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Meta-Analysis
. 2017 Apr 28;4(4):CD002902.
doi: 10.1002/14651858.CD002902.pub4.

Psychological interventions for coronary heart disease

Suzanne H Richards  1   2 , Lindsey Anderson  3 , Caroline E Jenkinson  2 , Ben Whalley  4 , Karen Rees  5 , Philippa Davies  6 , Paul Bennett  7 , Zulian Liu  8 , Robert West  9 , David R Thompson  10 , Rod S Taylor  3
Affiliations
Meta-Analysis

Psychological interventions for coronary heart disease

Suzanne H Richards et al. Cochrane Database Syst Rev. .

Abstract

Background: Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

Objectives: To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

Search methods: We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

Selection criteria: We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

Data collection and analysis: Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

Main results: This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

Authors' conclusions: This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

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Conflict of interest statement

SR is currently a coinvestigator on the CADENCE study (funded by the UK NIHR HTA 12/189/06). This study is a feasibility and pilot study aimed at developing enhanced psychological care for people with new‐onset depression using cardiac rehabilitation services (ISRCTN34701576).

LA is an author on several other Cochrane cardiac rehabilitation reviews.

CJ declares she has no conflicts of interest.

KR, PB, and RW were authors of the first version (2004) of this Cochrane Review.

BW, KR, PD, PB, ZL, RW, DRT, and RST were authors of the second version (2011) of this Cochrane Review.

KR is an author on several other Cochrane cardiac rehabilitation reviews.

RST is an author on several other Cochrane cardiac rehabilitation reviews. RST is currently the co‐chief investigator on the programme of research with the overarching aims of developing and evaluating a home‐based cardiac rehabilitation intervention for people with heart failure and their carers (UK NIHR PGfAR RP‐PG‐0611‐12004). RST is currently a coinvestigator on the CADENCE study (funded by the UK NIHR HTA 12/189/06). This study is a feasibility and pilot study aimed at developing enhanced psychological care for people with new onset depression using cardiac rehabilitation services (ISRCTN34701576).

Figures

1
1
Flow diagram summarising study selection. N: number of RCT: randomised controlled trial
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
4
4
Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for total mortality (Analysis 1.1).
5
5
Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for revascularisation (coronary artery bypass graft surgery and percutaneous coronary intervention combined) (Analysis 1.3).
6
6
Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for non‐fatal myocardial infarction (Analysis 1.4).
7
7
Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for depression (Analysis 1.5).
8
8
Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for stress (Analysis 1.7).
9
9
Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for cardiac mortality (Analysis 1.2).
10
10
Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for anxiety (Analysis 1.6).
1.1
1.1. Analysis
Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 1: Total mortality
1.2
1.2. Analysis
Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 2: Cardiac mortality
1.3
1.3. Analysis
Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 3: Revascularisation (coronary artery bypass graft surgery and percutaneous coronary intervention combined)
1.4
1.4. Analysis
Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 4: Non‐fatal myocardial infarction
1.5
1.5. Analysis
Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 5: Depression
1.6
1.6. Analysis
Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 6: Anxiety
1.7
1.7. Analysis
Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 7: Stress
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to studies excluded from this review

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Bettencourt 2005 {published data only}
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Mittag 2006 {published data only}
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Moser 2012 {published data only}
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Moulaert 2013 {published data only}
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Mulligan 2008 {published data only}
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Nordmann 2001 {published data only}
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Novoa 2008 {published data only}
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Nyklicek 2014 {published data only}
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Oldenburg 1995 {published data only}
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Ornish 1998 {published data only}
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Orth‐Gomer 2009 {published data only}
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Parent 2000 {published data only}
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Paul 2006 {published data only}
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Petrie 2002 {published data only}
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PRECOR Group 1991 {published data only}
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Pullen 2008 {published data only}
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Quist‐Paulson 2003 {published data only}
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Reid 2003 {published data only}
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Robert‐McComb 2004 {published data only}
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Rollman 2011 {published data only}
    1. Rollman BL, Belnap BH, He F, Mazumdar S, Schulberg HC, Reynolds CF. Impact of collaborative care for depression following coronary artery bypass graft (CABG) surgery by baseline mood symptom severity. Psychosomatic Medicine 2011;73(3):A120-1.
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Russell 2013 {published data only}
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Salminen 2005 {published data only}
    1. Salminen M, Isoaho R, Vahlberg T, Ojanlatva A, Irjala K, Kivel SL. Effects of health advocacy, counseling, and activation among older coronary heart disease (CHD) patients. Aging - Clinical and Experimental Research 2005;17(6):472-8. - PubMed
Salmoirago‐Blotcher 2013 {published data only}
    1. Salmoirago-Blotcher E, Crawford SL, Carmody J, Rosenthal L, Yeh G, Stanley M, et al. Phone-delivered mindfulness training for patients with implantable cardioverter defibrillators: results of a pilot randomized controlled trial. Annals of Behavioral Medicine 2013;46:243-50. - PMC - PubMed
Scholz 2006a {published data only}
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Scholz 2006b {published data only}
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Seekatz 2013 {published data only}
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Senuzun 2006 {published data only}
    1. Senuzun F, Fadiloglu C, Burke L, Payzin S. Effects of home-based cardiac exercise program on the exercise tolerance, serum lipid values and self-efficacy of coronary patients. European Journal of Cardiovascular Prevention and Rehabilitation 2006;13(4):640-5. - PubMed
Seskevich 2004 {published data only}
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Shemesh 2011 {published data only}
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Sheps 2004 {published data only}
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Shively 2011 {published data only}
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Sinclair 2005 {published data only}
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Sniehotta 2006 {published data only}
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Sogolitappeh 2009 {published data only}
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Stein 2010 {published data only}
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Taghadosi 2014 {published data only}
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Vatutin 2013 {published data only}
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Wan 2005 {published data only}
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Wensaas 2014 {published data only}
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Wyer 2001 {published data only}
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Zhu 2006 {published data only}
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Zuidersma 2013 {published data only}
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References to studies awaiting assessment

