Qualitative Analysis of Emotional Distress in Cardiac Patients From the Perspectives of Cognitive Behavioral and Metacognitive Theories: Why Might Cognitive Behavioral Therapy Have Limited Benefit, and Might Metacognitive Therapy Be More Effective?

Loneliness and repetitive negative thinking mediate the link between social health and cardiac distress in heart disease patients

Cardiovascular diseases are the leading cause of mortality worldwide, contributing to one-third of global deaths. Beyond physical health, heart disease is associated with cardiac distress, an emotional response that can negatively impact recovery and well-being. Understanding the psychological and social mechanisms underlying cardiac distress is crucial for improving patient outcomes. This study examines how social health (social support and social isolation) influences cardiac distress, with loneliness and repetitive negative thinking as mediators. To evaluate a theoretical model linking social health to cardiac distress, mediated by loneliness and repetitive negative thinking in patients with heart disease. A cross-sectional, correlational study was conducted in 2024 with 400 cardiac patients from two hospitals and one private clinic in Amol, Iran. Participants completed validated questionnaires assessing cardiac distress, social support, social isolation, loneliness, and repetitive negative thinking. Structural equation modeling was used for data analysis. Social isolation (r = 0.47, p < 0.001) and repetitive negative thinking (r = 0.50, p < 0.001) were significantly associated with greater cardiac distress. Social support negatively predicted both loneliness (β = - 0.32, p < 0.001) and cardiac distress (β = - 0.25, p < 0.01). Indirect effects showed that social support reduced cardiac distress by decreasing loneliness and repetitive negative thinking (β = - 0.23, p < 0.01), while social isolation increased cardiac distress through its influence on loneliness and repetitive negative thinking (β = 0.18, p = 0.05). The model explained 47.4% of the variance in cardiac distress. These findings highlight the importance of social health in managing cardiac distress among heart disease patients. Strengthening social support may alleviate loneliness and reduce repetitive negative thinking, ultimately improving emotional well-being and health outcomes. Future research should explore targeted interventions addressing these psychosocial factors to effectively reduce cardiac distress.

Cost-effectiveness of metacognitive therapy for cardiac rehabilitation participants with symptoms of anxiety and/or depression: analysis of a randomised controlled trial

OBJECTIVES

The burden of cardiovascular disease (CVD) is increasing. Cardiac rehabilitation (CR) is a complex intervention offered to patients with CVD, following a heart event, diagnosis or intervention, and it aims to reduce mortality and morbidity. The objective of this within-trial economic evaluation was to compare the cost-effectiveness of metacognitive therapy (MCT) plus usual care (UC) to UC, from a health and social care perspective in the UK.

METHODS

A multicentre, single-blind, randomised controlled trial (ISRCTN74643496) was conducted in the UK involving 332 patients with CR with elevated symptoms of anxiety and/or depression and compared group-based MCT with UC. The primary outcome of the cost-effectiveness analysis was quality-adjusted life-years (QALYs). The time horizon of the primary analysis was a 12-month follow-up. Missing data were imputed using multiple imputation. Uncertainty was explored by probabilistic bootstrapping. Sensitivity analyses tested the impact of the study design and assumptions on the incremental cost-effectiveness ratio.

RESULTS

In the primary cost-effectiveness analysis, MCT intervention was dominant, with a cost-saving (net cost -£219; 95% CI -£1446, £1007) and QALY gains (net QALY 0.015; 95% CI -0.015, 0.045). However, there is a high level of uncertainty in the estimates. At a threshold of £30 000 per QALY, MCT intervention of around 76% was likely to be cost-effective.

CONCLUSIONS

Results suggest that intervention may be cost-saving and health-increasing; however, findings are uncertain and subject to limitations. Further research should aim to reduce the uncertainty in the findings (eg, with larger sample sizes) and explore potential longer-term economic benefits associated with MCT in this setting.

Cardiac rehabilitation: the gateway for secondary prevention

Cardiac rehabilitation (CR) is a multidisciplinary supervised programme which typically consists of tailored exercise and education on lifestyle management and risk factor modification in cardiac patients. Participation in CR reduces morbidity and mortality, while improving quality of life following major cardiovascular events. Despite the benefits of CR, it is underutilised, generally in the 20%-30% range for eligible patients. Participation and adherence rates are particularly suboptimal in vulnerable populations, such as those of lower socioeconomic status and women. Interventions such as automated referral to CR or hybrid/virtual programmes can increase enrolment to CR. This review summarises the components of CR and provides recommendations for providers regarding participation and adherence. To better engage a larger proportion of CR-eligible patients, CR programmes may need to expand or adjust ways to deliver secondary prevention.

