scispace - formally typeset

Journal ArticleDOI

Modification of coronary-prone behaviors in coronary patients of low socio-economic status.

21 Apr 2005-Spanish Journal of Psychology (Cambridge University Press)-Vol. 8, Iss: 1, pp 68-78

TL;DR: Results showed that only the psychological treatment group significantly reduced Pressured Drive and Speed-Impatience after treatment, and at 1- and 2-year follow-up, and are considered a reliable first step in the process of validating this program designed to improve coronary heart disease patients' quality of life.

AbstractThe purpose of this study is to determine the effectiveness of a group cognitive-behavioral treatment to modify coronary-prone behaviors in patients from a fairly low social and educational level. Participants were 98 male coronary patients randomly allocated to one experimental and two control groups. All groups received standard medical treatment. The experimental group received an additional psychological treatment and one of the two control groups received a health education treatment. Results showed that only the psychological treatment group significantly reduced Pressured Drive and Speed-Impatience after treatment, and at 1- and 2-year follow-ups. Depression was also significantly reduced only in this group at 2-year follow-up. The results are considered a reliable first step in the process of validating this program designed to improve coronary heart disease patients' quality of life.

Summary (3 min read)

Sample and Selection Procedure

  • The climate of this region is mild and the life-style largely rural, the most important economic activities involving service to the tourism industry.
  • After this session, the psychologist in charge of the program had an individual meeting with each participant to inform them to which group they had been assigned.
  • In the first year of the project, both the PsT and HET groups were randomly drawn and allocated, but the resulting differences in education within the generally low educational level of the groups made it difficult to carry out the treatment programs and to achieve intragroup interaction.

Instruments

  • The dependent variables were assessed in group by the first author of this paper, assisted by a minimum of three collaborating psychologists.
  • The Structured Interview was necessarily carried out individually.
  • This questionnaire evaluates four factors (Anger/Arousal, Hostile Outlook, Anger-In, and Anger-Out) and a Total Anger Scale calculated by adding the individual's scores over the four factors.
  • The authors used the Spanish adapted translation by Conde, Esteban, and Useros (1976) .

Procedure

  • The total number of sessions and general training procedure were the same in the PsT and the HET groups.
  • Stress management, working on recognition of personal triggers and on how to cope with stressful situations.
  • To ensure the integrity and quality of the treatment, a Therapist's Guide was compiled.
  • A) clinical manifestations and treatment modalities, b) signs and alarm symptoms, c) risk factors, also known as 2. CHD.
  • At the end of each session, the group leaders gave out homework that was checked at the beginning of the following session with the patients' active participation.

Data Analysis

  • The effects of the treatment were analyzed by a repeated measures general linear model.
  • The results at 1 year were analyzed by a 3 ϫ 2 factorial design, with one betweengroup factor with three levels (PsT, HET, and SMT) and one within-group factor (the time of measure, with two times: before and after treatment).
  • The treatment effects, including the 2 years of follow-up, were analyzed using a 2 ϫ 4 design with one between-group factor with two levels (PsT and HET) and one within-group factor with four levels (times of measure: before treatment, after concluding treatment, and at 1-and 2-year follow-up).
  • All analyses were carried out using the SPSS 10.0 computer program.

Results

  • The recruitment process and the results of this can be seen in Diagram I. Average attendance across the 24 sessions of the program in the PsT group was 20.64 (86% of the sessions) and 19.68 (82%) in the HET group, with a range of attendance in each group of 12-24 individuals.
  • Dropouts in the treatment groups were those who did not attend 50% of meetings.
  • In the control group, the authors included as dropouts those who only filled in all the questionnaires once.

MODIFICATION OF CORONARY

  • As can be observed, the 68 participants of the three groups were homogeneous in all variables except for age.
  • The participants of the PsT group were younger than those of the control groups, which did not differ in this variable.
  • The age difference among groups was not associated with statistically significant differences in the dependent variables studied.
  • Comparisons of the 68 completers and the 30 dropouts did not show significant differences in any of the descriptors of the groups.

Type-A Behavior (FTAS)

  • The analyses indicated that there were no significant differences among groups before or after treatment.
  • The within-group contrasts, however, showed significant differences between the first and second time of measurement in the PsT group, as can be seen in Table 2 .
  • The post-hoc contrasts indicated that the significant differences in this factor corresponded exclusively to the changes of the PsT group.

Type-A Behavior (Structured Interview)

  • The contrasts by groups indicated that in the Total Scale, significant reduction between the pre-and posttreatment times of measurement appeared only in the PsT group, as can be seen in Table 2 .
  • This significant reduction is due mainly to Factor 3, Speed/Impatience, in which only the PsT group showed significant differences between times of measurement.
  • The significant effect in Factor 2, Anger-Out, vanished when analyzed by groups.

