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Counseling, Group Therapy Improve Depression, Social Support for Heart Attack Patients

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Duke Health News 919-660-1306

DURHAM, N.C. -- A national trial conducted at eight medical
centers, including Duke University Medical Center, has
demonstrated that psychological counseling and group therapy
significantly improves depression and social isolation for
patients who have suffered a heart attack.

The findings are important, researchers said, because about
half of all heart attack victims become depressed, which will
hinder many from regaining their health. The results of the
trial, which enrolled 2,481 heart attack patients, were
published today (June 18, 2003) in the Journal of the American
Medical Association.

While the trial did not achieve its primary goal of
demonstrating that cognitive behavioral therapy (CBT) could
reduce the rates of death or recurrent heart attack after an
initial heart attack, the researchers believe that the results
further highlight the importance of treating depression and
addressing social support issues in this group of patients.
They also said that while there was no improvement in mortality
rates, decreasing depression and increasing social support
improved the quality of life of these patients.

CBT consisted of weekly individual therapy sessions,
supplemented in some cases with group sessions, aimed at
helping patients modify their habitual negative thought
patterns and alter their reactions to stressful situations.

"Although the intervention did not provide a survival
benefit up to 30 months after the heart attack, it did succeed
in decreasing depression and increasing social support,
especially during the first six months," said psychologist
James Blumenthal, Ph.D., who led the Duke portion of the trial.
"This demonstrates that patients who are depressed or have low
social support following a heart attack should be followed, and
if the symptoms do not clear up, they should be considered for
treatment.

Dubbed ENRICHD (Enhancing Recovery in Coronary Heart Disease
Patients), the trial was supported by a $29.6 million grant
from the National Heart, Lung and Blood Institute. It was the
first multi-center trial supported by the National Institutes
of Health to investigate the promise of such behavior therapy
interventions in patients with heart disease.

One goal of the trial was to enroll a representative
population of patients, and the researchers believe they
succeeded, enrolling 1,084 women and 1,397 men and 34 percent
minorities.

Patients were given standardized tests to determine levels
of depression and social support within 28 days of being
admitted to the hospital following their heart attack. Patients
found to be depressed and/or isolated were then randomized into
one of two groups: one group received individual counseling and
group therapy, while the second group received the standard
cardiac care provided by their personal physicians. Patients
with higher levels of depression, or who were unresponsive to
CBT, were also treated with anti-depressant medication.

The psychological tests were repeated six months later and
then annually.

In terms of the CBT group, scores on standard inventories of
depression improved 20 percent after six months, while tests of
social isolation improved 50 percent, when compared to patients
who did not receive intervention.

Another encouraging aspect of the trial, according to
Blumenthal, was that this non-pharmacological approach could
readily be implemented at smaller hospitals as well as the
large academic centers.

"While eight major medical centers were involved, most of
the centers had a network of smaller community hospitals within
their systems where patients were enrolled and treated,"
Blumenthal said. "This leads us to believe that such cognitive
behavioral techniques can be successfully delivered in a
multitude of settings."

Interestingly, the researchers detected a gender difference
in patients' response to CBT.

"While not statistically significant, there was a trend
toward men in the CBT condition exhibiting greater reductions
in mortality and morbidity compared to women," Blumenthal said.
"More studies are needed to better understand this differential
response to therapy between men and women."

The results of the trial also suggest the need for
additional studies to determine the optimal timing and duration
of psychological interventions and to identify the biological
and behavioral pathways that link psychosocial health with
cardiovascular disease.

"We have always been very interested in evaluating
behavioral, non-pharmacologic approaches to treating
depression," Blumenthal said. "Because up to one-third of
depressed patients may not respond to drug therapy, and those
who do take drugs may complain of side effects, it is important
to find effective, alternative approaches."

Blumenthal is currently leading a trial to determine whether
exercise can be an effective treatment for depression in
middle-aged and older adults. An earlier Duke trial
demonstrated that supervised exercise was just as effective as
the most commonly used anti-depression medication in improving
the symptoms of depression.

The new trial, called SMILE (Standard Medical Intervention
and Long-term Exercise) is building upon the earlier trial by
randomizing patients to supervised exercise, exercise at home,
standard anti-depressant medication or placebo.

Cardiovascular disease is the leading cause of death in the
United States. It is estimated that about 13 million Americans
suffer from coronary artery disease. Each year, up to one-third
of the 1.5 million Americans who suffer heart attacks will die.
Not only could psychological treatment result in fewer
hospitalizations and lives saved, it may help reduce the cost
of treating heart patients with high-tech therapies, now
estimated at $100 billion a year, Blumenthal said.

Other participating medical centers in the ENRCHD trial were
the University of Alabama at Birmingham, University of Miami,
Yale University/Harvard University, Washington University in
St. Louis, University of Washington in Seattle, Stanford
University, and Rush-Presbyterian-St. Luke's Medical Center in
Chicago. The University of North Carolina at Chapel Hill served
as the Coordinating Center.

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