Psychological distress in coronary heart disease : Risk indicators, treatment and cardiovascular prognosis

The aims of this thesis were to: (1) explore factors associated with emotional distress; (2) investigate psychosocial stress as a risk factor for cardiovascular (CV) morbidity in patients with coronary heart disease (CHD); (3) investigate the impact of group-based stress management on psychological outcomes, and if that mediates risk of CV events; and (4) evaluate an internet-based cognitive behavioral therapy (iCBT) for emotional distress in patients with a recent myocardial infarction (MI). In Study I, data from the national registry SWEDEHEART on 27,267 MI patients < 75 years was used. Study II was a prospective longitudinal study with 14,577 patients with stable CHD. Psychosocial stress was assessed with a questionnaire and patients were followed-up for clinical events on average 3.7 years. In Study III, a group-based stress management was evaluated in a randomized controlled trial of 362 CHD patients. Psychological outcomes (stress, somatic anxiety, depression and vital exhaustion) were assessed at five time-points over two years. Joint modelling for longitudinal and time-to-event data was used to analyze if reduction in the psychological outcomes mediated the positive effect the treatment had on later CV events. Study IV describes Study V and includes a pilot study investigating the acceptability of the intervention used. In Study V 239 MI patients were recruited to evaluate iCBT versus usual care in a randomized clinical trial. In summary, in Study I, sociodemographic factors, previous psychiatric diagnosis and readmission for CV events were associated with incident and persistent emotional distress post-MI. In Study II, after multivariable adjustments, depressive symptoms, financial stress and living alone were all independently associated with CV death or the composite of CV death, non-fatal MI or non-fatal stroke. These results emphasize the importance of targeting psychosocial factors in order to optimize secondary prevention. In Study III, somatic anxiety was the only targeted psychological outcome affected positively by stress management, and may have in turn reduced subsequent CV events. Other mediating factors remain to be identified. Study IV indicated the intervention used in Study V was acceptable. Study V concluded that iCBT was not superior to usual care for emotional distress in post-MI patients and treatment adherence was unexpectedly low. Potential reasons for the low adherence require further exploration

Psychological distress in coronary heart disease : Risk indicators, treatment and cardiovascular prognosis

The aims of this thesis were to: (1) explore factors associated with emotional distress; (2) investigate psychosocial stress as a risk factor for cardiovascular (CV) morbidity in patients with coronary heart disease (CHD); (3) investigate the impact of group-based stress management on psychological outcomes, and if that mediates risk of CV events; and (4) evaluate an internet-based cognitive behavioral therapy (iCBT) for emotional distress in patients with a recent myocardial infarction (MI). In Study I, data from the national registry SWEDEHEART on 27,267 MI patients < 75 years was used. Study II was a prospective longitudinal study with 14,577 patients with stable CHD. Psychosocial stress was assessed with a questionnaire and patients were followed-up for clinical events on average 3.7 years. In Study III, a group-based stress management was evaluated in a randomized controlled trial of 362 CHD patients. Psychological outcomes (stress, somatic anxiety, depression and vital exhaustion) were assessed at five time-points over two years. Joint modelling for longitudinal and time-to-event data was used to analyze if reduction in the psychological outcomes mediated the positive effect the treatment had on later CV events. Study IV describes Study V and includes a pilot study investigating the acceptability of the intervention used. In Study V 239 MI patients were recruited to evaluate iCBT versus usual care in a randomized clinical trial. In summary, in Study I, sociodemographic factors, previous psychiatric diagnosis and readmission for CV events were associated with incident and persistent emotional distress post-MI. In Study II, after multivariable adjustments, depressive symptoms, financial stress and living alone were all independently associated with CV death or the composite of CV death, non-fatal MI or non-fatal stroke. These results emphasize the importance of targeting psychosocial factors in order to optimize secondary prevention. In Study III, somatic anxiety was the only targeted psychological outcome affected positively by stress management, and may have in turn reduced subsequent CV events. Other mediating factors remain to be identified. Study IV indicated the intervention used in Study V was acceptable. Study V concluded that iCBT was not superior to usual care for emotional distress in post-MI patients and treatment adherence was unexpectedly low. Potential reasons for the low adherence require further exploration

Psychological distress in coronary heart disease : Risk indicators, treatment and cardiovascular prognosis

