The group counseling v exercise therapy study. A controlled intervention with subjects following myocardial infarction. Psychological rehabilitation after myocardial infarction: multicentre randomised controlled trial. Psychological effects of a short behavior modification program in patients with acute myocardial infarction or coronary artery bypass grafting. A randomized controlled trial. Improving psychologic adjustment to chronic illness in cardiac patients. The role of depression and anxiety. Psychological and quality-of-life outcomes from a comprehensive stress reduction and lifestyle program in patients with coronary artery disease: results of a randomized trial. Effect of relaxation therapy on cardiac events after myocardial infarction: a 5-year follow-up study. Effects of a health education programme with telephone follow-up during cardiac rehabilitation. Behavioral effects of a comprehensive, multifactorial program for lifestyle change after percutaneous transluminal coronary angioplasty: a prospective, randomized controlled study. Effect of intervention for psychological distress on rehospitalization rates in cardiac rehabilitation patients. Effects of a stress management program on vital exhaustion and depression in women with coronary heart disease: a randomized controlled intervention study. Guideline-based early rehabilitation after myocardial infarction. A pragmatic randomised controlled trial. Management after myocardial infarction: a controlled trial of the effect of group psychotherapy. Brief group therapy in myocardial infarction rehabilitation: three- to four-year follow-up of a controlled trial. Psychosocial nursing therapy following sudden cardiac arrest: impact on two-year survival. Women's hearts--stress management for women with ischemic heart disease: explanatory analyses of a randomized controlled trial. Effects of treating exhaustion in angioplasty patients on new coronary events: results of the randomized Exhaustion Intervention Trial (EXIT). Feasibility of altering type A behavior pattern after myocardial infarction. Recurrent Coronary Prevention Project Study: methods, baseline results and preliminary findings.
One hundred six postmyocardial infarction subjects who either achieved a mean work load of less than seven mets on treadmill testing, who were rated as anxious and/or depressed, or who met both criteria, participated in a controlled study comparing the rehabilitation effectiveness of exercise therapy and group counseling. Each intervention lasted 12 weeks. Follow-up evaluations were scheduled at three months, six months and one year. Exercise substantially increased mean work capacity, decreased fatigue, lessened anxiety and depression, and promoted independence and sociability. Counseling substantially reduced depression and promoted a sense of friendliness, and decreased interpersonal friction as well as greater independence and sociability. The control group reported no substantial change on any measured factor. Neither counseling nor exercise had an effect on mortality though subjects in the exercise group reported fewer major cardiovascular sequelae. To evaluate rehabilitation after myocardial infarction.
                Randomised controlled trial of rehabilitation in unselected myocardial infarction patients in six centres, baseline data being collected on admission and by structured interview (of patients and spouses) shortly after discharge and outcome being assessed by structured interview at six months and clinical examination at 12 months.
                Six district general hospitals.
                All 2328 eligible patients admitted over two years with confirmed myocardial infarction and discharged home within 28 days.
                Rehabilitation programmes comprising psychological therapy, counselling, relaxation training, and stress management training over seven weekly group outpatient sessions for patients and spouses.
                Anxiety, depression, quality of life, morbidity, use of medication, and mortality.
                At six months there were no significant differences between rehabilitation patients and controls in reported anxiety (prevalence 33%) or depression (19%). Rehabilitation patients reported a lower frequency of angina (median three versus four episodes a week), medication, and physical activity. At 12 months there were no differences in clinical complications, clinical sequelae, or mortality.
                Rehabilitation programmes based on psychological therapy, counselling, relaxation training, and stress management seem to offer little objective benefit to patients who have experienced myocardial infarction compared with previous reports of smaller trials. The effects of a short intervention on behavioral risk factor modification in patients with coronary artery disease (CAD) on Type A behavior, vital exhaustion, and depression were studied in a randomized controlled trial.
                Acute myocardial infarction patients or patients who underwent coronary artery bypass grafting (CABG) were randomly assigned to an 8-week multiple risk modification group program (n = 94) or to a control group (n = 90) that received usual care with standard physical exercise training. Patients were assessed before intervention, directly after intervention, and at 9-month follow-up.
