseases. Therefore, PNES patients represent a heterogeneous group with different causative disorders. The etiology is still poorly understood. Previous concepts assume an increased rate of trauma disorders in PNES, which has been proven several times by previous studies 1 2. The clinical picture is threatening, which means that those affected often receive intensive care measures without benefiting from them 3. PNES patients accumulate especially in epilepsy centers, since a diagnostic differentiation from epileptic seizures is possible at those specialized centers. Often, the transition from making the diagnosis in epilepsy centers to follow-up treatment in psychosomatic/psychiatric settings is difficult. A reason could be that patients and practitioners are often involved in somatic disease concepts, which might be caused by the threatening clinical picture of PNES 28. Due to this difficulties, a special outpatient clinic was set up at the Charité Berlin for people with dissociative seizures, which settles in the transition from neurology to psychosomatics and works as a cooperation project 27. Out of the ambulance, a group treatment program (CORDIS) was developed, which aims at a better care of PNES patients at the interface between neurology and psychosomatic medicine. This modularized 10-week treatment program will be presented in this article and is the subject of a currently ongoing randomized, controlled evaluation study. The pilot data from the ongoing RCT study presented here showed significant effects in the effectiveness of the program, in particular the primary and secondary outcome measures.

Anxiety Disorders and Medical Comorbidity: Treatment Implications

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).

Body-Centered Interventions for Psychopathological Conditions: A Review

World-wide, billions of dollars are spent each year on body-centered interventions to alleviate both physical and psychological pathologies. Given the high demand and increasing popularity of body-centered interventions, there is need for a systematic organization of empirical evidence associated with body-centered therapies. This article reviews the psychological effects of body-centered interventions on emotional well-being, including both self and other-administered (receptive) therapies. Theory behind body-centered interventions rely upon the bidirectional communication pathway between the brain and body. We investigated the bidirectional communication pathway between the brain and body by evaluating evidence across multiple body-centered therapies. The research reviewed includes studies that investigate effects of massage therapy, reflexology, acupuncture, functional relaxation, emotional freedom technique, Rolfing, yoga, tai-chi, and dance/movement therapy on psychological conditions across the lifespan. Results demonstrated that overall, massage therapy, tai-chi, dance/movement therapy, functional relaxation, reflexology, acupuncture and emotional freedom technique seem to alleviate stress, depression, anxiety, bipolar disorder and facilitate pain reduction. Of these, the most robust evidence available was for massage therapy, indicating it is an effective intervention for numerous age groups and populations. Rolfing and reflexology had the least amount of support, with few studies available that had small sample sizes. Although these conclusions are limited by scarcity of high-quality empirical data and contradictory findings, available evidence indicates that body-centered interventions can be effective in reducing psychopathology and supports the proposed mechanism of the bidirectional pathway between the brain and body: the body holds the potential to influence the mind. Integrating body-centered therapies in both clinical settings and as self-care could lead to better outcomes. Lastly, we propose the first taxonomy of body-centered interventions and empirical evidence of their effectiveness for clinicians and researchers.

Group body psychotherapy for the treatment of somatoform disorder - a partly randomised-controlled feasibility pilot study

BACKGROUND

Clinical outcomes for patients with heterogeneous somatoform disorder (bodily distress disorder, including medically unexplained symptoms) are suboptimal, new treatments are required to improve acceptance. Body-oriented psychological therapy approaches have been identified as potentially beneficial additions to the portfolio of treatments. This study was aiming to assess the acceptability, the potential benefits, and associated change processes of manualised group body psychotherapy (BPT) for outpatients with Somatoform Disorder.

METHODS

A randomized controlled feasibility trial was carried out with follow-up at 6 months after baseline assessments using the Primary Health Questionnaire (PHQ), Somatic Symptom Screening Scale (SOMS-7), quality of life ratings (Short-Form Health Survey-36; SF-36) and body image measures (Dresden Body Image Questionnaire). Acceptance was assessed with the Helping Alliance Scale (HAS).