Ma 2010 {published data only}
    1. Ma TK, Cheung WY, Ho K, Cheung YP. Effect of the psychological intervention on coronary heart disease patients after PTCA. Shanxi Medical Journal 2010;7:600-1.

References to ongoing studies

Albus 2014 {published data only}
    1. Albus C, Beutel ME, Deter HC, Fritzsche K, Hellmich M, Jordan J, et al. A stepwise psychotherapy intervention for reducing risk in coronary artery disease (SPIRR-CAD) - rationale and design of a multicenter, randomized trial in depressed patients with CAD. Journal of Psychosomatic Research 2011;71:215-22. - PubMed
    1. Deter H C, Orth-Gomer K, Herrmann-Lingen C, Albus C, Bosbach A, Juenger J, et al. A psychosocial intervention in patients with coronary artery disease shows different effects in men and women-new findings from the SPIRR-CAD trial. Psychosomatic Medicine 2015;77(3):A135.
    1. Deter HC, Orth-Gomer K, Herrmann-Lingen CH, Albus CH, Boese A, Juenger J, et al. Psychosocial gender differences in coronary artery disease and effect of a psychosocial intervention on vital exhaustion findings from the SPIRR-CAD trial. European Heart Journal 2014;35:225.
Barley 2014 {published data only}
    1. Achilla E, McCrone P, Phillips R, Barley EA, Mann A, Tylee A. UPBEAT-UK: cost-effectiveness of nurse-led case management and usual care for patients with coronary heart disease and co-morbid depression. Journal of Mental Health Policy and Economics 2013;16:S1.
    1. Barley EA, Walters P, Haddad M, Phillips R, Achilla E, McCrone P, et al. The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study. PLoS One 2014;9:e98704. - PMC - PubMed
    1. Tylee A. UPBEAT-UK: a pilot randomised controlled trial of case management for depressed primary care patients with symptomatic coronary heart disease. www.isrctn.com/ISRCTN21615909 (date first assigned 22 April 2010).
Eckert 2010 {published data only}
    1. Eckert K, Schrader G, Wilkinson D, Askew D, Dick M, Wade T, et al. Detection and management of depression in patients with chronic heart disease: the TAKE heart in primary care cluster randomised controlled trial. Heart Lung and Circulation 2010;19:S240-1.
Norlund 2015 {published data only}
    1. Norlund F, Olsson EM, Burell G, Wallin E, Held C. 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. Trials 2015;16:154. - PMC - PubMed
Richards 2016 {published data only}
    1. Richards SH, Dickens C, Anderson R, Richards DA, Taylor RS, Ukoumunne OC, et al. Assessing the effectiveness of enhanced psychological care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): study protocol for a pilot cluster randomised controlled trial. Trials 2016;17:59. - PMC - PubMed
Spatola 2014 {published data only}
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Tully 2016 {published data only}
    1. Tully PJ, Turnbull DA, Horowitz JD, Beltrame JF, Selkow T, Baune BT, et al. Cardiovascular Health in Anxiety or Mood Problems Study (CHAMPS): study protocol for a randomized controlled trial. Trials 2016;17:18. - PMC - PubMed

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