Anger( MAI)

  • Only the group that received PsT reduced its degree of physiological activation after the treatment.
  • As can be seen in Table 5 , when analyzing by times of measure and groups, this significant effect appeared between the Time 1, before treatment, and all the other times of measurement only in the PsT group.
  • In the HET group, this effect appeared between Times 1-3 and 1-4.
  • The analyses of these significant effects by groups indicated that differences in Anger/Arousal appeared in the PsT group between Time 1 and all the other times of measurement, and in the HET group between Times 1-3 and 1-4.

Discussion

  • The distinctive characteristic of this study is that it involved male coronary patients of low socio-economic level, a group traditionally under-represented in intervention programs (Smith et al., 2002) .
  • The dropout rate is less than that of similar studies, a result that indicates that the treatment program fulfilled the participants' needs and expectations.
  • After treatment, the PsT group did not present statistically significant within-group changes, but its initial scores dropped after treatment and continued to decrease during the 2-year follow-up, until finally showing a statistically significant change between Times 1-4.
  • The authors conclude that the treatment designed to modify coronary-prone behaviors was able to modify some behavioral components of the TABP-Pressured Drive and Speed-Impatience-but not the components with a more emotional content or those involving a deeper strata of the personality, such as anger and competitiveness.

Did you find this useful? Give us your feedback

...read more

Content maybe subject to copyright    Report

The purpose of this study is to determine the effectiveness of a group cognitive-behavioral
treatment to modify coronary-prone behaviors in patients from a fairly low social and
educational level. Participants were 98 male coronary patients randomly allocated to one
experimental and two control groups. All groups received standard medical treatment.
The experimental group received an additional psychological treatment and one of the
two control groups received a health education treatment. Results showed that only the
psychological treatment group significantly reduced Pressured Drive and Speed-Impatience
after treatment, and at 1- and 2-year follow-ups. Depression was also significantly reduced
only in this group at 2-year follow-up. The results are considered a reliable first step in
the process of validating this program designed to improve coronary heart disease patients’
quality of life.
Keywords: coronary patients, coronary-prone behaviors, depression, low socio-economic
status, cognitive-behavioral treatment, Type A behavior
Este estudio pretende conocer la efectividad de un tratamiento cognitivo-conductual
aplicado a grupos de enfermos coronarios de un nivel educativo y status social
predominantemente bajo para modificar conductas prono-coronarias. Método: La
distribución de los 98 varones enfermos coronarios en un grupo experimental y dos de
control se realizó al azar. Los tres grupos recibieron el tratamiento médico estándar. El
grupo experimental recibió adicionalmente un tratamiento psicológico y uno de los dos
grupos de control recibió además un programa de educación para la salud. Los resultados
mostraron que sólo el grupo que recibió el tratamiento psicológico redujo significativamente
su Comportamiento Apresurado y su Prisa-Impaciencia después del tratamiento y durante
los dos años de seguimiento posteriores al tratamiento. La depresión también se redujo
sólo en este grupo tras los dos años de seguimiento. Los resultados se consideran un
primer paso fiable en el proceso de validar este programa diseñado para mejorar la
calidad de vida de los pacientes coronarios.
Palabras clave: pacientes coronarios, conductas prono-coronarias, depresión, estatus
socio-económico bajo, tratamiento cognitivo-conductual, conducta tipo A
Modification of Coronary-Prone Behaviors in Coronary Patients
of Low Socio-Economic Status
Antonio del Pino
1
, Mª Teresa Gaos
1
, Ruth Dorta
1
, and Martín García
2
1
La Laguna University
2
Cardiology Service of La Laguna University Hospital
The Spanish Journal of Psychology Copyright 2005 by The Spanish Journal of Psychology
2005, Vol. 8, No. 1, 68-78 1138-7416
This study was financed by the Autonomous Government of the Canary Islands. We gratefully acknowledge Margaret Gillon Dowens
and Dulce Mª Rodríguez for their revision of the English text and the anonymous reviewers for their suggestions. We are also indebted
to M. Friedman and the co-workers of the San Francisco Coronary/Cancer Prevention Project and acknowledge their influence, particularly
concerning procedure.
Correspondence concerning this article should be addressed to: Antonio del Pino, Department of Personality, Assessment, and
Psychological Treatments. La Laguna University. Campus de Guajara, 38205. La Laguna. Islas Canarias (Spain). E-mail: apino@ull.es
68

