Depressive symptoms are common in patients with cardiovascular disease (CVD). CVD has a negative impact on patients’ prognosis and health-related quality of life (HRQoL). Guidelines for the treatment of CVD recommend treatment of depressive symptoms. However, the detection rate of depressive symptoms in CVD care is low and patients are therefore at risk of not receiving treatment. The reason for the low detection rate in CVD patients has not been fully explored, but may be related to healthcare professionals or the patients themselves. CVD patients’ experience of how depressive symptoms are discussed or managed by healthcare providers has not currently been fully explored. Today, cognitive behavioural therapy (CBT) is the recommended treatment for mild to moderate depressive symptoms and has been found to be effective in CVD patients. One problem with CBT is the low access to the treatment, which is mainly due to a lack of psychotherapists. A solution could be to use the internet to provide CBT (iCBT), since this has been shown to be effective in the treatment of depressive symptoms in non- CVD populations and is as effective as regular CBT. At the time when this thesis was planned there was a lack of iCBT studies on patients with CVD and depressive symptoms, and more research regarding iCBT in CVD has been called for in the literature. 

Aim

The overall aim of this thesis was to generate knowledge which can lead to improvements in the care of patients with CVD and depressive symptoms. This is done by exploring how depressive symptoms are managed in the healthcare setting from the patient’s perspective, and by evaluating the effects and experiences of an iCBT programme for depressive symptoms in patients with CVD. 

Design and methods

This thesis represents two quantitative and two qualitative studies that were performed on the same cohort of participants (n=144) recruited to a randomised controlled trial (RCT) aiming to evaluate a nine-week iCBT programme (n=72) adapted for patients  with CVD and depressive symptoms. In the RCT, the comparator was a nine-week online discussion forum (n=72). These participants were recruited via an invitation letter sent to patients diagnosed with CVD (i.e. coronary heart disease, atrial fibrillation/atrial flutter or heart failure) who had contacted four hospitals in southeast Sweden during the past year. Study I had a qualitative study design with an inductive semantic approach. The sample (n=20) was recruited from those who had performed iCBT and had completed at least one module of the treatment programme. The interviews were conducted by telephone using a semi-structured interview guide. Study II was designed as an RCT, and compared the effect of a nine-week iCBT programme adapted for CVD (n=72) with nine weeks of ODF (n=72) on depressive symptoms in CVD patients. Data regarding depressive symptoms and HRQoL was collected at baseline and at nine weeks post-intervention. Study III used the same cohort as study I, and had a qualitative study design with an inductive latent approach. Study IV used a quantitative longitudinal and explorative design. Data regarding depressive symptoms was collected at baseline, at nine weeks post-intervention and at six- and twelve-month follow-ups. 

Results

The mean age of the participants in studies II and IV was 63 years, and 61% (n=89) were men. Atrial fibrillation/flutter was found in 56% (n=81), 44% (n=63) had coronary heart disease and 26% (n=38) had heart failure. The mean age of the participants in studies I and III (n=20) was 62 years, and 55% (n=11) were men. 

The patients experienced how depressive symptoms were addressed and managed in clinical cardiac care encounters under three main themes: “Not being seen as a whole person”; “Denying depressive symptoms”; and “I was provided with help”. The RCT study showed that iCBT after nine weeks was more effective than ODF in terms of decreasing depressive symptoms and improving HRQoL. At six- and twelve-month follow-ups, the improvements in depressive symptoms in the iCBT group were sustained. At the twelve-month follow-up, it was those who had more depressive symptoms at baseline who also experienced more improvements in depressive symptoms through iCBT, whereas those with heart failure were less likely to improve.  

The experience of participating in the iCBT programme was perceived as: taking control of the disease; not just a walk in the park; and feeling a personal engagement with the iCBT programme. 

Conclusions

CVD patients experienced that healthcare professionals focused on somatic symptoms and did not address their depressive symptoms. On the other hand, CVD patients did not always understand that they had depressive symptoms – or denied having depressive symptoms – when meeting healthcare professionals. Those who had received treatment had taken the initiative to address this by themselves or through support from family or friends. 

A nine-week iCBT programme adapted for CVD and guided by nurses with clinical experience of CVD and psychiatry and a brief education in iCBT seems to be useful for decreasing depressive symptoms and improving HRQoL. The effect of iCBT seems to be more beneficial in CVD patients with higher levels depressive symptoms, whereas the effect of iCBT on heart failure patients is less certain. 

The iCBT programme adapted to CVD seems to provide knowledge, and was experienced by patients as helpful for taking control of their disease. A CVD-adapted iCBT programme including feedback from nurses with clinical experience of CVD and psychiatry was helpful for engaging with and motivating carrying out the iCBT programme. Participating in the iCBT programme can be demanding and emotionally challenging, but is sometimes necessary to achieve improvements in depressive symptoms.