Rehabilitation of post MI depression and psychological invalidism: a pilot study

Characteristics of psychological interventions that improve depression in people with coronary heart disease: a systematic review and meta-regression

OBJECTIVE

Despite previous intervention trials, it is unclear which psychological treatments are most effective for people with coronary heart disease (CHD). We have conducted a systematic review with meta-regression to identify the characteristics of psychological interventions that improve depression and depressive symptoms among people with CHD.

METHODS

Searches of multiple electronic databases up to March 2012 were conducted, supplemented by hand-searching of identified reviews and citation tracing of eligible studies. Studies were included if they reported a randomized controlled trial of a psychological intervention for people with CHD and included depression as an outcome. Data on main effects and characteristics of interventions were extracted from eligible studies. Standardized mean differences (SMDs) were calculated for each study and pooled using random-effects models. Random-effects multivariate meta-regression was performed to identify treatment characteristics associated with improvements in depression.

RESULTS

Sixty-four independent treatment comparisons were identified. Psychological interventions improved depression, although the effect was small (SMD=0.18, p<.001). Problem solving (SMD=0.34), general education (SMD=0.19), skills training (SMD=0.25), cognitive-behavioral therapy (CBT; SMD=0.23), and relaxation (SMD=0.15) had small effects on CHD patients who were recruited irrespective of their depression status. Among high-quality trials of depressed CHD patients, only CBT showed significant but small effects (SMD=0.31). When entered into multivariable analysis, no individual treatment component significantly improved depression.

CONCLUSIONS

CBT and problem solving should be considered for inclusion in future treatment developments and randomized controlled trials. However, the effects are small in magnitude, and there is room to develop new interventions that may be more effective.

Relationship of Quality of Life and Perceived Control With Posttraumatic Stress Disorder Symptoms 3 to 6 Months After Myocardial Infarction

PURPOSE

This study examined whether psychological variables were associated with posttraumatic stress disorder (PTSD) symptoms 3 to 6 months after myocardial infarction.

METHODS

The sample included 52 patients with myocardial infarction. A structured interview was used to obtain information about PTSD symptoms, quality of life, and ratings of perceived control, danger, and predictability, as well as information about stressful events that occurred during hospitalization.

RESULTS

Four patients (7.7%) met criteria for the diagnosis of PTSD. Elevated PTSD scores were associated with poorer quality of life (r = -0.32 to -0.79). Lower perceived control was associated with higher PTSD symptom scores (r = -0.30 to -0.52). Finally, PTSD scores were significantly correlated with the number of times patients were readmitted to the hospital (r = 0.35-0.57).

CONCLUSIONS

Approximately 8% of patients experienced PTSD 3 to 6 months following MI. Increasing levels of PTSD symptoms were correlated with poorer quality of life. Perceived lack of control during the MI and multiple hospitalizations may be related to the severity of PTSD symptoms.

The cardiac anxiety questionnaire: development and preliminary validity

Heart-focused anxiety (HFA) is the fear of cardiac-related stimuli and sensations because of their perceived negative consequences. Although HFA is common to a wide variety of persons who experience chest pain and distress, it often is unrecognized and misdiagnosed, particularly in cardiology and emergency room patients without and with heart disease. To address these concerns, this article reports on the development and preliminary psychometric evaluation of the Cardiac Anxiety Questionnaire (CAQ) designed to measure HFA. In Study 1, 188 cardiology patients completed the CAQ. Item and factor analyses indicated a three-factor solution pertaining to heart-related fear, avoidance, and attention. Reliability analysis of the 18-item CAQ revealed good internal consistency of the total and subscale scores. In Study 2, 42 patients completed the CAQ and several other anxiety-related questionnaires to assess its convergent and divergent properties. Although preliminary validity results are promising, further psychometric study is necessary to cross-validate the CAQ, examine its test-retest reliability, and confirm the stability of the factor structure. Taken together, the CAQ appears to assess HFA, and may therefore be a useful instrument for identifying patients with elevated HFA without and with heart disease.