RESULTS

A total of 24 patients were recruited to participate. Sixteen patients were randomly assigned to receive either manualised BPT or TAU, eight patients were directly assigned to BPT. Drop-out rates were acceptable, patients reported to be highly satisfied with the group intervention. Somatic symptom levels reduced significantly in the BPT group. Additionally, a significant effect on self-acceptance and the mental component of quality of life was observed.

CONCLUSION

Group body psychotherapy is a feasible and acceptable treatment for patients with somatoform disorder and a larger trial studying the effectiveness of BPT in these patients should be conducted.

TRIAL REGISTRATION

Retrospectively registered SRCTN12277345 ; Trial Registraton Date: 27/03/2019.

Self-Management Interventions for Women With Cardiac Pain: A Systematic Review and Meta-analysis

BACKGROUND

Cardiac pain is considered the primary indicator of coronary artery disease (CAD). Existing reviews lack appropriate numbers of women or sex-based subgroup analyses, or both; thus, the benefits of self-management (women with cardiac pain actively participating in their own care and treatment) remain uncertain.

METHODS

Using methods described by the Evidence for Policy and Practice Information and Co-ordinating Centre at the Institute of Education, 7 databases were systematically searched to examine and synthesize the evidence on self-management interventions for women with cardiac pain and cardiac pain equivalents, such as fatigue, dyspnea, and exhaustion.

RESULTS

Our search yielded 22,402 article titles and abstracts. Of these, 57 randomized controlled trials were included in a final narrative synthesis, comprising data from 13,047 participants, including 5299 (41%) women. Self-management interventions targeting cardiac pain in women compared with a control population reduced (1) cardiac pain frequency and cardiac pain proportion (obstructive and nonobstructive CAD), (2) fatigue at 12 months, and (3) dyspnea at 2 months. There was no evidence of group differences in postprocedural (percutaneous coronary intervention or cardiac surgery) pain. Results indicated that self-management interventions for cardiac pain were more effective if they included a greater proportion of women (standardized mean difference [SMD], -0.01; standard error, 0.003; P = 0.02), goal setting (SMD, -0.26; 95% confidence interval [CI], -0.49 to -0.03), and collaboration/support from health care providers (SMD, -0.57; 95% CI, -1.00 to -0.14).

CONCLUSIONS

The results of this review suggest that self-management interventions reduce cardiac pain and cardiac pain equivalents.

Novel primary care treatment package for patients with medically unexplained symptoms: a cohort intervention study

Background

Existing care models for patients with persistent medically unexplained symptoms (MUS) do not adequately address the needs of these patients. New and innovative intervention strategies are necessary to achieve better health and corresponding economic outcomes.

Aim

To explore the feasibility of implementing a pragmatic care package that provides primary care treatment for patients with persistent MUS and to evaluate recruitment, retention, and acceptability as well as the potential impact on clinical outcomes and service utilisation.

Design & setting

Prospective cohort intervention study involving a cluster of seven GP surgeries in Newham, East London, providing a 'One-Stop-Shop' primary care treatment service.

Method

The care package included: identification, assessment, engagement, psychoeducation, and a choice of group interventions (mindfulness-based stress reduction [MBSR] and body-oriented psychological therapy [BOPT]). Baseline and follow-up data on somatic symptom levels (PHQ-15), health-related quality of life (SF-36, EQ-5D) and service utilisation was analysed.

Results

In total, 145 patients were referred and assessed for eligibility, and 93 were included in the study. Participants engaged well with different components of the care package and gained significant improvements in somatic symptom levels with corresponding increases of quality-of-life ratings and a reduction in healthcare utilisation (GP contacts and referrals to specialist services) as well as associated healthcare costs.

Conclusion

The primary care treatment package can be successfully implemented in primary care at a relatively low cost and easily adopted into routine care. The body-oriented approach is well accepted by clinicians and patients. Controlled trials should be conducted to test the efficacy of the treatment package.

