Internet-Delivered, Therapist-Assisted Treatment for Anxiety and Depression in Patients with Cardiovascular Disease: Evidence-Base and Challenges.

PURPOSE OF REVIEW: This review focuses on the efficacy of internet-based psychological interventions for patients with cardiovascular disease (CVD) and comorbid anxiety and depression. Anxiety and depression comprise barriers for treatment adherence and are associated with poorer patient-reported and clinical outcomes, and greater health care costs. RECENT FINDINGS: Internet-based, therapist-assisted interventions targeting anxiety and depression can be as efficacious as face-to-face therapy and may have some advantages, as patients can do it from their own laptop/smartphone at home at a time of their convenience, which may facilitate a better integration in their lives. To enhance the field of internet-based therapy for patients with CVD, we need to involve patients in the development of interventions, focus on developing standards for adherence and assessment of fidelity, and assess and augment health literacy in patients to safeguard equality in health care.

Validity of the 15-item social inhibition questionnaire in outpatients receiving psychological or psychiatric treatment: The association between social inhibition and affective symptoms.

OBJECTIVE: Social inhibition may promote symptoms of depression and anxiety in adults from an outpatient hospital population. The current work builds on a previously corroborated construct of social inhibition and examines the psychometric properties of this assessment tool and its predictive validity in the adult outpatient hospital population. METHODS: A total of 350 adult outpatients receiving treatment at the department of Medical Psychology or Psychiatry completed measures of social inhibition and symptoms of anxiety (7-item Generalized Anxiety Disorder scale) and depression (9-item Patient Health Questionnaire). Factor analyses, reliability estimates, and regression analyses were used to replicate the robustness of the model of social inhibition, and the 15-item Social Inhibition Questionnaire (SIQ15). RESULTS: In the current sample (N = 350; Mage = 45 years; 67.4% women), factor analyses confirmed the previously suggested three-factor model of social inhibition as measured by the SIQ15. The subscales of behavioral inhibition, interpersonal sensitivity and social withdrawal proved to be internally consistent (Cronbach's α between 0.87/0.95) and stable over time (test-retest reliability between r = 0.76/0.83). At baseline, interpersonal sensitivity and social withdrawal were associated with anxiety and depressive symptoms. At three months follow-up, only interpersonal sensitivity was related to depressive symptoms. CONCLUSIONS: Social inhibition is associated with anxiety and depression at baseline and can be reliably assessed with the SIQ15 in an outpatient hospital population. The association of interpersonal sensitivity with depressive symptoms at three-month follow-up suggests an important aim for future research on the development of preventive methods for affective symptoms in socially inhibited outpatients.

Validity of the newly developed 4-item ANXiety-scale in patients with an implantable cardioverter defibrillator: A 12-month follow-up study.

BACKGROUND: Subclinical anxiety symptoms are associated with risk of impaired mental and physical health status, ventricular tachyarrhythmias and mortality, in patients with an implantable cardioverter defibrillator (ICD). This study evaluates the validity of the brief and new 4-item Anxiety Scale (ANX4) and its predictive value in relation to health status 12-months post ICD implantation. METHODS: A total of 288 ICD patients completed the ANX4 questionnaire. Factor analysis was performed to assess the validity of the scale. In a subsample of N = 212 patients, regression analysis was performed to assess questionnaires' predictive value of health status at 12-months follow-up. RESULTS: Analyses of the ANX4 revealed a one-factor structure with a high internal consistency (α = 0.894). The ANX4 correlated significantly with existing generic and disease specific measures of anxiety symptoms STAI-S (r = 0.62), GAD-7 (r = 0.58), HADS-A (r = 0.66) and ICD related concerns (ICDC) (r = 0.44). Baseline anxiety symptoms were associated with lower levels of physical (ß = -0.276; p < .001) and mental (ß = -0.551; p < .001) health status 12-months post ICD implantation, adjusting for demographic and clinical variables. CONCLUSIONS: The 4-item ANX4 shows to be a valid measure of anxiety symptoms in ICD patients and predicts physical and mental health status up to 12 months follow-up. Further studies are warranted to replicate these findings, determine the cut-off score for clinical relevant symptoms, and whether the ANX4 can be used in other populations.