Functional status and depression among men and women with congestive heart failure

OBJECTIVE

The study was designed 1) to examine the prevalence of depression in patients with congestive heart failure (CHF); 2) to explore associations between the physician's rating of functional status (NYHA class) and patient's assessment of functional status (physical limitation, dyspnea) with symptoms of depression; and 3) to explore gender related differences in relation to physician's rating and patient's rating of function status, and symptoms of depression.

METHOD

A sample of 119 clinically stable heart failure patients (85 males and 34 females) was recruited from an outpatient cardiology hospital practice. The patients underwent a physical examination and completed a set of questionnaires. Prevalence of depressive symptoms and the association of these symptoms with NYHA class and patient's perceived functional status was studied.

RESULTS

Findings indicate that depressive symptoms were not predominant among this sample of CHF patients. Path analyses showed non-significant direct associations between NYHA class as well as patient's perception of dyspnea with depression. In contract, the subjective indicator of physical limitations was strongly associated with symptoms of depression among the males, but this relation was not significant among the females.

CONCLUSIONS

Results suggest that men and women respond differently to the burden of heart failure. However, interpretation of the results from the present study should be considered as tentative and additional research is required to examine mechanisms that explain gender differences in response to heart failure.

Development of an instrument to measure cardiac illness dependency

OBJECTIVE

Dependency is frequently mentioned in the literature as a response of patients with cardiac disease. The purpose of this study was to develop and test a measure of dependency occurring in response to a cardiac illness. Illness dependency is defined as the need for emotional protection and social support after a significant change in health.

DESIGN

Instrument development study.

SAMPLE

Convenience sample of 311 patients with cardiac disease.

RESULTS

The final version of the instrument has 25 items, each of which is measured on a 5-point Likert-type scale. Content validity was demonstrated using a panel of experts. Internal consistency of the total scale was 0.90; subscale alpha coefficients ranged from 0.64 to 0.81. Exploratory factor analysis supported a four factor solution: Attention, Reassurance, Concern, and Assistance, which accounted for 57.4% of the variance in scores. Discriminant validity was demonstrated by a low correlation with neuroticism. Social desirability of responses was minimal.

CONCLUSION

Internal consistency reliability, content validity, and discriminant validity of the Illness Dependency Scale have initial support. This instrument is ready for use in research in which the investigator wishes to measure dependency associated with cardiac illness.

Relationship between hope and self-esteem in renal transplant recipients

In the transplant community great emphasis is placed on health and well-being. Because hope and self-esteem are linked with a positive health outcome, knowledge of transplantation should include an understanding of the extent to which hope is influenced by self-esteem. Few researchers have addressed the topic of hope and its impact on self-esteem; therefore, we sought to ascertain whether a relationship exists between hope and self-esteem in renal transplant recipients.

Psychosocial recovery from a cardiac event: the influence of perceived control

OBJECTIVE

To determine the relationship between patients' feelings of control at baseline and psychosocial recovery 6 months after their cardiac event.

PATIENTS

One hundred seventy-six patients who had had myocardial infarction, had undergone coronary artery bypass or both.

DESIGN

In this longitudinal, comparative survey patients with high perceptions of control were compared with those with low perceptions of control at baseline to determine differences in psychosocial recovery 6 months later.

OUTCOME MEASURES

Psychosocial recovery was operationalized as anxiety, depression, and hostility (measured by Multiple Affect Adjective Checklist) and overall psychosocial adjustment to illness (measured by Psychosocial Adjustment to Illness Scale).

RESULTS

Significant differences were seen in psychosocial recovery between patients with feelings of high control versus those with feelings of low control (p = 0.006). Patients with feelings of high control at baseline were less anxious (p = 0.002), less depressed (p = 0.001), less hostile (p = 0.02), and had better psychosocial adjustment (p = 0.009) at a 6-month follow-up than those with feelings of low control.

CONCLUSION

Feelings of perceived control are important for psychosocial recovery after a cardiac event.