The aims of this thesis were to: (1) explore factors associated with emotional distress; (2) investigate psychosocial stress as a risk factor for cardiovascular (CV) morbidity in patients with coronary heart disease (CHD); (3) investigate the impact of group-based stress management on psychological outcomes, and if that mediates risk of CV events; and (4) evaluate an internet-based cognitive behavioral therapy (iCBT) for emotional distress in patients with a recent myocardial infarction (MI). In Study I, data from the national registry SWEDEHEART on 27,267 MI patients < 75 years was used. Study II was a prospective longitudinal study with 14,577 patients with stable CHD. Psychosocial stress was assessed with a questionnaire and patients were followed-up for clinical events on average 3.7 years. In Study III, a group-based stress management was evaluated in a randomized controlled trial of 362 CHD patients. Psychological outcomes (stress, somatic anxiety, depression and vital exhaustion) were assessed at five time-points over two years. Joint modelling for longitudinal and time-to-event data was used to analyze if reduction in the psychological outcomes mediated the positive effect the treatment had on later CV events. Study IV describes Study V and includes a pilot study investigating the acceptability of the intervention used. In Study V 239 MI patients were recruited to evaluate iCBT versus usual care in a randomized clinical trial. In summary, in Study I, sociodemographic factors, previous psychiatric diagnosis and readmission for CV events were associated with incident and persistent emotional distress post-MI. In Study II, after multivariable adjustments, depressive symptoms, financial stress and living alone were all independently associated with CV death or the composite of CV death, non-fatal MI or non-fatal stroke. These results emphasize the importance of targeting psychosocial factors in order to optimize secondary prevention. In Study III, somatic anxiety was the only targeted psychological outcome affected positively by stress management, and may have in turn reduced subsequent CV events. Other mediating factors remain to be identified. Study IV indicated the intervention used in Study V was acceptable. Study V concluded that iCBT was not superior to usual care for emotional distress in post-MI patients and treatment adherence was unexpectedly low. Potential reasons for the low adherence require further exploration

Factors associated with emotional distress in patients with myocardial infarction : Results from the SWEDEHEART registry

Background: Emotional distress, symptoms of depression and anxiety, is common among patients after a myocardial infarction (MI), and is associated with an increased risk of cardiovascular morbidity. Real world population data on factors associated with emotional distress in MI patients are scarce. The aim was to determine factors associated with incident emotional distress two and 12 months post MI respectively, and with persistent emotional distress, versus remittent, in patients <75 years old. Design: This was a registry-based observational study. Methods: Data from the national SWEDEHEART registry on 27,267 consecutive patients with a first-time MI, followed up at two and 12 months post MI ( n = 22,911), were included in the analyses. Emotional distress was assessed with the EuroQol-5D questionnaire. Several candidate sociodemographic and clinical factors were analysed for their association with emotional distress in multivariate models. Results: Symptoms of emotional distress were prevalent in 38% and 33% at two and 12 months post MI respectively. At both time-points, previous depression and/or anxiety, readmission for new cardiovascular event, female gender, younger age, born outside the neighbouring Nordic countries, smoking and being neither employed nor retired showed the strongest associations with emotional distress. Other factors related to medical history, the MI and its care or were only modestly associated with emotional distress. Persistent emotional distress was associated with younger age, female gender, smoking and being born outside of the Nordic countries. Conclusion: Previous depression/anxiety, female gender, younger age, smoking, born outside of the Nordic countries, neither employed nor retired and readmission due to cardiovascular events were strongly associated with emotional distress post MI. These factors may be of relevance in tailoring rehabilitation programmes

Management of emotional distress following a myocardial infarction : a qualitative content analysis

Myocardial infarction (MI) is one of the leading causes of mortality and disability worldwide. Emotional distress, such as anxiety and depression, are common among MI patients. The aim of this study was to investigate emotional reactions following MI and to explore how MI patients self-manage their emotional distress using the perspective of an explanatory behavioural model of depression and anxiety. Written testimonies from 92 MI patients starting an internet-based cognitive behavioural therapy (iCBT) were analysed using qualitative content analysis with a mixed deductive and inductive approach. Six themes were identified. The first three highlight the emotional reactions post-MI: Hypoarousal reactions and low mood; Hyperarousal reactions; and A changed sense of self and outlook on life. The following three themes describe strategies for managing emotional distress: Avoidance of potentially rewarding situations; Avoidance of heart relevant stimuli triggering anxiety; and Engaging in potentially positive activities and acceptance. The MI experience may trigger emotional reactions, with a particular emphasis on heart-focused anxiety, depression and a shift in the perception of one's identity. Patients tend to manage emotional distress through social withdrawal and experiential avoidance which likely maintains the distress. Applying a behavioural model to the management of emotional distress following MI is suited

Treatment Activity, User Satisfaction, and Experienced Usability of Internet-Based Cognitive Behavioral Therapy for Adults With Depression and Anxiety After a Myocardial Infarction : Mixed-Methods Study