The results of the psychological interventions carried out
until fifteen years ago for the type A behavior pattern and for
coronary heart disease were reflected in the meta-analysis of
Nunes, Frank, and Kornfeld (1987). The effect sizes of the
Type-A behavior pattern (TABP) change ranged from 0.02 to
1.27, with a mean of 0.61. No single treatment modality could
be considered efficacious, although the change of the TABP
effect size did correlate positively and significantly with the
number of treatment modalities used, and the combination of
an educational component, a coping method, either relaxation
or cognitive therapy, and a behavioral rehearsal achieved the
most significant TABP changes. Fernández-Abascal, Martín,
and Domínguez (2003) reviewed this issue in detail.
Linden, Stossel, and Maurice (1996) found in their meta-
analysis that the addition of psychosocial treatment to
standard cardiac rehabilitation regimes reduced psychological
distress during the first 2 years and that the patients who did
not receive psychosocial treatment had greater mortality and
cardiac recurrence rates during the first 2 years of follow-
up. The meta-analysis of Dusseldorp, van Elderen, Maes,
Meulman, and Kraaij (1999) examined the effects of
psychoeducational programs for coronary heart disease (CHD)
patients. The results suggest positive distal effects (34%
reduction in cardiac mortality, and 29% reduction in
recurrence of myocardial infarction) and significant positive
effects on proximal targets such as blood pressure, cholesterol,
and smoking behavior, but not on anxiety or depression.
The authors of these meta-analyses point out that these
programs should be adapted to the characteristics of different
groups of patients, especially groups of low socio-economic
status (Smith, Kendall, & Keefe, 2002), and the priority of
discovering the active components of the programs, so as to
reduce their duration and improve cost-benefit relationships.
The present study is an attempt to validate a treatment
program. While we acknowledge the influence, particularly
concerning procedure, of M. Friedman and co-workers from
the San Francisco Coronary/Cancer Prevention Project,
however, our theoretical perspective is closer to the
cognitive-behavioral orientation of Roskies (1987).
The aim of this study is to determine the effectiveness
of a cognitive-behavioral intervention trial to modify
coronary-prone behaviors, specifically the TABP components,
in people from a fairly low social and educational level who
have suffered from angina pectoris and/or myocardial
infarction. Using the treatment package strategy (Kazdin,
& Wilson, 1978), we began by elaborating a wide spectrum
cognitive-behavioral treatment package, so that in subsequent
research this treatment package could be dismantled.
Method
Sample and Selection Procedure
The sample was composed of males treated in the
University Hospital of the Canary Islands. The climate of
this region is mild and the life-style largely rural, the most
important economic activities involving service to the tourism
industry. The pace of life in the islands is, therefore, rather
slower than in more industrialized areas.
All the patients treated in the Cardiologist Service between
the years 1992-1995 were given information about secondary
prevention of CHD by a cardiologist and were invited to
participate in the project if they fulfilled the following three
conditions: (a) reliably documented evidence of CHD (in
most cases after catheterization), (b) no recommendation of
immediate surgical intervention, and (c) no medical or
psychological co-morbidity requiring individual intervention.
The project was developed in three stages or years. At
the beginning of each year, a meeting was organized with
the first 60 coronary patients who fulfilled the eligibility
requirements and had expressed interest in the project while
in hospital. At this meeting, the patients were given a short
explanation of the advantages of participating in a
Psychological Treatment (PsT) program or a Health
Education Treatment (HET) program to prevent reoccurrence
of coronary episodes. The need for participants in the control
group, who received only the University Hospital standard
medical treatment (SMT) program for coronary patients was
also explained, as was the calendar of the treatment programs
and the responsibilities acquired by the participants.
After this meeting, the research team allocated the
participants to the various groups. The first 40 volunteers
were allocated at random either to the PsT or the HET
groups, and the last 20 to volunteer, or those who would
have had difficulty in attending the treatment sessions at
that time, were assigned to the SMT control group. The
research design thus involved one experimental group, which
received the SMT and the PsT, and two control groups, one
that received both the SMT and the HET, and the other that
received only the SMT. This latter group was, in fact, a
waiting-list control group, as the members had the
opportunity to participate in the psychological or educational
treatment groups in subsequent years of the project.
At a second meeting, the patients who were still
interested in the program filled out a form with their personal
data and signed their free consent to participate and to
acknowledge their awareness of the commitment they
assumed as participants. In this session, the nurses and the
psychologists in charge of the treatments and a physician
acting for the University Hospital also signed the
responsibilities that each assumed. The participants also
filled in the psychological tests and questionnaires. After
this session, the psychologist in charge of the program had
an individual meeting with each participant to inform them
to which group they had been assigned.
In the first year of the project, both the PsT and HET
groups were randomly drawn and allocated, but the resulting
differences in education within the generally low educational
level of the groups made it difficult to carry out the treatment
programs and to achieve intragroup interaction.
MODIFICATION OF CORONARY-PRONE BEHAVIORS
69