Anxiety and self-care following myocardial infarction

The purpose of this study was to examine the relationship between trait and state anxiety experienced during hospitalization for an acute myocardial infarction and self-care behaviors several weeks after the infarction. Sixty-two male (n = 39) and female (n = 23) subjects were interviewed during their hospital stay and again 3 months after discharge. State and trait anxiety were measured by the Spielberger State-Trait Anxiety Inventory Test. Medication, exercise, smoking, diet, and stress management self-care were measured by Miller's Health Behavior Scale. The findings revealed low correlations between trait anxiety and exercise performance, medication administration, stress management, and smoking cessation behavior, and between state anxiety and smoking behavior. The findings were interpreted in light of the conceptual differences between state and trait anxiety, and suggest that mental health interventions during hospitalization should emphasize teaching patients to manage their own anxiety instead of directly intervening to reduce current levels of anxiety among this population.

Cardiac rehabilitation program participation and outcomes after myocardial infarction

Rehabilitation programs for myocardial infarction (MI) survivors are designed to alter survivors' self-care patterns and to improve long-term physical and psychological outcomes. The purpose of this study was to examine the relationship between participation in cardiac rehabilitation and health state; days of reduced activity; anxiety; depression; self-esteem; quality of life; and performance of exercise, diet, medication, stress-modification, and smoking-reduction self-care behaviors after MI. Interviews were conducted with 197 women and men 1 to 2 years after their initial MI to measure health state, mood, self-esteem, quality of life, and relevant self-care behaviors. Rehabilitation center records were reviewed to determine participation in rehabilitation programs. Rehabilitation participation was significantly associated with health state; days of reduced activity; self-esteem; quality of life; and performance of exercise, diet, and medication self-care. These findings suggest that participation in cardiac rehabilitation is a worthwhile intervention that facilitates recovery from myocardial infarction.

Anxiety, depression, quality of life, and self-care among survivors of myocardial infarction

This article examines the relationship between anxiety, depression, quality of life, and performance of suggested self-care behaviors among older adult myocardial infarction survivors. Interviews were conducted with 94 adults aged 65 years and older. The Profile of Mood States was used to measure anxiety and depression. Quality of life was measured with the Perceived Quality of Life scale. The Health Behavior Scale was used to measure performance of suggested self-care behaviors (modify diet, administer medications, manage stress, exercise, and reduce smoking). Depression scores accounted for 49% of the variance in quality of life scores. Depression scores predicted each of the self-care behavior scores. Anxiety scores did not predict quality of life scores or any self-care behavior score. Findings suggest that mental health interventions should become an integral part of formal cardiac rehabilitation programs soon after the infarction; interventions for depression long after the infarction are needed as well.

Myocardial infarction survivors: age and gender differences in physical health, psychosocial state and regimen adherence

Little is known about women's and older adults' experiences after myocardial infarction (MI). The purpose of this study was to determine if gender and age differences exist in psychosocial condition, health state and therapeutic regimen adherence among MI survivors. Adults aged 40 to 88 years (n = 197) were interviewed 1 to 2 years after their first MI. The Profile of Mood States was used to measure anxiety and depression, the Personal Resources Questionnaire was used to measure social support, the Rosenberg Self-Esteem scale was used to measure self-esteem, the Perceived Quality of Life scale was used to measure quality of life, and the Health Behaviour Scale was used to assess therapeutic regimen adherence. Cardiac rehabilitation participation was recorded from rehabilitation centre records. Subjective health appraisals were assessed using investigator-developed questions. Increased age was associated with higher depression scores, lower quality of life, less social support, less participation in formal cardiac rehabilitation, less therapeutic exercise and poorer general health. Women reported poorer health than men. Findings indicated older males may be at risk for lower social support and continued smoking after infarction. These findings suggest that the often-reported experience of middle-aged males post-MI cannot be generalized to all adults experiencing infarction.

Depression after acute myocardial infarction. The role of primary care physicians in rehabilitation

Depression is a common problem after myocardial infarction. Diagnosis is facilitated by use of the criteria for depression in the Diagnostic and Statistical Manual of Mental Disorders and self-rating questionnaires. Treatment may involve both psychological and pharmacologic interventions. The patient's medical status must be carefully assessed before administration of antidepressant medication. All antidepressants are contraindicated immediately after myocardial infarction. When signs and symptoms of depression are exhibited early in the recovery phase, alprazolam (Xanax) may offer advantages over more traditional antidepressants. Further research is necessary to determine the safety of newer antidepressants.