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SPECIAL ISSUE: COMORBIDITY STUDIES |
From the Faculty of Nursing (S.C.) and the Department of Psychiatry (N.F.-S., F.L.), University of Montreal; the Research Center, Montreal Heart Institute (S.C., N.F.-S., F.L.); and the Department of Psychiatry (N.F.-S, F.L.) and School of Nursing (N.F.-S.), McGill University, Montreal, Canada.
Address reprint requests to: Sylvie Cossette, Montreal Heart Institute Research Center, 5000 Belanger St. E., Montreal, QC, Canada, H1T 1C8. Email: cossets{at}scinf.umontreal.ca
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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METHODS: We studied 433 patients (36.0% women) from the M-HART treatment group who received two home visits after achieving a high psychological distress score (ie, 
5) on the General Health Questionnaire (GHQ). Short-term GHQ success was determined by a return to a normal GHQ score (<5) or a reduction of 50% after the two visits. Patients with short-term successful and unsuccessful GHQ outcomes were compared for mid-term maintenance of success, 1-year death and readmission rates, and 1-year depression and anxiety symptoms.
RESULTS: Patients with short-term GHQ success were more likely to show mid-term GHQ success (p < .001), marginally less likely to die of any causes (p = .087), less likely to die of cardiac causes (p = .043), less likely to be readmitted for any reason (p < .001) and for cardiac reasons (p < .001), and less likely to have high depression (p < .001) and anxiety (p < .001) at 1-year than patients with short-term unsuccessful GHQ outcomes. Results held for men and women and were not altered by controlling for potential confounders. However, the number of deaths prevented analysis with statistical controls.
CONCLUSIONS: Post–myocardial infarction interventions that reduce psychological distress have the potential to improve long-term prognosis and psychological status for both men and women.
Key Words: myocardial infarction • psychosocial interventions • psychological distress • mortality • readmissions.
Abbreviations: BDI = Beck Depression Inventory; CI = confidence interval; GHQ = General Health Questionnaire; ICDA = International Classification of Diseases, Adapted; LVEF = left ventricular ejection fraction; M-HART = Montreal Heart Attack Readjustment Trial; MI = myocardial infarction; OR = odds ratio; PSSS = Perceived Social Support Scale; S-STAI = State Scale of the State-Trait Anxiety Inventory.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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Jones and West (5) randomly assigned 2328 post-MI patients to a program of psychosocial rehabilitation or a control group. The post-discharge program included seven 2-hour sessions provided by clinical psychologists involving a combination of "psychological therapy, counseling, relaxation training, and stress management training." Results showed that the program had no impact on either psychological outcomes or prognosis at either the 6-month or 1-year follow-up. Interestingly, although the sample in the Jones and West study was as large as the samples of all previous trials combined, their results did not agree with those of the meta-analyses summarizing the previous studies.
A few months after the Jones and West study (5) was published, M-HART investigators (4) also failed to show a significant impact of psychosocial intervention on psychological outcomes and prognosis. M-HART was a clinical trial in which 1376 post-MI patients were randomly assigned to a program of home nursing interventions or usual care. The M-HART approach was based on evidence linking stressful life events with reinfarctions, angina episodes, and mortality (6). It was reasoned that if distress could be reduced, post-MI prognosis would be improved. All patients in the M-HART treatment group received a monthly telephone call to screen for psychological symptoms of distress. Patients with high distress scores on any monthly call or who were readmitted received home nursing visits targeting their sources of stress. These visits were individually tailored and varied in content, frequency, and number on the basis of individual patient needs. Despite the considerable amount of nursing provided, treatment–control group comparisons showed that the program was only marginally significant in reducing symptoms of depression and anxiety for men (p = .13 and p = .061, respectively) and that it had no impact on psychological symptoms for women (p = .56 and p = .66, respectively). Furthermore, although the M-HART program did not have a significant impact on 1-year cardiac mortality in men (p = .94), cardiac mortality was marginally greater in women in the treatment group than in the control group (p = .064).