                The intervention was effective in reducing hostility and total Type A behavior at postintervention (P = .01) and at 9-month follow-up (P = .03). The intervention had no overall impact on vital exhaustion and depression, measured by the Beck Depression Inventory (BDI), whereas we unexpectedly found that the percentage of patients with major depression was reduced in the control group but not in the intervention group.
                The results indicate that a short behavioral intervention for coronary patients can result in relatively large and persistent reductions in cognitive aspects of Type A behavior and hostility, in particular. In view of the unwanted findings on the diagnosis of depression, however, we do not unequivocally advise the intervention to the general population of AMI and CABG patients. Poor mood adjustment to chronic medical illness is often accompanied by decrements in function.
                To evaluate the effectiveness of a telephone-based intervention for psychologic distress and functional impairment in cardiac illness.
                Randomized, controlled trial.
                We recruited survivors of acute coronary syndromes using the Hospital and Anxiety Depression Scale (HADS) with scores indicative of mood disturbances at 1-month postdischarge. Recruited patients were randomized to experimental or control status. Intervention patients received 6 30-minute telephone counseling sessions to identify and address illness-related fears and concerns. Control patients received usual care. Patients' responses to the HADS and the Workplace Social Adjustment Scale (WSAS) were collected at baseline, 2, 3, and 6 months using interactive voice recognition technology. At baseline, the PRIME-MD was used to establish diagnosis of depression. We used mixed effects regression to study changes in outcomes.
                We enrolled 100 patients. Mean age was 60; 67% of the patients were male. Findings confirmed that the intervention group had a 27% improvement in depression symptoms (P=.05), 27% in anxiety (P=.02), and a 38% improvement in home limitations (P=.04) compared with controls. Symptom improvement tracked those for WSAS measures of home function (P=.04) but not workplace function.
                The intervention had a moderate effect on patient's emotional and functional outcomes that were observed during a critical period in patients' lives. Patient convenience, ease of delivery, and the effectiveness of the intervention suggest that the counseling can help patients adjust to chronic illness. Stress reduction and comprehensive lifestyle modification programs have improved atherosclerosis and cardiac risk factors in earlier trials. Little is known about the impact of such programs on quality-of-life (QoL) and psychological outcomes. Given recent significant improvements in cardiac care, we evaluated the current benefit of stress reduction/lifestyle modification on QoL and emotional distress in patients with coronary artery disease (CAD).
                101 patients (59.4 +/- 8.6 years, 23 female) with CAD were randomized to a 1-year lifestyle/stress management program (n = 48) or written advice (n = 53). QoL and psychological outcomes were assessed with the SF-36, Beck Depression, Spielberger State/Trait Anxiety, Spielberger State/Trait Anger and Perceived Stress Inventories. Group repeated-measures analyses of variance were performed for all measures.
                Adherence to the program was excellent (daily relaxation practice 39 +/- 5 vs. 5 +/- 8 min, respectively; p < 0.001). Both groups improved comparably in most dimensions of QoL, and significantly greater improvements for the lifestyle group were found for physical function and physical sum score (p = 0.046 and p = 0.045). Depression, anxiety, anger and perceived stress were reduced similarly in both groups. However, intervention x gender interaction effects revealed greater benefits among women in the lifestyle intervention vs. advice group for depression and anger (p = 0.025 and p = 0.040), but no effects for men.
                A comprehensive lifestyle modification and stress management program did not improve psychological outcomes in medically stable CAD patients. The program did appear to confer psychological benefits for women but not men. Further trials should investigate gender-related differences in coronary patient responses to behavioral interventions.
                Copyright (c) 2005 S. Karger AG, Basel. Evidence suggests that breathing and relaxation therapy may influence cardiac events in persons after acute myocardial infarction (MI). The authors studied the effects of breathing and relaxation therapy on rates of cardiac events and cost effectiveness in past MI patients.
                Patients (n = 156) were chosen randomly to receive either exercise training plus relaxation therapy (relaxation group; n = 76) or exercise training only (control group; n = 80). The occurrence of major cardiac events and cardiac rehospitalizations in the two treatment groups was compared.
