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Behind the Screen: -Internet-Based Cognitive Behavioural Therapy to Treat Depressive Symptoms in Persons with Heart Failure
Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0003-3964-747X
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction

The prevalence of depressive symptoms in persons with heart failure is higher than in age- and gender-matched populations not suffering from heart failure. Heart failure in itself is associated with an unpredictable trajectory of symptoms, a poor prognosis, high mortality and morbidity, and low health-related quality of life (HrQoL). With the addition of depressive symptoms to heart failure the negative health effects increase further. Though the negative consequences of depressive symptoms in heart failure are well known, there is a knowledge gap about the course of depressive symptoms in heart failure and about how to effectively manage these symptoms. Pharmacological treatment with serotonin reuptake inhibitors has not been able to demonstrate efficacy in persons with heart failure. In a few studies, cognitive behavioural therapy (CBT) delivered face-to-face, has demonstrated effects on depressive symptoms in persons with heart failure. However, currently there are barriers in delivering face-to-face CBT as there is a lack of therapists with the required training. As a solution to this, the use of Internet-based CBT (ICBT) has been proposed. ICBT has been shown to be effective in treatment of mild and moderate depression but has not been evaluated in persons with heart failure.

Aim

The overall aim of this thesis was to describe depressive symptoms over time and to develop and evaluate an ICBT intervention to treat depressive symptoms in persons with heart failure.

Design and Methods

The studies in this thesis employ both quantitative (Studies I, II and III) and qualitative (Studies II and IV) research methods. The sample in Study I (n=611) were recruited in the Netherlands. The participants (n=7) in Study II were recruited via advertisements in Swedish newspapers. Studies III and IV used the same cohort of participants (Study III n=50, Study IV n=13). These participants were recruited via an invitation letter sent to all persons who had made contact with healthcare services in relation to heart failure during the previous year, at the clinics of cardiology or medicine in four hospitals in southeast Sweden.

Study I had a quantitative longitudinal design. Data on depressive symptoms was collected at baseline (discharge from hospital) and after 18 months. Data on mortality and hospitalisation was collected at 18 and 36 months after discharge from hospital. Study II employed three differentBehind the Screen2patterns of design, as follows: I) The development and context adaptation of the ICBT program was based on research, literature and clinical experience and performed within a multi-professional team. II) The feasibility of the program from the perspective of limited efficacy and function was investigated with a quantitative pre-post design. III) Participants’ experience of the ICBT program was investigated with a qualitative content analysis. Data on depressive symptoms was collected pre and post intervention. The time used for support and feedback was logged during the intervention, and qualitative interviews were performed with the participants after the end of the intervention. Study III was designed as a randomised controlled trial. A nine-week ICBT program adapted to persons with heart failure and depressive symptoms was tested against an online moderated discussion forum. Data on depressive symptoms, HrQoL and cardiac anxiety was collected at baseline (before the intervention started) and after the end of the intervention (approximately 10 weeks after the start of the intervention). Study IV had a qualitative design to explore and describe participants’ experiences of ICBT. The participants were recruited from within the sample in Study III and all had experience of ICBT. Data collection occurred after the ICBT program ended and was carried out using qualitative interviews by telephone.

Results

The mean age of the samples used in this thesis varied between 62 and 69 years of age. Concerning the symptom severity of heart failure, most persons reported New York Heart Association (NYHA) class II (40-57%) followed by NYHA class III (36-41%). Ischaemic heart disease was the most common comorbidity (36-43%). The vast majority had pharmacological treatment for their heart failure. Six percent of the persons in Study I used pharmacological antidepressants. In Studies II and III, the corresponding numbers were 43% and 18% respectively.

Among persons hospitalised due to heart failure symptoms, 38% reported depressive symptoms. After 18 months, 26% reported depressive symptoms. Four different courses of depressive symptoms were identified: 1) Non-depressed 2) Remitted depressive symptoms. 3) Ongoing depressive symptoms. 4) New depressive symptoms. The highest risk for readmission to hospital and mortality was found among persons in the groups with ongoing and new depressive symptoms.

A nine-week ICBT program consisting of seven modules including homework assignments on depressive symptoms for persons with heart failure was developed and tested. The RCT study (Study III) showed no significant difference in depressive symptoms between ICBT and a moderated discussion forum. Within-group analysis of depressive symptoms demonstrated a significant decrease of depressive symptoms in the ICBT group but not in the discussion forum group.

The participants’ experience of ICBT was described in one theme: ICBT- an effective, but also challenging tool for self-management of health problems. This theme was constructed based on six categories: Something other than usual healthcare; Relevance and recognition; Flexible, understandable and safe; Technical problems; Improvements by live contact; Managing my life better.

