Supporting mental health recovery in patients with heart disease: a commentary

This invited commentary refers to ‘Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation: Cochrane systematic review and meta-analysis’ by C.F. Ski et al., https://doi.org/10.1093/eurjcn/zvae113. Anxiety and depression are common after an acute cardiac event or diagnosis.1 While initial worries and mood changes resolve spontaneously for some patients, around one in three experience anxiety or depression symptoms that are severe and persistent enough to warrant intervention.2 Left untreated, post-event mental health problems compromise recovery, being associated with non-adherence to prescribed cardiac medications and recommended lifestyle changes, non-attendance at cardiac rehabilitation programmes, and reduced quality of life.1 Indeed, patients with post-event anxiety or depression are at increased risk of hospital readmission, cardiac-event recurrence, and premature mortality.1 As such, current guidelines for the management of heart disease recommend that patients with heart disease be screened for anxiety and depression to identify those requiring treatment.3–5 Recommended treatments include psychological therapy, physical activity prescription, collaborative care, and prescription of selective serotonin reuptake inhibitor (SSRI) medication.3–5 In this issue, the paper ‘Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation: Cochrane systematic review and meta-analysis’6 presents a comprehensive systematic review and meta-analysis of psychological interventions to support mental health recovery in patients with heart disease. Building on previous Cochrane reviews of psychological interventions for coronary heart disease (CHD),7–9 this new review adopted a broader scope by including trials of psychological interventions designed not only for CHD patients but also for those with heart failure (HF) and atrial fibrillation (AF). The review comprised 21 randomized controlled trials (RCTs) involving over 2500 patients, and reports on both psychological and clinical endpoints, namely anxiety, depression, quality of life, self-efficacy, hospitalizations, all-cause mortality, and major adverse cardiovascular events (MACE). The new review concludes that psychological interventions result in moderate reductions in anxiety (moderate certainty), depression (moderate certainty), and mental-health related quality of life (low certainty). Included studies most often involved the use of cognitive behaviour therapy (CBT) and its various forms, including motivational interviewing, behavioural social cognitive therapy, and mindfulness. Being an evidence-based treatment for cardiac-related mental health management, CBT is the recommended psychological approach in current clinical cardiac guidelines.3–5 Two previous systematic reviews that focussed specifically on CBT similarly concluded that this evidence-based approach reduces anxiety and depression and improves QoL in people with heart disease.10,11 Despite reporting benefits in terms of psychological outcomes, the new review found no evidence that psychological interventions reduced all-cause mortality or MACE in people with heart disease. This finding is consistent with several previous systematic reviews and meta-analyses,9,10,12 including an earlier review by Ski et al.12 published in this journal in 2016. In contrast, the 2017 Cochrane review by Richards et al.7,8 concluded that psychological interventions led to a 21% reduction in cardiac mortality, although no effects were observed for total mortality, revascularization, or non-fatal myocardial infarction.7,8 Unfortunately, as has been noted in all reviews undertaken to date, the evidence for secondary outcomes such as MACE and all-cause mortality remains sparse due to the low number of trials that have included these endpoints. Future RCTs of psychological interventions for cardiac populations should include clinical endpoints such as MACE and mortality where possible. Ski and colleagues point to the need to investigate subgroup differences in outcomes with a view to identifying patients who benefit most from treatment. In their analysis, they investigated the association between mental-health history and intervention outcomes, although found no evidence of an interaction. This raises the question of whether other patient characteristics, such as age, sex, or other demographic and clinical indices, might influence intervention outcomes. Our team recently published a 14-year mortality follow-up of a group-based CBT programme for patients with acute coronary syndrome that had shown short-term behavioural and psychological benefits, including decreased anxiety and depression, as well as dietary improvements.13,14 The follow-up study demonstrated a mortality benefit for patients who were 60 or younger at the time of their programme participation, but not for those aged over 60.15 We reasoned that younger age allows more time for improved psychological and behavioural status to impact positively on physiological cardiovascular risk factors, and thereby translate into a survival benefit. It is possible that subgroups of patients in previous study cohorts may have achieved morbidity or mortality benefits that, without subgroup analyses, were not identified. Future RCTs of psychological interventions for cardiac populations should consider subgroup analyses to identify the types of patients most likely to benefit and therefore inform the targeting and tailoring of interventions. While the present review broadened its scope to include trials involving patients with HF and AF, no studies of interventions for AF patients met the criteria for inclusion in the review. Our team has previously noted that current AF guidelines provide little or no attention to the psychological aspects of living with this condition.16 This highlights psychological support for AF patients as an area deserving of increased attention. Anxiety and depression play a crucial role in the onset and development of AF, and both are also common consequences of AF.16 Evidence shows that AF patients’ coping styles are significantly associated with anxiety and depression levels, suggesting that therapeutic approaches that support adaptive problem-solving coping might assist AF patients in the management of these common mental health problems.16 Clearly, more high quality RCTs are needed to identify effective psychotherapeutic approaches for this important patient group. The review by Ski and colleagues adds to the solid body of evidence that supports the benefits of psychological interventions for cardiac patients, most notably in terms of psychological outcomes such as anxiety and depression. The authors emphasize the low methodological quality of many available studies, and rightly point to the need for more rigorous research in this area. In particular, Ski and colleagues recommend continued focus on identifying the effective components of psychological interventions and the patient groups most likely to benefit from these treatments. Barbara Murphy (Conceptualization [lead], Writing—original draft [lead]), Michael Le Grande (Conceptualization [supporting], Writing—review & editing [equal]), and Alun Jackson (Conceptualization [supporting], Writing—review & editing [equal]) All authors have declared that no financial support was received from any organization for the submitted work. No data used in preparation of this manuscript.