Stein, Traci R. PhD, MPH; Olivo, Erin L. PhD, MPH; Grand, Sandy Hermele PhD; Namerow, Pearila B. PhD; Costa, Joseph MPAS, RPA-C; Oz, Mehmet C. MD
Depression is a serious and sometimes debilitating illness that continues to be a leading cause of disability in the United States.1 Kessler and colleagues2 found the prevalence rates of major depressive disorder in a 12-month period to be 6.7% and anxiety disorders to be 18.1%, although the risk for women was approximately 1.5 times greater than that for men. Prevalence rates of a mood disorder for patients with coronary heart disease (CHD) have been shown to be considerably higher, however.3–8
Furthermore, the symptoms of stress, depression, and anxiety among CHD and cardiac surgery patients have been shown to predict incidence of subsequent cardiac events, including additional myocardial infarctions and CHD mortality, and again, risks are higher for female patients.9–19 These findings constitute evidence of a perceptible link between patients' psychophysiological state during cardiac rehabilitation and their medical prognoses. In addition, this presents a challenge to health care providers to proactively address symptoms of stress, depression, and anxiety in cardiac surgery patients.
The current study aimed to assess the effectiveness of a guided imagery audiotape intervention for patients undergoing coronary artery bypass graft (CABG) surgery in terms of whether it could minimize postoperative psychological distress, in particular anxiety and depression. Secondary outcomes of interest included the impact of guided imagery on atrial fibrillation, hospital length of stay, number of patient pain medication requests, and complications of surgery. This article will discuss the impact of the intervention on depression and anxiety and describe the prevalence of any CAM therapies use in a subset of patients who completed measures at the 1-week and 6-month postoperative time points.
MOOD AND CARDIOVASCULAR DISEASE
Cardiovascular disease both is prevalent in the United States and poses significant risk of mortality, claiming more lives each year than the next 4 leading causes of death combined (ie, cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus).20 Over the course of the past several years, a number of studies have documented the connection between depression, anxiety, or both, and heart disease.19, 21–23 Individuals undergoing CABG often experience depression and anxiety as a side effect of the surgery itself with the evidence indicating that postoperative depression and anxiety occur in about 25% of patients undergoing this procedure.3–8 In addition, depression and anxiety are risk factors for further complications after surgery and continued heart-related health problems.24 The incidence of depression appears to vary along the recovery trajectory. Timberlake and colleagues25 found that 37% of their CABG patients were depressed during the immediate preoperative period. At 8 days postoperatively, this figure had risen to 50%, but by 8 weeks it had decreased to 24% and at 12 months it was 23%. Those CABG patients who were depressed or anxious preoperatively had higher levels of postoperative mood disturbance than those who were not depressed or anxious prior to the surgical procedure. Many patients experienced anxiety in the period immediately following surgery; however, those patients with high levels of trait (rather than state) anxiety were more likely to be depressed both pre- and postoperatively. Although postoperative rates of both depression and anxiety decreased over time, the 12-month rates of both were higher among patients with cardiovascular disease than in the general population.
Although the biological explanation for this side effect of the surgery is not yet well understood,26 depression is associated with significantly increased rates of postoperative cardiac events independently of other variables, including disease severity.21 Depression has been associated with increased cardiac mortality even 18 months postoperatively.4,24 Health care providers continue to be challenged to find ways to address the problems of depression and anxiety in a way that is palatable to patients, minimally invasive, and cost-effective.
COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) USE AMONG PATIENTS WITH CARDIOVASCULAR DISEASE
Patients with cardiovascular diseases have shown significant interest in CAM. A 1998 survey of 376 consecutive patients presenting for cardiac surgery at Columbia University Medical Center (CUMC) found approximately 75% of the sample reporting some form of CAM use in the previous year.27 Excluding the use of prayer and vitamins, roughly 44% of the sample reported CAM therapies use, which was comparable to Eisenberg's28 findings regarding CAM use in the general population. A more recent survey of cardiac surgery patients the night prior to surgery found 81% of the sample reporting CAM use in the past year.29
GUIDED IMAGERY AS A CAM TOOL
Guided imagery is a technique that focuses and directs the imagination.30,31 The practice of guided imagery mentally engages all of the senses via imaginal processes, is a relatively simple activity, and does not require the individual to maintain unwavering focus.32 Imagery has the capacity to deliver multiple layers of complex, encoded messages by way of simple symbols and metaphors,30,31 and through this process, images can transform mood by changing the ways in which people think, feel, and, ultimately, act.33 In psychotherapy, patients may be directed to use imagery for a variety of purposes, including regulating mood, revising unrealistic or unhealthy attitudes, and “practicing” more adaptive ways of coping.34 However, imagery can also be delivered via recording in the absence of a therapist.
