Suicidal ideation in female individuals with fibromyalgia and comorbid obesity: prevalence and association with clinical, pain-related, and psychological factors.

OBJECTIVE: Individuals with fibromyalgia report alarming levels of suicidal ideation, and comorbidity with other chronic health conditions such as obesity-a risk factor for suicidal ideation per se-could further complicate the clinical picture. The aim of this study is to determine, in a sample of women with fibromyalgia and comorbid obesity, the prevalence of suicidal ideation and to evaluate clinical, pain-related and psychological factors associated with suicidal ideation. METHODS: In total, 156 female individuals with fibromyalgia and obesity were recruited and completed a series of self-report measures that assessed (i) the level of pain intensity, (ii) depressive symptomatology, (iii) sleep quality, and (iv) pain catastrophizing. Suicidal ideation was evaluated by item #9 of the Beck Depression Inventory. In addition, information regarding previous suicide attempts and current opioid use was collected. RESULTS: 3n sum, 7.8% of participants reported presence of suicidal ideation. According to the results of the multiple logistic regression, depressive symptomatology, sleep quality, and pain catastrophizing were associated with the presence of suicidal ideation. DISCUSSION: The presence of suicidal ideation in our sample was significantly associated with depressive symptomatology, sleep quality, and pain catastrophizing. Our findings are the first to suggest a unique (ie, independent of depressive symptomatology, and sleep quality) association between pain catastrophizing and suicidal ideation in the context of fibromyalgia and comorbid obesity. In order to prevent and reduce suicidal ideation, these factors should be assessed and targeted in interventions for pain management. Future research should investigate the extent to which addressing depressive symptoms, sleep quality, and pain catastrophizing reduces suicidal ideation.

Study protocol of a clinical randomized controlled trial on the efficacy of an innovative Digital thErapy to proMote wEighT loss in patients with obesity by incReasing their Adherence to treatment: the DEMETRA study.

Despite the increasing importance of innovative medications and bariatric surgery for the treatment of obesity, lifestyle interventions (diet and physical activity) remain the first-line therapy for this disease. The use of digital devices in healthcare aims to respond to the patient's needs, in order to make obesity treatment more accessible, so our study aims to assess the safety and efficacy of a Digital Therapy for Obesity App (DTxO) for achieving weight loss and its maintenance in patients affected with obesity undergoing an experimental non-pharmacological treatment. Here we present the study protocol of a prospective, multicenter, pragmatic, randomized, double-arm, placebo-controlled, parallel, single-blind study on obese patients who will be treated with a new digital therapy to obtain an improvement in their disease condition through the application of different simultaneous strategies (a dietary regimen and personalized advice program, a tailored physical exercise program, a cognitive-behavioural assessment and program, alerts and reminders, dedicated section on prescribed drugs intake, and chat and online visits with clinical professionals). We believe that DTxO will offer a promising intervention channel and self-regulation tool holding the potentiality to decrease treatment burden and treat more patients thanks to the partial replacement of traditional medical consultation with digital or telephone management, improving self- engagement and reducing the high demands the "obesity pandemic" for both patients and national health services in terms of time, cost, and effort. Clinical trial registration: clinicaltrials.gov, identifier, NCT05394779.

The efficacy of a brief acceptance-based group intervention in a sample of female patients with fibromyalgia and comorbid obesity: a randomised controlled trial.

OBJECTIVES: A two-arm parallel randomised controlled trial was conducted to evaluate the efficacy of a group acceptance-based treatment (ABT) in improving pain acceptance, pain catastrophising, kinesiophobia, pain intensity and physical functioning compared to treatment as usual in patients with fibromyalgia (FM) and comorbid obesity. METHODS: Female individuals diagnosed with FM and obesity (n = 180) were randomly assigned to either a three-weekly group acceptance-based treatment plus treatment as usual (ABT+TAU) or only TAU. The variables of interest were assessed at baseline (T0) and after the interventions (T1). The treatment protocol for the ABT+TAU condition, designed for an inpatient rehabilitation context, is based on acceptance and commitment therapy but focuses specifically on pain acceptance, a crucial factor in fostering a more functional adaptation to chronic pain. RESULTS: Participants in the ABT+TAU group showed significant improvements in pain acceptance (i.e. the primary outcome), but also in pain catastrophising, kinesiophobia, and performance-based physical functioning (i.e. the secondary outcomes) compared to those in the TAU group. However, there were no significant differences in pain intensity between the two groups. CONCLUSIONS: These findings indicate that a brief group-based ABT intervention is effective in enhancing pain acceptance, reducing pain catastrophising and kinesiophobia, and improving performance-based physical functioning. Furthermore, the observed improvements in kinesiophobia and physical functioning may have particular relevance for individuals with comorbid obesity, as they can facilitate greater adherence to physical activity and promote weight loss.