Prevalence of anxiety and risk associated with ventricular arrhythmia in patients with an implantable cardioverter defibrillator.

BACKGROUND: Anxiety has been associated with adverse clinical outcomes in patients who have received an implantable cardioverter defibrillator (ICD). However, results are inconclusive likely due to different measures being used to assess anxiety. Hence, the current study aims to examine the prevalence and the association between anxiety, ventricular tachyarrhythmia's (VTa's) and all-cause mortality, respectively. METHODS: Patients who received an ICD for the first time were recruited from 6 Dutch referral hospitals as part of the WEBCARE trial. Patients filled in validated questionnaires (GAD-7, STAI-S, HADS-A, ANX4, ICDC, FSAS) to assess their baseline anxiety symptomatology. Logistic regression analysis and Cox Regression analysis were performed to examine the association between anxiety with 1) VTa's and 2) mortality, respectively. RESULTS: A total of 214 Patients were included in the analysis with mean age 58.9 and 82.7% being male. The prevalence rates of anxiety varied depending on which questionnaire was used 12.4% (GAD-7), 17.5% (HADS-A), and 28.1% (STAI-S). (Cox) Regression analysis revealed that none of the anxiety measures was associated with VTa's or all-cause mortality in the current sample. Stratifying the sample by gender, the analysis showed that GAD-7, STAI-S, and ANX4 scores were associated with increased risk of VTa's but only in male patients. CONCLUSIONS: Prevalence rates of anxiety varied depending on the measurement tool used. No significant association between anxiety and VTa's and all-cause mortality was observed in the total sample. GAD-7, STAI-S, and ANX4 were associated with increased risk for VTa's but only in male patients.

Personality traits, ventricular tachyarrhythmias, and mortality in patients with an implantable cardioverter defibrillator: 6 years follow-up of the WEBCARE cohort.

OBJECTIVE: Risk stratification within the ICD population warrants the examining of the role of protective- and risk factors. Current study examines the association between Type D personality, pessimism, and optimism and risk of ventricular tachyarrhythmias (VTa's) and mortality in patients with a first-time ICD 6 years post implantation. METHODS: A total of 221 first-implant ICD patients completed questionnaires on optimism and pessimism (Life Orientation Test) and Type D personality (Type D scale DS14) 10 to 14 days after implantation. VTa's and all-cause mortality 6 years post implant comprised the study endpoints. RESULTS: Ninety (40.7%) patients had experienced VTa's and 37 (16.7%) patients died, 12 (5.4%) due to a cardiac cause. Adjusted logistic regression analysis showed that pessimism was significantly associated with increased risk of VTa's (OR = 1.09; 95% CI = 1.00-1.19; p = .05). Type D personality (OR = 1.05; 95% CI = 0.47-2.32; p = .91) and optimism (OR = 1.00; 95% CI = 0.90-1.12; p = .98) were not associated with VTa's. None of the personality types were associated with mortality. CONCLUSION: Pessimism was associated with VTa's but not with mortality. No significant association with either of the endpoints was observed for Type D personality and optimism. Future research should focus on the coexistent psychosocial factors that possibly lead to adverse cardiac prognosis in this patient population.

Prevalence of anxiety in patients with an implantable cardioverter defibrillator: measurement equivalence of the HADS-A and the STAI-S.