In their discussion of the M-HART results, Frasure-Smith et al. (4) noted that their failure to influence prognosis, as well as the failure of Jones and West’s approach (5), may well have been linked to both programs’ lack of impact on psychological factors. In fact, the most recently published meta-analysis (7), which includes data from both of these trials, supports the notion that failure to alter various intermediate physiological, behavioral, and psychological factors may account for their lack of impact on prognosis.
Thus, one possible explanation for the outcomes of the M-HART program is that the intervention may have increased psychological distress in some patients and decreased it in others, preventing observation of any treatment impact on psychological symptoms in the overall sample. In this context, the present study involved secondary analysis of the M-HART data (4). The aim was to examine the relationships between short-term individual changes in psychological distress, mid-term improvement in psychological distress, and 1-year outcomes, including depression, anxiety, mortality, and hospital readmissions, within the treatment group.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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5) during any monthly monitoring call were visited at home by a project nurse, who developed an individually tailored plan of care to help reduce the patient’s distress symptoms. Although the content, timing, and pacing of home visits depended on each patient’s needs and thus varied from patient to patient, the interventions shared a common structure. Each nurse had her own caseload and continued to see the same patients as needed over the course of the project. The M-HART protocol called for at least two home visits. The goal of the first visit was to determine why the patient had an elevated GHQ score. Rather than using standard questions, nurses explored the following broad categories of stressors or problems in whatever order seemed appropriate: 1) patient’s physical condition (what happened at the time of the MI, how the patient been feeling since the MI); 2) treatment regimen (what the patient did or did not understand about medications, risk factors, activity levels, and diet); 3) patient’s emotional condition (morale, self-esteem, uncertainty, anxiety, and depression); 4) family’s reaction (how the spouse or significant other, children, and other family members were getting along; any sexual problems or concerns); 5) issues concerning work, either for pay or at home, and issues concerning retirement; and 6) other stressors in the patient’s life. Usually during the first visit, the nurse also did some teaching about cardiac disease or its treatment and arranged for a second visit at some time during the following month. Nurses always made themselves available between visits by providing a project telephone number. Whenever urgent medical or psychiatric problems came to light during the initial contact, the nurse arranged for treatment and/or referral as soon as possible. The nurses’ approaches in subsequent visits were guided by suggestions from other team members, including other project nurses and psychiatrists. Each week patients’ problems and nurses’ plans for intervention were reviewed in meetings lasting 2 to 3 hours. The teams for these meetings included a consistent group of three or four project nurses and one of the three project psychiatrists. During the second visit, the nurse continued to work on the major sources of stress identified in the first visit using her own clinical judgment and relying on the advice of her colleagues as she saw fit. Interventions typically involved a combination of emotional support, cognitive restructuring, education, and referral to family physicians, cardiologists, or other health resources. After the second visit, interventions continued as needed until the nurse and project team felt that the patient did not need additional contact and at least one monthly monitoring GHQ score was below 5. Patients in need of continued intervention at the end of the project were referred to local community health centers, general practitioners, or psychiatrists.
Patients in the treatment group received an average of 6 to 7 hours of nursing care, including a mean number of five to six visits over a period of 7 to 8 months. Although some patients received only two visits (N = 81), with visits occurring only during a 1-month period, others had 15 to 20 visits (N = 23) and continued to receive visits throughout the full year. Patients in the control group were not phoned on a monthly basis and did not receive any nursing visits.
Patients in both groups were interviewed in the hospital before randomization and 1 year after discharge. They responded to questions about sociodemographic variables (age, education, whether they lived alone, and whether they had any close friends) and medical history (smoking, previous MI, previous treatment for hypertension) and completed measures of depression (21-item BDI, Ref. 11), anxiety (20-item S-STAI, Ref. 12), anger expression (24-item Anger Expression Scale, Ref. 13), and perceived social support (12-item PSSS, Ref. 14).
