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Internet-based Cognitive Behavior Therapy for Symptoms of Depression and Anxiety among Patients with a Recent Myocardial Infarction: The U-CARE Heart Randomized Trial
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.ORCID iD: 0000-0001-8895-5247
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.ORCID iD: 0000-0002-1591-7407
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.ORCID iD: 0000-0002-1473-4916
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2018 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 20, no 3, article id e88Article in journal (Refereed) Published
Abstract [en]

Background: Symptoms of depression and anxiety are common after a myocardial infarction (MI). Internet-based cognitivebehavioral therapy (iCBT) has shown good results in other patient groups.

Objective: The aim of this study was to evaluate the effectiveness of an iCBT treatment to reduce self-reported symptoms ofdepression and anxiety among patients with a recent MI.

Methods: In total, 3928 patients were screened for eligibility in 25 Swedish hospitals. Of these, 239 patients (33.5%, 80/239women, mean age 60 years) with a recent MI and symptoms of depression or anxiety were randomly allocated to a therapist-guided,14-week iCBT treatment (n=117), or treatment as usual (TAU; n=122). The iCBT treatment was designed for post-MI patients.The primary outcome was the total score of the Hospital Anxiety and Depression Scale (HADS) 14 weeks post baseline, assessedover the internet. Treatment effect was evaluated according to the intention-to-treat principle, with multiple imputations. For themain analysis, a pooled treatment effect was estimated, controlling for age, sex, and baseline HADS.

Results: There was a reduction in HADS scores over time in the total study sample (mean delta=−5.1, P<.001) but no differencebetween the study groups at follow-up (beta=−0.47, 95% CI −1.95 to 1.00, P=.53). Treatment adherence was low. A total of46.2% (54/117) of the iCBT group did not complete the introductory module.

Conclusions: iCBT treatment for an MI population did not result in lower levels of symptoms of depression or anxiety comparedwith TAU. Low treatment adherence might have influenced the result.

Trial Registration: ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webciteat http://www.webcitation.org/6xWWSEQ22)

Place, publisher, year, edition, pages
2018. Vol. 20, no 3, article id e88
National Category
Psychology Cardiac and Cardiovascular Systems
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-336209DOI: 10.2196/jmir.9710ISI: 000428245500002PubMedID: 25873137OAI: oai:DiVA.org:uu-336209DiVA, id: diva2:1165409
Funder
Swedish Research Council, dnr 2009-1093Swedish Heart Lung Foundation, dnr E 148/11Forte, Swedish Research Council for Health, Working Life and Welfare, dnr 2014-4947Vårdal Foundation, dnr 2014-0114Available from: 2017-12-13 Created: 2017-12-13 Last updated: 2018-07-24Bibliographically approved
In thesis
1. Psychological distress in coronary heart disease: Risk indicators, treatment and cardiovascular prognosis
Open this publication in new window or tab >>Psychological distress in coronary heart disease: Risk indicators, treatment and cardiovascular prognosis
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aims of this thesis were to: (1) explore factors associated with emotional distress; (2) investigate psychosocial stress as a risk factor for cardiovascular (CV) morbidity in patients with coronary heart disease (CHD); (3) investigate the impact of group-based stress management on psychological outcomes, and if that mediates risk of CV events; and (4) evaluate an internet-based cognitive behavioral therapy (iCBT) for emotional distress in patients with a recent myocardial infarction (MI).

In Study I, data from the national registry SWEDEHEART on 27,267 MI patients < 75 years was used. Study II was a prospective longitudinal study with 14,577 patients with stable CHD. Psychosocial stress was assessed with a questionnaire and patients were followed-up for clinical events on average 3.7 years. In Study III, a group-based stress management was evaluated in a randomized controlled trial of 362 CHD patients. Psychological outcomes (stress, somatic anxiety, depression and vital exhaustion) were assessed at five time-points over two years. Joint modelling for longitudinal and time-to-event data was used to analyze if reduction in the psychological outcomes mediated the positive effect the treatment had on later CV events. Study IV describes Study V and includes a pilot study investigating the acceptability of the intervention used. In Study V 239 MI patients were recruited to evaluate iCBT versus usual care in a randomized clinical trial.