Previous research has revealed the effectiveness of guided imagery in a number of patient populations. Imagery has been helpful in reducing postoperative pain,35–37 depression, fatigue, and blood cortisol levels.38 More recently, 8 sessions of hypnosis via guided imagery were associated with accelerated wound healing in women who had undergone reduction mammaplasty.39 Self-hypnosis via audiocassette has been shown to be effective in enhancing relaxation and was easily implemented with patients undergoing cardiac surgery.40 In a different, nonrandomized trial with patients undergoing cardiac surgery, imagery used several times per day in the pre- and postoperative periods was associated with decreased length of hospital stay and pharmacy costs.41
A total of 138 patients scheduled to undergo CABG surgery or CABG plus aortic valve repair or replacement at CUMC were approached to take part in the study. Twenty-two refused participation and 46 others passively refused by not completing the baseline assessments. The most common reasons for passive refusal were feeling “too busy” and “too stressed” to complete the measures. Of the 70 remaining consented patients, 7 were not well enough postoperatively to complete the assessments at the 1-week postoperative time point. An additional 7 patients either ultimately did not undergo CABG surgery or had the surgery performed at another medical center. Those who completed baseline assessments, had cardiac surgery at CUMC, and completed postoperative assessments at the 1-week time point were included in the study. Thus, 56 patients were randomly assigned via coin-toss to 1 of 3 groups: guided imagery, music, or standard care control with a breakdown as follows: 20 patients in the guided imagery group, 17 patients in the music therapy group, and 19 patients in the standard care control group.
Of those in the original sample, 13 did not provide sufficient information at 6 months to be included in analyses for this time point. Thus, 6-month data presented here are for the 43 patients who completed at least two-thirds of the items at the 6-month postoperative time point. This resulted in a final distribution of 14 in the guided imagery group, 11 in the music-only group, and 18 in the standard care (no audiotape) control group.
Depression and anxiety were assessed via the Hospital Anxiety and Depression Scale (HADS).42 The HADS is a 14-item measure that includes a 7-item depression scale and a 7-item anxiety scale. The HADS anxiety and depression subscales have a Cronbach α of 0.83 and 0.82, respectively,43 which is similar to that of other assessment tools.44 The HADS was specifically constructed to be administered to medically ill patients and is widely used in hospital settings.42 HADS scores have sensitivity and specificity that are similar to other depression screening measures. In particular, the HADS has been used extensively and effectively among patients following a myocardial infarction.45 The HADS was specifically chosen to control for the physical symptoms of anxiety and depression that mimic symptoms of coronary artery disease and treatment, such as fatigue and difficulty sleeping. Sample HADS items include “I feel tense or wound up” and “I look forward with enjoyment to things.”
As an additional measure of mood, the current study also utilized the Profile of Mood States. The POMS has been validated with various medical populations and includes a Total Mood Disturbance scale along with additional mood subscales that include tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment.46,47
The guided imagery intervention, “Successful Surgery,” was developed by Belleruth Naparstek of Health Journeys, whose tape has been studied with a variety of populations48 and is reportedly used in more than 2000 hospitals, clinics, and other health care facilities in the United States.31 This audiotape was shown to be the most effective intervention when compared to 3 other taped imagery programs used with patients undergoing spinal surgery, radical neck dissection, joint replacement, or abdominal cancer resection.48 The “Successful Surgery” tape has been offered to patients undergoing CABG at CUMC since the late 1990s. The tape consists of suggestions and affirmations designed to help the patient relax and imagine a successful surgery experience. After listening to a guided progressive relaxation exercise, patients are directed to imagine themselves in the operating room, feeling safe and being attended to by compassionate medical staff. The imagery also directs patients to imagine undergoing their procedures with minimized blood loss and accelerated healing. In the background, relaxing music is played for the duration of the recording.
