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The Effectiveness of Cognitive Behavioural Therapy for Secondary Prevention of Coronary Heart Disease: A Meta-Analysis Open Access


Other title
coronary heart disease
secondary prevention
cognitive behavioral therapy
systematic review
Type of item
Degree grantor
University of Alberta
Author or creator
Ellis, Rebecca K.
Supervisor and department
Clark, Alexander M. (Faculty of Nursing)
Examining committee member and department
Davidson, Sandra (Faculty of Nursing)
Pituskin, Edith (Faculty of Nursing)
Kingston, Dawn (Faculty of Nursing)
Faculty of Nursing

Date accepted
Graduation date
Master of Nursing
Degree level
The effectiveness of secondary prevention (SP) for coronary heart disease (CHD) is well established. The poor integration of evidence into clinical practice remains problematic, in part due to the poor description of trials evaluating these programs. As a result, knowledge users remain unclear about which features of these SP interventions are effective for patients with CHD. The purpose was to determine the effectiveness of cognitive behavioural therapy (CBT)-based interventions for SP of CHD when compared to usual care, specialist care, or traditional cardiac rehabilitation (CR) programs. This was a systematic review of existing evidence, incorporating meta-analytic techniques. The authors searched MEDLINE (1992–2014), the EBM Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PsycINFO, and Scopus. They also contacted primary authors and hand-searched key journals, Google Scholar, and National Library of Medicine clinical trial registry (NLMCTR). An updated search of Google Scholar and NLMCTR was completed in March 2015. Two reviewers identified trials and extracted data independently; mean differences, standardized mean differences and summary risk ratios were calculated for identified outcomes using a random effects model. The authors identified 17 randomized controlled trials (RCT) (5060 patients with CHD) that met inclusion criteria. CBT-based interventions were more effective at reducing depression compared to non-CBT based CR, usual care or specialist care (11 trials, n=3133, 95% CI -0.29: -0.50 to -0.08). Multi-modality CBT-based interventions were more beneficial than specialist care alone (2 trials, n=272, 95% CI 0.27: -0.51 to -0.03), however, CBT based multi-modality interventions showed no added benefits over CR alone (3 trials, n=607, 95% CI 0.12: -0.12 to 0.35). In terms of stress reduction, CBT-based interventions were more beneficial than non-CBT based interventions (4 trials, n=642, 95% CI -1.41: -2.64 to -0.19). Finally, multiple modality CBT-based interventions had favorable non-significant effects on morbidity (3 trials, n=572, 95% CI 0.85: 0.67 to 1.08), mortality (3 trials, n=2965, 95% CI 0.52: 0.22 to 1.23) and stress (3 trials, n=395, 95% CI -1.41: -0.31 to 0.09). All outcomes were evaluated over a mean follow up of 19.2 months (SD=27.1). Interpretations were limited by the variable quality of included trials and by the heterogeneity of reported outcomes, comparisons, and poor description of the CBT-based interventions. Conclusions are tempered by concerns around generalizability; although women were well-represented in our review, ethnicity data were generally lacking. A number of trials purposively sampled depressed patients, thus this population may be overrepresented. Conclusions were not made on cost-effectiveness due to inconsistent availability of long-term data and absence of economic outcomes. In summary, CBT-based interventions more effectively reduce depression than interventions that do not use CBT as a theoretical basis. Given the global disease burden of depression, and the poor health effects of concomitant CHD and depression, these findings have significant implications for the provision of SP for CHD. In order to facilitate translation of these key findings to clinical practice, a stronger evidence base is needed. Investigators need to thoroughly report methods to facilitate risk of bias assessment. Complex healthcare interventions must be more comprehensively described to ensure clarity of which components contributed to successes or failures. Uniform strategies for evaluation should ensure researchers are making useful comparisons to deliver useable evidence. Finally, long-term follow up is required to measure cost-effectiveness and long-term benefits of SP interventions on CHD.
Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.
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