Altered recognition of fearful and angry facial expressions in women with fibromyalgia syndrome: an experimental case-control study.

Evidence relative to facial emotion recognition and the role played by alexithymia in fibromyalgia syndrome is rare and heterogeneous. In this work, we investigated this ability in fibromyalgia investigating the implicit behaviour in the facial emotion recognition task, focusing on fear and anger. Twenty women with fibromyalgia and twenty healthy women as controls performed a facial emotion recognition of fearful and angry expressions. Their implicit behaviour was scored in accordance with the redundant target effect. The level of alexithymic traits through a standard psychological questionnaire and its effect on behavioral performance were also assessed. Participants affected by fibromyalgia reported a lower level of accuracy in recognizing fearful and angry expressions, in comparison with the controls. Crucially, such a difference was not explained by the different levels of alexithymic traits between groups. Our results agreed with some previous evidence suggesting an altered recognition of others' emotional facial expressions in fibromyalgia syndrome. Considering the role of emotion recognition on social cognition and psychological well-being in fibromyalgia, we underlined the crucial role of emotional difficulties in the onset and maintenance of the symptoms life-span.

Catastrophizing, Kinesiophobia, and Acceptance as Mediators of the Relationship Between Perceived Pain Severity, Self-Reported and Performance-Based Physical Function in Women with Fibromyalgia and Obesity.

Purpose: Individuals with fibromyalgia and obesity experience significant impairment in physical functioning. Pain catastrophizing, kinesiophobia, and pain acceptance have all been identified as important factors associated with the level of disability. The objective of this study was to evaluate the role of pain catastrophizing, kinesiophobia, and pain acceptance as mediators of the association between perceived pain severity and physical functioning in individuals with fibromyalgia and obesity. Patients and Methods: In this cross-sectional study, 165 women with fibromyalgia and obesity completed self-report questionnaires of perceived pain severity (ie, Numeric Pain Rating Scale), pain catastrophizing (ie, Pain Catastrophizing Scale), kinesiophobia (ie Tampa Scale of Kinesiophobia), pain acceptance (ie, Chronic Pain Acceptance Questionnaire), and perceived physical functioning (ie, Physical Functioning subscale of the Fibromyalgia Impact Questionnaire). In addition, a performance-based test (ie, 6-minute walking test) was conducted to assess objective physical functioning. Two multiple mediation analyses were performed. Results: Pain acceptance and kinesiophobia mediated the relationship between pain severity and self-reported physical functioning. Pain catastrophizing and kinesiophobia mediated the relationship between pain severity and performance-based functioning. Conclusion: Pain acceptance, kinesiophobia, and pain catastrophizing should be addressed in rehabilitative intervention to improve physical functioning. Interestingly, the subjective and objective aspects of physical functioning are influenced by different factors. Therefore, interventions for women with fibromyalgia and obesity should focus on factors related to both subjective and performance-based physical functioning.

Investigating PTG in Cancer Patients: The Role of Time Dimension in the Experience of Personal Growth.

This study explored the experience of growth related to being a cancer patient by implementing a thematic analysis. An online questionnaire was completed by 69 patients narrating their growth experience related to cancer. Collected narratives were analyzed by running a deductive thematic analysis, starting from the five domains of the Post-Traumatic Growth Inventory (PTGI) and searching for the presence or absence of topics. Descriptive statistics and correlational analysis were performed. The five factors of the PTGI were identified in the narratives. The thematic analysis we performed defined a further theme that we labeled the "time dimension", which saturated 37.7% of the entire sample. The presences of four sub-themes related to the "time dimension" were also found: "tracing a new temporal rhythm", "the value of deserved time", "facing the caducity of life" and "a view on the future". Each sub-theme significantly correlated with the theme of the "time dimension". This emergent theme does not correlate in our results with other domains of personal growth in cancer previously described in the scientific literature, emerging as an independent variable not significantly associated with other domains of post-traumatic growth. Our results suggest further investigation in the role of the time dimension in the practical and emotional experience of growth with regard to cancer.

