Abstract
BackgroundDepression is a common cause of reduced well-being and prognosis in patients with cardiovascular disease (CVD). However, there is a lack of effective intervention strategies targeting depression.ObjectiveThe study aimed to evaluate the effects of a nurse-delivered and adapted internet-based cognitive behavioral therapy (iCBT) program aimed at reducing depression in patients with CVD.MethodsA randomized controlled trial was conducted. A total of 144 patients with CVD with at least mild depression (Patient Health Questionnaire–9 [PHQ-9] score ≥5) were randomized 1:1 to a 9-week program of iCBT (n=72) or an active control participating in a Web-based discussion forum (online discussion forum [ODF], n=72). The iCBT program, which included 7 modules, was adapted to fit patients with CVD. Nurses with an experience of CVD care provided feedback and a short introduction to cognitive behavioral therapy. The primary outcome, depression, was measured using PHQ-9. Secondary outcomes were depression measured using the Montgomery-Åsberg Depression Rating Scale–self-rating version (MADRS-S), health-related quality of life (HRQoL) measured using Short Form 12 (SF-12) survey and EuroQol Visual Analogue Scale (EQ-VAS), and the level of adherence. An intention-to-treat analysis with multiple imputations was used. Between-group differences in the primary and secondary outcomes were determined by the analysis of covariance, and a sensitivity analysis was performed using mixed models.ResultsCompared with ODF, iCBT had a significant and moderate treatment effect on the primary outcome depression (ie, PHQ-9; mean group difference=−2.34 [95% CI −3.58 to −1.10], P<.001, Cohen d=0.62). In the secondary outcomes, compared with ODF, iCBT had a significant and large effect on depression (ie, MADRS-S; P<.001, Cohen d=0.86) and a significant and moderate effect on the mental component scale of the SF-12 (P<.001, Cohen d=0.66) and the EQ-VAS (P<.001, Cohen d=0.62). Overall, 60% (n=43) of the iCBT group completed all 7 modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study owing to a high risk of suicide or deterioration in depression.ConclusionsNurse-delivered iCBT can reduce depression and improve HRQoL in patients with CVD, enabling treatment for depression in their own homes and at their preferred time.Trial RegistrationClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074
Highlights
BackgroundDepression is highly prevalent in patients with cardiovascular disease (CVD; ie, atrial fibrillation or atrial flutter, ischemic heart disease, and heart failure) [1], with an estimated prevalence of 20% to 40%
Patients were eligible for inclusion if they were aged 18 years or above and were receiving CVD treatment according to the current guidelines for heart failure, coronary artery disease, and atrial fibrillation from the European Society of Cardiology [15,16,17], had stable CVD (New York Heart Association [NYHA] class I-III), with no hospitalization related to CVD in the past 4 weeks, and suffered at least mild depressive symptoms (Patient Health Questionnaire–9 [Patient Health Questionnaire–9 randomized controlled trials (RCTs) (PHQ-9)] score ≥5 [18])
The number of patients who did not complete the 9-week trial period was similar in the 2 groups
Summary
BackgroundDepression is highly prevalent in patients with cardiovascular disease (CVD; ie, atrial fibrillation or atrial flutter, ischemic heart disease, and heart failure) [1], with an estimated prevalence of 20% to 40%. Potential bio-behavioral mechanisms underlying the negative effects of depression include impairment of self-care activities and/or elevations in the stress and inflammatory response systems [1,2]. This underscores the importance of treating depression in CVD. Pharmacological treatment of depression may be an option in patients with CVD, but the effects are small [1] Such treatment poses a challenge as adding another medication to the existing complex medical treatment may be perceived as burdensome and might increase the risk of developing side effects [3]. There is a lack of effective intervention strategies targeting depression
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