DEL PINO, GAOS, DORTA, AND MARTÍN
70
Therefore, in the following years, we decided to employ
stratified allocation. Two groups were formed according to
educational level, they were assigned a treatment program
at random, and this was alternated the following year.
Each year, there was the same number of patients in
the SMT control group as in the PsT and HET groups. The
total size of the sample was exclusively determined by the
number of volunteers, as information about the program
was given to all the patients of the Cardiology Service during
the 3-year duration of the project.
Instruments
The dependent variables were assessed in group by the
first author of this paper, assisted by a minimum of three
collaborating psychologists. The Structured Interview was
necessarily carried out individually.
The Framingham Type-A Scale (FTAS; Haynes, Levine,
Scotch, Feinleib, & Kannel, 1978). This scale measures
Pressured Drive and Competitiveness/Impatience (Houston,
Smith, & Zuraswski, 1986; del Pino, Gaos, & Dorta, 1997).
We used the version translated and adapted by del Pino,
Borges, Díaz, Suárez, and Rodríguez (1990).
The Structured Interview (SI; Chesney, Eagleston, &
Rosenman, 1980). The SI was applied as indicated in del
Pino, Gaos, and Dorta (1999). The SI is made up of three
factors (Competitiveness/Hard Driving, Anger-Out, and
Speed/Impatience). All the interviews were carried out by
two trained collaborators and the recordings of the interviews
were evaluated by a person who was ignorant of the research
project and specially trained for this evaluation task.
The Multidimensional Anger Inventory (MAI; Siegel,
1986). A version translated and adapted by Sánchez-Elvira,
Pérez, and Bermúdez (1991) was employed. This
questionnaire evaluates four factors (Anger/Arousal, Hostile
Outlook, Anger-In, and Anger-Out) and a Total Anger Scale
calculated by adding the individual’s scores over the four
factors.
The Beck Depression Inventory (BDI; Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961). We used the Spanish
adapted translation by Conde, Esteban, and Useros (1976).
Procedure
The total number of sessions and general training
procedure were the same in the PsT and the HET groups.
The PsT, summarized in del Pino (1998), consisted of
five parts:
1. Introduction to CHD and its contributing factors.
2. Tension control, including: (a) physical tension,
particularly relaxation practice; (b) behavioral tension
(time urgency); (c) modification of dysfunctional
thoughts, substituting them with productive thinking;
and (d) modification of negative emotions (anger-
hostility and frustration).
3. Stress management, working on recognition of
personal triggers and on how to cope with stressful
situations.
4. Planning and learning to enjoy events to reduce
tension and stress.
5. Lifestyle change as a lifetime aim.
The content and homework for each session and
suggestions for the participants were provided in the
Participant’s Guide, which was given to all the participants
in the PsT. All training sessions were directed and taught
by the first author of this article, with the collaboration of
the same three psychologists during the 3-year project. To
ensure the integrity and quality of the treatment, a Therapist’s
Guide was compiled.
The HET consisted of the following modules:
1. Heart anatomy and physiology.
2. CHD: a) clinical manifestations and treatment
modalities, b) signs and alarm symptoms, c) risk
factors.
3. Recommended lifestyle, including advice about
changing diet and certain patterns of coronary-prone
behaviors.
4. Medication: dosage conditions and effects.
The HET program was taught by a team of three nurses
who are teachers from the University of La Laguna School
of Nursing.
The 90-minute sessions involved an oral presentation
backed up by audiovisual material, followed by a question-
and-answer period. At the end of each session, the group
leaders gave out homework that was checked at the
beginning of the following session with the patients’ active
participation.
Both HET and the PsT were carried out in 24 group
sessions over a 9-month period, 12 meetings during the first
3 months, and 12 meetings during the following 6 months.
In the 10 months following the treatment programs, there
were 10 sessions (once a month) to maintain the effects of
the treatments.
Each group was comprised of a number of people that
ranged between a maximum of 12 and a minimum of 8.
Data Analysis
The effects of the treatment were analyzed by a repeated
measures general linear model. The results at 1 year were
analyzed by a 3 2 factorial design, with one between-
group factor with three levels (PsT, HET, and SMT) and
one within-group factor (the time of measure, with two
times: before and after treatment). The treatment effects,
including the 2 years of follow-up, were analyzed using a
2 4 design with one between-group factor with two levels
(PsT and HET) and one within-group factor with four levels
(times of measure: before treatment, after concluding
treatment, and at 1- and 2-year follow-up). All analyses were
carried out using the SPSS 10.0 computer program.

