CHICAGO—A brief psychoeducational intervention quelled anxiety and depression during the year after implantable cardioverter defibrillator insertion in the randomized multicenter PEACE trial, Sandra B. Dunbar, D.S.N., reported at the annual scientific sessions of the American Heart Association.
The counseling intervention in the PEACE (Psychoeducational Intervention in Internal Cardiac Defibrillator Patients) trial emphasized proactive coping skills geared to help patients live with serious arrhythmias, declining heart function, and the constant threat of device shocks, Dr. Dunbar said.
Many studies have documented that 20%–50% of implantable cardioverter defibrillator (ICD) recipients experience pronounced psychological distress. That's important not only because anxiety and depression take a heavy toll on quality of life, but also because such psychologic distress predisposes to additional arrhythmias, in turn triggering further ICD discharges, noted Dr. Dunbar, the Charles Howard Candler Professor of Cardiovascular Nursing at Emory University, Atlanta.
PEACE was a five-center trial funded primarily by the National Institutes of Health. It involved 266 unselected new ICD recipients randomized to usual care or to the counseling intervention conducted either in groups or over the phone.
The psychoeducational intervention was provided by cardiovascular nurses. It consisted of a half-hour one-on-one session on the day of discharge following ICD insertion, then four 90-minute face-to-face group or individual telephone sessions starting about 6 weeks post discharge. Because the study results were the same regardless of whether patients were counseled by telephone or in groups, data from the two intervention arms were combined.
The day-of-discharge session was devoted to training in acute symptom management; participants learned strategies to deal with the ICD shocks, including the associated pain and sleep disruption. They were sent home with a supporting audiotape and workbook. In the subsequent sessions, they learned standard cognitive behavioral techniques to deal with fear and anxiety, stop negative thoughts, seek out constructive social support, and engage in positive self-talk, along with relaxation skills.
At 12 months, mild to severe depressive symptoms as assessed by the Beck Depression Inventory-II were present in 31% of the usual care group, compared with 15% of psychoeducational intervention recipients.
Anxiety levels as measured by the State-Trait Anxiety Inventory generally declined over time in both groups; however, anxiety dropped significantly faster in the intervention arms. Moreover, at baseline one-fifth of PEACE participants scored 40 or higher on the State-Trait Anxiety Inventory, consistent with a moderate to severe anxiety disorder. By 3 months the prevalence had climbed to 34% in controls, compared with a 23% rate in the 111 patients in the combined intervention group.
Standardized testing also showed significantly lower illness appraisal scores in the intervention arms, meaning the counseling recipients had a lower level of perceived threat and distress regarding living with an ICD and life-threatening arrhythmias, Dr. Dunbar continued.
In an interview, Dr. Lynne Warner Stevenson called the PEACE findings “incredibly important.”
“In terms of the quality of life while the devices are in, it's critical that we not be doing harm by increasing the patient's anxiety and depression,” said Dr. Stevenson, director of the cardiomyopathy and heart failure program at Brigham and Women's Hospital, Boston.
“I'm hoping that preparing people for the fact that the device will go off and how to deal with that may help decrease the PTSD problem,” Dr. Stevenson said.
Medtronic Inc. and Guidant Corp. provided secondary funding for PEACE.
Mental distress predisposes to additional arrhythmias, in turn triggering further ICD discharges. DR. DUNBAR