A Randomized Controlled Trial on Functional Relaxation as an Adjunct to Psychoeducation for Stress

This randomized controlled trial investigated whether adding the psychodynamically based body-oriented psychotherapy “Functional Relaxation” (FR) to psychoeducation (PE) is more effective than PE alone to reduce stress and stress-associated complaints. Eighty-one participants with elevated stress-levels, ≥50 points on the global scale of the Perceived Stress Questionnaire (PSQ), received either 10 sessions of manualized FR + PE (n = 42) or two sessions of manualized PE alone (n = 39) in a group setting. Six FR trainers took part in this study. Stress-level (PSQ) was the primary outcome and secondary outcomes were depression (PHQ-9) and somatization (PHQ-15). Multilevel models for discontinuous change revealed that FR + PE was more helpful to reduce stress-levels than PE from pre-treatment to post-treatment (t0 → t1) as well as from pre-treatment to 6-month follow-up (t0 → t2) (both p < 0.05) with effect sizes (d) being medium for PE (d_{t0 → t1} = 0.57; d_{t0 → t2} = 0.67) and large for FR + PE (d_{t0 → t1} = 1.57; d_{t0 → t2} = 1.39). Moreover, FR + PE affected depression and somatization more positively than did PE from t0 to t1 as well as from t0 to t2 (all p < 0.05). Effect sizes for depression were small to medium for PE (d_{t0 → t1} = 0.52; d_{t0 → t2} = 0.37) and large for FR + PE (d_{t0 → t1} = 1.04; d_{t0 → t2} = 0.95). Effect sizes for somatization were small for PE (d_{t0 → t1} = 0.18; d_{t0 → t2} = 0.19) and medium to large for FR + PE (d_{t0 → t1} = 0.73; d_{t0 → t2} = 0.93). In summary, the combination of FR and PE was more effective than PE alone. The results of the present trial provide first evidence of FR as a potent component of stress interventions. Adding FR to such interventions might better help prevent clinically relevant disorders such as depression or somatization.

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

BACKGROUND

Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers.

METHODS

We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP.

RESULTS

We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions.

CONCLUSIONS

Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.

MAIN RESULTS

We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.

AUTHORS' CONCLUSIONS

This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment.

OBJECTIVES

To summarize treatment efficacy for patients presenting with NCCP.

METHODS

Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group).

RESULTS

Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions.

LIMITATIONS

Only a small number of studies were available.

CONCLUSIONS

Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.

The effect of brief functional relaxation on college students' needle anxiety during injected vaccinations

OBJECTIVE

This study examined the effect of brief functional relaxation (FR) training on needle anxiety (NA) during vaccinations.

PARTICIPANTS

From October 2010 through May 2012, 48 undergraduates were recruited through the psychology research participant pool.

METHODS

Students (N = 48) were randomly assigned to a 15-minute brief FR session delivered via MP3 player or a standard care condition (15 minutes of sitting quietly) prior to receiving injections at the immunization clinic. Measures were completed before (T1) and after (T2) the assigned condition, assessing expected NA, state anxiety, blood pressure, and heart rate; and after the injection (T3), self-reported NA during the injection.

RESULTS

Unexpectedly, the groups did not differ at T2. However, during the injection, brief FR participants indicated lower self-reported NA (T3) than standard care.

CONCLUSIONS

Brief FR is a simple, inexpensive technique that may reduce NA in college health settings and help decrease delays in treatment seeking.

Impact of applied progressive deep muscle relaxation training on the level of depression, anxiety and stress among prostate cancer patients: a quasi-experimental study

BACKGROUND

The aim of this study was to determine the impact of applied progressive muscle relaxation training on the levels of depression, anxiety and stress among prostate cancer patients.