Results
The recruitment process and the results of this can be
seen in Diagram I.
Average attendance across the 24 sessions of the
program in the PsT group was 20.64 (86% of the sessions)
and 19.68 (82%) in the HET group, with a range of
attendance in each group of 12-24 individuals. Dropouts
in the treatment groups were those who did not attend
50% of meetings. In the control group, we included as
dropouts those who only filled in all the questionnaires
once.
MODIFICATION OF CORONARY-PRONE BEHAVIORS
71
Diagram 1. Selection Procedure and Distribution of the Sample.
No follow-up
Analysed after:
1-year follow-up: n = 23
2-year follow-up: n = 19
Analysed after:
1-year follow-up: n = 23
2-year follow-up: n = 18
Analysed after 1 year: n = 22
No 2-year follow-up
Allocated to intervention (n = 33)
Received intervention
for 1 year (n = 23)
Dropouts (n = 10)
1-year follow-up: n = 19
2-year follow-up: n = 19
Lost to follow-up: (n = 4)
Reasons: 1 died
1 moved away
2 dropouts
1-year follow-up: n = 18
2-year follow-up: n = 18
Lost to follow-up (n = 5)
Reasons: 2 died
2 moved away
1 dropout
Allocated to intervention (n = 33)
Received intervention
for 1 year (n = 23)
Dropouts (n = 10)
Allocated to assessment (n = 32)
Assessed dependent variables
after 1 year (n = 22)
Dropouts (n = 10)
Assessed for eligibility:
(n = 493)
Attended first informative meeting
(n = 111)
Eligible and willing to participate
when in hospital
(n = 219)
Psychological Treatment Health Education Treatment Waiting List Control
Participants at the second meeting
who filled in the tests and signed
free consent (n = 98)
Excluded (n = 274):
Did not meet inclusion criteria (n = 246)
Refused to participate (n = 19)
Other reasons (n = 9)

DEL PINO, GAOS, DORTA, AND MARTÍN
72
Analyses of the proportional distribution of the
demographic and clinical characteristics of the three groups
(68 participants) and of these 68 participants compared to
the 30 dropouts can be seen in Table 1.
As can be observed, the 68 participants of the three
groups were homogeneous in all variables except for age.
The participants of the PsT group were younger than those
of the control groups, which did not differ in this variable.
The age difference among groups was not associated with
statistically significant differences in the dependent variables
studied.
Comparisons of the 68 completers and the 30 dropouts
did not show significant differences in any of the descriptors
of the groups.
Table 1
Demographic and Clinical Background of Experimental Groups
Total
Receptors of intervention Completers Noncompleters
(n = 68) (n = 30)
Psychological Health Education Control Analysis Analysis
(n = 23) (n = 23) (n = 22)
Variable n % n % n % χ
2
(df) n% n% χ
2
(df)
Occupational status 11.20(6) 5.26(3)
Executives 3 13 7 30 1 4 11 16 10 33
Self-employed 8 35 6 26 3 14 17 25 8 27
Clerical 4 17 2 9 3 14 9 13 1 3
Manual Workers 8 35 8 35 15 68 31 46 11 37
Employment status 6.47(4) 1.40(2)
Retired 4 17 5 22 7 32 16 24 9 30
Sick Leave/Unemployed 11 48 16 69 9 41 36 52 12 40
Employed 8 35 2 9 6 27 16 24 9 30
Educational level 8.92(4) 0.01(2)
No studies 3 13 9 39 11 50 23 34 10 34
Eighth grade 12 52 8 35 9 41 29 42 13 43
High school /Graduate 8 35 6 26 2 9 16 24 7 23
Marital status 0.28(2) 0.19(1)
Married 20 87 21 91 20 91 61 90 26 87
Other 3 13 2 9 2 9 7 10 4 13
Smoking status 1.62(4) 0.06(2)
Current smoker 12 52 13 56 9 41 34 50 16 53
Previous smoker 10 44 8 35 11 50 29 43 12 40
Never smoker 1 4 2 9 2 9 5 7 2 7
Arteries with Significant
Stenosis
a
3.40(4) 0.51(2)
1 6 35 4 24 6 37.5 16 32 5 24
2 8 47 6 35 4 25.0 18 36 9 43
3 3 18 7 41 6 37.5 16 32 7 33
M SDM SDM SDF
(2,.65) M SD M SD t(96)
Age 49.65 8.22 6.70 7.19 58.09 5.45 9.31*** 54.76 7.90 52.90 6.27 1.14
FTAS 0.55 0.26 0.51 0.25 0.47 0.23 0.59 0.51 0.24 0.45 0.29 1.03
SI 90.00 9.01 90.42 9.21 90.04 7.12 0.02 90.15 8.36 90.43 15.98 –0.16
MAI 86.04 17.29 85.70 17.92 78.36 20.43 1.22 83.44 18.63 81.50 15.83 0.50
BDI 11.87 6.86 14.52 6.43 16.18 5.44 2.71 14.16 6.44 13.90 7.40 0.17
Note. FTAS: Framingham Type A Scale; SI: Structured Interview; MAI: Multidimensional Anger Inventory; BDI: Beck Depression Inventory.
a
Data not available for all of the patients in the study.
*** p < .001.