Is Whole-Body Cryostimulation an Effective Add-On Treatment in Individuals with Fibromyalgia and Obesity? A Randomized Controlled Clinical Trial.

Pain severity, depression, and sleep disturbances are key targets for FM rehabilitation. Recent evidence suggests that whole-body cryostimulation (WBC) might be an effective add-on treatment in the management of FM. The purpose of this study was to evaluate the effects of an add-on WBC intervention to a multidisciplinary rehabilitation program on pain intensity, depressive symptoms, disease impact, sleep quality, and performance-based physical functioning in a sample of FM patients with obesity. We performed a randomized controlled trial with 43 patients with FM and obesity undergoing a multidisciplinary rehabilitation program with and without the addition of ten 2-min WBC sessions at -110 °C over two weeks. According to our results, the implementation of ten sessions of WBC over two weeks produced additional benefits. Indeed, both groups reported positive changes after the rehabilitation; however, the group that underwent WBC intervention had greater improvements in the severity of pain, depressive symptoms, disease impact, and quality of sleep. On the contrary, with respect to performance-based physical functioning, we found no significant between-group differences. Our findings suggest that WBC could be a promising add-on treatment to improve key aspects of FM, such as pain, depressive symptoms, disease impact and poor sleep quality.

Sleep disturbances and sleep disorders as risk factors for chronic postsurgical pain: A systematic review and meta-analysis.

This systematic review and meta-analysis aimed at evaluating the role of sleep disturbances and sleep disorders in influencing presence and intensity of chronic postsurgical pain (CPSP). We included cohort studies which enrolled adults, assessed sleep disturbances or disorders before surgery, measured pain intensity, presence of pain, or opioid use at least three months after surgery. Eighteen studies were included in a narrative synthesis and 12 in a meta-analysis. Sleep disturbances and disorders were significantly related to CPSP, with a small effect size, r = 0.13 (95% CI 0.06-0.20). The certainty of evidence was rated low due to risk of bias and heterogeneity. In subgroup analyses the above association was significant in studies that used pain intensity as the outcome, but not in those that used presence of pain; in studies on patients who underwent total knee arthroplasty or other surgeries, but not in those on patients who had breast cancer surgery or total hip arthroplasty; in the single study that assessed insomnia and in studies that assessed sleep disturbances as predictors. A meta-regression showed that the follow-up length was positively associated with the overall estimate. Our findings suggest that presurgical sleep disturbances and disorders should be evaluated to detect patients at risk for CPSP. Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=272654.

Psychological Aspects of Treatment with Intragastric Balloon for Management of Obesity: A Systematic Review of the Literature.

INTRODUCTION: Optimizing maintenance of weight loss for people with obesity following intragastric balloon (IGB) therapy hinges on the degree to which health care providers can recognize both the impact of emotional problems and mood difficulties on their capacity to self-manage, and requirements for additional support. However, there is limited research on the psychological correlates of IGB therapy. This systematic review, for the first time, attempts to identify and synthesize the empirical evidence for the reciprocal influence between psychological variables and IGB outcomes. METHODS: A literature search was performed in the PubMed, SCOPUS, MEDLINE, and Google Scholar databases. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least 2 reviewers. The selected articles were assessed for quality using the Strengthening the Reporting of Observational Studies Epidemiology (STROBE) checklist. Data were extracted to address the review aims and presented as a narrative synthesis. The review protocol was preregistered (Prospero CRD42019121291). RESULTS: A total of 16,179 titles, 14,369 abstracts, and 51 full-text articles were screened, of which 16 studies were included. Findings suggest that female gender, older age, basic educational level, and single/divorced civil status, together with lower levels of depression, binge eating, higher perceived quality of life, and motivation to change were predictors of enhanced IGB treatment outcomes. Dissatisfaction with treatment was higher in those with impaired obesity-related social-life difficulties. The IGB treatment was effective in reducing weight and improving depression, anxiety, eating disorder symptoms, and the overall life quality of patients with obesity - mainly within 6 months from the device positioning and in conjunction with conventional therapies. DISCUSSION/CONCLUSION: In line with the available literature on obesity and bariatric surgery interventions, poor mental health appears to be an important barrier for successful weight loss among patients with obesity undergoing IGB treatment. In order to improve the efficacy and effectiveness of the IGB therapy, more comprehensive and standardized studies are needed to provide insight into the psychological mechanisms maintaining weight management issues.

