Brief group therapy following myocardial infarction: eighteen-month follow-up of a controlled trial

Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis

A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane's tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54⁻0.85) and ET (HR = 0.75, 95% CrI = 0.60⁻0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57⁻0.99), ET (HR = 0.75, 95% CrI = 0.56⁻0.99) and PE (HR = 0.68, 95% CrI = 0.47⁻0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58⁻0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.

Return to work after myocardial infarction/coronary artery bypass grafting: patients' and physicians' initial viewpoints and outcome 12 months later

Nonmedical factors play an important role in determining whether patients resume their work after myocardial infarction or CABG. The main questions dealt with in this study are: What is the respective basis of physicians' and patients' judgements as far as vocational disabilities are concerned, and what are the decisive factors that facilitate a prediction as to who will return to work and who will not? 132 male patients participating in a cardiac rehabilitation program served as subjects. The age group was limited to patients between 40 and 59 yr of age. The work situation 12 months following rehabilitation is known for 119 subjects; 74 had resumed their occupations. Results of regression analyses show that patients' and physicians' views on disabilities and re-employment are based on different factors. The physicians derive their estimates mainly from medical variables (cardiac status and comorbidity), whereas the patients' views are based on the overall health status, their former job status, job satisfaction, and negative incentives for the return to work. Three variables were found that allow a prediction to be made as to re-employment in 85% of all cases: (1) age, (2) patients' feelings about the extent to which they are disabled by their cardiac problem, and (3) the physicians' views on the extent to which the patient is vocationally disabled by his overall medical situation. Medical variables (e.g. cardiac status) had little relevance to re-employment. The results are discussed with regard to the consequences for cardiac rehabilitation.

Enhancing recovery in coronary heart disease patients (ENRICHD): study design and methods. The ENRICHD investigators

Psychosocial factors, particularly depression and lack of social support, are important predictors of morbidity and mortality in patients with coronary heart disease. This article describes the design and methods of the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study, a multicenter, randomized clinical trial involving 3000 patients enrolled after acute myocardial infarction. ENRICHD aims to investigate the effects of a psychosocial intervention that targets depression and/or low social support on survival and reinfarction among adult men and women who are at high risk for recurrent cardiac events because of psychosocial factors (depressive or social isolation). Design features include the use of an individually tailored yet standardized intervention, rigorous clinical trial methods, and enrollment of a large number of women and minorities.

Patient and spouse responses to education early after myocardial infarction

The impact of a post myocardial infarction education programme was assessed by comparing the increase in knowledge of patients and spouses about CHD in two hospitals, one (A) with and the other (B) without such a programme. Subjects completed the same two questionnaires twice, once within 4 days of admission and again within 16 days of leaving hospital. Q1 contained 83 questions about CHD and Q2, consisted of seven questions of immediate practical relevance to their convalescence. When the two hospitals were compared the only significant changes were observed in the responses of spouses and patients from hospital A. Spouses in A increased their scores on Q1 by a mean of 7.13% (p 0.001) in contrast to a fall of 2.01% in B. The mean increase in scores on Q2 for patients in A was 19.3% (p 0.001). It is concluded that an education programme increases the knowledge of patients and spouses but that their learning ability differs. Whilst it is suggested that spouses are included in patient education it appears likely that their educational needs may differ from those of the patient.

The role of psychological intervention in the management of patients after myocardial infarction

A review of the literature suggests that it is neither appropriate nor cost-effective to involve as a routine all patients who have suffered a myocardial infarction in a traditional outpatient rehabilitation programme where physical conditioning is the principal (or only) ingredient. However, there is evidence to show that psychological intervention programmes that provide short-term psychological support, health education and intervention in coronary risk behaviour influence favourably both physical and psychosocial outcome. The case is put forward for intervention, during the first few days of the patient's admission to hospital, with a treatment package that comprises health education and relaxation therapy. The need for further interventions such as counselling, behavioural therapy, and physical conditioning may be assessed, depending on the patient's response to the initial programme.

Group process expectations and outcome with post-myocardial infarction patients

Post-myocardial infarction patients participating in a 12-session group therapy program completed self-rating measures ranking group process variables before and after therapy. Learning positive qualities, experimenting with new behavior, receiving advice and guidance, and gaining cognitive insight by learning how their lifestyle plays a role in the development and management of their coronary condition were most valued. Interpersonal learning, catharsis, and testing group acceptance by revealing embarrassing things about oneself were ranked lowest. These results are examined in the context of previous descriptions of coronary patients' behavior in therapy.

Evaluative research in consultation-liaison psychiatry. Review of the literature: 1970-1981

In the last decade, the biopsychosocial concept of medicine had flourished clinically in the form of consultation-liaison (C-L) psychiatry. However, full acceptance by the medical profession will depend, in part, upon scientific demonstration that psychological and social factors influence biological medical illness, and that C-L psychiatric teaching and patient intervention can improve the medical treatment of patients. This review surveys the literature over the last 10 years that describes and evaluates C-L activities as they impact upon clinical medicine and medical education. A conceptual grid for organizing research in the field is presented that distinguishes decision-oriented, or descriptive studies, from conclusion-oriented, or outcome studies. Further, this grid specifies the focus of the C-L activity, either the patient or health care professional. It seems clear that the very recent shift from descriptive studies to more outcome-oriented research, particularly regarding patient outcomes, should be the direction of the future. A greater emphasis on defining the exact components of C-L work that are most useful is also indicated. Several other specific recommendations for evaluative research in C-L psychiatry conclude this review.

