Psychological Interventions for Depression and Anxiety in Patients With Coronary Heart Disease or Heart Failure

Are psychological interventions safe and effective for the treatment of depression and anxiety in patients with coronary heart disease (CHD) or heart failure (HF)?

Compared with no psychological intervention, psychological interventions are safe and effective for improving depression, anxiety, and mental health–related quality of life (QOL) at 6 to 12 months in patients with CHD or HF.¹ (Strength of Recommendation: B, limited-quality patient-oriented evidence.)

More than 30% of patients with cardiovascular disease are estimated to also have depression or anxiety, which can result in increased morbidity and mortality.^2–4 Mental health treatment for anxiety and depression significantly reduces rehospitalization and mortality rates.⁵ The authors of this Cochrane review sought to evaluate the benefits and risks of psychological treatment for depression and anxiety in patients with cardiovascular disease.¹

This Cochrane review comprised 21 randomized controlled trials that included 2,591 adults who had CHD or HF with or without anxiety or depression.¹ Six studies included participants with existing depression, one study involved participants with existing anxiety, and two studies included patients with existing depression or anxiety; the remaining 12 studies did not specify. Five studies were conducted in the United States; four in the United Kingdom; three in Australia; three in Sweden; and one each in China, Germany, Italy, Hong Kong, Iran, and the Netherlands. Sixteen studies included patients with CHD, including myocardial infarction and acute coronary syndrome, and five studies examined individuals with HF. Psychological interventions included cognitive behavior therapy (14 studies), motivational interviewing (two studies), mindfulness, behavioral social cognitive therapy, metacognitive therapy, eye movement desensitization and reprocessing, and behavioral activation (one study each). Only one study used pharmacotherapy as a cointervention.

At 6 to 12 months, psychological treatment slightly improved depression (standardized mean difference [SMD] = −0.36; 95% CI, −0.65 to −0.06; 20 trials; n = 2,531; moderate-certainty evidence) and anxiety (SMD = −0.57; 95% CI, −0.96 to −0.18; 17 trials; n = 2,235; moderate-certainty evidence) compared with no psychological intervention.¹ Psychological treatment slightly improved mental health–related QOL at 6 to 12 months (SMD = 0.63; 95% CI, 0.01–1.26; 12 trials; n = 1,454; low-certainty evidence), although it did not show benefit in physical health–related QOL in the same time frame. There was no reported evidence of a difference in adverse events between the intervention and comparison groups.

Due to substantial heterogeneity and variability of psychological interventions and outcome measures across studies, the generalizability of the effect of psychological interventions on depression and mental health–related QOL among individuals with CHD or HF was limited.¹

The American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines recommends psychological interventions with or without pharmacotherapy for mental health conditions in patients with chronic coronary disease.⁶ Further study is needed to determine which interventions and what duration and timing are best, but family physicians may consider psychological interventions for patients with CHD or HF, given the apparent clinical effectiveness and safety.

The practice recommendations in this activity are available at https://www.cochrane.org/CD013508.