Psychological distress in patients with cardiovascular disease: time to do something about it?

In the last decade, psychological distress such as depression and anxiety have been recognized as risk factors for poorer quality of life and a worse prognosis in patients with cardiovascular disease (CVD).1 European Society of Cardiology guidelines on CVD prevention state that healthcare professionals in clinical practice, such as nurses and physiotherapists, working in cardiac rehabilitation, are in the unique position to provide support to patients with psychosocial risk factors.2 But to be able to provide such support, these professionals need effective tools. This requires research that focuses on what to do about psychological distress. However, much of the CVD research continues to focus on the prevalence, relationships to, and effects of psychological distress in CVD patients and studies on interventions are scarce. A critical reader may now argue that there are studies that have evaluated such interventions. Yes, this is certainly true. There are studies that evaluate intervention in patients with psychological distress in CVD, however many of these studies have not been able to support the benefits of intervention. There are important lessons to be learned from these studies that can provide important insights when designing future psychological interventional studies for CVD patients. Many psychological intervention studies have included participants regardless of whether they experience clinically relevant psychological distress or not and floor effects may at least partly explain why only modest effect sizes have been found.3,4 This can be compared with testing the effect of antibiotics in patients who do not have an infection. Thus, if we want to evaluate the effect of psychological interventions on for example symptoms of depression we should only include people who have clinically relevant symptoms of depression, for example only those scoring over a certain cut-off on an established depression questionnaire such as the Patient Health Questionnaire-9. In a review regarding the effects of psychosocial interventions in CVD, Klainin-Yobas et al.5 reported that of 30 studies only 18 reported significant short-term effects and only three found significant long-term effects. Klainin-Yobas et al.5 discussed that those interventions with only short-term effects often included massage, music therapy, progressive muscle training, or interventions focusing on information and education about for example risk factor reduction or self-care management. Klainin-Yobas et al.5 highlighted the importance of the intervention having a theoretical basis that explains in what way the intervention work, both in the short- and long term. When it comes to psychological distress in CVD, cognitive behavioural therapy (CBT) seems to be the most common theory, and interventions based on CBT principles also seem to give the best effects on depression and anxiety.3,4,6 Today there are newer forms of CBT, such as acceptance commitment therapy and mindfulness-based interventions,7 interventions that also are likely to be useful for CVD patients . It is however not certain that these newer forms are more effective than regular CBT, but it is possible that these newer forms increase the possibilities to adapt psychological interventions to better fit the patient’s preferences. The length of CBT programs generally varies between 10 and 20 1-h sessions. In the meta-analysis evaluating the effect of CBT in CVD patients by Reavell et al.6 longer CBT interventions were recommended with the potential to achieve improved long-term effects. Hence, briefer CBT interventions should probably not be offered unless further research shows that they work. The increased interest for E-health and the ongoing COVID pandemic highlight the need to provide psychological interventions via the internet, such as internet-CBT (ICBT). Surprisingly, ICBT studies in patients with CVD are rare.5 However, we and another research group have recently reported that ICBT can reduce both depression and anxiety in CVD patient’s post-treatment and after 3 months.8,9 Preliminary analyses of own data also indicated significant long-term effects on depression at 6- and 12-month follow-up. We also reported that ICBT improved physical activity, thus with reduced depression an increase in physical activity followed.10 ICBT has also an advantage over regular CBT as it is both staff and time saving. In our study, nurses with experience of cardiac care and with only a short introduction in CBT provided feedback on homework assignments using approximately a total of 3 h per patient for 9 weeks of ICBT. Depressed CVD patients seem to have both medical and psychosocial issues11 which need to be approached in psychological interventions. These issues can be adressed by using an ICBT programme in which the content is tailored to fit the context of CVD8,9 for example by using psychoeducative treatment modules covering living with CVD as well as how depression can be related to CVD. Moreover, in our study these issues could also be met by feedback from the nurses as mentioned above. In a own still unpublished qualitative studythis type of feedback and CVD adapted content contributed to participants perceiving the ICBT programme as credible and supported them in the experience of being able to control their lives with CVD (M. Westas et al. submitted for publication). This suggests that internet-based psychological interventions such as ICBT can be offered to CVD patients with psychological distress, although more research is needed. Conflict of interest: None of the authors have any conflict of interest to declare. The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Cardiovascular Nursing or of the European Society of Cardiology.