Psychological factors and trajectories of post-surgical pain: A longitudinal prospective study.

A significant proportion of patients do not experience relief from pain during the early postsurgical period after joint arthroplasty and are at risk for developing chronic pain. The objectives of this study were to identify biopsychosocial factors associated with acute postsurgical pain trajectories and with pain intensity and interference after 1, 3, and 12 months. Two hundred ten patients listed for joint arthroplasty filled a presurgical battery of questionnaires assessing presurgical pain intensity, catastrophizing, emotional distress, state anxiety and depression, self-efficacy, central sensitization, and executive functions. From the day after surgery, they were asked to fill a 7-day diary, including questions about postsurgical pain and postsurgical state catastrophizing. Finally, they provided data about pain intensity and interference after 1, 3, and 12 months. Predictors of acute pain trajectories were investigated using multilevel growth curve analysis. Results showed that central sensitization was a predictor of the intercept of pain trajectories and daily postsurgical catastrophizing was a significant covariate of pain intensity in the acute phase. Analyses of follow-up data showed that central sensitization was a predictor of pain intensity and pain interference at 3 and 12 months, that emotional distress was related with pain intensity and interference at 1 month, and with pain interference at 3 months, and that cognitive flexibility was associated with pain interference at 1 month. Assessment of these factors could enable to identify patients at risk for worse outcomes and to plan targeted treatments to be implemented during the patient's inward stay.

The Role of Pain Catastrophizing and Pain Acceptance in Performance-Based and Self-Reported Physical Functioning in Individuals with Fibromyalgia and Obesity.

Impaired physical functioning is one of the most critical consequences associated with fibromyalgia, especially when there is comorbid obesity. Psychological factors are known to contribute to perceived (i.e., subjective) physical functioning. However, physical function is a multidimensional concept encompassing both subjective and objective functioning. The contribution of psychological factors to performance-based (i.e., objective) functioning is unclear. This study aims to investigate the contribution of pain catastrophizing and pain acceptance to both self-reported and performance-based physical functioning. In this cross-sectional study, 160 participants completed self-report measures of pain catastrophizing, pain acceptance, and pain severity. A self-report measure and a performance-based test were used to assess physical functioning. Higher pain catastrophizing and lower pain acceptance were associated with poorer physical functioning at both self-reported and performance-based levels. Our results are consistent with previous evidence on the association between pain catastrophizing and pain acceptance with self-reported physical functioning. This study contributes to the current literature by providing novel insights into the role of psychological factors in performance-based physical functioning. Multidisciplinary interventions that address pain catastrophizing and pain acceptance are recommended and might be effective to improve both perceived and performance-based functioning in women with FM and obesity.

The Reliability and Agreement of the Fibromyalgia Survey Questionnaire in an Italian Sample of Obese Patients.

The Fibromyalgia Survey Questionnaire (FSQ) was self-administered by a sample of 207 Italian individuals with obesity to screen for fibromyalgia (FM). We aimed to investigate the inter-rater reliability and the agreement in the detection of FM symptomatology between the self-administered FSQ and the clinical interview conducted by a rheumatologist. All the patients were divided randomly into two groups (group A and group B): a rheumatologist first interviewed patients of group A and after 48 h, the patients completed the self-report FSQ. Patients of group B first completed the FSQ and 48 h later were interviewed by a rheumatologist. The agreement between the measurements was good with the Bland-Altman analysis showing low bias scores for the two subscales of the FSQ. Results showed that 33% of the sample satisfied the criteria for a diagnosis of fibromyalgia. The FSQ is a self-reporting measure that showed substantial reliability providing fast screening for FM symptomatology.

Preoperative psychological characteristics affecting mid-term outcome after bariatric surgery: a follow-up study.

BACKGROUND: The purpose of this study was to investigate the relationship between preoperative psychological factors and percentage of total weight loss (%TWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB) to identify possible psychological therapy targets to improve the outcome of bariatric surgery. METHODS: Seventy-six patients completed the Hamilton's Anxiety and Depression Scales (HAM-A, HAM-D) and Toronto Alexithymia Scale (TAS-20) the day before surgery (T0). The pre-operative body weight and the %TWL at 3 (T1), 6 (T2), and 24-30 (T3) months were collected. RESULTS: At T3, depressed and alexithymic patients showed a lower %TWL compared to non-depressed patients (p = 0.03) and to non-alexithymic patients (p = 0.02), respectively. Finally, patients who had at least one of the three analyzed psychological factors showed less weight loss, at T2 (p = 0.02) and T3 (p = 0.0004). CONCLUSIONS: Psychological factors may also affect long-term outcome of bariatric surgery. This study shows an association between alexithymia/depression pre-operative levels and the weight loss at 30 months'follow-up after bariatric surgery. LEVEL OF EVIDENCE: Level III, longitudinal cohort study.

