Lundgren Johan Gustav, Dahlström Örjan, Andersson Gerhard, Jaarsma Tiny, Kärner Köhler Anita, Johansson Peter
Division of Nursing Science, Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden.
J Med Internet Res. 2016 Aug 3;18(8):e194. doi: 10.2196/jmir.5556.
Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategies for depressive symptoms in patients with HF still remain to be established. Internet-based cognitive behavioral therapy (ICBT), as guided self-help CBT programs, has shown good effects in the treatment of depression. Until now, ICBT has not been evaluated in patients with HF with depressive symptoms.
The aims of this study were to (1) evaluate the effect of a 9-week guided ICBT program on depressive symptoms in patients with HF; (2) investigate the effect of the ICBT program on cardiac anxiety and QoL; and (3) assess factors associated with the change in depressive symptoms.
Fifty participants were randomized into 2 treatment arms: ICBT or a Web-based moderated discussion forum (DF). The Patient Health Questionnaire-9 was used to measure depressive symptoms, the Cardiac Anxiety Questionnaire (CAQ) was used to measure cardiac-related anxiety, and the Minnesota Living with Heart Failure questionnaire was used to measure QoL. Data were collected at baseline and at follow-up at the end of the 9-week intervention. Intention-to-treat analysis was used, and missing data were imputed by the Expectation-Maximization method. Between-group differences were determined by analysis of covariance with control for baseline score and regression to the mean.
No significant difference in depressive symptoms between the ICBT and the DF group at the follow-up was found, [F(1,47)=1.63, P=.21] and Cohen´s d=0.26. Secondary within-group analysis of depressive symptoms showed that such symptoms decreased significantly in the ICBT group from baseline to the follow-up (baseline M=10.8, standard deviation [SD]=5.7 vs follow-up M=8.6, SD=4.6, t(24)=2.6, P=.02, Cohen´s d=0.43), whereas in the DF group, there was no significant change (baseline M=10.6, SD=5.0, vs follow-up M=9.8, SD=4.3, t(24)=0.93, P=.36. Cohen´s d=0.18). With regard to CAQ and QoL no significant differences were found between the groups (CAQ [d(1,47)=0.5, P=.48] and QoL [F(1,47)=2.87, P=.09]). In the ICBT group in the CAQ subscale of fear, a significant within-group decrease was shown (baseline M=1.55 vs follow-up M=1.35, P=.04). In the ICBT group, the number of logins to the Web portal correlated significantly with improvement in depressive symptoms (P=.02), whereas higher age (P=.01) and male sex (P=.048) were associated with less change in depressive symptoms. This study is underpowered because of difficulties in the recruitment of patients.
Guided ICBT adapted for persons with HF and depressive symptoms was not statistically superior to participation in a Web-based DF. However, within the ICBT group, a statically significant improvement of depressive symptoms was detected.
Clinicaltrials.gov NCT01681771; https://clinicaltrials.gov/ct2/show/NCT01681771 (Archived by WebCite at http://www.webcitation.org/6ikzbcuLN).
抑郁症状以及焦虑症状和生活质量（QoL）下降的相关共存情况在心力衰竭（HF）患者中很常见。然而，HF患者抑郁症状的治疗策略仍有待确立。基于互联网的认知行为疗法（ICBT）作为指导性自助认知行为疗法项目，已在抑郁症治疗中显示出良好效果。到目前为止，ICBT尚未在有抑郁症状的HF患者中进行评估。
本研究的目的是：（1）评估为期9周的指导性ICBT项目对HF患者抑郁症状的影响；（2）调查ICBT项目对心脏焦虑和生活质量的影响；（3）评估与抑郁症状变化相关的因素。
50名参与者被随机分为2个治疗组：ICBT组或基于网络的适度讨论论坛（DF）组。使用患者健康问卷-9来测量抑郁症状，使用心脏焦虑问卷（CAQ）来测量与心脏相关的焦虑，使用明尼苏达心力衰竭生活问卷来测量生活质量。在基线和9周干预结束时的随访中收集数据。采用意向性分析，缺失数据用期望最大化方法进行估算。通过协方差分析并控制基线分数和均值回归来确定组间差异。
随访时ICBT组和DF组在抑郁症状方面未发现显著差异，[F(1,47)=1.63，P=.21]，Cohen's d=0.26。抑郁症状的组内二次分析表明，ICBT组从基线到随访抑郁症状显著减少（基线M=10.8，标准差[SD]=5.7，随访M=8.6，SD=4.6，t(24)=2.6，P=.02，Cohen's d=0.43），而DF组没有显著变化（基线M=10.6，SD=5.0，随访M=9.8，SD=4.3，t(24)=0.93，P=.36，Cohen's d=0.18）。关于CAQ和生活质量，两组之间未发现显著差异（CAQ [d(1,47)=0.5，P=.48]，生活质量[F(1,47)=2.87，P=.09]）。在ICBT组的恐惧CAQ子量表中，组内有显著下降（基线M=1.55，随访M=1.35，P=.04）。在ICBT组中，登录网络门户的次数与抑郁症状的改善显著相关（P=.02），而年龄较大（P=.01）和男性（P=.048）与抑郁症状变化较小有关。由于患者招募困难，本研究的效能不足。
适用于有抑郁症状的HF患者的指导性ICBT在统计学上并不优于参与基于网络的DF。然而，在ICBT组内，抑郁症状有统计学上的显著改善。
Clinicaltrials.gov NCT01681771；https://clinicaltrials.gov/ct2/show/NCT01681771（由WebCite存档于http://www.webcitation.org/6ikzbcuLN）。