Protocol for an implementation study of group metacognitive therapy for anxiety and depression in NHS cardiac rehabilitation services in England (PATHWAY-Beacons)

Background

Cardiac rehabilitation (CR) services aim to improve heart disease patients' health and quality of life and reduce the risk of further cardiac events. Depression and anxiety are common among CR patients but psychological treatments have usually had small effects. In contrast, the recent NIHR-funded PATHWAY trial found that group Metacognitive Therapy (MCT) was associated with improvements in anxiety and depression when added to CR and was more effective than usual CR alone. The next stage is to test implementation of MCT within the National Health Service through the creation of a network of CR beacon sites. The study will test the quality of data capture following addition of a new MCT data-field to the national audit of cardiac rehabilitation (NACR), examine level of adoption at sites, examine mental health outcomes benchmarked against usual CR and the PATHWAY data, examine the enablers and barriers to implementation and the expected resource requirements. The study has been registered: NCT05956912 (13th July, 2023).

Methods

Beacon sites will be recruited as preliminary adopters of group MCT from NHS CR services in England. A national invitation for expressions of interest from CR services will be issued and those meeting eligibility criteria will be considered for inclusion. Two staff at each site will receive training in MCT, and mixed-methods will be used to address questions concerning the quality of patient data recorded, level of adoption at sites, the characteristics of patients attending MCT, the impact of adding MCT to CR on mental health outcomes, and patient, healthcare staff and commissioner views of barriers/enablers to implementation. Exploration of implementation will be informed by Normalisation Process Theory.

Discussion

The study will support development of an NHS roll-out strategy, assess the mental health outcomes associated with MCT, examine treatment fidelity in real-world settings, and evaluate revised data collection structures that can be used to assess the impact of national-level implementation.

Trial Registration

NCT05956912; 13th July 2023.

Qualitative analysis of emotional distress in burns, plastic and reconstructive surgery patients from the perspectives of cognitive and metacognitive models

Introduction

Burns and other injuries requiring plastic and/or reconstructive surgery (BPRS) are lifechanging, often unexpected, and increase the risk of psychiatric morbidity. There are no published studies we are aware of that explores the applicability of psychological models to BPRS patients. Cognitive behavioural therapy (CBT) is the benchmark treatment in mental health but may be less effective in physical health settings. Metacognitive therapy (MCT)can be more effective than CBT in mental health settings and shows promise in reducing anxiety and depression symptoms in people with cancer and cardiac disease. The present study explored the psychological experiences (feelings, thoughts, and coping strategies) of BPRS patients, and whether the concepts underpinning cognitive and metacognitive models can be elicited from these accounts.

Method

Semi structured interviews were conducted with 11 patients recruited from a BPRS psychology service. Data was analysed using Thematic Analysis. Patients described a range of emotions including low mood, anxiety, anger, guilt, loss, and negative thinking.

Results

From the perspective of the cognitive model, there were examples of each of 10 pre-specified distorted thinking types (cognitive distortions), and patient talk seemed to fit problem-specific cognitive models. From the perspective of the metacognitive model, all patients described the "cognitive attentional syndrome," i.e., how they engaged in repetitive negative thinking (worry, rumination) and thought-focused regulation strategies. Patient talk also demonstrated both positive and negative metacognitive beliefs.

Conclusion

The implications of applying the findings from each model to clinical practice are discussed. The metacognitive model may offer benefits in clinical practice that should be investigated further.

Cardiac Rehabilitation practitioners' views on patients' psychological needs: a qualitative study

Background

Psychological difficulties are prevalent in patients undergoing Cardiac Rehabilitation (CR). Recent guidelines recommend that practitioners inquire and address patients' psychological concerns during CR. Therefore, Study One aimed to explore practitioners' understanding of patients' psychological needs, their confidence in supporting those needs, and their views on whether current CR meets patients' needs. Study Two aimed to validate Study Ones' findings among a wider sample of CR practitioners.

