Can Cognitive Behaviour Therapy Be Beneficial for ...

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Curr Heart Fail Rep DOI 10.1007/s11897-014-0244-2

SELF-CARE AND HEALTH OUTCOMES (T JAARSMA, SECTION EDITOR)

Can Cognitive Behaviour Therapy Be Beneficial for Heart Failure Patients? Johan Lundgren & Gerhard Andersson & Peter Johansson

# Springer Science+Business Media New York 2014

Abstract This review aims to summarize the theory of cognitive behavioural therapy (CBT) as well as the current evidence for whether CBT can be beneficial for patients with heart failure (HF). Depression and/or anxiety are common in HF patients. However, participation in disease management programmes does not seem to be beneficial for these problems. CBT, which focuses on the identification and changing of dysfunctional beliefs and thoughts and on behaviour therapy, is a possible treatment option. The number of CBT studies on HF is small and they are often not designed as randomized controlled trials. However, the studies on HF indicate that CBT can decrease depression as well as anxiety and suggest that relaxation exercises with elements of CBT may decrease symptom burden. Before implementation in clinical practice, more knowledge is needed about how CBT programmes should be designed, where CBT should be delivered and who should deliver CBT.

Keywords Cognitive behavioural therapy . Heart failure . Depression . Anxiety

This article is part of the Topical Collection on Self-Care and Health Outcomes J. Lundgren Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden G. Andersson Department of Behavioural Sciences and Learning, Linköping University, SE-581 83 Linköping, Sweden e-mail: [email protected] P. Johansson (*) Department of Cardiology and Department of Medical and Health Sciences, Linköping University, SE-581-85 Linköping, Sweden e-mail: [email protected]

Introduction Cardiovascular disease is one of the leading causes of disability and death in the developed world [1]. In Europe, CVD alone accounts for 43 % of all deaths of all ages (i.e. >4 million deaths annually) [2]. Heart failure (HF) can be seen as the end stage of CVD [3] and is caused by an underlying impairment of cardiac function which is manifested in disturbing symptoms such as dyspnoea, fatigue and oedema [4]. The prevalence of HF increases with age, and most patients have other comorbid heart diseases and/or other somatic diseases such as diabetes and/or chronic pulmonary disease [4]. HF includes a complex medical treatment and self-care regimes as well as other symptoms. All these aspects are likely to limit the patients’ physical, psychological and social functions [4–6]. Moreover, the trajectory of HF includes unpredictable symptoms that frequently change, leading to good and bad days [7] and increased risk of hospitalization or death due to worsening HF [8, 9]. Thus, HF constitutes an unpredictable threat to patients’ daily functioning and health, which can cause the HF patients to feel fear and insecurity [10]. Many HF patients suffer from different types of psychological problems such as depression [11] and/or anxiety [12] as well as insomnia [13]. For example, depression has important implications for the patient with HF. Compared to HF patients without depression, those with depression report a poorer quality of life [14], are more frequently re-hospitalized [15] and have higher health-care costs [16] and a shorter life expectancy [15]. Thus, in HF, depression can be regarded as a potential, but a modifiable, risk factor for impairment of quality of life as well as poorer prognosis. Anti-depressant treatment with selective serotonin receptor antagonists (SSRI) may be one option to treat depression. The number of studies evaluating the benefit of anti-depressant treatment in patients with HF is small, and convincing results have not been

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obtained. For example, in the large-scaled SADHART study, SSRI compared to placebo did not result in greater reduction in depression or improvement in the composite cardiovascular end point [17•]. Moreover, the addition of an anti-depressant to the existing complex medical treatment for HF (angiotensin-converting enzyme inhibitors, beta-blockers, mineral receptor antagonists, diuretics) may be perceived as burdensome as it increases the complexity of the medical treatment regimen and also increases the risk of developing side effects. This suggests that HF patients with psychological problems such as depression need other treatment options than antidepressant medication. Cognitive behavioural therapy (CBT) may be one such alternative since it has been shown to be capable of treating different psychological problems such as depression [18], anxiety [19] and insomnia [20]. The aim of this review therefore was (1) to summarize the theory about CBT (2) and summarize current evidence on whether CBT can be beneficial for patients with HF.

