The Effect of Psychotherapy on Anxiety, Depression, and Quality of Life of Patients with Heart Failure: A Randomized Clinical Trial

Rocha, Isaura; Cavalcanti, Ana Dantas; Figueiredo, Lyvia; Pereira, Juliana; Oliveira, Samara de; Cruz, Danilo da; Freitas, Rodrigo de; Mesquita, Evandro Tinoco

doi:10.36660/ijcs.20190190

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International Journal of Cardiovascular Sciences

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ORIGINAL ARTICLE • Int J Cardiovasc Sci 34 (2) • Mar-Apr 2021 • https://doi.org/10.36660/ijcs.20190190 copy

The Effect of Psychotherapy on Anxiety, Depression, and Quality of Life of Patients with Heart Failure: A Randomized Clinical Trial

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Patients with heart failure often experience depression, anxiety, and impacts on quality of life. Psychotherapeutic interventions have been used for chronic conditions, including cardiovascular diseases, showing improvement in mental health. However, no studies have assessed the effects of a psychological intervention using psychoanalysis on patients with heart failure.

Objective

To assess the effect of short-term psychotherapy on depressive symptoms, anxiety, and quality of life of patients seen at a specialty clinic.

Method

A randomized clinical trial with scales to assess outcomes before and after psychotherapy, under the perspective of psychoanalysis, with 12 weekly sessions. The Beck Depression Inventory, the Beck Anxiety Inventory, and the Minnesota Living with Heart Failure Questionnaire were used. The mean initial and final scores for quality of life, anxiety, and depression were compared using Student’s t-test for independent samples when distribution was normal, or Mann-Whitney test when distribution was non-normal. A bivariate p-value < 0.05 was considered statistically significant for all analyses.

Results

This study involved 32 patients, 50% were female, mean age was 64.3±11.6, and most participants were New York Heart Association (NYHA) functional class I (56.3%). For anxiety (p = 0.196), there was no statistically significant difference between groups. For quality of life and depression, there was a statistical difference (p = 0.009 and 0.035, respectively), with a medium effect (Cohen’s d = 0.593) on quality of life.

Conclusion

Short-term psychotherapy in outpatients with heart failure showed an impact on depression and quality of life but did not improve anxiety. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

Heart Failure; Anxiety; Depression; Quality of Life; Psychotherapy; Mental Health; Psychoanalytic Therapy

Treatment Plan
Sessions	Description of activities	Aspects addressed and assessed by the psychologist (concepts of psychology and psychoanalysis)
1^st	- Explain the psychotherapeutic process thoroughly, stating the importance of following the treatment plan. - Identify together with patients three priority aspects for treatment.	- Initial demands - Diagnosis = traumatic event (intense event that individuals are unable to react properly and that causes pathogenic effects on psychic organization). - Representations of the disease and fantasies (subjects represent, somewhat distorted by defensive processes, the fulfillment of a wish) - Assessment of bonds (affective bonds) and affection - Psychoeducation - Psychic ambivalences and conflicts - Defense mechanisms (aims to reduce or eliminate any danger to the biopsychological individual) - Conscious vs. unconscious - Free association method (connection between two or more psychic elements spontaneously) - Insights
2^nd to 8^th	- Address issues related to the disease, self-care, personal needs, life expectations, personal and family history, self-perception, bonds, beliefs, religiousness, etc. - Clarify patients’ doubts with the help of the multidisciplinary team, if necessary. - Invite family members, if possible, for assistance and guidance, especially on how to help/facilitate/encourage patients to have better adherence to treatment and better coping with the disease. - Assess the possibility of adjustments in lifestyle as well as encourage changes in habits, offering support and outlining coping strategies (including social, family, and religious support, social, leisure, and/or physical activities, public spaces, specialty clinics, etc.). - Discuss the progress of the process with patients and make adjustments, if necessary. - Discuss the possibility of changing the priority aspects of treatment. - Provide feedback to patients. - Address changes in personal choices. - Address the impacts and limitations of the disease and think of possibilities or alternatives for everyday life, be it work, social interaction, or family environment.
9^th	- Address treatment closure and aspects related to the termination of this bond, as well as highlight the gains obtained during therapy.
10^th and 11^th	- Address some possible issues.
12^th	- End the process, reinforcing all topics covered, and hand over the discharge guidance sheet. - Deliver referral to patients who need to continue treatment. - Administer a final questionnaire. - New administration of the Beck Anxiety/Depression Inventory (BAI and BDI) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) by a psychologist or a nursing student.