                At 5-year follow-up, 12 cardiac deaths had occurred, 5 in the relaxation group and 7 in the control group, reinfarction occurred in 10 and 12 patients, and cardiac surgery was performed in 2 and 11, respectively. In total, 15 (20%) and 26 (33%) patients, respectively, experienced at least one cardiac event (odds ratio [OR] for the relaxation group: 0.55, 95% confidence interval [CI] 0.29-1.05; adjusted for risk factors OR 0.52, 95% CI 0.28-0.99). Regarding all cardiac rehospitalizations, in the relaxation group, 30 patients (39%) had experienced 52 cardiac events, for which the patients were hospitalized for a total of 476 days. In the control group, 38 patients (48%) had experienced 78 cardiac events (OR 0.72; 95% CI 0.38-1.36), comprising 719 days of hospitalization. The total number of hospitalizations was reduced by 31% as a result of relaxation instruction.
                In the long-term, the disease course after myocardial infarction is influenced favorably by giving relaxation therapy in addition to cardiac rehabilitation. The extra costs of the therapy are compensated by a decrease in hospitalization for cardiac problems. A health education and counselling programme was offered to myocardial infarction patients during and after hospitalization. A randomized pre-test-post-test control group design was used to evaluate the effects of the experimental intervention. During hospitalization the intervention consisted of two individual counselling sessions and two group health education sessions focusing on medication, healthy habits, anxiety and depression. On completion of these sessions, weekly telephone calls were made to patients for a period of six weeks after discharge from hospital. The intervention was offered to 30 myocardial infarction patients and their partners (the experimental group) in addition to standard medical care. Thirty control patients received standard medical care only. Two months after myocardial infarction, patients in the experimental condition reported a significantly greater increase in physical activity, and a significantly greater decrease in unhealthy eating habits. No effects were found regarding smoking cessation, anxiety and depression. Twelve months after discharge from hospital patients in the experimental condition reported a significantly greater decrease in unhealthy eating habits. No effects were found regarding smoking cessation, physical activity, anxiety and depression. In addition, two months after myocardial infarction, it was found that patients whose partners participated in the health education sessions showed a significantly greater decrease in smoking and unhealthy eating habits and a significantly greater increase in physical activity than patients with no partner participating. Twelve months after discharge the only significant result favouring the patients whose partner participated in the health education sessions concerned smoking cessation. A group of 93 coronary patients recently treated with percutaneous transluminal coronary angioplasty (PTCA) were randomly assigned to either an intervention or a control group. Subjects in the intervention group participated in a comprehensive behaviorally oriented program aimed at achieving significant long-term changes in risk factor-related lifestyle behavior. Assessments of lifestyle behaviors, psychological factors, biological risk factors, and rehabilitation as well as secondary prevention endpoints were carried out, at inclusion and after 12 months. Results showed that the intervention patients, as compared with controls, improved significantly on measures assessing smoking, exercise, and diet habits. These self-rated changes were confirmed by weight reductions and improved exercise capacity, as well as by between-group differences in subclinical chest pain during an exercise test. However, few effects were found on the different psychological variables, as well as on morbidity or return to work. Psychosocial factors affect the development of coronary heart disease and morbidity and mortality of patients with known coronary heart disease. A prior study has shown that psychological distress in patients with known coronary heart disease increased medical and economic costs. This study examined the effects of commonly available psychological interventions offered to patients entering cardiac rehabilitation after hospitalization for angina, myocardial infarction, angioplasty, or coronary artery bypass grafting. A total of 380 patients were screened with the Symptom Checklist-90-Revised (SCL-90-R). Those with T-scores > or = 63 (> or = 91 percentile) on the General Severity Index (GSI) subscale were randomly assigned to usual care or special intervention. Special intervention included a psychiatric evaluation, plus one to seven sessions of behavioral therapy. The percentage of patients rehospitalized for cardiac symptoms within 12 months of psychological evaluation was 43% for special intervention and 40% for usual care (NS). A correction for crossover between the treatment groups resulted in a favorable trend toward intervention, with 35% of the psychologically treated patients rehospitalized vs. 48% of the untreated patients (NS). Although there was a nonsignificant reduction of the SCL-90-R's GSI T-score, the depression score was significantly reduced in the special intervention group. Psychosocial factors, including depression and vital exhaustion (VE) are associated with adverse outcome in coronary heart disease (CHD). Women with CHD are poor responders to psychosocial treatment and knowledge regarding which treatment modality works in them is limited. This randomized controlled clinical study evaluated the effect of a 1-year stress management program, aimed at reducing symptoms of depression and VE in CHD women.
