Study addresses potential benefits of treating anxiety in coronary artery disease

A study published in the current issue of Psychotherapy and Psychosomatics addresses the potential benefits of treating anxiety in coronary artery disease.

Similar to depression, anxiety is common after acute coronary syndromes (ACS), and is an independent predictor of worse outcomes. Yet, post-ACS psychological interventions have focused on treating depression. The Authors of this study previously reported that an enhanced depression care intervention involving patient preference for problem-solving therapy (PST), antidepressant medications, or both followed by stepped care according to treatment response was effective at reducing depressive symptoms after ACS with an effect size of 0.59 SD. In this study they report the independent effect of this intervention on anxiety. Briefly, hospitalized ACS patients who were persistently depressed were recruited from 5 US hospitals between 2005 and 2008 and randomized to enhanced depression care or to usual care on a 1: 1 basis. Anxiety and depressive symptoms were assessed within 1 week of hospitalization, and at 3, 5, 7, and 9 months. Anxiety was measured using the 7-item anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A). Depressive symptoms were assessed by the BDI. Outcome assessors were blinded to group assignment.

At 9 months, enhanced care patients showed a significant decrease in HADS-A compared to the 3-month pre-RCT assessment (p<0.001), whereas there was no significant change in usual care patients (p = 0.76), consistent with an effect size of enhanced care on anxiety of 0.53. Change in HADS-A was moderately correlated with change in BDI (p<0.001). Controlling for depression, the effect of enhanced care on anxiety was decreased by about 1 point, but remained significant (p = 0.02). A subgroup analysis suggested a benefit of enhanced care on anxiety in women but not men. These results demonstrate that enhanced depression care involving patient treatment preference of PST and/or antidepressant medications followed by stepped care has collateral benefits on anxiety in post-ACS patients. Symptoms of anxiety are common after ACS, can decrease treatment adherence, lower quality of life, and contribute to worse cardiovascular prognosis. Yet, similar to depression, anxiety is often not assessed after ACS and patients with elevated anxiety often go untreated. Thus the current findings demonstrate one viable approach to improving care for anxious post-ACS patients. The use of PST may have contributed to the collateral benefit of the intervention on anxiety. PST is a patient-directed as opposed to disease-focused therapy in which patients are taught how to systematically evaluate and address individual psychosocial problems of their  choosing. Interestingly, over 60% of enhanced care patients initially chose PST over antidepressant medications. In conclusion, future interventions to reduce psychological distress after ACS should assess their effectiveness on both depression and anxiety symptoms. Those interventions with pleiotropic effects on both anxiety and depression may be best suited to not only improve quality of life in ACS survivors, but potentially, to reduce the risk of psychological distress on adverse cardiovascular outcomes. Future trials should consider whether to target depressed patients, alone, or to broaden enrollment criteria to include patients with depression and/or anxiety after ACS.