Methods

This study consisted of two interrelated qualitative interviews. Study One utilised qualitative interview data from the PATHWAY trial (REC Reference:15/NW/0163), while Study Two utilised new interview data collected as part of the PATHWAY Beacons study (REC Reference: 22/HRA/2220). In Study One semi-structured interviews with six CR practitioners were analysed using thematic analysis. In Study Two, 11 CR practitioners across England were interviewed using member-checking principles. Transcripts were coded systematically using the codes developed in Study One and, through constant comparative analysis.

Results

Four main themes were identified: staff's awareness of mental health problems, CR patients' needs, staff's self-efficacy to support patients' psychological needs, and current psychological provision in CR. The main themes and 11 subthemes were transferable to a wider range of CR practitioners, thereby indicating the trustworthiness of the findings.

Conclusion

Practitioners described that patients experience a range of psychological concerns, including adjustment difficulties, anxiety, and cardiac and noncardiac worries. Most practitioners normalise patient concerns and offer relaxation techniques. However, practitioners have noted that patients often have complex psychological needs, but practitioners' confidence in discussing and supporting psychological concerns varies. Practitioners expressed the need for training to support patients' psychological needs.

Cardiac rehabilitation for children and young people (CardioActive): protocol for a single-blind randomised feasibility and acceptability study of a centre-based cardiac rehabilitation programme versus usual care in 11-16 years with heart conditions

BACKGROUND

Congenital heart conditions are among the most common non-communicable diseases in children and young people (CYP), affecting 13.9 million CYP globally. While survival rates are increasing, support for young people adjusting to life with a heart condition is lacking. Furthermore, one in three CYP with heart conditions also experiences anxiety, depression or adjustment disorder, for which little support is offered. While adults are offered cardiac rehabilitation (CR) to support their mental and physical health, this is not offered for CYP.One way to overcome this is to evaluate a CR programme comprising exercise with mental health support (CardioActive; CA) for CYP with heart conditions. The exercise and mental health components are informed by the metacognitive model, which has been shown to be effective in treating anxiety and depression in CYP and associated with improving psychological outcomes in adult CR.

METHOD AND ANALYSIS

The study is a single-blind parallel randomised feasibility trial comparing a CR programme (CA) plus usual care against usual care alone with 100 CYP (50 per arm) aged 11-16 diagnosed with a heart condition. CA will include six group exercise, lifestyle and mental health modules. Usual care consists of routine outpatient management. Participants will be assessed at three time points: baseline, 3-month (post-treatment) and 6-month follow-up. Primary outcomes are feasibility and acceptability (ie, referral rates, recruitment and retention rates, attendance at the intervention, rate of return and level of completion of follow-up data). Coprimary symptom outcomes (Strength and Difficulties Questionnaire and Paediatric Quality of Life) and a range of secondary outcomes will be administered at each time point. A nested qualitative study will investigate CYP, parents and healthcare staff views of CR and its components, and staff's experience of delivering CA. Preliminary health economic data will be collected to inform future cost-effectiveness analyses. Descriptive data on study processes and clinical outcomes will be reported. Data analysis will follow intention to treat. Qualitative data will be analysed using thematic analysis and the theoretical framework of acceptability.

ETHICS AND DISSEMINATION

Ethical approval was granted on 14 February 2023 by the Greater Manchester East Research Ethics Committee (22/NW/0367). The results will be disseminated through peer-reviewed journals, conference presentations and local dissemination.

TRIAL REGISTRATION NUMBER

ISRCTN50031147; NCT05968521.

Experience sampling methodology study of anxiety and depression in adolescents with epilepsy: The role of metacognitive beliefs and perseverative thinking

Emotional distress is common in young people with epilepsy (YPwE). According to the Self-Regulatory Executive Function (S-REF) model, maladaptive metacognitive beliefs and perseverative thinking are fundamental in the development and maintenance of emotional distress. As emotional distress and perseverative thinking can highly fluctuate over short intervals in YPwE, it is important to account for this variability when testing the utility of psychological models. Experience sampling methodology (ESM) was therefore used to explore the momentary relationship between metacognitive beliefs, perseverative thinking, and emotional distress in YPwE. Eighteen participants diagnosed with epilepsy (aged 12-17 years) completed the 10-day ESM period. Participants were prompted to complete the ESM assessment five times daily. The ESM assessment assessed participant's momentary levels of metacognitive beliefs, perseverative thinking (i.e., worry and rumination), and emotional distress (i.e., anxiety and depression). A series of multilevel regression analyses indicated that metacognitive beliefs were significantly positively associated with worry, rumination, anxiety and depression. After controlling for worry and rumination, respectively, metacognitive beliefs did not account for additional variance in anxiety or depression. Findings provide preliminary support for the utility of the S-REF model for emotional distress in YPwE. Metacognitive therapy, which is underpinned by the S-REF model, may be an appropriate intervention for emotional distress in YPwE. Future studies should assess the mediational relationship between metacognitive beliefs, perseverative thinking, and emotional distress using time-lagged models.