                Patients were 247 women, < or =75 years, recruited consecutively after a cardiac event and randomly assigned to either stress management (20 2-h sessions) and medical care by a cardiologist, or to obtaining usual health care as controls. Measurements at; baseline (6-8 weeks after randomization), 10 weeks (after 10 intervention sessions), 1 year (end of intervention) and 1-2 years follow-up.
                For VE, intention to treat analysis showed effects for time (P < 0.001) and time x treatment interaction (P = 0.005), reflecting that both groups improved over time, and that the decrease of VE was more pronounced in the intervention group. However, the level of VE was higher in the intervention group than amongst controls at baseline, 22.7 vs. 19.4 (P = 0.036) but it did not differ later. The change in depressive symptoms did not differ between the groups.
                CHD women attending our program experienced a more pronounced decrease in VE than controls. However, as they had higher baseline levels, due to regression towards the mean we cannot attribute the decrease in VE to the intervention. Whether the program has long-term beneficial effects needs to be evaluated. To determine the effectiveness of individualised educational behavioural treatment delivered by cardiac nurses in hospital compared to usual care for patients following acute myocardial infarction.
                One hundred and fourteen consecutive patients were randomised to receive the intervention or usual care. Outcome assessment was by self-report questionnaire (the Hospital Anxiety and Depression Scale and Dartmouth COOP Health Status), interview at 1 month, and self-report at 3 and 12 months. The primary outcome was improvement in the Dartmouth COOP total score from baseline to 3 months.
                Four patients needed to be treated to give an additional patient with improvement in health status at 3 months (number needed to treat [NNT] 4, 95% confidence intervals [CIs] 3 to 12). The intervention group were more confident about returning to activities 1 month after discharge from hospital. Treated patients had fewer further treatment needs.
                An individualised educational behavioural treatment delivered by cardiac nurses in hospital may have substantial benefits. A large-scale pragmatic RCT is needed. nan A trial of brief group therapy as part of a rehabilitation program for postmyocardial infarction (MI) patients was carried out. Forty-four patients surviving their first MI were randomly allocated to either group therapy or control group status and were followed over 4 years. An additional group of 17 patients were referred for post-MI group therapy sessions after the termination of the controlled experiment and were followed for 3 years. Patients who received group therapy had significantly less follow-up coronary morbidity and mortality, and returned to work at significant higher percentages than control patients. Although neither group therapy nor control group patients meaningfully altered conventional coronary risk factors, group therapy patients (in the controlled trial) successfully altered selected coronary-prone behaviors. Educational information regarding the physiological and psychological aspects of coronary heart disease, presented in the group therapy sessions, was forgotten over follow-up. It is concluded that the supportive aspects of the group therapy experience played the most important role in determining the rehabilitation advantages seen for treatment patients. Although psychosocial therapy has been shown to reduce mortality after myocardial infarction, it is unknown whether the benefits of psychosocial therapy on mortality reduction extend to out-of-hospital sudden cardiac arrest, a main cause of cardiovascular mortality.
                Describe efficacy of psychosocial therapy on two-year cardiovascular mortality in sudden cardiac arrest survivors.
                Survivors of out-of-hospital ventricular fibrillation or asystole (N = 129), documented by electrocardiograms from registries of a citywide Medic One unit and two countywide emergency units, were randomized into a two group, experimental, longitudinal design. The intervention consisted of 11 individual sessions, implementing three components: physiologic relaxation with biofeedback training focused on altering autonomic tone; cognitive behavioral therapy aimed at self-management and coping strategies for depression, anxiety, and anger; and cardiovascular health education. The primary outcome measure was cardiovascular mortality.
