Abstract
Introduction: Cognitive behavioral therapy (CBT) alleviates emotional distress in mental health settings, but has only modest effects in cardiac patients. Metacognitive therapy (MCT) also alleviates depression and anxiety in mental health settings and is in its initial stages of evaluation for cardiac patients.Aim: Our objective is to compare how CBT and MCT models conceptualize cardiac patients' distress, and to explore why CBT has had limited benefit for cardiac patients and whether MCT has the potential to be more efficacious.Method: Forty-nine cardiac rehabilitation patients, who screened positively for anxiety and/or depression, provided semi-structured interviews. We analyzed transcripts qualitatively to explore the “fit” of patients' accounts of their distress with the main elements of cognitive behavioral and metacognitive theories. Four illustrative cases, representative of the diverse presentations in the broader sample, were analyzed in detail and are presented here.Results: Conceptualizing patients' distress from the perspective of CBT involved applying many distinct categories to describe specific details of patients' talk, particularly the diversity of their concerns and the multiple types of cognitive distortion. It also required distinction between realistic and unrealistic thoughts, which was difficult when thoughts were associated with the risk or consequences of cardiac events. From the perspective of MCT a single category—perseverative negative thinking—was sufficient to understand all this talk, regardless of whether it indicated realistic or unrealistic thoughts, and could also be applied to some talk that did not seem relevant from a CBT perspective.Discussion: Conceptualizing distress from the perspective of CBT presents multiple, diverse therapeutic targets, not all of which a time-limited therapy would be able to address. Given the difficulty of identifying them as unrealistic or not, thoughts about disease, death or disability may not be amenable to classic CBT techniques such as reality testing. MCT proved more parsimonious and, because it did not distinguish between realistic and unrealistic thoughts, might prove a better fit to emotional distress in cardiac patients.
Highlights
Cognitive behavioral therapy (CBT) alleviates emotional distress in mental health settings, but has only modest effects in cardiac patients
A meta-analysis found that generalized anxiety disorder and panic disorder are over twice as prevalent in coronary heart disease (CHD) patients than in the general population, and are comorbid with depressive disorders in approximately 50% of cases, a rate of comorbidity that is similar to community and psychiatric samples (Tully et al, 2016)
From the perspective of Cognitive Behavioral Therapy (CBT), we identified relatively focused and distinct sections of patients’ talk that contained Negative automatic thought (NAT), and that displayed many cognitive distortions (Beck, 1976), it was often difficult to agree which category of distortion to allocate specific NATs to
Summary
Cognitive behavioral therapy (CBT) alleviates emotional distress in mental health settings, but has only modest effects in cardiac patients. Reviews of studies of depression in patients with myocardial infarction (MI) found that 20% of patients from eight studies that used structured clinical interviews reached criteria for major depression, and 14 studies that used validated self-report measures identified depression in 40% of MI patients (Carney and Freedland, 2003; Thombs et al, 2006) Emotional distress in this population is linked to poorer quality of life, increased risk of future cardiac events and mortality, increased use of healthcare, and poorer treatment adherence (Frasure-Smith et al, 2000; Bush et al, 2001; Lespérance et al, 2002; Gehi et al, 2005; Goyal et al, 2005; Carney et al, 2008; Yohannes et al, 2010; Dickens et al, 2012; Müller et al, 2012; Tully et al, 2016).
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