Characteristics of the index MI (thrombolysis at admission, revascularization during admission, non–Q wave MI, Killip class, whether a stress test was performed and its results, LVEF) and treatment at discharge (prescription of ß-blockers, angiotension-converting enzyme inhibitors, aspirin, and diabetes medication) were abstracted from hospital charts. Medical outcomes at 1-year were based on information provided by the Régie de l’Assurance Maladie du Québec, hospital charts, and telephone follow-ups. Causes of death were classified as cardiac or noncardiac by two cardiologists blinded to M-HART group allocation. A trained research nurse classified discharge diagnoses for all hospital readmissions as cardiac or noncardiac based on ICDA codes and discharge summaries.
Methods for the Secondary Analyses
Sample selection.
Because we wanted to assess the relationships between changes in distress and long-term outcomes in patients who received some nursing interventions, only treatment group patients who were visited by a nurse were included in the present secondary analyses. Although the majority of M-HART patients received more than two visits, the nursing protocol called for a minimum of two visits, and using the first two visits to evaluate the potential short-term impact of nursing provided the largest sample size. To assess short-term changes in distress, we took the GHQ score just before the first home visit as the starting point and compared it with the GHQ score obtained after the second home visit. The major independent variable for the secondary analyses is the change between these two scores. In the following discussion, the terms "previsit GHQ" and "postvisit GHQ" refer to the GHQ score collected before the first home visit and that collected after the second home visit, respectively. Because the nursing visits were initiated on the basis of the first high GHQ score, which could have happened at any point in the year, the timing of the two visits and of the previsit and postvisit GHQ scores in relation to the index MI varies from patient to patient. However, for three-quarters of patients included in the secondary analyses, the high GHQ score that led to the first nursing visit occurred 1 week after discharge. On average, the first visit took place 7.4 days (SD = 5.3) after the high GHQ score, and the second visit occurred 18.5 days (SD = 7.6) later. Although we assessed changes in distress after the first two home visits, 87% of patients included in the secondary analyses had subsequent visits, with a mean of 4.5 additional visits per patient. We also chose to limit the time interval between the two GHQ assessments to 2 months because with longer time intervals, there would have been a greater chance for factors other than the two home visits to influence psychological distress (ie, internal validity issue). Finally, the monthly monitoring calls were scheduled every 4 weeks independently of the pacing and number of visits, but their actual timing varied depending on the availability of the patients. Therefore, the mean time interval between the two GHQ scores included in the assessment of change in distress in the present secondary analyses was 40.3 days (SD = 14.6, range = 18–71 days).
In summary, the sample for the present secondary analyses consists of patients in the M-HART treatment group who received at least two home visits in response to a high GHQ score (ie, 5) within a maximum of 2 months after the high score. As shown in Table 1, 433 of the 692 patients in the M-HART treatment group met these criteria and were included in the secondary analyses.
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In this context the present study examined short-term changes in psychological distress in terms of either a return to normality or an improvement of 50% in the number of GHQ symptoms on the postvisit GHQ score. GHQ scores <5 were considered to represent a return to normal. The cutoff score of 5 on the GHQ was previously found to identify patients likely to be rehospitalized for cardiac problems in a pretest in a similar post-MI sample (10), and it predicted cardiac mortality and recurrence of MI over a period of 5 years in an another study involving 229 MI patients (23). This was the level used in the M-HART protocol to determine whether patients would receive nursing visits and when it was appropriate to stop intervention.
Mid-term changes in psychological distress.
To evaluate the maintenance of short-term changes in distress over the first two nursing visits, we examined the GHQ score just after the postvisit GHQ score (ie, within the following 2 months). Some 422 of the 433 patients in the secondary analyses had at least one GHQ score within the 2 months after the postvisit GHQ score (mean = 31.4 days, SD = 7.8, range = 17–71 days). Mid-term success on the GHQ was defined as a GHQ score subsequent to the postvisit score used for assessing short-term changes that either remained normal or dropped into the normal range (ie, <5).