Citations
More filters

Journal ArticleDOI
TL;DR: To assess the effectiveness of psychological interventions compared with usual care for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress, a Cochrane systematic review is published.
Abstract: BACKGROUND: Psychological interventions can form part of comprehensive cardiac rehabilitation programmes (CCR). These interventions may include stress management interventions, which aim to reduce stress, either as an end in itself or to reduce risk for further cardiac events in patients with heart disease. OBJECTIVES: To determine the effectiveness of psychological interventions, in particular stress management interventions, on mortality and morbidity, psychological measures, quality of life, and modifiable cardiac risk factors, in patients with coronary heart disease (CHD). SEARCH STRATEGY: We searched CCTR to December 2001 (Issue 4, 2001), MEDLINE 1999 to December 2001 and EMBASE 1998 to the end of 2001, PsychINFO and CINAHL to December 2001. In addition, searches of reference lists of papers were made and expert advice was sought. SELECTION CRITERIA: RCTs of non-pharmacological psychological interventions, administered by trained staff, either single modality interventions or a part of CCR with minimum follow up of 6 months. Adults of all ages with CHD (prior myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, angina pectoris or coronary artery disease defined by angiography). Stress management (SM) trials were identified and reported in combination with other psychological interventions and separately. DATA COLLECTION AND ANALYSIS: Studies were selected, and data were abstracted, independently by two reviewers. Authors were contacted where possible to obtain missing information. MAIN RESULTS: Thirty six trials with 12,841 patients were included. Of these, 18 (5242 patients) were SM trials. Quality of many trials was poor with the majority not reporting adequate concealment of allocation, and only 6 blinded outcome assessors. Combining the results of all trials showed no strong evidence of effect on total or cardiac mortality, or revascularisation. There was a reduction in the number of non-fatal reinfarctions in the intervention group (OR 0.78 (0.67, 0.90), but the two largest trials (with 4809 patients randomized) were null for this outcome, and there was statistical evidence of publication bias. Similar results were seen for the SM subgroup of trials. Provision of any psychological intervention or SM intervention caused small reductions in anxiety and depression. Few trials reported modifiable cardiac risk factors or quality of life. REVIEWERS' CONCLUSIONS: Overall psychological interventions showed no evidence of effect on total or cardiac mortality, but did show small reductions in anxiety and depression in patients with CHD. Similar results were seen for SM interventions when considered separately. However, the poor quality of trials, considerable heterogeneity observed between trials and evidence of significant publication bias make the pooled finding of a reduction in non-fatal myocardial infarction insecure.

421 citations


Reference EntryDOI
TL;DR: Psychological treatments appear effective in treating psychological symptoms of CHD patients and Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.
Abstract: Background: Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures. Objectives: Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac‐related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study‐level predictors of the impact of these interventions. Search methods: The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review. Selection criteria: Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow‐up of six months. Adults with specific diagnosis of CHD. Data collection and analysis: Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information. Main results: There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non‐fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): ‐0.21 (95% CI ‐0.35, ‐0.08) and anxiety, SMD: –0.25 (95% CI ‐0.48 to –0.03). Results for mortality indicated some evidence of small‐study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type‐A behaviours (s = ‐0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (s = 0.23, p = 0.03), (3) included client‐led discussion and emotional support as core therapeutic components (s = 0.31, p < 0.01), or (4) included family members in the treatment process (s = 0.26, p < 0.01) were significantly less effective. Authors' conclusions: 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.