BACKGROUND: Knowledge about user experiences may lead to insights about how to improve treatment activity in Internet-based cognitive behavioral therapy (iCBT) to reduce symptoms of depression and anxiety among people with a somatic disease. There is a need for studies conducted alongside randomized trials, to explore treatment activity and user experiences related to such interventions, especially among people with older age who are recruited in routine care. OBJECTIVE: The aim of the study was to explore treatment activity, user satisfaction, and usability experiences among patients allocated to treatment in the U-CARE Heart study, a randomized clinical trial of an iCBT intervention for treatment of depression and anxiety following a recent myocardial infarction. METHODS: This was a mixed methods study where quantitative and qualitative approaches were used. Patients were recruited consecutively from 25 cardiac clinics in Sweden. The study included 117 patients allocated to 14 weeks of an iCBT intervention in the U-CARE Heart study. Quantitative data about treatment activity and therapist communication were collected through logged user patterns, which were analyzed with descriptive statistics. Qualitative data with regard to positive and negative experiences, and suggestions for improvements concerning the intervention, were collected through semistructured interviews with 21 patients in the treatment arm after follow-up. The interviews were analyzed with qualitative manifest content analysis. RESULTS: Treatment activity was low with regard to number of completed modules (mean 0.76, SD 0.93, range 0-5) and completed assignments (mean 3.09, SD 4.05, range 0-29). Most of the participants initiated the introduction module (113/117, 96.6%), and about half (63/117, 53.9%) of all participants completed the introductory module, but only 18 (15.4%, 18/117) continued to work with any of the remaining 10 modules, and each of the remaining modules was completed by 7 or less of the participants. On average, patients sent less than 2 internal messages to their therapist during the intervention (mean 1.42, SD 2.56, range 0-16). Interviews revealed different preferences with regard to the internet-based portal, the content of the treatment program, and the therapist communication. Aspects related to the personal situation and required skills included unpleasant emotions evoked by the intervention, lack of time, and technical difficulties. CONCLUSIONS: Patients with a recent myocardial infarction and symptoms of depression and anxiety showed low treatment activity in this guided iCBT intervention with regard to completed modules, completed assignments, and internal messages sent to their therapist. The findings call attention to the need for researchers to carefully consider the preferences, personal situation, and technical skills of the end users during the development of these interventions. The study indicates several challenges that need to be addressed to improve treatment activity, user satisfaction, and usability in internet-based interventions in this population

Treatment of depression and anxiety with internet-based cognitive behavior therapy in patients with a recent myocardial infarction (U-CARE Heart) : study protocol for a randomized controlled trial

Background: Major depression and depressive symptoms are common in patients with a recent myocardial infarction (MI), and depression is associated with adverse cardiovascular outcomes. Anxiety post-MI is less studied, but occurs commonly in patients with heart disease, and is also considered a risk factor for recurrence of cardiac events. Cognitive behavior therapy (CBT) is an established therapy for depression and anxiety disorders. To the best of our knowledge, there have not been any studies to determine if internet-based CBT (iCBT) can reduce the symptoms of depression and anxiety in patients with a recent MI. The main aim of the U-CARE Heart trial is to evaluate an iCBT intervention for patients with a recent MI. Methods/design: This is a randomized, controlled, prospective study with a multicenter design. A total of 500 participants will be randomized at a 1:1 ratio, around two months after an acute MI, to either iCBT or to a control group. Both groups will receive an optimal standard of care according to guidelines. The intervention consists of a self-help program delivered via the internet with individual online support from a psychologist. Treatment duration is 14 weeks. The primary outcome is change in patients' self-rated anxiety and depression symptoms from baseline to end of treatment. An internal pilot study was conducted indicating sufficient levels of study acceptability and engagement in treatment. Discussion: The present study is designed to evaluate an iCBT intervention targeting symptoms of depression and anxiety in a post-MI population. If effective, iCBT has several advantages, and will potentially be implemented as an easily accessible treatment option added to modern standard of care

Predicting Adherence to Internet-Delivered Psychotherapy for Symptoms of Depression and Anxiety After Myocardial Infarction : Machine Learning Insights From the U-CARE Heart Randomized Controlled Trial