In summary, in Study I, sociodemographic factors, previous psychiatric diagnosis and readmission for CV events were associated with incident and persistent emotional distress post-MI. In Study II, after multivariable adjustments, depressive symptoms, financial stress and living alone were all independently associated with CV death or the composite of CV death, non-fatal MI or non-fatal stroke. These results emphasize the importance of targeting psychosocial factors in order to optimize secondary prevention. In Study III, somatic anxiety was the only targeted psychological outcome affected positively by stress management, and may have in turn reduced subsequent CV events. Other mediating factors remain to be identified. Study IV indicated the intervention used in Study V was acceptable. Study V concluded that iCBT was not superior to usual care for emotional distress in post-MI patients and treatment adherence was unexpectedly low. Potential reasons for the low adherence require further exploration.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 75
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1412
Keywords
psychological distress, myocardial infarction, coronary heart disease, depression, anxiety, stress, cognitive behavioral therapy, iCBT, stress management, cardiac rehabilitation
National Category
Cardiac and Cardiovascular Systems Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:uu:diva-336234 (URN)978-91-513-0192-1 (ISBN)
Public defence
2018-02-14, Sal IV, Gamla universitetshuset, Biskopsgatan 3, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Funder
Swedish Research Council, 2009–1093
Available from: 2018-01-24 Created: 2017-12-13 Last updated: 2018-03-07
2. Remote delivery of psychological interventions: Impact and acceptability of preventive strategies to improve risk factors associated with coronary heart disease
Open this publication in new window or tab >>Remote delivery of psychological interventions: Impact and acceptability of preventive strategies to improve risk factors associated with coronary heart disease
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Depression, anxiety and excessive weight are public health concerns that have been associated with an increased risk and worse prognosis of coronary heart disease. Remote delivery of psychological interventions may be an effective preventive strategy to improve these lifestyle-related risk factors as treatment may be delivered to many people at a low cost and reduce stigma related to seeking help. The general contribution of this thesis is to investigate the impact and indicators of treatment acceptability in contexts where this type of delivery may improve access to psychological interventions. The aim of Study I was to investigate whether stigma predicts the intention to seek help via the Internet compared to face to face among undergraduate students (N=267) and primary care patients (N=195). The results indicate that Internet-based interventions may improve intentions to seek help among individuals who are reluctant to seek psychological treatment face to face due to stigma. In Study II, the effect of a guided Internet-based Cognitive Behavior Therapy (iCBT) and Treatment-As-Usual (TAU) was compared to TAU only to reduce symptoms of depression and anxiety among patients with a recent myocardial infarction (N=239) in a randomized controlled trial. The results indicate no difference in symptoms of depression and anxiety between the groups. Study III describe treatment activity among participants allocated to the iCBT intervention in Study II (N=117). Furthermore, user experiences were explored using a semi-structured interview with 21 of these participants. The results indicate overall low treatment activity and different preferences regarding the web-based portal, treatment program and therapist communication. The aim of Study IV was to evaluate the impact and investigate indicators of treatment acceptability of a guided Acceptance and Commitment Therapy (ACT) self-help intervention to improve value attainment related to health and reduce experiential avoidance among individuals with overweight or obesity using a multiple baseline design (N=13). The results indicate that theACT intervention may be an acceptable intervention to improve value attainment related to health and decrease experiential avoidance. In conclusion, the studies in this thesis illustrate several challenges related to the willingness to seek and engage in Internet-based interventions. Furthermore, the results indicate varying responses to the remote delivery of ACT. The principal findings are discussed in relation to methodological limitations. Possible strategies to improve the take-up rates, adherence and treatment satisfaction are suggested as well as areas of future research.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 75
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences, ISSN 1652-9030 ; 156
Keywords
Depression, anxiety, overweight, obesity, technology-assisted interventions, Cognitive Behavioral Therapy, Acceptance and Commitment Therapy
National Category
Social Sciences
Research subject
Psychology
Identifiers
urn:nbn:se:uu:diva-354028 (URN)978-91-513-0373-4 (ISBN)
Public defence
2018-09-14, Blåsenhus, Betty Pettersson-salen (14:031), Campus Blåsenhus, von Kreamers allé 1A och 1C, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2018-08-22 Created: 2018-06-18 Last updated: 2018-08-28

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Norlund, FredrikaWallin, EmmaOlsson, ErikWallert, JohnBurell, Gunillavon Essen, LouiseHeld, Claes

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