One-year outcomes.
Outcomes at 1 year included all-cause mortality, cardiac mortality, and readmission between the postvisit GHQ score and the end of the first postdischarge year. One-year follow-up interviews were conducted for 408 of the 418 surviving patients in the secondary analysis sample. In addition to the 10 patients who did not take part in follow-up interviews, 9 had incomplete data on the 1-year BDI (11) and 6 had incomplete data on the 1-year S-STAI (12). This resulted in a total sample of 399 for the 1-year BDI and 402 for the 1-year S-STAI. Although this means that there was complete psychological follow-up data on a full 95.5% of survivors, those without data were on average about 5 years older and were probably somewhat sicker (not revascularized at index, no prescription for ß-blockers at discharge) than patients with complete data.
The psychometrics of the BDI have been extensively documented (24), and high internal consistency coefficients (0.73–0.95) have been demonstrated in various samples. Furthermore, the BDI has been found to predict mortality over at least the first 18 months after an MI (25). The psychometrics of the S-STAI were documented by Spielberger (12), who reported high internal consistency coefficients (
value of 0.86–0.94) with lower stability over time (test-retest reliability of 0.16–0.62), reflecting the theoretically transient nature of state anxiety. The S-STAI has been shown to be responsive to transient feelings of anxiety under stressful conditions for samples of both male and female college students and surgical patients (12, 26).
Statistical Analyses
Statistical analyses were carried out using SPSS for Windows, version 9.0.0 (27). Separate logistic regression analyses were performed for mid-term GHQ changes and 1-year all-cause mortality, cardiac mortality, all-cause readmissions, and cardiac readmissions using short-term successful or unsuccessful GHQ outcome as the independent variable. Because of the gender differences in program impact observed in the overall M-HART study, we also used logistic regression analysis to examine whether the relationships between short-term GHQ outcomes and mid- and long-term outcomes were similar for both genders. Interaction effects involving gender were assessed by repeating each logistic regression analysis and forcing in gender with the independent variable short-term GHQ outcome on the first step, followed by the addition of the interaction of gender and short-term outcomes on the second step. The likelihood ratio test was used to assess the degree to which the interaction improved each model. Analysis of covariance was used to assess differences in mean BDI scores at 1 year between patients with successful and unsuccessful GHQ outcomes using baseline BDI scores as the covariate. Gender and the interaction of gender by short-term GHQ success were included as between-subject factors. Parallel procedures were used to assess differences in anxiety scores (S-STAI) at 1 year. All tests were two-tailed. For main effects, p values 
.05 were considered statistically significant and those >.05 and .10 were considered marginal. However, because of our interest in potential gender differences, we explored interactions with gender when p values were .15, provided there were at least 10 patients per cell involved in the interaction.
