Combination of Exercise and CBT Improves Outcomes in Depressed Patients with Heart Failure

newstudy-graphic-66x60.jpg A recent study appearing in the Journal of Psychosomatic Research aimed to examine the effectiveness of exercise combined with Cognitive Behavioral Therapy (CBT) as a treatment for heart failure. Participants were divided into four groups: 18 patients were assigned to complete a 12-week home-based exercise program in addition to 12 weeks of CBT, 19 patients were assigned to complete 12 weeks of CBT alone, 20 patients were assigned to complete only a 12-week home-based exercise program, and 17 patients were assigned to receive usual care. All of the participants were stable New York Heart Association Class II (mild) to III (moderate) heart failure patients that had been diagnosed with depression.  Patients with Class II heart failure experience fatigue, palpitations or dyspnea when undergoing ordinary physical activity.  Patients with Class III heart failure experience those same symptoms when undergoing less than ordinary physical activity. The patients were evaluated before treatment, after 12 weeks of treatment, and 3 months after the end of treatment. To evaluate the participants, the researchers used the Hamilton Rating Scale for Depression (HAM-D) to determine depressive symptom severity, a 6-minute walk test (6MWT) to determine physical function, and the Minnesota Living with Heart Failure Questionnaire to determine health-related quality of life (HRQOL). The combination group showed the greatest decrease in HAM-D scores (-10.4), while the usual care group showed the least decrease (-6.2), though none of the groups showed a statistically significant decrease. The combination group also showed a large improvement in the 6MWT at the three-month follow-up. Within the cross-section of moderately-to-severely depressed participants across all groups, only those in the combination group sustained lower HAM-D scores, showed significant improvement in the 6MWT, and showed the greatest increase in HRQOL.

American Heart Association Advisory Regarding Depression, Coronary Heart Disease, and CBT

NewStudy-Graphic-72x72_edited-3 Circulation: The American Heart Association issued an advisory regarding the need for screening, referral, and treatment of depression in people with coronary heart disease (CHD). Depression is more prevalent in CHD patients and can contribute to a number of negative outcomes for the disease. Major depression that is comorbid with CHD is associated with more ambulatory and emergency care visits, days spent in bed because of illness, and functional disability; it is also associated with worse coronary prognoses. Additionally, depression is associated with decreased adherence to medications, medical treatment regimens, successful modifications of other cardiac risk factors, and participation in cardiac rehabilitation. Regardless of whether “depression affects cardiac outcomes directly or indirectly, the need to screen and treat depression is imperative.”

The advisory included the use of the Patient Health Questionnaire as part of the assessment of depression and depressive symptoms. Once depression is diagnosed, the three recommendations for treatment are antidepressant drugs, physical activity, and cognitive behavioral therapy (CBT), alone and/or in combination. At least 12 to 16 sessions of cognitive behavioral therapy over 12 weeks were advocated to achieve remission of moderate to severe depression.

Advisory authors: J. H. Lichtman, J. T. Bigger, J. A. Blumenthal, N. Frasure-Smith, et al.

Refractory angina (chronic chest pain) positively affected by CBT

People with chronic refractory angina are frequently hospitalized with severe chest pain. A recent study in the Journal of Pain and Symptom Management indicates that outpatient cognitive-behavioral therapy improves angina status and quality of life, and reduces hospital admissions. In this study, after patients participated in a brief CBT protocol, admissions for chest pain were reduced from 2.40 per patient per year to 1.78. Only 8 myocardial infarctions (MI) were recorded in the year after in enrollment the program, whereas 32 were recorded in the year prior. Additionally, overall mortality was lower than in comparable groups treated with surgery.

Patients who are incapacitated by angina suffer “intense anxiety and apprehension” as a result of the pain itself, and of their assumptions about what the pain indicates about their underlying heart conditions. Using a 5-item questionnaire, patients’ misconceptions and counter-therapeutic beliefs and behaviors were identified. One typical finding was that angina patients avoid exercise, for example, because of a mistaken belief that it will damage their hearts. This maladaptive behavior, which results from this misconception, actually increases their risk of MI. The authors challenged these beliefs and offered evidence-based, alternative explanations for their symptoms.

The authors indicate that brief outpatient CBT was effectively used to educate patients and demystify angina, which produced “an immediate and sustained reduction in hospital admission.”

Study authors: R. K. G. Moore, D. G. Groves, J. D. Bridson, A. D. Grayson, H. Wong, A. Leach, R. J. P. Lewin, M. R. Chester 


CBT reduces fear and restores function for patients after cardiac defibrillator implantation

A recent article in Current Psychiatry reviews the negative effects on quality of life for people who receive an implantable cardioverter defibrillator (ICD) for irregular heart rhythms. These effects are particularly severe after the first experience of a “shock”—or ICD discharge. Though life-saving, these high-energy electrical discharges (shocks) are typically painful, and many patients experience anxiety, anger, and a sense of helplessness.

After a shock, patients instinctively begin to analyze the events or behaviors leading to the shock—which are often routine and not truly associated with the discharge event—so that they can avoid or even eliminate them from their lives. The fear of another shock and the fear of anything that could precipitate one can result in a “fear of fear” cycle. Patients may then start limiting their lifestyles so dramatically that depression ensues.

The authors suggest that this scenario can be avoided by routine cognitive-behavioral assessments during follow-up visits after the ICD implantation. Ideally, treatment consists of a combination of medication, psychotherapy, and support. With CBT, patients are guided to see how their thoughts about the device might be erroneous. Daily logs of ICD-related thoughts and cognitive re-structuring are useful CBT strategies.

In an example referenced in this article, eight sessions of CBT, which included exposure therapy and relaxation training, allowed a patient to resume most of his activities, and had a beneficial effect on his personal relationships and quality of life.

Study authors: D. P. Gibson, K. K. Kuntz