Counseling, Group Therapy Improve Depression, Social Support for Heart Attack Patients
A national trial conducted at eight medical centers, including Duke University Medical Center, has demonstrated that psychological counseling and group therapy significantly improves depression and social isolation for patients who have suffered a heart attack.
The findings are important, researchers said, because about half of all heart attack victims become depressed, which will hinder many from regaining their health. The results of the trial, which enrolled 2,481 heart attack patients, were published today (June 18, 2003) in the Journal of the American Medical Association.
While the trial did not achieve its primary goal of demonstrating that cognitive behavioral therapy (CBT) could reduce the rates of death or recurrent heart attack after an initial heart attack, the researchers believe that the results further highlight the importance of treating depression and addressing social support issues in this group of patients. They also said that while there was no improvement in mortality rates, decreasing depression and increasing social support improved the quality of life of these patients.
CBT consisted of weekly individual therapy sessions, supplemented in some cases with group sessions, aimed at helping patients modify their habitual negative thought patterns and alter their reactions to stressful situations.
"Although the intervention did not provide a survival benefit up to 30 months after the heart attack, it did succeed in decreasing depression and increasing social support, especially during the first six months," said psychologist James Blumenthal, Ph.D., who led the Duke portion of the trial. "This demonstrates that patients who are depressed or have low social support following a heart attack should be followed, and if the symptoms do not clear up, they should be considered for treatment.
Dubbed ENRICHD (Enhancing Recovery in Coronary Heart Disease Patients), the trial was supported by a $29.6 million grant from the National Heart, Lung and Blood Institute. It was the first multi-center trial supported by the National Institutes of Health to investigate the promise of such behavior therapy interventions in patients with heart disease.
One goal of the trial was to enroll a representative population of patients, and the researchers believe they succeeded, enrolling 1,084 women and 1,397 men and 34 percent minorities.
Patients were given standardized tests to determine levels of depression and social support within 28 days of being admitted to the hospital following their heart attack. Patients found to be depressed and/or isolated were then randomized into one of two groups: one group received individual counseling and group therapy, while the second group received the standard cardiac care provided by their personal physicians. Patients with higher levels of depression, or who were unresponsive to CBT, were also treated with anti-depressant medication.
The psychological tests were repeated six months later and then annually.
In terms of the CBT group, scores on standard inventories of depression improved 20 percent after six months, while tests of social isolation improved 50 percent, when compared to patients who did not receive intervention.
Another encouraging aspect of the trial, according to Blumenthal, was that this non-pharmacological approach could readily be implemented at smaller hospitals as well as the large academic centers.
"While eight major medical centers were involved, most of the centers had a network of smaller community hospitals within their systems where patients were enrolled and treated," Blumenthal said. "This leads us to believe that such cognitive behavioral techniques can be successfully delivered in a multitude of settings."
Interestingly, the researchers detected a gender difference in patients' response to CBT.
"While not statistically significant, there was a trend toward men in the CBT condition exhibiting greater reductions in mortality and morbidity compared to women," Blumenthal said. "More studies are needed to better understand this differential response to therapy between men and women."
The results of the trial also suggest the need for additional studies to determine the optimal timing and duration of psychological interventions and to identify the biological and behavioral pathways that link psychosocial health with cardiovascular disease.
"We have always been very interested in evaluating behavioral, non-pharmacologic approaches to treating depression," Blumenthal said. "Because up to one-third of depressed patients may not respond to drug therapy, and those who do take drugs may complain of side effects, it is important to find effective, alternative approaches."
Blumenthal is currently leading a trial to determine whether exercise can be an effective treatment for depression in middle-aged and older adults. An earlier Duke trial demonstrated that supervised exercise was just as effective as the most commonly used anti-depression medication in improving the symptoms of depression.
The new trial, called SMILE (Standard Medical Intervention and Long-term Exercise) is building upon the earlier trial by randomizing patients to supervised exercise, exercise at home, standard anti-depressant medication or placebo.
Cardiovascular disease is the leading cause of death in the United States. It is estimated that about 13 million Americans suffer from coronary artery disease. Each year, up to one-third of the 1.5 million Americans who suffer heart attacks will die. Not only could psychological treatment result in fewer hospitalizations and lives saved, it may help reduce the cost of treating heart patients with high-tech therapies, now estimated at $100 billion a year, Blumenthal said.
DURHAM, N.C. - http://www.dukemednews.org