MATERIALS AND METHODS

A quasi-experimental study was conducted at the University Malaya Medical Centre (UMMC) and Universiti Kebangsaan Malaysia Medical Centre (UKMMC) over six months. Prostate cancer patients from UMMC received the intervention and patients from UKMMC were taken as controls. The level of depression, anxiety and stress were measured using Depression, Anxiety Stress Scales - 21 (DASS-21).

RESULTS

A total of 77 patients from the UMMC and 78 patients from the UKMMC participated. At the end of the study, 90.9% and 87.2% of patients from the UMMC and UKMMC groups completed the study respectively. There were significant improvements in anxiety (p<0.001, partial ?2=0.198) and stress (p<0.001, partial ?2=0.103) at the end of the study in those receiving muscle training. However, there was no improvement in depression (p=0.956).

CONCLUSIONS

The improvement in anxiety and stress showed the potential of APMRT in the management of prostate cancer patients. Future studies should be carried out over a longer duration to provide stronger evidence for the introduction of relaxation therapy among prostate cancer patients as a coping strategy to improve their anxiety and stress.

A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial

BACKGROUND

Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our aim was to examine efficacy of brief CBT in reducing anxiety and depressive symptoms in patients with noncardiac chest pain and comorbid panic and/or depressive disorders.

METHODS

In this 24-week randomized controlled trial comparing CBT (n = 60) versus treatment as usual (TAU, n = 53), we included all adults who presented at the cardiac emergency unit of a university hospital with noncardiac chest pain, scored ≥8 on the hospital anxiety and depression scale (HADS) and were diagnosed with a comorbid panic and/or depressive disorder with the Mini International Neuropsychiatric Interview. CBT consisted of six individual sessions. Main outcome was disease severity assessed with the clinical global inventory (CGI) by a blinded independent rater.

RESULTS

ANCOVA in the intention-to-treat and completer sample showed that CBT was superior to TAU after 24 weeks in reducing disease severity assessed with CGI (P < .001). Secondary outcomes on anxiety (HADS-anxiety, state trait anxiety inventory (STAI)-trait) and depressive symptoms (Hamilton depression rating scale) were in line with these results except for HADS-depression (P = .10), fear questionnaire (P = .13), and STAI-state (P = .11).

CONCLUSIONS

Brief CBT significantly reduces anxiety and depressive symptoms in patients with noncardiac chest pain who are diagnosed with panic and/or depressive disorders. Patients presenting with noncardiac chest pain should be screened for psychopathology and if positive, CBT should be considered.

Affective temperament in women with functional aphonia

OBJECTIVES

The aim of the present study was to assess the affective temperament in women with functional aphonia.

STUDY DESIGN

Cross-sectional.

METHODS

Forty-one women with functional aphonia underwent an examination of affective temperament by means of the Temperament Evaluation of Memphis, Pisa and San Diego Autoquestionnaire.

RESULTS

Compared with the reference group, women with functional aphonia show significantly higher rates of depressive and anxious temperament.

CONCLUSIONS

The results of the present study are concordant with the previous findings, indicating elevated levels of depressive and anxious symptoms in aphonic patients. Implications for the therapy of functional aphonia as well as considerations for further studies are discussed.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To update the previously published systematic review.

SEARCH METHODS

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed-effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random-effects mean difference = -2.26 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects mean difference -0.81 95% CI -2.35, 0.74). There was no effect on severity (random-effects mean difference = -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

[Medically unexplained and somatoform complaints and disorders in the elderly: a systematic review of the literature]

OBJECTIVE

To provide a systematic overview of the research concerning the frequency of medically unexplained, somatoform complaints and disorders in the elderly, their risk factors, comorbidity, course, management in primary and secondary care, and psychotherapy.

METHOD

We evaluated 248 clinical and randomized trials, reviews, meta-analyses and practice guidelines for adult samples identified from "PubMed" and "PsycInfo" using the search terms "somatoform" OR "medically unexplained" OR "somatization" OR "somatisation" in combination with other terms for their relevance for the elderly. Other relevant trials were identified from the references from these publications.