Psychosocial factors associated with anxiety and depression in adolescents with epilepsy: A systematic review

Anxiety and depression are common in adolescents with epilepsy. Identifying psychosocial risk factors for anxiety and depression is essential for adolescents with epilepsy to receive appropriate support. This systematic review synthesised findings of studies examining the relationship between psychosocial factors and anxiety and/or depression in adolescents with epilepsy. Outcomes were anxiety, depression, and mixed anxiety & depression. Six electronic databases were searched for studies which: used cross-sectional or prospective designs; quantitatively evaluated the relationship between psychosocial factors and anxiety and/or depression; presented results for adolescents with epilepsy aged 9-18 years; and used validated measures of anxiety and/or depression. Psychosocial factors were categorised as intrapersonal, interpersonal, or parent-specific factors. Sixteen studies (23 articles) were included. All but one were cross-sectional. Regarding intrapersonal factors, alternative mental health difficulties were consistently positively associated with all three outcomes. Negative attitude towards epilepsy, lower seizure self-efficacy, lower self-esteem and stigma were consistently positively associated with depression. Interpersonal factors (i.e., lower family functioning assessed from an adolescent's perspective) and parent-specific factors (i.e., parental stigma, stress, anxiety and psychopathology) were positively associated with at least one outcome. Adolescent epilepsy management should exceed assessment of biological/biomedical factors and incorporate assessment of psychosocial risk factors. Prospective studies examining the interplay between biological/biomedical factors and the psychosocial factors underpinning anxiety and depression in adolescents with epilepsy are needed.

Improving mental well-being in psychocardiology-a feasibility trial for a non-blended web application as a brief metacognitive-based intervention in cardiovascular disease patients

Background

Many patients with cardiovascular disease also show a high comorbidity of mental disorders, especially such as anxiety and depression. This is, in turn, associated with a decrease in the quality of life. Psychocardiological treatment options are currently limited. Hence, there is a need for novel and accessible psychological help. Recently, we demonstrated that a brief face-to-face metacognitive therapy (MCT) based intervention is promising in treating anxiety and depression. Here, we aim to translate the face-to-face approach into digital application and explore the feasibility of this approach.

Methods

We translated a validated brief psychocardiological intervention into a novel non-blended web app. The data of 18 patients suffering from various cardiac conditions but without diagnosed mental illness were analyzed after using the web app over a two-week period in a feasibility trial. The aim was whether a non-blended web app based MCT approach is feasible in the group of cardiovascular patients with cardiovascular disease.

Results

Overall, patients were able to use the web app and rated it as satisfactory and beneficial. In addition, there was first indication that using the app improved the cardiac patients' subjectively perceived health and reduced their anxiety. Therefore, the approach seems feasible for a future randomized controlled trial.

Conclusion

Applying a metacognitive-based brief intervention via a non-blended web app seems to show good acceptance and feasibility in a small target group of patients with CVD. Future studies should further develop, improve and validate digital psychotherapy approaches, especially in patient groups with a lack of access to standard psychotherapeutic care.

Metacognitive therapy home-based self-help for anxiety and depression in cardiovascular disease patients in the UK: A single-blind randomised controlled trial

BACKGROUND

Anxiety and depression in cardiac rehabilitation (CR) are associated with greater morbidity, mortality, and increased healthcare costs. Current psychological interventions within CR have small effects based on low-quality studies of clinic-based interventions with limited access to home-based psychological support. We tested the effectiveness of adding self-help metacognitive therapy (Home-MCT) to CR in reducing anxiety and depression in a randomised controlled trial (RCT).