Conclusion

After discharge from hospital, depressive symptoms decrease spontaneously among a large proportion of persons with heart failure, though depressive symptoms are still common in persons with heart failure that are community dwelling. Depressive symptoms in persons with heart failure are associated with increased risk of death and hospitalisation. The highest risks are found among persons with long-term ongoing depressive symptoms and those developing depressive symptoms while not hospitalised.

ICBT for depressive symptoms in heart failure is feasible. An intervention with a nine-week guided self-help program with emphasis on behavioural activation and problem-solving skills appears to contribute to a decrease in depressive symptoms and improvement of HrQoL.

When ICBT is delivered to persons with heart failure and depressive symptoms the participants requests that the ICBT is contextually adapted to health problems related to both heart failure and depressive symptoms. ICBT is experienced as a useful tool for self-care and something other than usual healthcare. ICBT also requires active participation by the persons receiving the intervention, something that was sometimes experienced as challenging.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. , 110 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1603
Keyword [en]
Cognitive behavioural therapy, Depression, Heart failure, Internet-based cognitive behavioural therapy, Patients’ experiences, Self-care, Telehealth
Keyword [sv]
Depression, Egenvård, Hjärtsvikt, Internetbaserad kognitiv beteendeterapi, Kognitiv beteendeterapi, Patienters upplevelse, Telehälsa
National Category
Nursing
Identifiers
URN: urn:nbn:se:liu:diva-143312DOI: 10.3384/diss.diva-143312ISBN: 9789176854020 (print)OAI: oai:DiVA.org:liu-143312DiVA: diva2:1162338
Public defence
2018-01-12, K3, Kåkenhus, Campus Norrköping, Norrköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-12-04 Created: 2017-12-04 Last updated: 2017-12-11Bibliographically approved
List of papers
1. Time-course of depressive symptoms in patients with heart failure
Open this publication in new window or tab >>Time-course of depressive symptoms in patients with heart failure
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2013 (English)In: Journal of Psychosomatic Research, ISSN 0022-3999, E-ISSN 1879-1360, Vol. 74, no 3, 238-243 p.Article in journal (Refereed) Published
Abstract [en]

Background It is unclear how depressive symptoms in patients with heart failure develop

over time and whether this trajectory of depressive symptoms is associated with hospital admission and prognosis.

Aim To describe the time-course of depressive symptoms and determine the relationship with hospital admission and mortality.

Method Data was analysed using 611 patients with completed CES-D questionnaires at baseline and at 18 months. Data on hospital readmission was collected 18 months after discharge and data on mortality was collected 18 and 36 months post-discharge.

Results The prevalence of depressive symptoms was 38% (n=229) at discharge and 26% (n=160) after 18 months. A total of 140 (61%) of the 229 patients with depressive symptoms at discharge had recovered from depressive symptoms after 18 months whereas 71 (18%) of the 382 non-depressed developed depressive symptoms and 89 (39%) of the 229 depressed remained depressed. Depressive symptoms at discharge were not associated with mortality after 18 months but patients with recently (i.e. during 18 months) developed depressive symptoms showed a significantly higher risk for cardiovascular readmissions (HR 1.7, p=0.016). After 36 months, patients with developed depressive symptoms after discharge were at a higher risk of all-cause mortality (HR 2.0, p=0.012) and there was a trend towards a higher risk of all-cause mortality in patients with ongoing depressive symptoms (HR 1.7, p=0.056).

Conclusion A significant proportion of patients with HF, who were reported depressive symptoms at discharge recovered from depressive symptoms during the following 18 months. However, patients who remained having depressive symptoms or patients who developed depressive symptoms had a worse prognosis.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82345 (URN)10.1016/j.jpsychores.2012.09.019 (DOI)000315548600010 ()
Available from: 2012-10-01 Created: 2012-10-01 Last updated: 2017-12-07
2. Internet-based cognitive behavior therapy for patients with heart failure and depressive symptoms: A proof of concept study
Open this publication in new window or tab >>Internet-based cognitive behavior therapy for patients with heart failure and depressive symptoms: A proof of concept study
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2015 (English)In: Patient Education and Counseling, ISSN 0738-3991, E-ISSN 1873-5134, Vol. 98, no 8, 935-942 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The aim was (1) to describe the development of a guided internet-based CBT (ICBT) program adapted to patients with heart failure (HF) and (2) to evaluate the feasibility of the ICBT program in regard to depressive symptoms, the time used by health care providers to give feedback, and participants perceptions of the ICBT program. Method: A multi-professional team developed the program and seven HF patients with depressive symptoms were recruited to the study. The Patient Health Questionnaire-9 (PHQ-9) and the Montgomery Asberg Depression Rating-Self-rating scale (MADRS-S) were used to measure depression, and patients were interviewed about their perceptions of the program. Results: Based on research in HF and CBT, a nine-week program was developed. The median depression score decreased from baseline to the end of the study (PHQ-9: 11-8.5; MADRS-S: 25.5-16.5) and none of the depression scores worsened. Feedback from health care providers required approximately 3 h per patient. Facilitating perceptions.(e.g. freedom of time) and demanding perceptions (e.g. part of the program demanded a lot of work) were described by the patients. Conclusion: The program appears feasible and time-efficient. However, the program needs to be evaluated in a larger randomized study.