Because the current study did not include patients in the control group of M-HART (they did not have monthly GHQ monitoring calls), the statistical control of potential confounders between short-term changes in distress and mid- and long-term outcomes is particularly important. To examine the impact of short-term GHQ success on mid-term and long-term outcomes independent of the disease and sociodemographic factors associated with short-term success, which could potentially confound the relationships, we built a model predictive of short-term GHQ success in both women and men. We began by forcing in the gender and baseline interactions with cell sizes of at least 10 and p values .15 as well as their component main effects. We then performed multivariate backward stepwise analyses of the remaining baseline variables that were related to short-term success independent of gender. Results were confirmed using forward stepwise procedures with entry and removal criteria of p < .10 and p > .15. The resulting model was used to control for potentially confounding covariates in the assessment of each mid-term and long-term outcome. For categorical outcomes, the variables included in the covariate model were forced into a logistic regression analysis on the first step, with short-term success entered on the second step. The degree to which this model was improved by the addition of short-term success was assessed using the likelihood ratio test. Analyses of covariance for the long-term outcomes of depression and anxiety at 1 year were also repeated including the potentially confounding covariates with a dichotomous level of measurement as an additional between-subjects factor and potential confounders with a continuous level of measurement as additional covariates.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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Independent Variable: Short-Term Changes in Distress
Some 241 patients (55.7%) were classified as having successful short-term GHQ outcomes over the first two nursing visits; that is, their postvisit GHQ score dropped below 5 (49.5%) or was reduced by 50% without a return to normal (6.2%). However, only 48.7% of women (N = 76) showed successful short-term GHQ improvements, compared with 59.6% of men (N = 165; p = .029). Other background characteristics associated with successful outcomes are shown in Table 2 along with the separate patterns of differences for men and women. Short-term GHQ success was not related to age; level of education; living alone; perceived social support; smoking status; previous MI; reported history of treatment for hypertension; thrombolysis; Killip class; LVEF; anger expression; prescription of ß-blockers, angiotensin-converting enzyme inhibitors, and aspirin at discharge; or readmission before the previsit GHQ score. However, in addition to the fact that men were more likely to have successful outcomes than women, successful outcomes were significantly or marginally more common in patients with close friends, patients who were revascularized (by PTCA or bypass) during the index admission or before the previsit GHQ score, and patients with lower baseline BDI, S-STAI, and anger expression scores. Finally, as shown in Table 2, three of the interactions between baseline characteristics, gender, and short-term GHQ outcomes were significant at p < .12: gender and performance of a stress test at baseline, gender and non–Q wave MI, and gender and diabetes (prescription of diabetic medication). Visual inspection of the pairs of means for men and women showed that although the presence of new Q waves on the electrocardiogram was not related to short-term GHQ success in men, women with new Q waves tended to have lower success rates than those with non–Q wave MI. Similarly, whether a stress test was performed at baseline seemed to be more important for women than for men, with women without a stress test being somewhat less likely to have successful outcomes. Finally, although women with diabetes had lower short-term GHQ success rates than nondiabetic women, diabetes was unrelated to GHQ success for men. The patterns for all these interactions were similar and suggest that women with unsuccessful outcomes were somewhat sicker than those with successful outcomes but that the differences in outcome associated with disease severity were not as noticeable for men.
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Mortality.
Between the postvisit GHQ and the 1-year follow-up, there were 15 deaths (3.5%), including 12 from cardiac causes (2.8%). As shown in Table 3, patients with successful short-term GHQ outcomes were marginally less likely to die of any cause and significantly less likely to die of cardiac causes than patients with unsuccessful GHQ outcomes. Furthermore, men were significantly less likely to die than women, both for all-cause and cardiac mortality. Although the small number of deaths prevents assessment of the interaction of gender and short-term GHQ outcomes, the tendency for higher mortality in patients with unsuccessful short-term GHQ changes was present for both women and men.
Readmissions.
There were 163 patients (37.6%) readmitted for either cardiac or noncardiac reasons between the postvisit GHQ score and the 1-year follow-up. As shown in Table 3, patients with successful short-term GHQ outcomes were significantly less likely to be readmitted after the postvisit GHQ score than patients with unsuccessful GHQ outcomes. Results for cardiac readmissions were similar. Women were marginally more likely to be readmitted overall, whereas cardiac readmission rates for both genders were similar. The interactions involving gender and short-term GHQ outcomes were not significant for either all-cause or cardiac readmissions, and the direction of the link between short-term GHQ success and readmissions was the same for men and women.
Psychological outcomes at 1 year.