METHODS AND FINDINGS

We ran a single-blind, multi-centre, two-arm RCT. A total of 240 CR patients were recruited from 5 NHS-Trusts across North West England between April 20, 2017 and April 6, 2020. Patients were randomly allocated to Home-MCT+CR (n = 118, 49.2%) or usual CR alone (n = 122, 50.8%). Randomisation was 1:1 via randomised blocks within hospital site, balancing arms on sex and baseline Hospital Anxiety and Depression Scale (HADS) scores. The primary outcome was the HADS total score at posttreatment (4-month follow-up). Follow-up data collection occurred between August 7, 2017 and July 20, 2020. Analysis was by intention to treat. The 4-month outcome favoured the MCT intervention group demonstrating significantly lower end of treatment scores (HADS total: adjusted mean difference = -2.64 [-4.49 to -0.78], p = 0.005, standardised mean difference (SMD) = 0.38). Sensitivity analysis using multiple imputation (MI) of missing values supported these findings. Most secondary outcomes also favoured Home-MCT+CR, especially in reduction of post-traumatic stress symptoms (SMD = 0.51). There were 23 participants (19%) lost to follow-up in Home-MCT+CR and 4 participants (3%) lost to follow-up in CR alone. No serious adverse events were reported. The main limitation is the absence of longer term (e.g., 12-month) follow-up data.

CONCLUSION

Self-help home-based MCT was effective in reducing total anxiety/depression in patients undergoing CR. Improvement occurred across most psychological measures. Home-MCT was a promising addition to cardiac rehabilitation and may offer improved access to effective psychological treatment in cardiovascular disease (CVD) patients.

TRIAL REGISTRATION

NCT03999359.

Metacognitive Short-Term Intervention in Patients With Mental Disorders Following Cardiovascular Events

Background

Mental disorders are common among patients with severe cardiovascular diseases (CVD). Yet, there is a lack of easily accessible evidence-based treatments. Recent research indicates elevated prevalence of dysfunctional metacognitions in patients with mental disorders following cardiovascular events. As metacognitive therapy (MCT) is an established treatment to modify metacognitions, we tested if a brief metacognitive intervention via videotelephony is effective in this patient group.

Methods

A brief MCT treatment was tailored to CVD patients and designed as a face-to-face internet-based intervention. Five patients with CVDs and comorbid mental disorders underwent a psychocardiological examination and diagnostic approach. Each patient participated in eight 50 min sessions via encrypted video messenger service. Metacognitions, depression and anxiety symptoms and quality of life were assessed by self-report measures pre- and post-treatment. Patients rated dysfunctional thought processes, current psychological impairment, and treatment satisfaction after each session. Intended follow-up measures were not reported due to missing data.

Results

For most patients, the brief metacognitive intervention was associated with a decrease in dysfunctional metacognitions and a reduction of symptoms of anxiety and depression post-treatment. Psychological and physiological quality of life improved. Patients reported high satisfaction with the tailored treatment.

Conclusion

Our results suggest that a brief internet-based metacognitive treatment may be a promising tool for patients with CVDs and comorbid mental disorders. Feasibility and acceptance of the intervention was rated high by the patients. Further research is necessary to support the preliminary findings and to adapt and evaluate the intervention in a controlled clinical trial setting.

[Long-term course of heart disease: How can psychosocial care be improved?]

Cardiovascular diseases, which primarily include coronary artery disease (CAD), heart failure (HF) and cardiac arrhythmias, are the leading causes of death in the European Union and responsible for most of the serious courses of coronary disease. Acute events are usually the focus of clinical attention. In contrast, there are hardly any structured care and therapy concepts for the long-term course of these diseases. Based on a literature review, this article provides an overview of the long-term consequences and long-term care of heart diseases. Deficits in the psychosocial care of patients and possible solutions are discussed.Patients with CAD often experience problems with medication adherence and compliance to behavioural recommendations due to inadequate long-term psychosocial care. Psychological comorbidities reduce the quality of life and are a driver for health-damaging behaviour. Patients with cardiac arrhythmias often get into a vicious circle of recurrent physical complaints interacting with anxiety and panic attacks and the associated use of outpatient, emergency, or inpatient care facilities. In the course of heart failure, a clinically significant growing number of patients are treated with antidepressants, the benefit of which is rather doubtful.The apparent deficits in long-term psychosocial care of cardiovascular disease and the quality of life of patients could be improved through the increased use of systematic collaborative care models by specialised care facilities with the involvement of general practitioners.

