Aerobic exercise combined with cognitive behavioral therapy may improve physical function, reduce depressive symptoms and enhance quality of life in depressed heart failure patients, researchers reported at the American Heart Association’s 9th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
In a new study, researchers divided 74 heart failure patients with depression into four groups: one group received a 12-week, home-based program of exercise and psychological counseling; a second received psychological counseling alone; a third received exercise alone; and a fourth received usual care.
“By combining exercise with psychological counseling, these depressed patients do better in all parameters compared to the other groups,” said Rebecca Gary, Ph.D., lead author of the study and assistant professor in the School of Nursing at Emory University in Atlanta, Ga. “This may be the best method for improving their depression, symptom severity, and quality of life.”
Participants in the randomized, controlled pilot study were average age 66. The majority of patients were Caucasian and 57 percent were women. All participants were diagnosed with clinical depression, determined by psychiatric tests, using DSM-IV criteria and the Hamilton Rating Scale for Depression.
The participants were either New York Heart Association class II or class III heart failure patients. Class II patients have a slight limitation of physical activity. They are comfortable at rest but ordinary physical activity results in fatigue, palpitation, dyspnea or angina. Class III patients have a marked limitation of physical activity. They are comfortable at rest but less than ordinary activity causes fatigue, palpitation, dyspnea or angina.
“What makes this study different from other studies of exercise in heart failure patients is that all these patients were clinically depressed,” Gary said.
The four groups were assessed at four time intervals: baseline, after the 12-week intervention program, following the three-month telephone follow-up and at six months.
The exercise component was a 12-week, progressive program, with low-to-moderate intensity exercise, involving walking outdoors. Patients were encouraged to walk three times per week for at least 30 minutes. Patients in the combined program or exercise-only group received heart rate monitors and were taught how to self-monitor their exertion level, and when to stop exercising. All patients, despite initial symptoms and some being quite debilitated, achieved these goals.
A physical function test, the six-minute walk test, was administered at each of the time intervals.
“The cognitive behavioral therapy was geared toward changing the attitude of the patients about their illness,” Gary said. “We wanted them to change their negative thoughts and beliefs and restructure and reformat how they think about their illness and limitations. For example, we developed a volunteer and activities sign-up sheet in each community that provided transportation for those who wanted to get out of the home or contribute in some way.”
Cognitive therapy sessions were conducted, one-on-one in the home, once a week, for 12 weeks by psychiatric nurse specialists and Ph.D. students trained in counseling techniques.
Patients in the combined exercise and behavioral therapy group improved significantly better in the six-minute walk test than the other groups.
The combined group lowered depression symptoms by 10 points over the usual care group. A decrease in scores of 50 percent or more or a HAM-D score of less than 8 indicates remission of depression symptoms. Interestingly, although depressive symptoms were also reduced in the counseling-only group, they perceived their quality of life to be worse than the combined group or exercise group. The combined group lowered depression symptoms by 10 points over the usual care group.
Co-authors are: S. Dunbar, D.S.N.; E. Cress, Ph.D.; and G. Cotsonsis, Ph.D.
The study received funding from the American Heart Association “Beginning Grant in Aid” program from the association’s Southeast Affiliate.
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