                Risk of cardiovascular death was significantly reduced 86% by psychosocial therapy, p = .03. Six of the seven cardiovascular deaths in the control group were caused by ventricular arrhythmias. The cardiovascular death in the therapy group was due to stroke. Controlling for depression, previous myocardial infarction, low ejection fraction, decreased heart rate variability, and ventricular ectopic beats had little impact on estimated treatment effect. The risk of all-cause mortality was reduced by 62% in the therapy group, p = .13. There were a total of three deaths in the therapy group and eight deaths in the control group.
                Psychosocial therapy significantly reduced the risk of cardiovascular death in sudden cardiac arrest survivors. This randomized controlled study aimed to evaluate the effects on psychosocial variables of a 1-year group-based cognitive-behavioral stress management program developed specifically for women with ischemic heart disease.
                The present explanatory (per protocol) analyses include 80 women who were randomized to a 1-year cognitive-behavioral stress management program and 86 who were randomized to usual care (age = 35-77 years). Data were obtained before randomization and after 1 year, when the intervention group had completed the program.
                There were no statistically significant differences between the intervention and usual care groups in the psychosocial endpoints at randomization. Both groups improved in all psychosocial variables during the 1-year study period, but the rate of improvement was significantly greater in the intervention group for self-rated stress behavior (P = .006) and vital exhaustion (P = .03). Although changes were in favor of the treatment group also for depressive mood and quality of life, the rates of improvement between the 2 groups did not reach statistical significance (P = .23 and P = .10, respectively).
                A 1-year cognitive-behavioral stress management program designed specifically for women improved psychological well-being in some aspects in comparison with usual care. Extreme fatigue is a common complaint in percutaneous coronary intervention (PCI) patients, and is associated with an increased risk for new cardiac events. The objective of the Exhaustion Intervention Trial (EXIT) was to determine whether a behavioral intervention on exhaustion reduces the risk of a new coronary event after PCI.
                Seven hundred ten consecutive patients, ages 35 to 68 years, who felt exhausted after PCI were randomized into an intervention group and a usual-care group. The intervention was based on group therapy focusing on stressors leading to exhaustion, and on support for recovery by promoting rest and making rest more efficient. One month after PCI, 50% of the patients felt exhausted. The intervention reduced the odds of remaining exhausted at 18 months by 56% in those without a previous history of coronary artery disease (CAD) (OR = 0.44; 95% CI 0.29-0.66), but had no effect on exhaustion in those with a history of CAD (OR = 0.93; 95% CI 0.56-1.55; p = .78). The intervention did not reduce the risk of a new coronary event within 2 years (RR = 1.14; 95%CI 0.82-1.57). Post-hoc analyses suggest that the effect of the intervention was limited by a positive history of CAD, the presence of a chronic, painful condition (especially rheumatism), and by opposite effects on early and late cardiac events.
                A behavioral intervention in PCI patients has a beneficial effect on feelings of exhaustion. It could not be demonstrated that the intervention reduces the risk of a new coronary event within 2 years. We studied 1035 consecutive postinfarction patients to determine the feasibility of altering type A behavior and the effect such alteration might have on subsequent rates of infarction and cardiovascular death. Approximately 300 subjects were enrolled in small groups and primarily received cardiologic counseling on the usually accepted coronary risk factors. Six hundred subjects received, in addition to cardiologic counseling, advice and instructions designed to diminish the intensity of their type A behavior. The remaining subjects, serving as controls, received no counseling, but were examined and interviewed annually, as were those who dropped out of counseling groups. More than 98% of the 1035 subjects exhibited moderate-to-severe type A behavior during a videotaped structured interview. After the first year of this 5-year study, the rates of infarction and cardiovascular death were lower (p less than 0.01 and p less than 0.05, respectively) among subjects who received both cardiologic and behavioral counseling than among the control subjects. The rate of nonfatal infarction was lower (p less than 0.05) among subjects who received behavioral counseling than among those who received only cardiologic counseling or those who dropped out of either counseling group. The circumstances that most often preceded recurrent infarction or cardiovascular death were emotional crisis, excess physical activity, ingestion of a single fatty meal or a combination of these phenomena.
Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.