The music audiotape contained the same relaxing music featured in the guided imagery tape but without any voiceover.
After providing informed consent, all patients in the current study completed the HADS, the POMS, and a demographic questionnaire at baseline. Patients kept diaries in which they recorded the number of times that they listened to their respective intervention tapes throughout their preoperative preparation and then completed all measures at 1 week postoperatively and again 6 months postoperatively. Since the cardiothoracic surgery service at CUMC offers patients access to massage, additional audiotapes, and referrals to CAM practitioners upon request, all patients were surveyed at the 1-week postoperative time point as to what other CAM interventions, if any, they used during the hospitalization.
The current study randomly assigned patients to 1 of 3 groups: the guided imagery condition, the music therapy condition, or standard care. As there is evidence that music therapy can help minimize patient anxiety,49–51 the music therapy condition was included to control for the relaxation effect of the music as well as the social support and expectancy effects of being assigned to an intervention group. In this way, we hoped to assess the discrete effect of guided imagery beyond the benefits associated with the music tape.
Patients in the guided imagery and music groups were asked to listen to audiotapes at least once a day, every day, for 1 week before surgery and more often if they desired. As surgery consults generally occur 2 to 4 weeks prior to surgery, this allowed patients ample time to listen to their respective audiotapes prior to the procedure. Patients in both intervention groups were also asked to listen to their tapes intraoperatively, as described by Dreher.48 Those in the intervention groups were contacted by phone the day prior to surgery to remind them to bring their tapes and tape players to the hospital. However, if patients forgot either of the above on the day of surgery, tapes and/or tape players were provided for them.
Patients in the standard care group received no intervention other than the medical procedure. As described previously, since CAM use tends to be higher in medically ill patients, and because the cardiothoracic surgery service offers access to CAM therapies, including audiotapes, for those who desire them, patients were surveyed as to whether they received any CAM therapies during their hospital stay, as well as regarding their use of other CAM therapies during the postoperative follow-up period.
At each postsurgery time point, patients received follow-up measures that were mailed to their homes as well as prestamped and addressed envelopes with which to return the questionnaires to the interviewer. A research assistant contacted patients by phone up to 2 times to remind them to mail in the surveys if they had not already done so within 2 weeks.
Statistical analyses were conducted using SPSS for Windows (version 14.0).52 Univariate procedures were used to analyze groups for overall comparability (chi-square for categorical data and ANOVAs for continuous data). Multiple regression analyses were conducted to assess predictors of postoperative psychological functioning.
Baseline descriptive and comparability analyses
The demographics of the current sample of patients are presented in Table 1. The majority of the patients were male (69.6%) and white (91.1%), with a mean age of 66 years. Most of these patients were married (76.8%). More than half reported a history of smoking (60.7%), with some also having a medical history of other serious illness in addition to their coronary artery disease (37.5%).
The baseline psychological and medical history of the current sample is presented in Table 2. Chi-square analyses were conducted to assess preoperative functioning for all 3 groups of patients in order to ascertain whether their health status and histories were similar at baseline. Despite randomization, there were significantly more women in the intervention groups than in the control group (Table 1). Comparability analyses were conducted for patients' preoperative psychological functioning as well (Table 3). Analyses of variance revealed no significant between-group differences in preoperative anxiety or depression on the HADS. The POMS Total Mood Disturbance scale scores were also comparable for all 3 groups. However, the analyses did reveal significant differences in the POMS' Anger-Hostility subscale, which was the highest in the music group.
