Effect of cognitive behavioral therapy on depressive symptom reduction among rural patients with coronary heart disease: does caregiving status matter?

Abstract Background Adults with coronary heart disease (CHD) or heart failure (HF) are at heightened risk for depressive symptoms and often have limited access to treatment. Many also provide informal care to an ill family member while managing their own condition, so called caregiver-patients, where caregiving burden can further exacerbate depressive symptoms. Although cognitive behavioral therapy (CBT) effectively reduces depressive symptoms, evidence is limited for CHD or HF patients who have caregiving responsibilities. It remains unclear whether caregiving status influences engagement in CBT and degree of symptom reduction in this population. Purpose To determine whether caregiving status moderates the effectiveness of two virtual modalities (therapy-guided via videoconference vsCBT versus self-guided internet-based iCBT) on depressive symptom reduction among rural adults with CHD or HF. Method This secondary analysis using data from a parallel-group randomization clinical trial comparing two CBT modalities. Adult outpatients with at least mild depressive symptoms (Patient Health Questionnaire [PHQ-9 =5) completed a 12-week CBT intervention and were followed at 3, 6 and 12 months. Depressive symptoms (primary outcome) were assessed using PHQ-9 at each time point. Caregiving status was assessed with a single item and categorized as: caregiver-patient; non-caregiver with ill family; and non-caregiver patients without ill family. Intervention effect was evaluated using repeated measures ANOVA, stratified by caregiving status. Results Of 291 participants (mean age = 57.3 ±12.4 years; 50.2% male; 54.3% married; 94.8% White), 16.5% were caregivers, and 15.5% were non-caregivers with an ill family member, while 68% were non-caregivers without ill family. At baseline, age, sex, or depressive symptom did not differ between intervention arms. Caregivers were significantly older and more often female than other groups, but depressive symptom levels were similar across caregiving status group. By 12 months, 101 participants (38.1%) withdrew, with the highest attrition among caregivers (45.8%). Before 3-months, 39.6% of caregivers withdrew; early withdrawal was 28.3% for vcCBT and 26.7% for iCBT groups. As shown Figure 1 and 2, depressive symptoms decreased for overtime regardless of caregiving status in both CBT modality (vcCBT, Time effect, P .001; iCBT, Time effect, P . 001). Conclusion Caregiver-patients with CHD or HF who had mild or greater depressive symptoms successfully reduced depressive symptoms similarly to non-caregiver-patients in both intervention modalities. However, they had the highest and earliest attrition, underscoring the need for targeted engagement and retention strategies.Figure 1.Effect of iCBTFor image description, please refer to the figure legend and surrounding text. Figure 2.Effect of vcCBTFor image description, please refer to the figure legend and surrounding text.