Place, publisher, year, edition, pages
Elsevier, 2015
Keyword
Internet; Cognitive behavior therapy; Heart failure; Depression
National Category
Sociology Basic Medicine
Identifiers
urn:nbn:se:liu:diva-120266 (URN)10.1016/j.pec.2015.04.013 (DOI)000357246000003 ()25990216 (PubMedID)
Available from: 2015-07-24 Created: 2015-07-24 Last updated: 2017-12-04
3. The Effect of Guided Web-Based Cognitive Behavioral Therapy on Patients With Depressive Symptoms and Heart Failure: A Pilot Randomized Controlled Trial.
Open this publication in new window or tab >>The Effect of Guided Web-Based Cognitive Behavioral Therapy on Patients With Depressive Symptoms and Heart Failure: A Pilot Randomized Controlled Trial.
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2016 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 18, no 8, 1-13 p., e194Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategies for depressive symptoms in patients with HF still remain to be established. Internet-based cognitive behavioral therapy (ICBT), as guided self-help CBT programs, has shown good effects in the treatment of depression. Until now, ICBT has not been evaluated in patients with HF with depressive symptoms.

OBJECTIVE: The aims of this study were to (1) evaluate the effect of a 9-week guided ICBT program on depressive symptoms in patients with HF; (2) investigate the effect of the ICBT program on cardiac anxiety and QoL; and (3) assess factors associated with the change in depressive symptoms.

METHODS: Fifty participants were randomized into 2 treatment arms: ICBT or a Web-based moderated discussion forum (DF). The Patient Health Questionnaire-9 was used to measure depressive symptoms, the Cardiac Anxiety Questionnaire (CAQ) was used to measure cardiac-related anxiety, and the Minnesota Living with Heart Failure questionnaire was used to measure QoL. Data were collected at baseline and at follow-up at the end of the 9-week intervention. Intention-to-treat analysis was used, and missing data were imputed by the Expectation-Maximization method. Between-group differences were determined by analysis of covariance with control for baseline score and regression to the mean.

RESULTS: No significant difference in depressive symptoms between the ICBT and the DF group at the follow-up was found, [F(1,47)=1.63, P=.21] and Cohen´s d=0.26. Secondary within-group analysis of depressive symptoms showed that such symptoms decreased significantly in the ICBT group from baseline to the follow-up (baseline M=10.8, standard deviation [SD]=5.7 vs follow-up M=8.6, SD=4.6, t(24)=2.6, P=.02, Cohen´s d=0.43), whereas in the DF group, there was no significant change (baseline M=10.6, SD=5.0, vs follow-up M=9.8, SD=4.3, t(24)=0.93, P=.36. Cohen´s d=0.18). With regard to CAQ and QoL no significant differences were found between the groups (CAQ [d(1,47)=0.5, P=.48] and QoL [F(1,47)=2.87, P=.09]). In the ICBT group in the CAQ subscale of fear, a significant within-group decrease was shown (baseline M=1.55 vs follow-up M=1.35, P=.04). In the ICBT group, the number of logins to the Web portal correlated significantly with improvement in depressive symptoms (P=.02), whereas higher age (P=.01) and male sex (P=.048) were associated with less change in depressive symptoms. This study is underpowered because of difficulties in the recruitment of patients.

CONCLUSIONS: Guided ICBT adapted for persons with HF and depressive symptoms was not statistically superior to participation in a Web-based DF. However, within the ICBT group, a statically significant improvement of depressive symptoms was detected.

CLINICALTRIAL: Clinicaltrials.gov NCT01681771; https://clinicaltrials.gov/ct2/show/NCT01681771 (Archived by WebCite at http://www.webcitation.org/6ikzbcuLN).

Keyword
Internet; Internet-based cognitive behavioral therapy; cognitive behavioral therapy; depression; eHealth; heart failure
National Category
Other Medical Sciences not elsewhere specified
Identifiers
urn:nbn:se:liu:diva-130548 (URN)10.2196/jmir.5556 (DOI)000382314400001 ()27489077 (PubMedID)
Note

Funding agencies: Swedish Heart and Lung Association [E087/13, E08/14]; Medical Research Council of Southeast Sweden [FORSS-374721, FORSS-470121]; Region Ostergotland [LIO-355611, LIO-374831, LIO-443711, LIO-470271]

Available from: 2016-08-15 Created: 2016-08-15 Last updated: 2017-12-04Bibliographically approved

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