Cognitive Behaviour Therapy CBT is usually a short form of psychological treatment that has two distinct strands that are integrated in the term CBT. First, behaviour therapy was developed and established in the 1960s, even though the dominant form of psychotherapy by that time was psychodynamic psychotherapy and psychoanalysis. Behaviour therapy is based on learning theory, and concepts such as classical and operant conditioning are used. Behaviour is viewed as a product of the interaction between the human and consequences in the environment. Several treatment techniques used in CBT are derived from behaviour therapy, such as exposure and behavioural action [21]. In the early 1970s, cognitive therapy was developed. In this therapy form, the focus is on cognition, with the basic model being that our thoughts and beliefs influence our emotion and behaviour. Many treatment techniques are derived from this approach, such as thought records, Socratic listening and working with negative automatic thoughts and core beliefs [22]. Behaviour therapy and cognitive therapy are integrated in CBT, which now can be regarded as an umbrella term for a range of procedures and techniques based on clinical observations and rigorous empirical research. More recently, for example, a form of CBT focused on acceptance has been developed, and there are several forms of CBT specifically targeted at certain problems and groups. Given this diversity, it may be useful to delineate what characterizes CBT in general. First, CBT starts by providing a treatment rationale which is presented after information on patient history and presenting problem has been collected. Second, CBT more or less always includes some form of homework. Thus, it is not enough just to see the therapist, and change must be implemented in real life, which is handled by collaborating with the patient and

prescribing homework. Apart from those two aspects, it could be argued that CBT is closely aligned with empirical research and that CBT constantly changes based on the outcome of research, but that characteristic is shared with many forms of psychological treatment. An additional feature is the good working alliance between the therapist and the patient. This is a common aspect of most psychotherapies. There is however evidence to suggest that CBT can be delivered with only minor contact with a therapist (e.g. by email or phone). Thus, the role of the therapeutic alliance may not be as important in CBT as in other forms of psychotherapy. CBT has been adapted and tested for a range of psychiatric and somatic conditions and, in addition, several other problems that are not in the clinical domain [23]. For example, there are many controlled trials on the use of CBT for depression, anxiety disorders and somatic disorders such as chronic pain [18, 19, 24]. Other health problems such as insomnia and stress have also been the target of CBT interventions and treatment studies [23]. Overall, if any psychotherapy has been tested for a condition and found to be effective, it is almost always CBT. There are other psychotherapies, but rarely, if ever, do they result in better outcomes than CBT [25]. Interestingly, CBT can be effectively delivered as a faceto-face treatment, as group treatment or as guided selfhelp. A new form of CBT has emerged during the last 15 years, and it is now established that CBT can be delivered via the Internet and yield equivalent outcomes as in face-to-face CBT [26] but with the caveat that Internet CBT needs to be guided by a clinician. Automated Internet treatments tend to be associated with large dropout rates and smaller effects, whereas guided interventions have smaller dropout rates and larger effects [26].

Cognitive Behaviour Therapy in Patients with Heart Failure Cognitive Behaviour Therapy for Patients with a Defined Psychological Problem There are a limited number of studies (n=4) that have evaluated the effect of CBT on patients with HF and who also have a specific psychological problem. However, two studies reported on the effect of a CBT programme on depression in HF patients [27•, 28] and two other studies have evaluated both depression and anxiety [29, 30•]. Only two of these were randomized controlled trials (RCTs) [27•, 28]. CBT Programmes for Patients with Heart Failure An overview of the CBT programmes is shown in Table 1. Three of the CBT programmes were 6 and 12 weeks, respectively, and were performed in HF outpatients (n=10, n=74,

Curr Heart Fail Rep Table 1

Content of the cognitive behavioural programmes that was evaluated on heart failure patients with depression or depression and anxiety

Cully et al. [29]

Dekker et al.[28] RCT

Gary et al. [27•] RCT

CBT-programme

Provided by

Six 50-min sessions and three telephones booster sessions post-treatment (week 8, 10, 12) Core modules sessions 1 and 2 (in person): 1. Outline, direction and goal setting. Psychoeducation: chronic cardiopulmonary disease and stress. Homework 2. Review of homework. Self-management by understanding personal impact and increasing control. Homework Elective modules sessions 3 to 5 (in person or by telephone): Managing your physical health including 6 submodules (exercise, nutrition, contact with doctor, medications, self-care, sleep hygiene) Power of thoughts including 3 submodules (behavioural activation, relaxation, problems solving) Wrap-up session (week 6) (in person or by telephone): Review treatment progress. Encourage and empower patients to maintain positive changes. Post-treatment three telephones booster sessions (week 8, 10, 12) One 30-min session in hospital including: 1. Psycho-education about heart failure and depression 2. Thoughts, feelings and behaviours 3. Patients story 4. Thought stopping 5. Affirmation 6. Homework 1 week after discharge 5–10-min telephone booster 12-week programme 1 h/week in patients’ home. CBT according to Beck’s model of depression including: 1. Establish contact with the patient 2. Principle of the cognitive model (agenda, thoughts, behaviour) 3. Discussion about depression and negative schema 4. Teach the patient about CBT methods that may be used (automatic thoughts, activity schedules, role playing and homework) 5. Establish mutual collaborative goals 6. Clarify concerns and answering questions about CBT