PURPOSE: The Hospital Anxiety and Depression Scale (HADS-A) and State-Trait Anxiety Inventory (STAI-S) are popular instruments for assessing anxiety and are considered interchangeable, although little is known about their equivalence. Hence, we examined whether the two instruments are (i) equivalent with respect to determining the prevalence of probable clinical anxiety levels and (ii) reflect variation on a common anxiety attribute. METHODS: Score and construct concordance were evaluated using equipercentile equating and bifactor modeling, respectively. Secondary data from the WEBCARE trial and the MIDAS study were used for the current study, where patients implanted with a first-time implantable cardioverter defibrillator completed both the HADS-A and the STAI-S within 10 days post implant. RESULTS: Data from 710 patients were included in the analyses. Results showed that the STAI-S produced a higher prevalence rate than the HADS-A (39% vs. 23%). A crosswalk table was generated with equivalent scores and cutoffs for the HADS-A and STAI-S, respectively. Bifactoring suggested that HADS-A and STAI-S largely tapped into the same generic anxiety attributes. CONCLUSIONS: STAI-S and HADS-A reflect a common anxiety attribute, but using the recommended cutoff scores on the respective measures show very different prevalence rates and would classify patients as anxious with the STAI-S who would not be identified as such with the HADS-A. Clinicians and researchers should be aware of the inequivalence when using these measures for screening and determining the prevalence of probable clinical anxiety levels.

Sleep disturbance in patients with an implantable cardioverter defibrillator: Prevalence, predictors and impact on health status.

BACKGROUND: Sleep disturbances are highly prevalent in patients with cardiac diseases and associated with poor health outcomes. However, little is known about sleep disturbance in patients with an implantable cardioverter defibrillator. AIMS: We examined the prevalence and predictors of sleep disturbance and the impact on perceived health status in a Dutch cohort of implantable cardioverter defibrillator patients. METHODS: Patients ( n=195) enrolled in the Web-based distress program for implantable cardioverter defibrillator patients (WEBCARE) trial completed questionnaires at the time of implantable cardioverter defibrillator implantation, three, six and 12 months afterwards. Sleep disturbance was assessed with the corresponding item #3 of the Patient Health Questionnaire 9. RESULTS: At baseline, 67% ( n=130) reported sleep disturbance (cut off ≥1). One year later, the prevalence was 57% ( n=112). Younger age (odds ratio=0.96, 95% confidence interval 0.92-0.99; p=0.012) and high negative affectivity/low social inhibition (odds ratio=4.47, 95% confidence interval 1.52-13.17; p=0.007) were associated with sleep disturbance at 12 months in adjusted analyses. Sleep disturbance was not associated with health status at 12 months. Charlson Comorbidity Index, anxiety, Type D personality and high negative affectivity/low social inhibition were associated with impaired health status at follow-up. CONCLUSIONS: Sleep disturbance was highly prevalent in patients with an implantable cardioverter defibrillator. Younger age and high negative affectivity predicted sleep disturbance 12 months post-implantation independent of other demographic, clinical, intervention and psychological covariates. Sleep disturbance was not associated with impaired health status at the 12-month follow-up.

Optimism as predictor of patient-reported outcomes in patients with an implantable cardioverter defibrillator (data from the WEBCARE study).

OBJECTIVE: The implantable cardioverter defibrillator (ICD) is the treatment of choice for prevention of sudden cardiac death. However, a subgroup of ICD patients experiences psychological adjustment problems post implant. To date, positive psychological constructs (e.g. optimism) have been understudied in this population. Hence, we examined the association between optimism and anxiety, depression, and health status at 12-months post implant. METHODS: Patients (N=171) enrolled in the WEB-based distress management study for ICD patients were included in the analyses. Optimism and pessimism (LOT), and Type D personality (DS14) were administered at baseline, while anxiety (GAD-7), depression (PHQ-9), and health status (SF-12) were assessed at 12-months. RESULTS: The mean age was 59.6±10.06 with 81% being male. After controlling for demographic, personality, and clinical variables, baseline optimism was associated with lower anxiety (ß=-0.210; p=0.011) and depression (ß=-0.222; p=0.005), and better physical (ß=0.227; p=0.004) and mental health status (ß=0.350; p=0.000) at follow-up. Optimism was also associated with change in mental health status (ß=0.195; p=0.007) but not with change in anxiety, depression, and physical health status at follow-up. CONCLUSIONS: Our findings indicate that optimism is associated with less distress and possibly helps safeguard mental health in ICD patients. Increase optimism might be the way forward to reduce long-term distress and impaired health status. TRIAL REGISTRATION: http://www.ClinicalTrials.gov. Identifier: NCT00895700.