Evaluating Metacognitive Therapy to Improve Treatment of Anxiety and Depression in Cardiovascular Disease: The NIHR Funded PATHWAY Research Programme

BACKGROUND

Anxiety and depression contribute to poorer physical and mental health outcomes in cardiac patients. Psychological treatments are not routinely offered in cardiac care and have mixed and small effects. We conducted a series of studies under the PATHWAY research programme aimed at understanding and improving mental health outcomes for patients undergoing cardiac rehabilitation (CR) through provision of metacognitive therapy (MCT).

METHODS

PATHWAY was a series of feasibility trials, single-blind, multicenter, randomized controlled trials (RCTs), qualitative, stated preferences for therapy and health economics studies.

FINDINGS

Patients felt their psychological needs were not met in CR and their narratives of distress could be parsimoniously explained by the metacognitive model. Patients reported they would prefer therapy over no therapy as part of CR, which included delivery by a cardiac professional. Two feasibility studies demonstrated that RCTs of group-based and self-help MCT were acceptable, could be embedded in CR services, and that RCTs of these interventions were feasible. A definitive RCT of group-MCT within CR (n = 332) demonstrated significantly greater reductions in the severity of anxiety and depression, exceeding CR alone, with gains maintained at 12 month follow-up (SMD HADS total score = 0.52 at 4 months and 0.33 at 12 months). A definitive trial of self-help MCT is ongoing.

CONCLUSION

There is a need to better meet the psychological needs of CR patients. Embedding MCT into CR demonstrated high acceptability and improved efficacy on psychological outcomes. Results support roll-out of MCT in CR with evaluation of national implementation.

REGISTRATION

URL: NCT02420431; ISRCTN74643496; NCT03129282.

Delivery preferences for psychological intervention in cardiac rehabilitation: a pilot discrete choice experiment

Background

Cardiac rehabilitation (CR) is a programme of care offered to people who recently experienced a cardiac event. There is a growing focus on home-based formats of CR and a lack of evidence on preferences for psychological care in CR. This pilot study aimed to investigate preferences for delivery attributes of a psychological therapy intervention in CR patients with symptoms of anxiety and/or depression.

Methods

A discrete choice experiment (DCE) was conducted and recruited participants from a feasibility trial. Participants were asked to choose between two hypothetical interventions, described using five attributes; intervention type (home or centre-based), information provided, therapy manual format, cost to the National Health Service (NHS) and waiting time. A separate opt-out was included. A conditional logit using maximum likelihood estimation was used to analyse preferences. The NHS cost was used to estimate willingness to pay for aspects of the intervention delivery.

Results

35 responses were received (39% response rate). Results indicated that participants would prefer to receive any form of therapy compared with no therapy. Statistically significant results were limited, but included participants being keen to avoid not receiving information prior to therapy (β=−0.270; p=0.03) and preferring a lower cost to the NHS (β=−0.001; p=0.00). No significant results were identified for the type of psychological intervention, format of therapy/exercises and programme start time. Coefficients indicated preferences were stronger for home-based therapy compared with centre-based, but this was not significant.

Conclusions

The pilot study demonstrates the feasibility of a DCE in this group, it identifies potential attributes and levels, and estimates the sample sizes needed for a full study. Preliminary evidence indicated that sampled participants tended to prefer home-based psychological therapy in CR and wanted to receive information before initiating therapy. Results are limited due to the pilot design and further research is needed.

Improving the Effectiveness of Psychological Interventions for Depression and Anxiety in Cardiac Rehabilitation: PATHWAY-A Single-Blind, Parallel, Randomized, Controlled Trial of Group Metacognitive Therapy

BACKGROUND

Depression and anxiety in cardiovascular disease are significant, contributing to poor prognosis. Unfortunately, current psychological treatments offer mixed, usually small improvements in these symptoms. The present trial tested for the first time the effects of group metacognitive therapy (MCT; 6 sessions) on anxiety and depressive symptoms when delivered alongside cardiac rehabilitation (CR).

METHODS

A total of 332 CR patients recruited from 5 National Health Service Trusts across the North-West of England were randomly allocated to MCT+CR (n=163, 49.1%) or usual CR alone (n=169, 50.9%). Randomization was 1:1 via minimization balancing arms on sex and Hospital Anxiety and Depression Scale scores within hospital site. The primary outcome was Hospital Anxiety and Depression Scale total after treatment (4-month follow-up). Secondary outcomes were individual Hospital Anxiety and Depression Scales, traumatic stress symptoms, and psychological mechanisms including metacognitive beliefs and repetitive negative thinking. Analysis was intention to treat.