278 citations


Journal ArticleDOI
TL;DR: PT of cardiac patients reduces mortality and event recurrence and appears only in men even after controlling for age differences, suggesting the timing for the initiation of PT may be a critical mediating variable for mortality outcomes.
Abstract: Previous reports of the effectiveness of psychological treatments (PTs) for cardiac patients reveal inconsistent results. We determined overall effects and gender differences. Eligible studies were randomized controlled trials, containing a PT arm. The authors identified 43 relevant randomized trials; 23 reported mortality data for 9856 patients. The odds-ratio (OR) for all-cause mortality at follow-up of 2 years or less, comparing PT plus usual care vs. usual care only, was OR 0.72 [95% confidence interval (CI) 0.56-0.94], but weakened with longer follow-up (OR 0.89; 95% CI 0.80-1.10). Mortality benefits only applied to men (OR 0.73, 95% CI 0.57-1.00; OR 1.01; 95% CI 0.87-1.72 for women). Trials initiating treatment at least 2 months after a cardiac event showed greater mortality benefits than those initiating treatment right after the event (OR 0.28; 95% CI 0.11-0.70 vs. OR 0.87; 95% CI 0.86-1.15, respectively). Mortality benefits due to PT were achieved despite small concomitant changes in negative affect. PT of cardiac patients reduces mortality and event recurrence. The mortality benefits appeared only in men even after controlling for age differences. The timing for the initiation of PT may be a critical mediating variable for mortality outcomes.

245 citations


01 Aug 2012
TL;DR: Overall, QI interventions were not shown to reduce disparities, and some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.
Abstract: Objective This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care. Data sources We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO. Review methods All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision. Results Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities--specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men. Conclusions The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventions are effective at reducing disparities remains unclear. This report should not be construed to assess the general effectiveness of QI in the health care setting; rather, QI has not been shown specifically to reduce known disparities in health care or health outcomes. In a few instances, some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.

231 citations


Journal Article
Abstract: We performed a comprehensive review of the literature to determine whether or not a relationship between depression and coronary artery disease exists. Our literature search supports the following: Depression and coronary artery disease have a bidirectional relationship, i.e., coronary artery disease can cause depression and depression is an independent risk factor for coronary artery disease and its complications; depression may contribute to sudden cardiac death and increase all causes of cardiac mortality; and depression contributes to unhealthy lifestyle and poor adherence to treatment. We review various pathophysiological links between depression and coronary artery disease and screening for depression in at-risk patients for coronary artery disease. We also discuss pharmacological treatments, their implications, and various behavioral treatments.

160 citations


References
More filters

Journal ArticleDOI
TL;DR: The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out and a wide variety of psychiatric rating scales have been developed.
Abstract: The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations." Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15These have been well summarized in a review article by Lorr11on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific

33,299 citations


Journal ArticleDOI
TL;DR: There was limited evidence of the specific effectiveness of interpersonal psychotherapy and none for cognitive behavior therapy, but Superior recovery rates were found for both interpersonal Psychotherapy and imipramine plusclinical management, as compared with placebo plus clinical management.
Abstract: • We investigated the effectiveness of two brief psychotherapies, interpersonal psychotherapy and cognitive behavior therapy, for the treatment of outpatients with major depressive disorder diagnosed by Research Diagnostic Criteria. Two hundred fifty patients were randomly assigned to one of four 16-week treatment conditions: interpersonal psychotherapy, cognitive behavior therapy, imipramine hydrochloride plus clinical management (as a standard reference treatment), and placebo plus clinical management. Patients in all treatments showed signifi-cant reduction in depressive symptoms and improvement in functioning over the course of treatment. There was a consistent ordering of treatments at termination, with imipramine plus clinical management generally doing best, placebo plus clinical management worst, and the two psychotherapies in between but generally closer to imipramine plus clinical management. In analyses carried out on the total samples without regard to initial severity of illness (the primary analyses), there was no evidence of greater effectiveness of one of the psychotherapies as compared with the other and no evidence that either of the psychotherapies was significantly less effective than the standard reference treatment, imipramine plus clinical management. Comparing each of the psychotherapies with the placebo plus clinical management condition, there was limited evidence of the specific effectiveness of interpersonal psychotherapy and none for cognitive behavior therapy. Superior recovery rates were found for both interpersonal psychotherapy and imipramine plus clinical management, as compared with placebo plus clinical management. On mean scores, however, there were few significant differences in effectiveness among the four treatments in the primary analyses. Secondary analyses, in which patients were dichotomized on intial level of severity of depressive symptoms and impairment of functioning, helped to explain the relative lack of significant findings in the primary analyses. Significant differences among treatments were present only for the subgroup of patients who were more severely depressed and functionally impaired; here, there was some evidence of the effectiveness of interpersonal psychotherapy with these patients and strong evidence of the effectiveness of imipramine plus clinical management. In contrast, there were no significant differences among treatments, including placebo plus clinical management, for the less severely depressed and functionally impaired patients.

