Psychosocial interventions in cardiovascular disease – what are they?

There is growing interest in psychosocial factors in the etiology and prognosis of coronary heart disease.1–3 There is also recent interest in psychosocial interventions as a means to improve outcome in this patient group,4,5 including those with chronic heart failure6 or referred for cardiac rehabilitation,7 and for their support givers.8 However, there is a lack of consistency in the way psychosocial interventions are defined, delivered and tested, thus complicating or rendering meaningless any evaluation of efficacy. For instance, in trials and meta-analyses the term psychosocial interventions has often not been defined at all4 or defined in detail, such as ‘a structured nonpharmacologic intervention conducted by health professionals that is focused on improving the psychologic and/or social aspects of a patient’s health'.6 Typically, the term psychosocial intervention is used when a more apt description would be behavioral, educational, psychological or social intervention. Indeed, some recent reviews of behavioral or nonpharmacological interventions have included studies that are deemed psychosocial interventions9 or have elements of them.10 In fact, the terms psychosocial and behavioral interventions are often used synonymously and many supposed psychosocial interventions tend to be a mixture of some or all of these components, e.g. psycho-educational. We suggest, however, that the term should be reserved only for interventions that combine psychological (e.g. cognitive behavioral therapy) and social (e.g. social support) components, whilst acknowledging that psychological and social benefits may accrue, for example, from the education and exercise provided in a cardiac rehabilitation program. An example of a true psychosocial intervention is the ENRICHD (Enhancing Recovery in Coronary Heart Disease) study11 which addressed depression and social support. To improve transparency of psychosocial interventions and enable their reproducibility, comparison and evaluation, a proposed taxonomy that cuts across four dimensions is helpful.5 This taxonomy examines along a continuum: What is the risk factor (social, psychosocial or psychological)? What level is the intervention aimed at (individual, family, group, organizational, community or societal)? When along the spectrum of disease do we intervene (primary prevention, pre-event or secondary prevention)? Where do we intervene (population, moderate risk or high risk)? Thus, for example, an intervention for a psychological risk factor may be aimed at an individual at high risk. It is suggested also that more attention be paid to the theory that is driving psychosocial interventions12 and to methods that describe and decompose them.13 For example, definitions of intervention delivery and content characteristics should include mode, materials, location, schedule, scripting, interventionist characteristics, adaptability, implementation, content strategies and mechanisms of action.14,15 This recognizes that psychosocial interventions are essentially complex interventions16 with the potential to result in significant health gains. Developing such interventions involves identifying the existing evidence, identifying and developing theory and modeling process and outcomes. Evaluating these interventions involves assessing effectiveness (and cost-effectiveness), measuring outcomes and understanding the change process.16 In evaluating psychosocial interventions, a choice of study designs is available, depending on the research questions and circumstances. Experimental designs are preferred to observational designs in most circumstances, but are not always practicable. In some circumstances a quasi-experimental design may be considered. In others, randomization, for example, may be impractical or unnecessary.16 It is only by applying such taxonomies that we will enhance the ability to develop, describe and measure psychosocial interventions consistently, permit replication, make comparisons across studies and isolate causal factors that achieve desired outcomes. Then there can be confidence in the term psychosocial intervention. The authors have no competing interests to report.