The effect of psychological intervention on recovery from surgery and heart attacks: an analysis of the literature

A quantitative review of 34 controlled studies demonstrates that, on the average, surgical or coronary patients who are provided information or emotional support to help them master the medical crisis do better than patients who receive only ordinary care. A review of 13 studies that used hospital days post-surgery or post-heart attack as outcome indicators showed that on the average psychological intervention reduced hospitalization approximately two days below the control group's average of 9.92 days. Most of the interventions were modest and, in most studies, were not matched in any way to the needs of particular patients or their coping styles. Beyond the intrinsic value of offering humane and considerate care, the evidence is that psychological care can be cost-effective.

Psychological responses to illness and outcome after survived myocardial infarction: a long term follow-up

Psychological responses to illness were examined in 120 survivors of myocardial infarction (MI) within two weeks of the clinical event. An attempt was then made to follow these patients over two years to investigate the influence of illness behaviour on outcome, defined cardiologically, occupationally and subjectively. Illness behaviour related only tenuously to cardiological and occupational outcome at two years after MI, though associations were rather more prominent where a subjective assessment of well-being constituted the outcome variable. This was in contrast with associations evidence eight months after MI. It was suggested that the influence of illness behaviour on the more objective and important measures of outcome (cardiological and occupational) is almost fully apparent at eight months after MI.

Psychological intervention in coronary heart disease: a review

Psychological intervention studies designed to reduce cardiac morbidity are reviewed. Preliminary findings suggest that various psychotherapeutic modalities may be effective. Such studies also provide an avenue through which the physical and psychological mechanisms involved in coronary heart disease and their interactions may be clarified. Implications for clinical interventions are also discussed.

Changing the coronary-prone (type A) behavior pattern in a nonclinical population

This report presents the design and initial findings of an attempt to reduce the risk of coronary heart disease in healthy men by modifying their type A behavior pattern. A group of 27 professional and executive volunteers, aged 39--59, who had been medically assessed as free from coronary heart disease, were randomly assigned to brief psychotherapy and behavior therapy groups. Each treatment group met for 14 sessions over a period of 5 months. Pre- and postmeasures of physiological (serum cholesterol, serum triglycerides, blood pressure) and psychological (anxiety, psychological symptoms, satisfaction) variables were taken. Results indicate that both treatment groups changed in the desired direction on most of the psychological and physiological variables without apparent change in habits of diet, exercise, smoking, or work load. The findings are provocative, but only tentative, leaving questions of clinical validity, durability, and generalizability unresolved. Nevertheless, they indicate that this approach to modifying type A behavior may reduce coronary risk and therefore warrants further exploration.

Medically and surgically treated coronary patients in cardiovascular rehabilitation: a comparative study

Mood and physical performance were assessed in medically and surgically treated patients with coronary artery disease referred to a cardiovascular rehabilitation program early in convalescence. Surgically treated patients reported less mood disturbance prior to training and demonstrated greater gains in exercise tolerance. Medically managed patients had more mood disturbance prior to training and greater mood improvement in the six week rehabilitation program. Improvements in mood were independent of improvement in exercise tolerance. Group differences in mood state could not be attributed to the use of defensive denial, time from discharge, severity of coronary disease, or age of patient. The psychological and physical impact of bypass surgery contributes to the mood and physical performance of postoperative patients.

A typology of responses to illness in survivors of myocardial infarction

One hundred and eighteen survivors of myocardial infarction were assigned scores on eight dimensions of illness behaviour recently described as arising in response to myocardial infarction. These data were subjected to a cluster analysis to produce an optimal solution of four homogeneous clusters of patients. The first contained patients who, on clinical grounds, appeared to be claiming illness as a highly significant and consequential occurrence in their lives; the second accepted illness but experienced a marked affective response to it; the third appeared to adopt a realistic approach to illness and be coping adequately; and the fourth seemed to be denying (or at least minimizing) both the presence of serious illness and its possible consequences. These findings were discussed in terms of their bearing on prognosis, within the context of abnormal illness behaviour.

The liaison psychiatrist in cardiovascular rehabilitation: an overview

Depression, anxiety and fear of recurrence following myocardial infarction often lead to disability in excess of actual cardiac impairment in a large number of patients. The high social, economic and emotional cost of psychogenic cardiac invalidism has stimulated the development of cardiovascular rehabilitation programs throughout the country. The liaison psychiatrist can play a critical role in the rehabilitation effort. This paper describes the psychological impact of the rehabilitation process in combating psychogenic cardiac disability. The conflicts of the post-infarction patient and their management by the rehabilitation team are presented from the perspective of the team psychiatrist. Cardiovascular rehabilitation as described is a productive area for psychiatric liaison, through individual consultation, group therapy sessions and team meetings which address the psychosocial issues of convalescence.

Denial and rehabilitation of the post-infarction patient

The use of denial has been widely accepted as an adaptive and protective coping mechanism in the acute phase of myocardial infarction. Although instrumental in lowering anxiety and mortality in the acute phase of coronary care, the use of denial creates hazards for the patient in convalescence. These hazards, not well known to intensive care personnel but all too apparent to the liaison psychiatrist working in cardiovascular rehabilitation, include a high vulnerability to disruptive anxiety and even psychosis at times of transition from greater to lesser intensity nursing care and a maladaptive resistance to rehabilitation efforts in convalescence. Failure of denial under the stress of transition may produce a transient paranoid psychosis with a clear sensorium, a variant of Abram's "cardiac psychosis." Maintenance of the defense in convalescence leads to noncompliance with medical advice and rejection of rehabilitation efforts, increasing the risk of reinfarction. A case report is presented illustrating both hazards. Recommendations for management include early recognition, supportive psychotherapy, education and mobilization in the acute phase of coronary care. Cardiovascular conditioning and reshaping of risk factors follow in convalescence. The physical and psychological benefits of this approach are reviewed. The adaptive value of denial in coronary patients is challenged from the long-term perspective of rehabilitation.