Annotated Abstracts of Journal Articles
2013, 4th Quarter
Annotations by Scott Beach, MD and Jeff Huffman, MD, FAPM
ANNOTATION (Beach & Huffman)
The Finding: The authors found that a short-term humanistic-existential psychotherapy (STP), when added to standard cardiac therapy in patients who underwent complete revascularization for acute myocardial infarction, improves cardiac symptoms, quality of life, and psychological and medical outcomes at one year, while also reducing readmissions.
Strengths and Weaknesses: Strengths included homogenous study group and careful design. Weaknesses included the fact that the therapy chosen is not widely utilized, was designed specifically for the study, and was delivered by a single practitioner. The delivery of therapy varied widely, with one patient receiving only 3 sessions, and others receiving 11 sessions. The total number of the patients in the study was relatively low, at 94, limiting generalizability. The primary endpoint chosen was a composite outcome consisting of new cardiac events and the occurrence of any clinically-significant new comorbidity (which ultimately included a variety of medical and psychiatric illnesses).
Relevance: This trial adds to the literature suggesting a role for various psychotherapies in improving cardiac and psychiatric outcomes for patients with acute cardiac illness. Despite the limitations, the therapy used was associated with lower rates of angina recurrence and fewer all-cause admissions, suggesting that broader trials, with multiple providers and better-defined, more traditional outcome measures are definitely indicated.
Background: Previous studies on cognitive and interpersonal interventions have yielded inconsistent results in ischemic heart disease patients.
Methods: 101 patients aged ≤70years, and enrolled one week after complete revascularization with urgent/emergent angioplasty for an AMI, were randomized to standard cardiological therapy plus short-term humanistic-existential psychotherapy (STP) versus standard cardiological therapy only. Primary composite end point was: one-year incidence of new cardiological events (re-infarction, death, stroke, revascularization, life-threatening ventricular arrhythmias, and the recurrence of typical and clinically significant angina) and of clinically significant new comorbidities. Secondary end points were: rates for individual components of the primary outcome, incidence of re-hospitalizations for cardiological problems, New York Heart Association class, and psychometric test scores at follow-up.
Results: 94 patients were analyzed at one year. The two treatment groups were similar across all baseline characteristics. At follow-up, STP patients had had a lower incidence of the primary endpoint, relative to controls (21/49 vs. 35/45 patients; p=0.0006, respectively; NNT=3); this benefit was attributable to the lower incidence of recurrent angina and of new comorbidities in the STP group (14/49 vs. 22/45 patients, p=0.04, NNT=5; and 5/49 vs. 25/45, p<0.0001, NNT=3, respectively). Patients undergoing STP also had statistically fewer re-hospitalizations, a better NYHA class, higher quality of life, and lower depression scores.
Conclusion: Adding STP to cardiological therapy improves cardiological symptoms, quality of life, and psychological and medical outcomes one year post AMI, while reducing the need for re-hospitalizations. Larger studies remain necessary to confirm the generalizability of these results.
ANNOTATION (Beach & Huffman)
The Finding: The authors found that depression/dysthymia, panic disorder, specific phobia, PTSD, and alcohol use disorder are all associated with self-report of heart disease, with depression being the weakest association of the three.
Strengths and Weaknesses: Strengths of the study include large sample distributed throughout multiple countries and assessment of multiple psychiatric diagnoses. A major weakness is that the presence of heart disease was determined by self-report, with questions including “Has a health professional ever told you that you have heart disease?” and “Have you ever had a heart attack?” Furthermore, psychiatric diagnoses were assessed retrospectively, which may have led to underreporting.
Relevance: The relationship between depression and acute coronary syndrome is well established and has been extensively studied. The relationship between alcohol use disorders and heart disease is less well established, but intuitive. Alcohol use disorders are in this study associated with cardiovascular disease, suggesting that treatment for such disorders should be studied more thoroughly in this population and should be a component of care-management studies. The relationship between anxiety disorders and heart disease has been posited, but this study strengthens the association and suggests that the relationship may even be stronger than that for depression. Further, as GAD was previously the anxiety disorder thought to have the strongest link to cardiac outcomes, this study suggests that panic disorder and PTSD are more strongly associated and warrant further investigation as well as treatment in patients with cardiac disease.