RESULTS

The adjusted group difference on the primary outcome, Hospital Anxiety and Depression Scale total score at 4 months, significantly favored the MCT+CR arm (-3.24 [95% CI, -4.67 to -1.81], P<0.001; standardized effect size, 0.52 [95% CI, 0.291 to 0.750]). The significant difference was maintained at 12 months (-2.19 [95% CI, -3.72 to -0.66], P=0.005; standardized effect size, 0.33 [95% CI, 0.101 to 0.568]). The intervention improved outcomes significantly for both depression and anxiety symptoms when assessed separately compared with usual care. Sensitivity analysis using multiple imputation of missing values supported these findings. Most secondary outcomes favored MCT+CR, with medium to high effect sizes for psychological mechanisms of metacognitive beliefs and repetitive negative thinking. No adverse treatment-related events were reported.

CONCLUSIONS

Group MCT+CR significantly improved depression and anxiety compared with usual care and led to greater reductions in unhelpful metacognitions and repetitive negative thinking. Most gains remained significant at 12 months. Study strengths include a large sample, a theory-based intervention, use of longer-term follow-up, broad inclusion criteria, and involvement of a trials unit. Limitations include no control for additional contact as part of MCT to estimate nonspecific effects, and the trial was not intended to assess cardiac outcomes. Nonetheless, results demonstrated that addition of the MCT intervention had broad and significant beneficial effects on mental health symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: ISRCTN74643496.

Development of an internet-delivered program and platform for the treatment of depression and anxiety in patients with ischemic heart disease in eMindYourHeart

To design and evaluate a mental health treatment program and internet-based delivery platform for patients with ischemic heart disease (IHD) attending cardiac rehabilitation with the aim of reducing the risks associated with anxiety and/or depression. Patients diagnosed with IHD and comorbid anxiety and/or depression. Participatory design of treatment program and internet platform through staged inclusion of participants in two groups. Group 1 was enrolled as co-researchers with prolonged engagement in the project. Group 2 participated only in the pilot evaluation workshop. Three patients were included in Group 1, two patients in Group 2. Inclusion of patients proved challenging, but the extended collaboration with co-researchers yielded valuable circumstantial insight and resulted in the design of a novel nine-module treatment program. Additionally, the inclusion of two participant groups helped shape the development of an internet platform based on an open-source content management system. Our grouped participation method contributes with several recommendations and reflections of advantages of this approach. Collaboration with co-researchers helped us gain a deeper understanding of the impact of language on self-perception and potential stigma. Prolonged participation led to a higher level of trust and familiarity, which enabled uncovering of issues otherwise hidden.

The Association Between Maladaptive Metacognitive Beliefs and Emotional Distress in People Living With Amyotrophic Lateral Sclerosis

OBJECTIVE

Approximately half of all people living with amyotrophic lateral sclerosis (ALS) experience persistent or recurrent emotional distress, yet little is known about the psychological processes that maintain emotional distress in this population. The self-regulatory executive functioning (S-REF) model specifies that maladaptive metacognitive beliefs and processes are central to the development and maintenance of emotional distress. This study explored whether maladaptive metacognitive beliefs are associated with emotional distress after controlling for demographic factors, time since diagnosis, and current level of physical functioning.

DESIGN

In a cross-sectional design, 75 adults with a diagnosis of ALS completed self-report questionnaires. Participants had a mean age of 60.40 years, mean duration of symptoms 63.92 months, and male:female gender ratio of 14:11.

MAIN OUTCOME MEASURES

Questionnaires assessed emotional distress (HADS, adapted for ALS), physical functioning (ALSFRS-R), repetitive negative thinking (RTQ-10), metacognitive beliefs (MCQ-30), and demographic factors.

RESULTS

Maladaptive metacognitive beliefs explained additional variance in emotional distress after controlling for age, gender, time since diagnosis, physical functioning, and repetitive negative thinking. Repetitive negative thinking partially mediated the relationships between positive and negative metacognitive beliefs and emotional distress.

CONCLUSIONS

These data support the utility of the metacognitive model in understanding emotional distress in people with ALS. Examination of the temporal relationship between maladaptive metacognitive beliefs and emotional distress in people living with ALS may help to guide the development of therapeutic approaches.

