Internet-Based Cognitive Behavioral Therapy for Patients Reporting Symptoms of Anxiety and Depression After Myocardial Infarction: U-CARE Heart Randomized Controlled Trial Twelve-Month Follow-up

Abstract

Background The U-CARE Heart trial was one of the first randomized controlled trials to evaluate the effect of internet-based cognitive behavioral therapy on self-reported symptoms of anxiety or depression for patients with a recent myocardial infarction. While the effects of internet-based cognitive behavioral therapy on Hospital Anxiety and Depression Scale (HADS) scores at 14 weeks postbaseline were not significant, in this study, we investigated possible long-term effects of treatment. Objective The aim of this study was to evaluate the long-term effectiveness of internet-based cognitive behavioral therapy on self-reported symptoms of anxiety and depression in patients 12 months after a myocardial infarction and to explore subsequent occurrences of cardiovascular disease events. Methods Shortly after acute myocardial infarction, 239 patients (33% female, mean age 59.6 years) reporting mild-to-moderate symptoms of anxiety or depression were randomized to 14 weeks of therapist-guided internet-based cognitive behavioral therapy (n=117) or treatment as usual (n=122). Data from national registries were used to explore group differences in clinical outcomes such as cardiovascular disease and cardiovascular-related mortality for a follow-up period of up to 5 years: group differences in HADS total score 1 year post–myocardial infarction, the primary outcome, was analyzed using multiple linear regression. Secondary outcomes, such as HADS anxiety and depression subscales and the Cardiac Anxiety Questionnaire total score (CAQ), which measures heart-focused anxiety, were analyzed in the same way. Multiple imputation was used to account for missing data, and a pooled treatment effect was estimated. Adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) for data pertaining to registry outcomes. Results Both groups reported lower HADS total scores 1 year after myocardial infarction than those at baseline. HADS total scores were not significantly different between the treatment and control groups 1 year after myocardial infarction (β=–1.14, 95% CI –2.73 to 0.45, P=.16). CAQ was the only measure improved significantly by internet-based cognitive behavioral therapy when compared with treatment as usual (β=–2.58, 95% CI –4.75 to –0.42, P=.02) before adjusting for multiple comparisons. The composite outcome of nonfatal cardiovascular events and cardiovascular-related mortality did not differ between groups but was numerically higher in the internet-based cognitive behavioral therapy group, who were at slightly greater risk (HR 1.8, 95% CI 0.96 to 3.4, P=.07). Adjusting for previous myocardial infarction and diabetes attenuated this estimate (HR 1.5, 95% CI 0.8 to 2.8, P=.25). Conclusions Internet-based cognitive behavioral therapy was not superior in reducing self-reported symptoms of depression or anxiety compared to treatment as usual at the 1-year follow-up after myocardial infarction. A reduction in cardiac-related anxiety was observed but was not significant after adjusting for multiple comparisons. There was no difference in risk of cardiovascular events between the treatment groups. Low treatment adherence, which might have affected treatment engagement and outcomes, should be considered when interpreting these results. Trial Registration ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 International Registered Report Identifier (IRRID) RR2-10.1186/s13063-015-0689-y

The effect of cognitive‐behavioral therapy on death anxiety and depression in patients with heart failure: A quasi‐experimental study

“…Another aim of this study was to evaluate the effect of CBT on depression in patients with heart failure. The results of our study showed that CBT had a positive effect on reducing depression in patients with heart failure, which was in line with those reported by Lv et al (2021), Liu et al (2021), A‐Tjak et al (2021), and Humphries et al (2021). A review of the literature showed that the effect of this therapeutic intervention on depression in patients with CVDs, especially in those with heart failure, was not well addressed.…”

A network meta-analysis of 12,116 individuals from randomized controlled trials in the treatment of depression after acute coronary syndrome

“…In total, 30 articles were included in this meta-analysis ( Fig 1 ). Ten articles originated from USA [ 25 , 37 – 45 ], 3 from Australia [ 24 , 46 , 47 ], Iran [ 48 – 50 ] and Netherlands [ 51 – 53 ], 2 from Canada [ 27 , 54 ] and Italy [ 55 , 56 ], and 1 each from China [ 57 ], India [ 58 ], Poland [ 59 ], Portugal [ 60 ], Singapore [ 20 ], South Korea [ 61 ], and Sweden [ 62 ]. All 30 articles were RCTs with low to moderate risk of bias ( S2 Table ).…”

“…In total, there were 12,116 patients included in the analysis, with the mean age ranging from 49.9 to 68.8 and proportion of female from 0.050 to 0.679. Of all patients, 3,118 received supplements [ 25 , 49 , 59 ], 1,619 received CBT [ 27 , 37 – 39 , 47 , 48 , 55 , 62 ], 1,123 patients received psychosocial therapy [ 20 , 43 – 45 , 50 , 52 , 54 , 56 , 57 , 60 ] 597 received antidepressants [ 40 , 41 , 51 , 53 , 58 , 61 ], and 202 received tele-intervention [ 24 , 46 ]. Combination therapy, a combination of antidepressants with CBT, was used in a study of 499 patients by Kronish et al [ 42 ] The mean duration of follow-up was 10.6 months (Standard Deviation: 9.6).…”

Achieving the Balance-A Systematic Review on Treating Depression Post Myocardial Infarction

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“…Most of these studies consider SSRIs as a first line treatment. The final aim of treating depression in MI patients is to improve the overall cardiac health [5]. In post-MI depressive patients, cardiac effects of depression treatment can also not be ignored.…”