The Predictive Role of Executive Functions and Psychological Factors on Chronic Pain after Orthopaedic Surgery: A Longitudinal Cohort Study.

Prevention and treatment of chronic post-surgical pain should be based on the early identification of patients at risk. The presence of a deficit in executive functions, along with the presence of psychological risk factors, could impair the use of appropriate pain coping strategies and might facilitate the transition to chronic post-surgical pain. A longitudinal cohort study was implemented. Patients listed for orthopaedic surgery were enrolled. Variables measured before surgery were pain intensity, the sensory, affective, cognitive and mixed components of pain, state and trait variables associated with the psychological status of the patient, fear of movement, pain catastrophizing, visual attention and cognitive flexibility. Pain intensity and the components of pain were re-evaluated after surgery and after three months. A linear mixed model was used to assess the predictors of pain intensity, and a multivariate linear mixed model was used to assess the predictors of the pain components. 167 patients were enrolled. Controlling for sex, age, pain duration and surgical procedure, catastrophizing and visual attention were predictors of pain intensity at follow-up. The sensory component of pain was predicted by state anxiety, healthcare-related fears, pain catastrophizing and visual attention. Anxiety and catastrophizing were predictors of the affective and evaluative components of pain. The mixed component of pain was predicted by state anxiety, healthcare-related fears and pain catastrophizing. Executive functions, along with psychological risk factors, shape the course of post-surgical pain. The efficacy of preventive and rehabilitation treatment could be possibly enhanced if these factors are treated.

Quality of life, pain, and psychological factors in patients undergoing surgery for primary tumors of the spine.

PURPOSE: Knowledge about quality of life (QOL), pain, and psychological factors in patients with primary tumors of the spine is limited, but is important in planning rehabilitation after surgery. Aims of this study were to assess the preoperative levels and improvement after surgery of these factors, and to identify the predictors of postoperative pain and QOL. METHODS: Patients with primary tumors undergoing spine surgery were matched for sex and age with patients with metastatic tumors. QOL was measured at baseline and three months after surgery with the physical (PCS) and mental (MCS) components SF-12 subscales, pain intensity with a numeric rating scale (NRS), depression with the Beck Depression Inventory (BDI). Preoperative SF-12, NRS, and BDI levels and differences in follow-up improvement in SF-12 and NRS were compared across samples. LASSO regressions were performed to find predictors of follow-up SF-12 and NRS. RESULTS: Patients with primary tumors showed better PCS and NRS, and similar BDI and MCS than patients with metastatic tumors. At follow-up, they showed stronger improvement in the MCS and no improvement in the PCS. All QOL scores were below those of the general population. Follow-up PCS was predicted by baseline PCS and BDI; MCS by baseline MCS; pain intensity by baseline pain intensity and BDI. CONCLUSION: Patients with primary tumors of the spine suffer from moderate levels of physical and mental impairment. Depression influences surgical outcomes.

Psychological Well-Being as an Independent Predictor of Exercise Capacity in Cardiac Rehabilitation Patients With Obesity.

Objective: Exercise capacity (EC) is a well-established predictor of cardiovascular health. It is notoriously influenced by several factors, but the independent effect of psychological well-being (PWB) on EC has not yet been explored. The present study aims to investigate (1) whether PWB is an independent predictor of EC over and above selected demographic, behavioral, and biomedical parameters in a sample of CR patients with obesity and (2) whether PWB is a stronger predictor of EC than the other variables. Methods: Data from 1968 patients were collected at the time of their inclusion in a cardiac rehabilitation (CR) program and retrospectively analyzed in a cross-sectional study. Since cardiorespiratory parameters defined in normal weight populations differ from those of their obese counterparts, an ad hoc validated formula taking body mass index (BMI) into consideration was used to predict EC. Results: A multiple regression analysis revealed left ventricular eject fraction (LVEF) to be the strongest predictor of EC, followed by PWB, type 2 diabetes (DM), smoking status, atrial fibrillation (AF), and education. Bayesian evaluation of informative hypotheses corroborated LVEF as the best predictor of EC, and confirmed the superiority of PWB over and above DM and smoking status in influencing EC. Conclusion: These findings strengthen the link between psychological and physical health, suggesting a better PWB is associated with greater EC. Prompt screening of a patient's mood and readiness to perform an active lifestyle would therefore enhance the long-term health benefits of CR.