A descriptive analysis of categorically recoded HADS values was conducted to determine how many patients met criteria for each level of depression and anxiety severity (Table 4). These analyses revealed that at baseline, 21% of the total sample met criteria for clinical depression with 9% falling into the moderate or severe categories.42 Preoperative assessment of the current sample of patients' depressive status is consistent with 25% of patients needing CABG surgery are depressed.3–6 It is important to note, however, that none of these cases was present in the guided imagery intervention group. Baseline assessment of anxiety as measured by the HADS revealed that 46% of the total sample could be categorized as having anxious symptoms in the borderline/mild, moderate, or severe category. Nine of these cases (16% of total sample) were in the guided imagery group. This finding is also consistent with previous research.53,54
Group treatment effects
As a result of the sample differences in gender, and because baseline levels of anxiety and depression are correlated with postoperative levels in this patient population,25 all analyses of postoperative mood included baseline mood and gender as covariates. Table 5 summarizes postoperative scores on each of the measures by group assignment. Regression analyses of group contrasts (imagery & music vs standard care, and a separate analysis of imagery vs music & standard care) showed no significant differences in adjusted postoperative scores at either the 1-week or 6-month time points for any outcome (POMS Total score, POMS subscale scores, and HADS anxiety and depression scores). The only significant predictors found in each model were baseline mood scores. Data from these analyses are not shown.
In-hospital CAM use
The use of any CAM therapy during the hospitalization period was recorded to determine whether those in the experimental groups used additional CAM therapies, as well as whether those in standard care used CAM during this time. Data were collected as dichotomous variables (CAM-use vs no CAM-use) regarding various CAM therapies, including the use of audiotapes, massage, energy healing, and others. Patients were asked to list any CAM therapies they used that were not specified on the questionnaire. A chi-square analysis (χ2(df = 2) = 4.36; P = .11) found no statistically significant between-group differences in CAM use during hospitalization. Rates of any in-hospital CAM use by group were guided imagery, 72.7% (n = 8); music, 63.6% (n = 7); and standard care, 35.3% (n = 6). We note, however, that these numbers are very small for analysis, permitting little power to detect differences among the groups. At the 6-month assessment, the use of 2 CAM therapies—vitamins or other supplements and prayer for health reasons—was notably higher than the use of any other CAM therapies during the recovery period. The use of unspecified dietary supplements was reported by 53.5% of the total sample (n = 23) and was comparable among the groups (imagery, 50%; music, 63.6%; standard care, 50%). Prayer for health reasons was used by almost 28% of the sample, with the greatest likelihood of use among those in the imagery (35.7%) and standard care (33.3%) groups.
Despite findings in previous studies linking the use of guided imagery to reduced depression and anxiety in medical and surgical patients, the results of the current study found no significant relationship between patients' 1-week or 6-month postoperative distress and the pre- and intraoperative use of the guided imagery or music audiotapes, even when controlling for baseline mood. As expected, preoperative depression significantly predicted postoperative depression, and preoperative anxiety significantly predicted postoperative anxiety.
In-hospital use of CAM therapies was prevalent in each of the 3 groups. Specifically, more than half of the total sample, and over a third of patients in the standard care group reported using CAM therapies in the hospital. In addition, a third of those reporting the use of in-hospital CAM indicated using 2 or more therapies. Six-month postoperative use of the 2 most popular CAM therapies, dietary supplements and prayer for health reasons, was comparable across the groups.
DISCUSSION AND RECOMMENDATIONS
This is the first randomized, controlled trial to examine whether a brief, time-limited audiotape intervention would impact depression and anxiety in CABG patients at these critical time points in the postoperative recovery period.
The lack of significant results with regard to the impact of the guided imagery intervention on mood may be explained in part by the likelihood that depression in this population may not be amenable to a very short-term pre- and intraoperative intervention. The relationship between depression and coronary artery disease is, as yet, unclear, and thus, depression is perhaps more difficult to treat. In addition, the fact that depression was virtually nonexistent in the imagery group at baseline made it impossible to detect any meaningful benefits associated with the intervention.
There were a number of limitations to this study. First, the small sample limited the power of our tests. Both this fact and the high rate of refusal limit the generalizability of these findings to the larger population of patients undergoing CABG at this medical center and elsewhere. Furthermore, the stress and chaotic nature of the days prior to surgery, as well as enrollment in competing trials, likely contributed to the high rate of refusal for this study.