The relationships between short-term GHQ outcomes and depression and anxiety scores at 1 year were examined using analyses of covariance. As shown in Table 3, patients with successful short-term GHQ outcomes had significantly lower mean 1-year BDI scores than patients with unsuccessful GHQ outcomes, even after controlling for baseline differences in BDI scores. Similar results were observed for anxiety. The interactions between successful short-term GHQ outcomes and gender were not significant for either depression or anxiety at 1 year. Again, the pattern of outcomes was similar in men and women. To get an idea of the clinical meaningfulness of these differences, we also examined the likelihood that patients with successful and unsuccessful short-term GHQ outcomes had 1-year BDI scores 10, indicating at least mild to moderate symptoms of depression. Only 16.2% of the patients with successful GHQ outcomes had 1-year BDI scores 10, compared with 46.6% of those with unsuccessful GHQ outcomes (OR = 0.22, 95% CI = 0.14–0.35, p < .001). In the absence of a recognized clinical cutoff score for the S-STAI, we used the upper quartile (ie, 43) to compare the proportion of patients with successful and unsuccessful short-term GHQ outcomes who had high anxiety scores at 1 year. Only 15.2% of patients with successful short-term GHQ outcomes were in the upper quartile of the S-STAI score, compared with 39.5% of the patients with unsuccessful GHQ outcomes (OR = 0.27, 95% CI = 0.17–0.44, p < .001). No interactions were found between short-term GHQ success and gender for dichotomized 1-year BDI (p = .74) or anxiety scores (p = .50), and the patterns of results were similar for men and women.
Control for Potential Confounders
Because the patients with successful short-term GHQ outcomes differed from those with unsuccessful outcomes on a number of background factors that could have made the unsuccessful patients more difficult to treat, and because these differences were more marked for women than men, we wanted to control for these differences to the extent possible with our sample size and the number of events experienced. We used stepwise procedures to build a combined model to predict short-term GHQ outcomes in both women and men. The final model included the continuous baseline BDI score, readmission between the two GHQ scores used for judging short-term success, and the interaction of gender and non–Q wave MI, the interaction of gender and performance of a stress test at baseline, and the interaction of gender and diabetes (prescription for diabetic medication). Overall this model had a Hosmer and Lemeshow goodness-of-fit 
2 value of 8.39 (df = 8, p = .39). The model is shown in Table 4.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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These results support the hypothesis that interventions that reduce psychological distress have the potential to improve cardiac prognosis and suggest that the overall failure of the M-HART program to alter prognosis may have been linked to its failure to lower distress in a large enough proportion of patients to be able to influence prognosis for the treatment group as a whole. These results are also consistent with the conclusions of the most recently published meta-analysis. Dusseldorp et al. (7) summarized the findings of 37 studies that evaluated the effectiveness of either stress-management programs or behavior modification/health education programs in improving post-MI prognosis. Interestingly, the meta-analysis also included evaluation of the impact of the programs on behavioral (eg, smoking and exercise) and psychological (depression and anxiety) risk factors that could explain how programs ultimately influence prognosis. Overall their findings indicate that programs that were successful in altering either behavioral or psychological risk factors had higher rates of success in reducing cardiac mortality than programs that did not alter these factors.
Above and beyond the relationship between short-term GHQ improvements and improved 1-year prognosis, the results also suggest that short-term reductions in distress were related to lower levels of depression and anxiety symptoms at 1 year. Furthermore, patients who did not show early improvements were unlikely to show later decreases in distress. Interestingly, these results are similar to those reported for antidepressant trials. Coryell et al. (28) found that patients who did not show a 40% to 50% reduction in depressive symptoms by 2 weeks after the initiation of medication had less chance of improving by 6 weeks than patients who showed early improvements in symptoms. This highlights the importance of evaluating short-term changes in distress after the initiation of nonpharmacological intervention programs and suggests that a stepped-care approach to changing or intensifying interventions in patients without early improvements in distress is probably warranted. Stepped care was first proposed for the treatment of hypertension (29) and has since been used in the treatment of other medical conditions, including diabetes (30) and asthma (31). Although stepped-care algorithms that do not take into account patient differences have been criticized (eg, Ref. 32) and recent literature suggests that individualized stepped care is probably best (33), the basic principle of evaluating short-term responses to treatment and changing treatment until a desired response is observed remains important. This was, in fact, the original intent of the M-HART program’s monthly GHQ monitoring calls, to let the team and nurses know when the nurse needed to try a different strategy. However, in light of the M-HART program’s overall failure and the current results suggesting that this approach did work for many patients, a more complex program of stepped care is probably needed. It might begin by giving all patients with distress above a certain point a general first-line approach such as that provided by the M-HART nurses. When positive changes in psychological responses do not occur in a relatively short time period (perhaps with two visits), it might be appropriate to change the approach to treatment from professionals more specialized in mental health approaches.
