Free Paper: Cognitive Behavior Therapy in the Treatment of LPSS and Depression

Identifying Research Question

The hypothesis of this paper seeks to determine whether mortality and recurrent infarction are minimized after using cognitive behavior therapy in the treatment of LPSS and depression when supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant in patients enrolled within 28 days after myocardial infarction. The null hypothesis states that treatment of depression and low perceived social support does not affect mortality and recurrent infarction. Independent variables are depression and low perceived social support; dependent variables are mortality and recurrent infarction.

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Data and Sampling Procedure

The targeted population of interest involved 2481 Myocardial Infarction patients of whom 1084 were women, and 1397 were male in a Randomized clinical trial from October 1996 to April 2001 enrolled from 8 clinical centers (Berkman et al., 2003). Distribution of randomized patients was as follows; 39% suffered from depression, 26% experienced low perceived social support, and 34% were both depressed and had Low Perceived Social Support (LPSS) (Blumenthal et al., 2003). Sampling was randomized to usual medical care or psychosocial intervention. Depressed patients were those who met Enhancing Recovery in Coronary Heart Disease (ENRICHD) improved criteria for major or minor depression (Blumenthal et al., 2003). Coordinating nurses received training on administration of interview, an evaluation made by psychologists and psychiatrists. LPSS criterion involved ENRICHD Social Support Instrument and based on support scales earlier found as causes of death in cardiac patients (Blumenthal et al., 2003). Equivalency, both those on usual medical care and cognitive behavior therapy (CBT) were patients of myocardial infection.

Measurements

The independent variable in this survey were participants with depression and LPSS with cognitive behavior therapy (CBT), with a selective serotonin reuptake inhibitor (SSRI) antidepressant and those on usual medical care (Berkman et al., 2003). The dependent variable sought whether mortality and recurrent infraction are reduced. Screening for major and minor depression was tested by a modified Diagnostic and Statistical Manual of Mental Disorders. LPSS was checked using the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI); Fourth Edition criteria and severity by the 17- item Hamilton Rating Scale for Depression (HRSD) (Berkman et al., 2003).

Cognitive behavior therapy was started on a median of 11 individual sessions throughout 6 months after an average of 17 days after myocardial index Infarction. 1145 patients out of 1238 randomized to psychosocial intervention making 92% received intervention as per protocol (Blumenthal et al., 2003). The median time for acute MI qualification was 6 days, 3 - 11 days being the interquartile range, median 11 sessions attended by patients had an interquartile range of 6 - 19 sessions (Blumenthal et al., 2003). Group therapy with selective serotonin reuptake inhibitor (SSRI) continued for patients scoring higher than 24 on HRSD or having fewer than 50% reduction in Beck Depression Inventory 5 weeks later (Berkman et al., 2003). Tests used included modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, and 17-item HRSD; Beck Depression Inventory Score was level of measurement for the dependent variable (Berkman et al., 2003).

Interventions

Design for the study was a randomized, parallel group trial with cognitive behavior therapy to compare the efficacy of a psychosocial intervention against usual care. It was initiated 17 days after index MI for a median of 11 individual sessions throughout 6 months with the addition of group therapy where appropriate. The therapy was underway soon after randomization and therapists scheduled more than a single session weekly when permitted. To solve logistical challenges, home visits for those discharged were arranged. Enrollment of patients happened in 28 days and those undergoing psychosocial intervention were attended to soonest after index myocardial infarction in the belief of optimal intervention (Blumenthal et al., 2003). Patients scoring higher than 24 on the Hamilton Rating Scale for Depression and those having less than 50% reduction in Beck Depression inventory scores received SSRI and consideration for pharmacotherapy (Berkman et al., 2003). Behavior therapy was used for ENRICHD intervention since it's an effective way to treat depressed patients with no cardiac problems (Blumenthal et al., 2003). For LPSS patients' cognitive therapy techniques addressed behaviors and cognitive conditions. A thorough assessment of the patient's social requirements, planning, and problem-solving skills were conducted during the first session of therapy (Blumenthal et al., 2003).

Psychologists from Beck Institute for Cognitive Therapy and research conducted training of therapists and also supervised quality and treatment protocol by assessing audiotapes from therapy sessions picked randomly (Berkman et al., 2003). The composite primary endpoint of death or recurrent myocardial infarction and secondary results included a change in HRSD for depression or ENRICHD Social Support Instrument scores for low perceived social support at 6 months (Berkman et al., 2003). Follow up averaged 3.4 years after first clinical trials.

Empirical Findings

Research hypothesis aims to determine whether recurrent infarction and mortality are reduced after depression treatment and low perceived social support after cognitive behavior therapy. CBT is supplemented with a selective serotonin reuptake inhibitor (SSRI) anti-depressant when indicated (Berkman et al., 2003). Findings revealed a mean change in the HRSD score -10.1 (7.8) in the depression and psychosocial intervention group vs. -8.4 (7.7) in the depression and usual care group (P<.001) (Berkman et al., 2003). Hamilton score reported for depressed patients only. Mean (SD) change in ESSI score, 5.9 (5.9) in the LPSS and psychosocial intervention group v 3.4 (6.0) in the LPSS and usual care group (P<.001) (Berkman et al., 2003). Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI) reported for patients with low social support only (Berkman et al., 2003). Intervention on psychosocial measures resulted after 6 months in a mean BDI of 9.1 and 12.2 for psychosocial intervention and usual care group respectively (Blumenthal, et al., 2003). At 29 months, the difference between psychosocial treatment and usual care patients for Myocardial Infarction or death was not significant: 24% v 24%, with a hazard ratio of 1.01 and 95% CI.

Conclusion

This study lists as the earliest in establishing relationships between psychosocial intervention on depressed patients, LPSS, mortality, and infarction. Unlike usual care psychosocial intervention, it improved LPSS and decreased depression but had little effect on the death endpoint and infarction.

Critical appraisal

The sample size of 2481 people is large enough to avoid the occurrence of the Type II error considerably. Measurements and scales used in the randomized controlled trials are reliable standards offering results of high reliability. In the study, the null hypothesis stands to declare that treatment of depression and LPSS do not affect mortality and recurrent infarction.

References

Berkman L. F., et al. (2003). Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Patients (ENRICHD) randomized trial. The Journal of American Medical Association, 289(23), 3106-16. Retrieved from https:/www.ncbi.nlm.nih.gov/pubmed/12813116.

Blumenthal, J., Carney, R.M, Burg, M. M., & Czajkowski, S. M. (2003). Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Patients (ENRICHD). The Journal of American Medical Association, 289(23), 3106 - 3116. doi: 10.1001/jama.289.233106.