Psychologist (clinical, postdoctoral and predoctoral)

n=29). [27•, 29, 30•]. In contrast, the CBT programme in Dekker et al. [28] consisted of a 30-min single session provided to hospitalized HF patients (n=41). In the studies found, CBT was provided individually and face to face [27•, 29, 30•] in patients’ homes [27•, 29], in hospital [28] or by telephone [29]. CBT was delivered by a psychologist, psychology students or nurse specialists. In three of the four studies, the participants received booster sessions post-treatment [27•, 28, 29]. The effect of booster sessions was not specifically evaluated in these studies. In light of the need the need to cut costs within the health-care sector, there may be a problem implementing CBT programmes which means that the therapist has to travel to meet the HF patients individually in their homes for 1 h per week over a period of 3 months. Telephone consultation could be another option and was used in one of the studies [29]; however it has not been reported how many patients preferred to have CBT by telephone.

Health clinical nurse specialist in collaboration with psychiatric nurse specialist

Trained psychiatric nurse specialists or psychology students

Compared to face to face, CBT by telephone seems to have less attrition, the same short-term effect, but worse long-term effect on depression [31]. Internet-based CBT (I-CBT) could be another option and has been shown to be effective in treating depression [32]. Compared to the face-to-face approach, I-CBT can be delivered to a vast number of patients at a low cost [33]. A second advantage is that health-care personnel with only a brief training period in CBT can perform I-CBT with good treatment results [34]. Another advantage is that the Internet enhances patients’ access to CBT and allows sessions to be performed at home and fitted into daily routines [35]. Thus, neither the patient nor the therapist needs to travel to an appointment. I-CBT has not yet been tested in patients with HF. The authors of this paper have developed an I-CBT programme for HF patients with depression, and it was recently tested in a feasibility study [36]. This I-CBT programme is at present under evaluation in an RCT study.

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CBT Programmes Targeting Depression in Patients with Heart Failure The study of Gary et al. [27•] evaluated the single as well as the combined effects of a 12-week home-based exercise (EX) and CBT programme on depression. The results showed that depression decreased in all groups (EX, CBT, CBT/EX, usual care), but not significantly. However, CBT/EX compared to other groups seemed to have a more sustained reduction in depression at the 12- and 24-week follow-ups. Minor or moderate/major depression at inclusion seems to play a role in the response to CBT. At the 24-week follow-up, remission from minor depression had occurred in all groups. But, from 8 to 24 weeks, the effect was greatest for those who received CBT only. For those with moderate/major depression, only those receiving CBT/EX had sustained lower depression at 12 and 24 weeks. CBT/EX was also more effective in reducing moderate depression to minor depression. The findings in the study of Gary et al. [27•] are in line with studies reporting that physical exercise can reduce depression [37]. Physical limitations and patients’ attitudes about physical impairment are both associated with depression in HF patients [38]. As such, adding a physical exercise programme on top of CBT may be beneficial when treating depression in HF patients’. Generic CBT programmes may not be optimal for targeting depression in patients with chronic disease [39]. This suggests that CBT programmes have to be adopted to fit the context of the disease, for example, by acknowledging the association between the physical illness and depression [39]. The CBT programmes of Cully et al. [29] and Dekker et al. [28] can be said to use this approach (Table 1). In Cully et al.[29], the participants’ mean score on the Beck Depression Inventory-II (BDI-II) decreased from 17.3 at baseline to 10.24 at 8 weeks, indicating a large effect size on depression (Cohen d=0.97) [29]. However, these results must be interpreted with caution since it was an open trial with a limited sample (n=10). Dekker et al. [28] used a randomized controlled design with a larger sample (n=41); however, in both the CBT as well as the control group, depression improved from baseline (in hospital) to 1 week and at 3 months. Despite this, the CBT group at 3 months had longer cardiac event survival. There are several possible explanations for the lack of effect on depression. One explanation could be that the CBT programme was too brief, i.e. 30 min compared to the other studies which provided CBT for approximately 1 h/week for 6 or 12 weeks (Table 1). Other explanations could be associated with the design of the study. In the first week after discharge from hospital, there was a strong remission of depressive symptoms in both groups. This and the fact that patients were screened for depression during hospitalization could suggest that the result could have been inflated by cases of “reactive depression”. In relation to screening for depression during hospitalization, a third explanation could be overlapping symptoms