Although there was no evidence that the relationship between short-term reductions in distress and mid-term and 1-year outcomes differed in men and women, women were significantly less likely to experience a reduction in psychological distress over the first two nursing visits. They were also marginally less likely than men to show improvements in their GHQ scores over the 2 months following the first visits. The same tendency was apparent in 1-year BDI and S-STAI scores, although the p values were >.10. In short, it seems that women may have been less responsive to the type of treatment provided by M-HART. However, as reported in the original M-HART results (4), women were at greater risk than men on most clinical, social, and psychological characteristics, including increased age, lower education level, lack of revascularization, and higher Killip class at the index admission. In fact, in the present study, gender was no longer related to short-term, mid-term, and long-term outcomes after statistical control for covariates. Thus, it is plausible that the higher psychological and disease-related vulnerability of women translated into difficulties in reducing psychological distress in a timely manner. This, in turn, may have contributed to worse long-term prognosis and psychological outcomes for women. However, it is important to note that women who did respond with a decrease in distress over the first two nursing visits experienced the same improvements in outcomes as men. Early evaluation of the impact of psychosocial intervention programs and referral to more intensive treatment modalities may be particularly important for women who have suffered an MI.
The M-HART program evaluated the combination of monthly telephone monitoring and nursing interventions as a package, and no data were collected on monthly distress levels in the control group. This means that all of the comparisons for the present secondary analyses took place between subgroups of treatment patients and prevents cause-and-effect inferences about the relationship between the nursing visits and short-term changes in distress levels. In addition, the small number of cardiac deaths by the time of the 1-year follow-up precludes statistical control for covariates. Nonetheless, the temporal ordering of the nursing visits, successful short-term changes in distress, mid-term outcomes, and 1-year outcomes provides some preliminary support for a possible impact of nursing visits on patient outcomes. Finally, to select potential confounders for statistical control as covariates, we performed interaction analyses by gender and built a model to predict short-term GHQ success for both men and women. However, there were about half as many women as men in the present sample, resulting in less statistical power for detecting background differences associated with success in women than in men (34). This limited our ability to control for covariates, and although differences in mid-term and long-term outcomes remained after statistical control, the model may have been overspecified for women. In sum, keeping in mind the limitations associated with secondary analyses, these results suggest that altering psychological risk factors may be an important avenue for improving both cardiac prognosis and quality of life. Clearly, more research is needed to better understand the process by which improvements in distress can be achieved and maintained. In addition, although the inability of the M-HART program to diminish psychological distress in women may have been related to women’s greater vulnerability, we know little about tailoring interventions to the specific needs of each gender. More research is needed to evaluate women’s particular needs after MI and to design specific stepped intervention programs relevant for both genders and for other subgroups as well, including those with significant physical or psychological comorbidity.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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NOTES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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Received for publication May 31, 2000.
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N. Frasure-Smith, F. Lesperance, G. Gravel, A. Masson, M. Juneau, and M. G. Bourassa Long-Term Survival Differences Among Low-Anxious, High-Anxious and Repressive Copers Enrolled in the Montreal Heart Attack Readjustment Trial Psychosom Med, July 1, 2002; 64(4): 571 - 579. [Abstract] [Full Text] [PDF]
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J. E. Dimsdale Comorbidity Studies: A Core Area for Psychosomatic Research Psychosom Med, March 1, 2001; 63(2): 201 - 202. [Full Text] [PDF]
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