SEATTLE – A brief cognitive biobehavioral intervention focused on preventing and managing depression reduces adverse outcomes of heart failure, according to results from a randomized trial reported at the annual meeting of the Heart Failure Society of America.
"A 6-week biobehavioral intervention in patients with heart failure really was successful in severing the link between depression and poor outcomes," according to the study’s lead investigator, Debra K. Moser, D.N.Sc., professor and chair of the College of Nursing at the University of Kentucky, Lexington. "These findings provide evidence for the effectiveness of biobehavioral approaches" in this population.
Dr. Debra K. Moser
Dr. Moser also noted that more than one-fifth of patients with heart failure have depression, as well as higher depressive symptoms – not necessarily clinical depression. Evidence suggests that in the heart failure population, such symptoms triple the risk of rehospitalization and double the risk of death (J. Am. Coll. Cardiol. 2006;48:1527-37).
Dr. Moser and her colleagues studied 278 patients with heart failure, assigning them to a biobehavioral intervention group (given both cognitive-behavioral therapy and biofeedback-relaxation therapy), an attention control group, or a usual-care control group. At baseline, patients were an average of 60 years old, roughly a third were women, and nearly half had New York Heart Association class III or IV heart failure. Mean depression scores on the 27-point Patient Health Questionnaire-9 were about 5.5; one-fourth of patients were taking antidepressants. Patients with heart failure were eligible for the trial if they had been on stable medication doses for at least 1 month, had not experienced a myocardial infarction or stroke in the previous 3 months, and did not have any cognitive impairment.
At 12 months’ follow-up, the biobehavioral intervention patients were about one-third less likely to have had a cardiac hospitalization or to die (28%) compared with the attention control group (40%) and the usual-care control group (38%).
Patients in the biobehavioral intervention group also had an improvement at 1 year in scores for health-related quality of life, measured with the Minnesota Living with Heart Failure questionnaire, whereas scores worsened in the other groups (P = .005).
Similarly, patients in the biobehavioral intervention group had an improvement at 1 year in scores for depression symptoms, whereas scores worsened in the other groups (P = .001). Some 13% of patients in the biobehavioral intervention group had depression at this time point, compared with 21% of those in the attention control group and 24% of those in the usual-care control group.
The biobehavioral intervention lasted 6 weeks, and consisted of 1-hour weekly sessions conducted by a therapist; it was designed to address depression and comorbid anxiety. "The therapist was a psychiatric nurse practitioner with extensive cardiac experience, and she was well suited to this project because she is from the part of Kentucky where many of the patients come from, so ... there is a lot of concordance between her style and her patients’," Dr. Moser explained.
The attention control condition also lasted 6 weeks, and consisted of 1-hour weekly sessions with the same nurse practitioner present, but entailed only unguided relaxation and the opportunity to speak with her.
Christine Moravec, Ph.D., of the Cleveland Clinic, pointed out that at this point it’s difficult to dissect out whether the benefits seen in the biobehavioral intervention were due to the cognitive-behavioral therapy or the biofeedback.
"That’s our next trial" Dr. Moser noted. "We will be looking at the combination of the two and [each] separately."
Reproducibility is another issue, noted Dr. Javed Butler of Emory University in Atlanta. "Can anybody who does this biobehavioral intervention expect the same results?"
"That’s actually the major question that I have," Dr. Moser acknowledged. The particular nurse practitioner who ran the biobehavioral intervention "is probably the best therapist for these people that I have ever seen, so I really do worry about the reproducibility.
"But also, it sort of speaks to maybe some of the failure of the other clinical trials that we have seen in treating depression for cardiac patients. We have had some colossal failures," she continued. "I don’t think that any therapist can do it. It takes a special therapist who can really connect with patients, and a lot of patients, who can individualize therapy and is concordant with the group. ... The negative impact of depression is so powerful that it bears looking at to try to really define what it is in the therapist-patient relationship that is important and that does need to be reproduced."
Interestingly, depression levels in the biobehavioral intervention group continued to decline over a year, whereas they increased in the control groups, according to Dr. Moser. "We think that that is how cognitive-behavioral therapy should work. It doesn’t of course work for everyone, but if it works, it should give you the skills to manage depressive symptoms in the long term," she said.