The Effect of Internet-Delivered Cognitive Behavioral Therapy Versus Psychoeducation Only on Psychological Distress in Patients With Noncardiac Chest Pain: Randomized Controlled Trial

Abstract

Background Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain. Objective This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP. Methods Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score ≥24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes. Results No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (≥11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group. Conclusions iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions. Trial Registration ClinicalTrials.gov NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112

Experience of internet‐delivered cognitive behavioural therapy among patients with non‐cardiac chest pain

“…The study was conducted according to the Helsinki Declaration and was approved by the Regional Ethical Review Board in Linköping, Sweden (codes 2017/343‐31). All participants signed a written informed consent prior to participation in the main study (Mourad et al, 2022).…”

“…Of these 48 (89%) in the iCBT group and 52 (95%) in the psychoeducation group completed the 5‐week program. The iCBT program was guided by a nurse therapist (Mourad et al, 2022). To be included in the RCT study patients had to be ≥18 years, had at least two health care consultations because of NCCP during the past 6 months, and experienced from cardiac anxiety (score ≥ 24 on the Cardiac Anxiety Questionnaire).…”

“…The iCBT program has been described elsewhere (Mourad et al, 2022). In brief, the program comprised five one‐week sessions and included psychoeducation about chest pain, avoidance of situations experienced as threatening, such as physical activities, and safety behaviours, mindfulness and exposure to physical activity with weekly homework assignments.…”

“…In Sweden, patients experiencing chest pain can seek emergency care without referral from primary care and mostly meet nurses in the first place, sometimes as the only caregiver at this visit (Mourad et al, 2012; Mourad et al, 2013) therefore, interventions that can be used by nurses to reduce psychological distress in patients with NCCP, are warranted. We have recently evaluated a five‐week nurse‐led iCBT program with the primary aim to decrease cardiac anxiety in patients with NCCP compared with psychoeducation only (Mourad et al, 2022). At the three‐month follow‐up, cardiac anxiety had decreased more in favour of the iCBT group, although not significant.…”

Living with non-cardiac chest pain—a qualitative study of spouses’ perspectives

“…Engagement with important others (such as spouses) has shown to be of importance among patients treated for psychological distress and can result in feelings of belonging, of being understood and acknowledged, and can motivate patients to engage in their treatment (26). However, despite many years of research on patients with NCCP (27,28), no studies have been conducted to explore spousesé xperiences of seeing their partners live with NCCP or spousal engagement in their partners treatment.…”