Background: Low adherence to recommended treatments is a multifactorial problem for patients in rehabilitation after myocardial infarction (MI). In a nationwide trial of internet-delivered cognitive behavior therapy (iCBT) for the high-risk subgroup of patients with MI also reporting symptoms of anxiety, depression, or both (MI-ANXDEP), adherence was low. Since low adherence to psychotherapy leads to a waste of therapeutic resources and risky treatment abortion in MI-ANXDEP patients, identifying early predictors for adherence is potentially valuable for effective targeted care. Objectives: The goal of the research was to use supervised machine learning to investigate both established and novel predictors for iCBT adherence in MI-ANXDEP patients. Methods: Data were from 90 MI-ANXDEP patients recruited from 25 hospitals in Sweden and randomized to treatment in the iCBT trial Uppsala University Psychosocial Care Programme (U-CARE) Heart study. Time point of prediction was at completion of the first homework assignment. Adherence was defined as having completed more than 2 homework assignments within the 14-week treatment period. A supervised machine learning procedure was applied to identify the most potent predictors for adherence available at the first treatment session from a range of demographic, clinical, psychometric, and linguistic predictors. The internal binary classifier was a random forest model within a 3×10–fold cross-validated recursive feature elimination (RFE) resampling which selected the final predictor subset that best differentiated adherers versus nonadherers. Results: Patient mean age was 58.4 years (SD 9.4), 62% (56/90) were men, and 48% (43/90) were adherent. Out of the 34 potential predictors for adherence, RFE selected an optimal subset of 56% (19/34; Accuracy 0.64, 95% CI 0.61-0.68, P<.001). The strongest predictors for adherence were, in order of importance, (1) self-assessed cardiac-related fear, (2) sex, and (3) the number of words the patient used to answer the first homework assignment. Conclusions: For developing and testing effective iCBT interventions, investigating factors that predict adherence is important. Adherence to iCBT for MI-ANXDEP patients in the U-CARE Heart trial was best predicted by cardiac-related fear and sex, consistent with previous research, but also by novel linguistic predictors from written patient behavior which conceivably indicate verbal ability or therapeutic alliance. Future research should investigate potential causal mechanisms and seek to determine what underlying constructs the linguistic predictors tap into. Whether these findings replicate for other interventions outside of Sweden, in larger samples, and for patients with other conditions who are offered iCBT should also be investigated

Internet-based Cognitive Behavior Therapy for Symptoms of Depression and Anxiety among Patients with a Recent Myocardial Infarction : The U-CARE Heart Randomized Trial

Background: Symptoms of depression and anxiety are common after a myocardial infarction (MI). Internet-based cognitivebehavioral therapy (iCBT) has shown good results in other patient groups. Objective: The aim of this study was to evaluate the effectiveness of an iCBT treatment to reduce self-reported symptoms ofdepression and anxiety among patients with a recent MI. Methods: In total, 3928 patients were screened for eligibility in 25 Swedish hospitals. Of these, 239 patients (33.5%, 80/239women, mean age 60 years) with a recent MI and symptoms of depression or anxiety were randomly allocated to a therapist-guided,14-week iCBT treatment (n=117), or treatment as usual (TAU; n=122). The iCBT treatment was designed for post-MI patients.The primary outcome was the total score of the Hospital Anxiety and Depression Scale (HADS) 14 weeks post baseline, assessedover the internet. Treatment effect was evaluated according to the intention-to-treat principle, with multiple imputations. For themain analysis, a pooled treatment effect was estimated, controlling for age, sex, and baseline HADS. Results: There was a reduction in HADS scores over time in the total study sample (mean delta=−5.1, P<.001) but no differencebetween the study groups at follow-up (beta=−0.47, 95% CI −1.95 to 1.00, P=.53). Treatment adherence was low. A total of46.2% (54/117) of the iCBT group did not complete the introductory module. Conclusions: iCBT treatment for an MI population did not result in lower levels of symptoms of depression or anxiety comparedwith TAU. Low treatment adherence might have influenced the result. Trial Registration: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webciteat http://www.webcitation.org/6xWWSEQ22

Attending Heart School and long-term outcome after myocardial infarction : A decennial SWEDEHEART registry study

Background: The Heart School is a standard component of cardiac rehabilitation after myocardial infarction in Sweden. The group-based educational intervention aims to improve modifiable risks, in turn reducing subsequent morbidity and mortality. However, an evaluation with respect to mortality is lacking. Aims: Using linked population registries, we estimated the association of attending Heart School with both all-cause and cardiovascular mortality, two and five years after admission for first-time myocardial infarction. Methods: Patients with first-time myocardial infarction (99% complete follow-up in the Causes of Death registry for outcome events. Of 192,059 myocardial infarction admissions, 47,907 unique patients with first-time myocardial infarction surviving to the first cardiac rehabilitation visit constituted the study population. The exposure was attending Heart School at the first cardiac rehabilitation visit 6–10 weeks post-myocardial infarction. Data on socioeconomic status was acquired from Statistics Sweden. After multiple imputation, propensity score matching was performed. The association of exposure with mortality was estimated with Cox regression and survival curves. Results: After matching, attending Heart School was associated (hazard ratio (95% confidence interval)) with a markedly lower risk of both all-cause (two-year hazard ratio = 0.53 (0.44–0.64); five-year hazard ratio = 0.62 (0.55–0.69)) and cardiovascular (0.50 (0.38–0.65); 0.57 (0.47–0.69)) mortality. The results were robust in several sensitivity analyses. Conclusions: Attending Heart School during cardiac rehabilitation is associated with almost halved all-cause and cardiovascular mortality after first-time myocardial infarction. The result warrants further investigation through adequately powered randomised trials