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

Ghassan Mourad, Magda Eriksson-Liebon, Patric Karlström, Peter Johansson, Ghassan Mourad, Magda Eriksson-Liebon, Patric Karlström, Peter Johansson

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.

Keywords: cardiac anxiety; cognitive behavioral therapy; health-related quality of life; internet delivered; noncardiac chest pain; psychological distress.

Conflict of interest statement

Conflicts of Interest: None declared.

©Ghassan Mourad, Magda Eriksson-Liebon, Patric Karlström, Peter Johansson. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 28.01.2022.

Figures

Figure 1
Figure 1
The CONSORT (Consolidated Standards of Reporting Trials) flowchart. iCBT: internet-delivered cognitive behavioral therapy.
Figure 2
Figure 2
Changes in cardiac anxiety over time between internet-delivered cognitive behavioral therapy (iCBT) and psychoeducation groups. CAQ: Cardiac Anxiety Questionnaire.
Figure 3
Figure 3
Changes in bodily sensations, depressive symptoms, EuroQol visual analog scale (EQ-VAS), and noncardiac chest pain (NCCP) frequency over time between internet-delivered cognitive behavioral therapy (iCBT) and psychoeducation groups. BSQ: Body Sensations Questionnaire; PHQ-9: Patient Health Questionnaire-9.

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