Rehabilitation after heart attackBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7071.1498 (Published 14 December 1996) Cite this as: BMJ 1996;313:1498
- Richard Mayou
- Clinical reader in psychiatry University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX
Should be more flexible, and integrated with cardiac aftercare and primary care
Psychological complications are common after myocardial infarction and can substantially increase the use of healthcare resources. At least a quarter of patients suffer clinically important problems, including distress for patients and families, psychologically determined effects on quality of life, and increased mortality in those who are depressed. Awareness of the size of the problem, and the need to encourage changes in lifestyle for secondary prevention, has led to the growth of rehabilitation programmes. These are usually separate from cardiological care, hospital based, and with a standard format of exercise training and didactic education. Despite the enthusiasm of therapists and patients, doubts remain about efficacy and delivery.
Few current programmes have specifically designed psychological components, but a recent review concluded that “the addition of psychosocial treatments to standard cardiac rehabilitation regimens reduces mortality and morbidity, psychological distress and some biological risk factors.”1 However, most published research has evaluated rather prolonged, elaborate interventions with selected subjects. There remains a need to show how effective psychological interventions could be simply delivered to large numbers of people in routine care.
In this week's BMJ (p000) West and colleagues describe a large multicentre trial of psychological treatment starting two to six weeks after myocardial infarction, the content of which was “chosen on the basis of professional wisdom at the time” and as being feasible in routine clinical care.2 It is notable that none of the authors had special psychological expertise, and there are no acknowledgements to psychological advice. The authors are somewhat reluctant to admit the clear finding of the ineffectiveness of a treatment which is appreciated by patients and partners and which therapists believed to be helpful.
There are two likely explanations for the negative finding. Firstly, many patients in the control group had a good outcome and did not require extra help when they had already made substantial progress in returning to full activity. Secondly, the intervention seems to have been inadequate for those who did have substantial psychologically determined complications; presumably these were heterogeneous but must have included anxiety, depression, excessive caution, poor compliance, and concern about non-specific physical symptoms.
How can we do better? Several smaller studies support an alternative approach: psychologically informed early routine care for all plus later selective extra care. There are encouraging reports about both components. Brief interventions delivered by nurses during and shortly after hospital admission3 4 and a behaviourally based, self help heart manual5 have been shown to be effective in reducing early distress and to have longer term benefits. At a later stage, more intensive and individually planned interventions based on proved psychological behavioural methods have been shown to be effective in treating emotional distress and in secondary prevention.6 In extending and applying these findings to routine care, it will be possible to make use of established knowledge about the systematic recognition of emotional and behavioural difficulties in people who are physically ill, the drug treatment of depression, and the design of cognitive-behavioural interventions (treatments which modify maladaptive beliefs, teach anxiety management, and offer procedures for graded change in behaviour).
We are, I believe, now in a position to design and evaluate new forms of cardiac rehabilitation that offers simple, flexible, and cost effective help that is psychologically and cardiologically informed. The immediate practical implications are that we should move away from standard hospital based programmes to more flexible care integrated with cardiac aftercare and with what is available in primary care.7 Rehabilitation therapists, usually nurses, will need multidisciplinary support and training to provide initial information and advice in discussions with patients and families, systematic assessment to recognise secondary prevention needs and psychosocial complications, and the skills to provide and organise flexible help later on. Psychological interventions are likely to be central, alongside exercise training or home based exercise programmes, vocational advice, and other practical help.6 They should be individually planned (in the same way as cardiological aftercare) and include cognitive behavioural treatment—for those who are anxious, overcautious, or worried about non-specific physical symptoms—and antidepressant drugs—for those who are substantially depressed and therefore at increased risk of dying. Future research needs to be directed to evaluating the components of rehabilitation in appropriate subgroups of patients.
The value of the negative findings of the multicentre trial by West et al is the clear demonstration that commonsense standard interventions are unhelpful and that we now need to look in different directions, especially to the application of psychological treatments that have been shown to be highly effective in psychiatry and other areas of medicine.8 Will those who practise cardiac rehabilitation be able to see this as a useful conclusion?