between HF and depression, i.e. false depressed cases were included. When patients were stabilized and discharged home, they became less depressive, less symptomatic or both. An important lesson is that spontaneous remission of depressive symptoms after hospital discharge will probably occur. Johansson et al. [15] showed that from initial assessment of depressive symptoms during hospitalization to re-assessment 18 months later, the occurrence of depressive symptoms decreased from 38 to 26 %. Fulop and colleagues reported that depressive symptoms in HF patients decreased from 36 % in hospital to 26 % 24 weeks post-discharge [16]. These experiences suggest it is advisable not to initiate treatment of depression during hospitalization for HF, but to wait until at least 1 month post-discharge, until patients have stabilized [16]. CBT Programmes Targeting both Depression and Anxiety in Patients with Heart Failure It is common for those with depression to have a comorbid anxiety. In a recent study of Dekker et al. [40], the vast majority of the HF patients with depression also had anxiety (i.e. 91 %). In the study of Cully et al. [29], 56 % of the sample had both depression and anxiety and their CBT programme also had medium-sized effect on anxiety (Cohen d=0.57). In another study, HF patients with both depression and anxiety received either depression treatment or treatment (n=15) for general anxiety disorder (GAD) (n=14) [30•]. The effect of CBT treatment for depression or GAD did not show any between-group differences. In other words, depression and GAD were generally effectively treated regardless of which primary treatment for depression or GAD was used. However, interaction analyses performed showed that GAD treatment, or decreasing GAD symptoms, and participation in a cardiac rehabilitation exercise programme were associated with reductions in somatic depressive symptoms. It is therefore possible that future CBT programmes adapted to HF patients should include components that target depression as well as anxiety, for example, by inclusion of relaxation or mindfulness exercises. CBT Programmes for Heart Failure Patients in General Some studies have included general HF patients and evaluated programmes including aspects that can be considered to be inspired by CBT (Table 2) [41, 42, 43•]. One study evaluated a nurse-facilitated cognitive behavioural self-management HF programme (n=260) [41] while the other programmes (n= 208 and n = 29) [42, 43•] focused on different stress management/relaxation techniques but also included topics such as changing behaviours, coping and HF self-management. Only one of the studies described above was labelled as RCT [41]. The two stress management/relaxation studies were

Curr Heart Fail Rep Table 2

Content of the cognitive behavioural programmes that was evaluated on heart failure patients in general

Cockayne et al.[41] RCT

Luskin et al. [42] Incomplete RCT

Sullivan et al. [43•]

Cognitive behavioural self-management. Up to six face-to-face sessions. The manual includes: 1. The Heart Failure plan, DVD, pocket-diary (also to control group) 2. Relaxation tape 3. Exercise in and around a chair 4. Learn to monitor symptoms and signs of HF 5. Discussions Goal settings Stress management. Group sessions during 10 weeks including 10-h training during eight weekly75-min session. General outline of the 8 sessions: 1. Orientation, class overview. Guided practice in relaxation 2. Stress management and cardiovascular disease and effect of stress on the body. Guided practice in relaxation 3. Discussion of stress management and self-care. Guided practice in relaxation 4. Discussion about behaviours, changing patterns. Guided practice in relaxation 5. Practice in thinking of ways to include stress management in daily life. Tips in deep breathing. Guided practice in relaxation 6. Discussion about different stress management techniques. Guided practice in relaxation 7. Discussions about mental health and suffering. Guided practice in relaxation 8. Review of the course. Reminders for the future. Participant feedback Homework: perform relaxation between sessions A mindfulness-based psychoeducational intervention. Group sessions, once a week for 2.25 h during 8 weeks Three main components were addressed each week: 1. Mindfulness-based stress reduction 2. Coping skills training including education in topics such as heart failure, treatment, exercise, diet, social supports tress management and healthy grieving 3. Expressive group discussion encouraging haring of emotional content and group affiliation