There were other issues with the sample besides its size. First, CAM use was substantial. As CAM therapies are routinely offered to all CABG patients at this medical center, this may well have contributed to our failure to find a significant relationship between the imagery intervention and decreased distress. Indeed, postoperative rates of depression in this sample were lower than is typical for CABG patients postoperatively, and it is reasonable to speculate that high CAM use was in some way related to this outcome. Although it is not possible to determine the specific amounts of CAM therapies used, as the information was provided dichotomously, given the high rates of CAM use in the general population and by medically ill patients in particular, it is reasonable to assume that the comparable CAM use in each of the 3 groups may have contributed to the similar reductions in anxiety and depression across conditions. Second, there was little variance across the groups in the pretest measures. The majority of subjects were within normal anxiety and depression levels at the start of the study, making it more difficult to detect differences in general. Relatedly, the use of any psychotropic medications was highest in the imagery group, followed by the music group. This may have played a role in either baseline mood or response to treatment; however, the small numbers in each group made it impossible to examine this statistically.
With regard to design, in studies where imagery was associated with significant benefits, the use of an imagery audiotape was often continued throughout the recovery period and sometimes used several times daily. Thus, there may be a dose-response effect we were not able to achieve here. Similarly, although the audiotape used in this trial was designed to cultivate a mental expectation of improved surgical outcomes, the explicit focus of the tape was not on fostering improvements in postoperative mood.
Yet, guided imagery appears to have been palatable to a sizable subset of patients who were assigned to receive this intervention. Specifically, more than half of those in both the imagery (n = 8; 57%) and music (n = 8; 73%) groups reported using their tapes at least once preoperatively. Perhaps most notably, the mean number of times patients listened to their tape preoperatively was more than twice as high in the imagery group (11.6 times) than in the music-only group (5.5 times). We have no reason to doubt that a sizeable proportion of patients might very well have used these or other tapes postoperatively had they been asked to do so. Had they been given a tape that was similar in terms of the richness of the imagery and the type of music featured but had been more explicitly focused on improving mood, it is certainly possible that they could have experienced improvements in mood similar to those found in other studies of imagery with both healthy and medically-ill patients.35–41
Given that CAM use is high in patients undergoing heart surgery, it is worth continuing to search for a cost-effective adjunctive therapy that is palatable to patients and does not interfere with conventional medical procedures. In this sample, in-hospital use of CAM therapies was high (ranging from 35% to 72% across the groups). Use was more than twice as high in the imagery group than in standard care, however, and this appears clinically meaningful. The notable rates of postoperative prayer and dietary supplement use in this population also indicate that CABG patients are amenable to adjunctive therapies. Importantly, the lack of a significant difference in additional CAM use across the groups may have obscured the effects of the interventions on mood. Thus, it will be important to gather specific data on type and frequency of CAM use to more adequately control for the effects of other therapies when studying imagery with future samples of cardiac surgery patients.
As the literature demonstrates a relationship between imagery and improved outcomes in other populations, and that depressed and anxious mood remain prevalent and are clearly linked to poor postoperative outcomes in this population, we recommend that future studies of imagery with CABG patients employ the use of an audiotape specifically designed to improve postoperative mood. Furthermore, it is important that patients be well-educated and supported in the regular use of the imagery throughout the recovery period, rather than only pre- and intraoperatively.
Perhaps the take-home message for health care providers, both CAM and conventional, is that as stated previously, a large number of CABG and other medically ill patients are willing to use CAM therapies—and use these anyway—whether or not the hospital provides them. Imagery and other CAM therapies can help reduce symptoms and improve patient well-being. CAM therapies such as imagery can be easily integrated into the hospital setting without undue burden to the already extraordinarily busy medical and nursing staff, and at minimal cost to patients or institutions. It is difficult to find a reason not to facilitate patients' use of this therapy given the research supporting imagery's benefits with a number of other populations.
Finally, as rates of depression are significantly higher in women, and women's postoperative outcomes differ from men's in terms of morbidity and mortality, it is important to strive to include more women in studies of patients with cardiovascular disease and particularly in those for which depression is a primary outcome. It is unclear whether women would have responded differently to the audiotapes, and this should be explored in future studies.
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