Utilising Patient and Public Involvement in Stated Preference Research in Health: Learning from the Existing Literature and a Case Study

Publications reporting discrete choice experiments of healthcare interventions rarely discuss whether patient and public involvement (PPI) activities have been conducted. This paper presents examples from the existing literature and a detailed case study from the National Institute for Health Research-funded PATHWAY programme that comprehensively included PPI activities at multiple stages of preference research. Reflecting on these examples, as well as the wider PPI literature, we describe the different stages at which it is possible to effectively incorporate PPI across preference research, including the design, recruitment and dissemination of projects. Benefits of PPI activities include gaining practical insights from a wider perspective, which can positively impact experiment design as well as survey materials. Further benefits included advice around recruitment and reaching a greater audience with dissemination activities, amongst others. There are challenges associated with PPI activities; examples include time, cost and outlining expectations. Overall, although we acknowledge practical difficulties associated with PPI, this work highlights that it is possible for preference researchers to implement PPI across preference research. Further research systematically comparing methods related to PPI in preference research and their associated impact on the methods and results of studies would strengthen the literature.

Metacognitive Therapy for Adjustment Disorder in a Patient With Newly Diagnosed Pulmonary Arterial Hypertension: A Case Report

Adjustment disorders (ADs) belong to the worldwide most diagnosed mental disorders and are particularly frequent in patients with an underlying physical illness. Pulmonary arterial hypertension (PAH) is a severe and disabling disease, which significantly impacts on quality of life and has high mortality rates. The authors here present the case of a young female who developed a severe adjustment disorder with both anxious and depressive symptoms after a diagnosis of PAH requiring intensive care treatment due to right heart failure. Psychosocial functioning was severely impaired, and physical health reduced. Following hemodynamic stabilization and the establishment of PAH treatment, the patient was admitted to the Department of Psychiatry, Social Psychiatry and Psychotherapy and received metacognitive therapy (MCT). AD with mixed anxiety and depressed mood was diagnosed according to DSM-V criteria. At the start of treatment, she reported significant mental distress, indicated by a total sum score of the Hospital Anxiety and Depression Scale (HADS) of 20 points. The 6-min walking distance was only 358 m before the patient was exhausted. She then was treated with MCT without further psychopharmacological drugs. After only four MCT sessions, she fully remitted from AD which was accompanied by an 11-point reduction in the HADS (to 9 points). MCT specific scores also improved (MCQ-30 sum score decreased from 77 to 35). Notably, physical capacity improved as well, documented by an improved walking distance (439 m; +22%). This is the first case of a patient with AD in the context of PAH treated with MCT. The case report suggests that MCT is a possible psychotherapeutic treatment option for AD in the context of a potentially life-threatening disease. The study design does not permit an attribution of outcome to MCT but it suggests MCT is a potentially viable and acceptable treatment option.

Testing relationships between metacognitive beliefs, anxiety and depression in cardiac and cancer patients: Are they transdiagnostic?

OBJECTIVE

Anxiety and depression symptoms are common in patients with physical health conditions. In the metacognitive model, beliefs about cognition (metacognitions) are a key factor in the development and maintenance of anxiety and depression. The current study evaluated if metacognitions predict anxiety and/or depression symptoms and if differential or common patterns of relationships exist across cardiac and cancer patients.

METHOD

A secondary data analysis with 102 cardiac patients and 105 patients with breast or prostate cancer were included. Participants were drawn from two studies, Wells et al. [1] and Cook et al. [2]. All patients reported at least mild anxiety or depression symptoms. Patients completed the Metacognitions Questionnaire 30 (MCQ-30) and the Hospital Anxiety and Depression Scale (HADS). Hierarchical linear regressions evaluated metacognitive predictors of anxiety and depression across the groups.

RESULTS

The results of regression analyses controlling for a range of demographics and testing for effect of illness type showed that uncontrollability and danger and positive beliefs were common and independent predictors of anxiety in both groups. There was one positive bi-variate association between metacognitive beliefs (uncontrollability and danger) and depressive symptoms.

CONCLUSIONS

Findings support the metacognitive model, suggesting that a common set of metacognitive factors contribute to psychological distress, particularly anxiety. Uncontrollability and danger metacognitions and positive beliefs about worry appear to make independent contributions to anxiety irrespective of type of physical illness. While metacognitive beliefs were not reliably associated with depressive symptoms this may be because the current sample exhibited low depression scores.