Background: Prior studies on the depression-heart disease association have not usually used diagnostic measures of depression, or taken other mental disorders into consideration. As a result, it is not clear whether the association between depression and heart disease onset reflects a specific association, or the comorbidity between depression and other mental disorders. Additionally, the relative magnitude of associations of a range of mental disorders with heart disease onset is unknown.
Methods: Face-to-face household surveys were conducted in 19 countries (n=52,095; person years=2,141,194). The Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Heart disease was indicated by self-report of physician’s diagnosis, or self-report of heart attack, together with their timing (year). Survival analyses estimated associations between first onset of mental disorders and subsequent heart disease onset.
Results: After comorbidity adjustment, depression, panic disorder, specific phobia, post-traumatic stress disorder and alcohol use disorders were associated with heart disease onset (ORs 1.3-1.6). Increasing number of mental disorders was associated with heart disease in a dose-response fashion. Mood disorders and alcohol abuse were more strongly associated with earlier onset than later onset heart disease. Associations did not vary by gender.
Conclusions: Depression, anxiety and alcohol use disorders were significantly associated with heart disease onset; depression was the weakest predictor. If confirmed in future prospective studies, the breadth of psychopathology’s links with heart disease onset has substantial clinical and public health implications.
ANNOTATION (Beach & Huffman)
This was a secondary analysis from a randomized trial of ‘blended’ collaborative care in depressed patients with diabetes or heart disease that addressed both psychiatric illness and medical targets. The collaborative care intervention was associated with some improvements in diet (days with healthy eating plan) and physical activity (days with 30 mins of exercise), but not in smoking, sitting time, or some specific dietary habits (high-fat diet, fruits and vegetables) or exercise (days/week exercising), as compared to usual care. There were also no significant differences in weight change over the study period.
Strengths and Weaknesses: The primary trial was a carefully designed randomized clinical trial, and the assessments of self-reported health behaviors were comprehensive and relevant, with multiple measures of diet and exercise, the two most important health behaviors. Weaknesses included a lack of any objective measures of health behaviors (e.g., step counters, dietary logs, physiologic smoking assessments); assessment of medication adherence (especially if objectively measured) would have been additionally useful.
Relevance:The primary TEAMCare trial found that collaborative care was associated with improvements in objective physical outcomes such as blood pressure and hemoglobin A1c, but it seems unlikely that these outcomes were solely (or primarily) mediated by improvements in these health behaviors. Collaborative care patients may have improved due to higher quality of medication treatment prompted by the care managers, to improved adherence to medications, or to physiologic effects related to better treatment of depression (e.g., improved autonomic function leading to more normal blood pressure). Given the high rates of health behavior nonadherence in medically ill patients with depression and the relatively modest effects on health behaviors, these results suggest that there is an opportunity for collaborative care models to have a greater impact on health behaviors, and future models should consider more intensive health behavior components of the intervention.
Purpose: The purpose of the study was to compare behavioral outcomes (physical activity, sedentary behavior, smoking cessation, diet) between the intervention and usual care conditions from the TEAMcare trial.
Methods: TEAMcare was a randomized trial among 214 adults with depression and poorly controlled diabetes and/or coronary heart disease that promoted health behavior change and pharmacotherapy to improve health. Behavioral outcomes were measured with the International Physical Activity Questionnaire (physical activity, sitting time) and the Summary of Diabetes Self-Care Activities Measure (smoking, diet, exercise). Poisson regression models among completers (N=185) were conducted adjusting for age, education, smoking status and depression.
Results: Intervention participants had more days/week following a healthy eating plan [relative rate=1.2, 95% confidence interval (CI)=1.1-1.4] and more days of participation in 30 min of physical activity (relative rate=1.2, 95% CI=1.1-2.0) compared to usual care. Intervention participants were more likely to meet physical activity guidelines (7.5% increase) compared to usual care (12% decrease; P=.053).
Conclusion: Diet and activity generally improved for those receiving the intervention, while there were no differences in some aspects of diet (fruit and vegetable and high-fat food intake), smoking status and sitting time between conditions in the TEAMcare trial.