The influence of preoperative psychological factors on weight loss after bariatric surgery: A preliminary report.

Aim of this study was to investigate relationship between preoperative psychological factors and % total weight loss after gastric bypass. 76 adult patients scheduled for bariatric surgery were preoperatively asked to complete anxiety and depression Hamilton scales and Toronto Alexithymia Scale. At 3- and 6-month follow-up, body weight was assessed. At 6-month follow-up, alexithymic patients showed a poorer % total weight loss compared with non-alexithymic patients ( p = .017), and moderately depressed patients showed a lower % total weight loss compared with non-depressed patients ( p = .011). Focused pre- and postoperative psychological support could be useful in bariatric patients in order to improve surgical outcome.

ACTonHEALTH study protocol: promoting psychological flexibility with activity tracker and mHealth tools to foster healthful lifestyle for obesity and other chronic health conditions.

BACKGROUND: Obesity and the state of being overweight are increasing steadily and becoming a global epidemic. Recent research reports 64% of the adult population as overweight in Europe and the USA. The social and economic impacts are increasing, and most of the rehabilitation programs, while effective in the short term, do not produce long-lasting results. An explanatory model from a behavioral perspective can describe the phenomena with the lack of sources of reinforcement related to healthful habits in a daily life context. METHODS/DESIGN: A randomized clinical trial combining single-subject studies and a four-arm group design will be conducted to compare the effect of the current standard in obesity treatment to Acceptance and Commitment Therapy (ACT) and wearable technology at different times, before starting intervention, at the end, and at follow-up visits of 3, 6, and 12 months measuring changes over time of physical activity and psychological well-being. DISCUSSION: The goal of this project, combining ACT and wearable technology, is to develop an effective intervention, efficient and sustainable, which even after discharge can provide adequate contingencies of reinforcement in the natural environment, integrating systematic measurements, continuous feedback, and individualized, values-based objectives. The intervention is aimed to provide a contingent reinforcement for healthful behaviors instead of reinforcing only the achievement of a significant weight loss. The aim of the project, combining Acceptance and Commitment Therapy and Wearable Technology, is to develop an effective, efficient and sustainable intervention able to provide a contingent reinforcement for healthy behaviors. The intervention is aimed to promote adequate healthy behaviors in the natural environment, integrating systematic measurements, continuous feedback and individualized values-based objectives, instead of reinforcing only the achievement of a significant weight loss. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03351712 . Registered on 24 November 2017.

Cross-Lagged Relations Between Exercise Capacity and Psychological Distress During Cardiac Rehabilitation.

Background: Poorer mental health is associated with lower exercise capacity, above and beyond the effect of other cardiovascular risk factors. However, the directionality of this relationship remains unclear. Purpose: The main aim of the present study was to clarify, with a cross-lagged panel design, the relationship between psychological status and exercise capacity among patients in a cardiac rehabilitation (CR) program. Methods: A clinical sample of 212 CR patients completed exercise-capacity testing and measures of depression and anxiety (Hospital Anxiety and Depression Scale) pre-CR and post-CR. Demographic and clinical data, including BMI and smoking history, were also collected. Multivariate stepwise regression analysis was performed to identify the best predictors of exercise capacity at discharge. Structural equation modeling was utilized to quantify the cross-lagged effect between exercise capacity and psychological distress. Results: Multivariate regression analysis revealed that higher levels of psychological distress pre-CR are predictively associated with less improvement in exercise capacity post-CR, beyond the effects of age, sex, and baseline functional status. Results from structural equation modeling supported a 1-direction association, with psychological distress pre-CR predicting lower exercise capacity post-CR over and above autoregressive effects. Conclusions: Study results did not support the hypothesis of a bidirectional relationship between psychological distress and EC. High levels of psychological distress pre-CR appeared to be longitudinally associated with lower exercise capacity post-CR, but not vice versa. This finding highlights the importance of assessing and treating both anxiety and depression in the early phase of secondary prevention programs.