The Effect of Brief Cognitive-Behavioral
Therapy for PTCA Patients
Background and Summary of Study Findings
William Stone RN MSN CNS
Coronary Angioplasty (PTCA) has become a major treatment modality
for patients with coronary artery disease (CAD). Recurrent disease
(myocardial infarction, restenois, recurrent pain, etc.) following
PTCA remains a significant problem. Psychological interventions
have been shown to reduce risk for recurrent events, but results
have been inconsistent. This study was designed to evaluate the
effectiveness of brief counseling (2 or 3 outpatient sessions of
90 minutes each) in reducing factors associated with coronary disease.
Data analysis revealed that the treatment group (n=11) achieved
a significant reduction in distress (measured by GHQ-20, p =.012)
and a small but significant reduction in anger (MMPI-2 anger content
scale, p=.046). The treatment group also had significant changes
in heart rate variability patterns (increase in total entrainment
score, p=.008), indicating beneficial improvements in autonomic
balance. No significant changes were seen in the comparison group
(n=5). These results suggest that brief counseling can be effective
in reducing risk for recurrent coronary events.
A number of studies
have shown that well-designed psychological interventions can be
very effective in reducing risk for recurrent coronary disease.
But other studies have shown similar interventions to have little
effect. Whether the interventions were successful or not, all of
these studies invested a substantial amount of time treating subjects
(from 14 to 57 hours per patient). The intervention reported here
involved an average of 5 hours per patient.
The Recurrent Coronary Prevention
Project (Freidman et al, 1986) targeted Type A behavior in patients
after myocardial infarction (post MI). The experimental group (n=592)
had a cumulative recurrence rate of roughly half that of the comparison
groups over a 4.5 year study period. More recently, Appels and colleagues
(1997) studied stress management for PTCA patients (n=95), and with
their intervention achieved a 50% reduction of recurrence over an
18 month period. Blumenthal and colleagues (1997) designed their
study to evaluate two interventions, stress management and exercise.
Results were gathered after 5 years, following an intensive 4-month
training program. There were 3 (9.1% of 33 subjects) cardiac events
in the stress management group, 7 (20.6% of 34) in the exercise
group, and 12 (30.0% of 40) in the usual care group.
However, stress management has not
been an effective intervention in all studies. In two large studies,
it had little effect on outcome (Jones and West, 1996; Frasure-Smith
et al, 1997). Full analysis of the problems that limited the effectiveness
of these interventions is beyond the scope of this summary, but
there is evidence that a specifically targeted approach is more
likely to have a significant impact. For example, treating identified
issues that are troubling the client (such as depression, or anger
and hostility) may be better than a generalized program of relaxation
techniques that are assumed to be helpful for everyone. Utilization
of a therapist with specialized training and expertise may also
improve the chance for success.
Subjects were recruited
while in the hospital, following PTCA. Patients were given an overview
of the study, and introduced to the harmful effects of hostility
and the benefits of social connection. Informed consent was obtained.
Pretests to measure distress (General Health Questionnaire, GHQ-20;Goldberg,
1972) , hostility (cynical distrust scale; Greenglass and Julkunen,
1989), and perception of control (control attitudes scale; Moser
and Dracup, 1995) were given at intake. These measures were repeated
at the conclusion of study. Subjects who were willing to take the
pre and post tests, but did not wish to take part in the intervention
(because of time commitment, travel distance, or other personal
reasons) were included in the comparison group. The anger scale
was added to the study after some subjects had already enrolled,
and was not administered to the comparison group (MMPI?2 anger content
scale, Kawachi et al, 1996). Subjects in the treatment group took
the anger scale prior to their first outpatient session, and at
the conclusion of study. The treatment group also had a 5-minute
heart rate variability (HRV) baseline recording, and another 5-minute
recording while practicing the Freeze-Frame technique. Total entrainment
scores were calculated using these recordings (Tiller, et al, 1996).
Subjects were asked to keep an anger
log for the first week or two following PTCA. The log is a record
of the frequency, intensity, and circumstances surrounding experienced
anger, serving to increase awareness of the individual's anger responses.
Subjects were also asked to complete Pennebaker's 20 minute writing
exercise at least 2 times (Pennebaker, 1995). This exercise is designed
to facilitate the release of emotional energy and helps to give
perspective and shed some light on the dynamics behind the episodes.
An attempt was made to schedule the
first outpatient session one to two weeks after discharge from the
hospital. This allowed for a timely review of the anger log and
written exercises. The Freeze-Frame technique (Tiller et al, 1996)
was introduced in this session. This technique is a 5-step method
designed to transform the habitual anger response, replacing it
with a positive mental state. The exercise helps to develop an emotional
space for consideration of alternative responses and solutions.
The following sessions were used to address any issues of concern
to the subjects, and for review and practice of the skills that
were taught in the earlier sessions.
The initial design for this study
excluded those with low hostility (a score of less than 10 on the
cynical distrust scale). It was thought that subjects with more
hostility would have a greater benefit from the intervention. This
design had to be modified because of difficulty in recruitment of
high hostility subjects. Most of those who were willing to take
the cynical distrust scale had relatively low scores, and those
that didn't want to participate often seemed more irritable and
distrustful. It was necessary to redesign the study to include all
consenting subjects, regardless of hostility score.
Results and Implications
A short course of 2
or 3 outpatient sessions achieved statistically significant decreases
in distress levels in this small study of 11 subjects (measured
by GHQ-20, p =.012). No significant changes were seen in the comparison
group (n=5). High distress levels have been associated with a threefold
increase in cardiac mortality (Frasure-Smith, 1991). A small but
significant reduction in anger was also achieved (MMPI-2 anger content
scale, p=.046). High anger has been associated with three times
the risk for recurrent events among males after PTCA (Mendes de
Leon et al, 1996). In this study, counseling and coaching was effective
in producing beneficial autonomic changes as documented by heart
rate variability (HRV) recordings (increases in total entrainment
score, p=.008). Evidence that suggests that these improvements will
reduce risk for CAD has been outlined (Tiller et al, 1996). The
importance of HRV patterns for coronary patients was demonstrated
in a study (n=808) by Kleiger and colleagues (1987) who found that
low HRV was associated with 5.3 times the mortality of high HRV.
Brief cognitive-behavioral therapy is a powerful intervention that
has a measurable impact upon mental factors that contribute to coronary
disease. These findings extend the mounting evidence that psychological
interventions, when properly designed, can reduce the risk of recurrent
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