RESULTS

Medically unexplained, somatoform complaints and disorders occur in older persons and are more frequent in elderly women than in elderly men. Although many studies found no increased frequency of somatoform complaints in the elderly, based on present research we cannot draw final conclusions concerning the frequency of somatoform disorders and complaints in the elderly, and we cannot give evidence based recommendations for their treatment in primary and secondary care and psychotherapy.

DISCUSSION

This situation results from the special problems encountered in the diagnosis of somatoform complaints and disorders in the elderly, from problems in conceptualisation also found in younger adults, and from the lack of research concerning treatment focussed solely on the old and very old.

Psychological interventions for coronary heart disease

BACKGROUND

Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures.

OBJECTIVES

Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac-related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study-level predictors of the impact of these interventions.

SEARCH STRATEGY

The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review.

SELECTION CRITERIA

Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow-up of six months. Adults with specific diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information.

MAIN RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non-fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): -0.21 (95% CI -0.35, -0.08) and anxiety, SMD: -0.25 (95% CI -0.48 to -0.03). Results for mortality indicated some evidence of small-study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type-A behaviours (ß = -0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (ß = 0.23, p = 0.03), (3) included client-led discussion and emotional support as core therapeutic components (ß = 0.31, p < 0.01), or (4) included family members in the treatment process (ß = 0.26, p < 0.01) were significantly less effective.

AUTHORS' CONCLUSIONS

Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Functional relaxation as complementary therapy in irritable bowel syndrome: a randomized, controlled clinical trial

OBJECTIVES

Irritable bowel syndrome (IBS) is a frequently disabling and almost invariably distressing disease with a high overall prevalence. Numerous trials identified the importance of psychogenic and emotional etiological factors, and this is obvious in clinical practice. Although relaxation techniques are frequently recommended, there is still a lack of evidence for their efficacy in the management of IBS. This study therefore aims to determine the efficacy of functional relaxation (FR) in IBS.

SUBJECTS

The subjects were 80 patients with IBS.

INTERVENTIONS

Participants were randomly allocated either to FR or to enhanced medical care (EMC: treatment as usual plus two counseling interviews) as control intervention with 2 weekly sessions over the 5-week trial each. Thirty-nine (39) patients completed FR and 39 received EMC.

OUTCOME MEASURES

An impairment-severity score (IS) was employed as the primary outcome parameter with assessment at baseline, after treatment, and again after 3-month follow-up.

RESULTS

FR was significantly superior to EMC with a standardized effect size of 0.85. The achieved effects through FR remained stable in terms of psychic and bodily impairment after 3-month follow-up.

CONCLUSIONS

The results of our trial suggest a positive effect of FR training on subjective functional impairment in the IS, if provided in addition to treatment as usual (TAU). There appears to be a clinically relevant long-term benefit of FR as a nonpharmacological and complementary therapy approach in IBS.

Effects of functional relaxation and guided imagery on IgE in dust-mite allergic adult asthmatics: a randomized, controlled clinical trial

Although relaxation and imagination techniques have repeatedly proven their effectiveness in asthma, nothing is known about the immunological effects of these complementary interventions. Therefore, the aim of this study is to investigate the effects of the brief relaxation technique of functional relaxation (FR) with guided imagery (GI) on serum IgE in adult patients with dust mite allergic asthma in a randomized, controlled trial. Sixty-four patients were treated over a 4-week period and assessed at baseline, after treatment and after 4 months for follow-up. Due to its significant role in the pathophysiology of allergic asthma, the serum IgE was employed as outcome measure in this investigation. Participation in FR, GI, and FR/GI led to decreases in serum IgE (IU/mL) of -54.7 +/- 67.1, -49.5 +/- 93.4, and -28.4 +/- 93.9 compared with an increase of 27.7 +/- 43.2 in CI. Our study confirmed a positive and clinically relevant effect of FR and GI on total serum IgE levels.