2,140 citations


"Modification of coronary-prone beha..." refers result in this paper

  • ...…rate during the year of treatment hardly reaches 31%, a lower percentage than the one provided in population-based studies (Chambless & Ollendick, 2001) and practically identical to that reported in studies about the effectiveness of treatments with specially controlled groups (Elkin et al., 1989)....

    [...]


Journal ArticleDOI
TL;DR: The work of several task forces and other groups reviewing empirically supported treatments (ESTs) in the United States, United Kingdom, and elsewhere is summarized here, along with the lists of treatments that have been identified as ESTs.
Abstract: ▪ Abstract Efforts to increase the practice of evidence-based psychotherapy in the United States have led to the formation of task forces to define, identify, and disseminate information about empirically supported psychological interventions. The work of several such task forces and other groups reviewing empirically supported treatments (ESTs) in the United States, United Kingdom, and elsewhere is summarized here, along with the lists of treatments that have been identified as ESTs. Also reviewed is the controversy surrounding EST identification and dissemination, including concerns abou research methodology, external validity, and utility of EST research, as well as the reliability and transparency of the EST review process.

1,881 citations


"Modification of coronary-prone beha..." refers result in this paper

  • ...The dropout rate during the year of treatment hardly reaches 31%, a lower percentage than the one provided in population-based studies (Chambless & Ollendick, 2001) and practically identical to that reported in studies about the effectiveness of treatments with specially controlled groups (Elkin et…...

    [...]


Journal ArticleDOI
TL;DR: The Framingham Type A behavior pattern and other psychosocial measures were not related to the level of CHD risk, as determined by the Framingham logistic equations.
Abstract: Questionnaires administered to 1822 members of the Framingham Heart Study from 1965 to 1967 provided measures of personality type, sociocultural mobility, situational stress and somatic strain. Clusters of questions selected by a panel of experts, and verified by item and factor analysis, formed scales of Type A behavior and other psychosocial states. The Framingham Type A behavior scale was significantly correlated with daily stress (.47), emotional lability (.43), tension (.42), anger symptoms (.34), and ambitiousness (.31). Women were less likely than men to be ambitious and to exhibit the Framingham Type A behavior, and were more likely than men to be emotionally labile, tense, and to suppress hostility. Few consistent associations were found between psychosocial stress measures and levels of blood pressure or cholesterol. Social status and marital conflicts were significantly associated with patterns of smoking. The Framingham Type A behavior pattern and other psychosocial measures were not related to the level of CHD risk, as determined by the Framingham logistic equations.

830 citations


Journal ArticleDOI
Abstract: Background: Narrative review strategies and meta-analyses have shown that drug treatment and exercise rehabilitation regimens can reduce psychological distress and postmyocardial infarction mortality and recurrence. Objective: To question whether the addition of psychosocial interventions improves the outcome of a standard rehabilitation regimen for patients with coronary artery disease. Methods: We performed a statistical meta-analysis of 23 randomized controlled trials that evaluated the additional impact of psychosocial treatment of rehabilitation from documented coronary artery disease. Anxiety, depression, biological risk factors, mortality, and recurrence of cardiac events were the clinical end points that were studied. Mortality data were available from 12 studies, and recurrence data were available from 10 of the 23 studies. Results: The studies had evaluated 2024 patients who received psychosocial treatment vs 1156 control subjects. The psychosocially treated patients showed greater reductions in psychological distress, systolic blood pressure, heart rate, and cholesterol level (with effect size differences of 0.34, -0.24, -0.38, and -1.54, respectively). Patients who did not receive psychosocial treatment showed greater mortality and cardiac recurrence rates during the first 2 years of follow-up with log-adjusted odds ratios of 1.70 for mortality (95% confidence interval [CI], 1.09 to 2.64) and 1.84 for recurrence (CI, 1.12 to 2.99). Conclusions: The addition of psychosocial treatments to standard cardiac rehabilitation regimens reduces mortality and morbidity, psychological distress, and some biological risk factors. The benefits were clearly evident during the first 2 years and were weaker thereafter. At the clinical level, it is recommended to include routinely psychosocial treatment components in cardiac rehabilitation. The findings also suggest an urgent need to identify the specific, most effective types of psychosocial interventions via controlled research. (Arch Intern Med. 1996;156:745-752)

515 citations


Frequently Asked Questions (1)
Q1. What contributions have the authors mentioned in the paper "Modification of coronary-prone behaviors in coronary patients of low socio-economic status" ?

Results showed that only the psychological treatment group significantly reduced Pressured Drive and Speed-Impatience after treatment, and at 1and 2-year follow-ups. Depression was also significantly reduced only in this group at 2-year follow-up.