based on group sessions [42, 43•] whereas the other study was performed as a face-to-face intervention [41]. Participants who received the nurse-facilitated cognitive behavioural self-management HF programme did not significantly differ compared to control with regard to hospital readmissions at the 12-month follow-up or changes in quality of life, knowledge of HF self-management or anxiety over time. However, the active group had significantly more depressive symptoms [41]. Jaarsma et al. [44] found the same type of experiences; patients who had depressive symptoms when joining an HF disease management programme had a poorer outcome (HF hospitalizations or deaths) compared to those without depressive symptoms. The exact mechanism behind this is beyond the topic of this paper; however, disease management programmes cannot be recommended as a treatment for depression in HF patients with depression [45]. On the other hand, the programmes focusing on stress management/ relaxation, but which also included topics considered as HFspecific issues, reported that depressive symptoms, tensionanxiety, perceived stress, 6-min walk test and quality of life were improved significantly by the intervention in both studies [42, 43•]. Mindfulness-based CBT programmes have been shown to be beneficial for reducing symptom burden in patients with irritable bowel syndrome [46]. This suggests that CBT programmes with mindfulness/relaxation exercises may

Specialist HF nurses

Psychotherapist

Cardiologist, psychiatrist, cardiology nurse rehabilitation counsellor All 4 were qualified mindfulness instructors.

be used as a tool to reduce symptom burden in HF patients without depression and anxiety.

Research Implications CBT in HF patients is still an area of novelty, and there is a need for well-designed RCT before we determine whether CBT can be beneficial for HF patients. On the other hand, much research on other patient groups has established CBT as a treatment of choice for different types of psychological problems. CBT research on cardiology patients in general and HF specifically may therefore instead focus on the development or refinement of existing CBT programmes to fit the context of HF patients. A question concerns the development of broad-spectrum CBT programmes that target, for example, both depression as well as anxiety, or, instead the development of individualized CBT programmes. In other words, a CBT programme that includes a large number of different and separate tools that are aimed to treat depression or anxiety or insomnia and which can be tailored to fit the HF patient’s specific psychological problem, for example, depression and anxiety or depression and insomnia. From a practical as well as an economical point of view, knowledge is also needed on

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how to provide CBT to HF patients and in which context, for example: in the patient’s home? HF clinic? Face to face? Group sessions? By telephone? From this point of view, ICBT can be seen as very interesting for research in cardiology. To further increase the possibility for implementation of CBT programmes in cardiology, there is also a need for studies that develop and evaluate brief programmes aimed at training lay providers, such as HF nurses or physiotherapists, to deliver CBT and other treatment methods such as mindfulness exercises. Moreover, researchers need to be careful to screen for and include depressed or anxious HF patients during hospitalization, since this approach increases the risk of including participants who will recover after discharge anyway. Patients in cardiology usually have two or three heart diseases, such as HF and coronary heart disease (CHD) and/or atrial fibrillation (AF). Most of them also have the same symptom profile (dyspnoea, fatigue, palpitations, pain) and the same type of medical treatment (ACE-inhibitor, beta-blocker, diuretics) and are usually given the same recommendations regarding nonpharmacological treatment (diet, physical exercise, stopping smoking). This raises an important question: instead of developing specific CBT programmes for HF, CHD and AF, should we start thinking about developing a CBT programme that targets patients with CVD (i.e. HF, CHD, AF). It is probably more likely that cardiology- or out-patient clinics would prefer to consider the implementation of such a CBT programme instead of three specific ones.

Conclusion HF patients with psychological problems such as depression or anxiety might not have optimal benefit from participation in an HF disease management programme. Specific methods aimed to target depression or anxiety in HF patients are therefore needed. One method could be CBT since it has been found to be effective in other patient groups. CBT studies on HF patients indicate positive effects of CBT on depression and anxiety as well as symptom burden. However, these results should be treated cautiously, since the number of studies is small and they often lack an adequate design. Questions on how CBT programmes should be designed, where CBT should be delivered and who should deliver CBT remains to be answered and clarified before CBT can be taken into consideration for implementation in HF care. Compliance with Ethics Guidelines

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Conflict of Interest Johan Lundgren, Gerhard Andersson and Peter Johansson declare that they have no conflict of interest.

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Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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