Characteristics	Control (n = 16)	Intervention (n = 16)	Total (n = 32)	p-value
Age, Years†	63.3±12.7	65.3±10.6	64.3±11.6	0.644§
Sex, Male*	8 (50.0)	8 (50.0)	16 (50.0)	0.638‡
Education, Elementary school*	13 (81.3)	14 (87.5)	27 (84.4)	0.499‡
Marital status, Married*	6 (37.5)	7 (43.8)	13 (40.6)	0.869‡
Occupation, Retired*	5 (31.3)	8 (50.0)	13 (40.6)	0.085‡
Hometown, São Gonçalo*	7 (43.8)	10 (62.5)	17 (53.1)	0.581‡
Income, US$200 - US$500*	7 (43.8)	7 (43.8)	14 (43.8)	0.817‡
Living alone, No*	11 (68.8)	14 (87.5)	25 (43.8)	0.197‡
Caregiver, No*	11 (68.8)	12 (75.0)	23 (71.9)	0.500‡
Hospitalization in the past year, No*	12 (75.0)	12 (75.0)	24 (75.0)	0.657‡
History of psychotropic drug use, No*	13 (81.3)	11 (68.8)	24 (75.0)	0.240‡
Children, Yes*	14 (87.5)	14 (87.5)	28 (87.5)	0.700‡
Functional class, NYHA I*	6 (37.5)	12 (75.0)	18 (56.3)	0.100‡
Arterial hypertension, Yes*	13 (81.3)	12 (75.0)	25 (78.1)	0.500‡
Diabetes mellitus, Yes*	4 (25.0)	5 (31.3)	9 (28.1)	0.500‡
Smoking, No*	13 (81.3)	13 (81.3)	26 (81.3)	0.673‡
Alcoholism, No*	14 (87.5)	14 (87.5)	28 (87.5)	0.700‡
Independence, Yes*	10 (62.5)	12 (75.0)	22 (68.8)	0.720‡

Variables	Control (n = 16)	Intervention (n = 16)	p-value
Affected areas
Emotions^\|\|	6 (37.5)	6 (37.5)	0.642
Marriage^†	2 (12.5)	3 (18.8)	0.500
Family^\|\|	4 (25.0)	6 (37.5)	0.352
Work^\|\|	5 (31.3)	6 (37.5)	0.500
Friends^†	3 (18.8)	3 (18.8)	0.673
Religion^†	0	2 (12.5)	0.242
None^†	2 (12.5)	2 (12.5)	0.700
Self-perception ^\|\|			0.548
Healthy	4 (25.0)	6 (37.5)
Sick without significant limitations	4 (25.0)	5 (31.3)
Sick with significant limitations	8 (50.0)	5 (31.3)
Expectations ^†			0.584
Healing	6 (37.5)	7 (43.8)
Self-care and better quality of life	9 (56.3)	9 (56.3)
None	1 (6.3)	0
Role in treatment†			0.500
Engaged and following all guidelines	13 (81.3)	12 (75.0)
Somewhat engaged and not always following all guidelines	3 (18.8)	4 (25.0)
Never following all guidelines	0	0

Scores	Control Initial (n = 16)	Intervention Initial (n = 16)	p-value Initial	Control Final (n = 16)	Intervention Final (n = 16)	p-value Final	Cohen’s d
Anxiety^†	8.5 (4.00-26.50)	13.5 (3.75-20.50)	0.956	11.00 (5.00-23.00)	8.00 (3.00-14.00)	0.196	-
Depression^†	19.5 (9.5-29.00)	12.5 (6.5-19.25)	0.102	11.50 (5-23.75)	8.25 (2.25-17.00)	0.035	-
Quality of life^\|\|	46.5±24.0	37.4±22.4	0.276	48.6±27.8	25.3±18.3	0.009	0.593

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