Regular Paper Psychother Psychosom 1992:58:97-102
Dimitris N. Mitsibounas E ñe D. Tsouna-Hadjis Vassilis R. Rotas Dimitris A. Sideris
Effects of Group Psychosocial Intervention on Coronary Risk Factors
Department of Clinical Therapeutics. Medical School of Athens University. Athens. Greece
Introduction Reducing the common risk factors is one of the main therapeutic approaches after an acute myocardial infarction. Diet and proper medication are the main approaches to this goal. Researchers are also concerned with psy chosocial factors which, according to a num
ber of studies [e.g. 1.2], seem to contribute to the evolution of coronary heart disease and the onset of acute myocardial infarction. Therapeutic interventions regarding the psychosocial risk factors may focus on the identification and alteration of type A person ality [3], life style change [4], or treatment of the patient's interpersonal conflicts that pre-
Dimitris N. Mitsibounas Department of Clinical Therapeutics Alexandra Hospital 80 E. Venizclou and K. Lourou Street G R -115 28 Athens (Greece)
©1992 S. Karger AG, Basel 0033-3190/92/ 0582-0097$2.75/G
Downloaded by: Kings's College London 137.73.144.138 - 10/19/2017 7:31:03 PM
KeyWords Group psychosocial intervention Myocardial infarction Coronary risk factors Cholesterol Triglycerides Smoking Blood pressure
Abstract The purpose of this study was to investigate whether a psycho social intervention approach aimed at resolving psychological conflicts could reduce the severity of risk factors for post-acute myocardial infarction patients. Twenty-three patients with a recent myocardial infarction participated in a group psychoso cial intervention program which lasted 1 year. Twenty other patients with recent myocardial infarction served as controls. Patients form both groups had regular clinical and laboratory follow-up as well as medication. Mean values for seven risk factors of coronary heart disease (smoking, S; body weight, W; serum cholesterol, C; triglycerides, T; systolic and diastolic blood pressure. SBP. DBP; scrum uric acid. U) were compared between the two groups in the 1st, 3rd, 6th and 12th months of the follow-up. The maximal mean improvements of the study versus the control group were as follows: W: -2.82 vs. -1.05 kg; C: - 56.04 vs. -6.25 mg/dl; T: -20.61 vs. -2.4 mg/dl; U: -0.57 vs. -0.9 mg/dl; S at 1 year -55.5 vs. -10% . It is concluded that group psychosocial intervention with post acute myocardial infarction patients considerably reduces some coronary-disease risk factors.
Materials and Methods Forty-three patients of both sexes with acute myo cardial infarction and no further complications were studied. All were Athenian residents. Among them 23 (19 men and 4 women) with a mean age ( ± SD) of 50.0 ± 8.9 were selected for the study group, while the remaining 20 patients (19 men and 1 woman) with an age of 56.0 ± 7.5 (t = 2.43, p < 0.05) served as the control group. The sex differences were not signifi cant. All patients were assessed on the 6th to 8th day of hospitalization for acute myocardial infarction. The assessment concerned the medical history, clinical and laboratory findings that certified the disease and an thropometric data. Exclusion criteria were an age > 70 years, the patients’ statement that they would not be able to attend regular sessions, or their refusal to par ticipate in a study that might involve open discussion of personal matters if they happened to be selected for the study group. After selection the patients were allo cated randomly to either the study or the control group. Study Group The patients selected for the study group were introduced to the psychosocial intervention groups. Before that, a semistructured personal interview re garding their psychosocial history took place, aimed at
98
identifying psychological fields of tension. A psycho logical field of tension [5] is defined as a serious psy chological conflict of the individual in his other trans action with the social environment. The individual feels that the conflict must be resolved, but is immobi lized because any way out appears unnacceptable, pro hibited or threatening. Exacerbations of fields of ten sion of varying nature were identified in 20 patients’ recent history, that is, within 1 month prior to the acute myocardial infarction. Groups of psychosocial intervention were formed with 5-7 patients in each. Overall, four such groups were formed for the 23 patients; they met with 2 psychosomatically oriented physicians and one psycholo gist every 2 weeks for 1 year in 1-hour meetings. The aim of the group meetings was to help patients realize that at least one of the alternative solutions to their conflict was socially (by the group) acceptable and therefore neither prohibited nor threatening. In the initial one or two sessions each patient was prompted to report possible conflicts with no apparent personally acceptable way-outs that had occurred to him or her up to 1 month prior to the infarction event. Group discus sion followed, aimed at finding socially acceptable alternative solutions. In subsequent sessions, similar conflicts were discussed that had occurred in the pre vious fortnight. Important events in the past history that might account for the patients' present preoccupa tions were sought and discussed. In addition, the patients were taught to regularly use relaxation tech niques. Besides group meetings, the patients had a clinical follow-up and electrocardiogram test every 2 weeks. Within 1 year, a treadmill exercise test and a 24-hour Holter monitoring were performed twice, and a coro nary arteriogram once. The values of patients’ common coronary risk fac tors [body weight, cholesterol, triglycerides, systolic and diastolic blood pressure (SBP and DBP). uric acid and smoking] were assessed at hospitalization (within the first month), and in the 3rd. 6th and 12th months. Control Group The patients of the control group had a clinical fol low-up and electrocardiogram once a month, a tread mill exercise test and 24-hour Holter monitoring twice a year, and coronary arteriography once a year. The values of the common risk factors were assessed ex actly as for the study group. The two groups were com pared regarding the values of these risk factors over a 1-year period after the myocardial infarction. Patients in both groups received medication as needed.
Mitsibounas/Tsouna-Hadjis/Rotas/ Sideris
Psychosocial Intervention and Risk Factors
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ceded the infarction incidence [5]. The vari ety of approaches [6] is indicative of the inherent difficulty involved in psychological research, namely that psychological outcomes can rarely be assesseed by objective measures. On the other hand, the indirect somatic out come may be measured accurately, although it is usually difficult to prove its connection with the psychological therapeutic method applied. In this study, a group psychosocial treat ment was applied aimed at resolving patients’ interpersonal conflicts, and the change in their risk factors was estimated. The change was compared to that of a control group in which no group psychosocial intervention was applied.
Table 1. Mean values ( ± SD) for coronary risk factors at four time points Risk factor
Study group 1st month
3rd month
6th month
12th month
1st month
3rd month
6th month
12th month
Weight kg Cholesterol mg/dl Triglycerides mg/dl Uric acid mg/dl SBP mm Hg DBP mm Hg Smoking
72.64 ±7.17 288.69 ±72.51 141.96 ±53.02 5.24 ±1.29 131.30 ±17.40 84.78 ±6.30 18/23 78.2%
70.82 ±7.04 242.61 ± 49.66 126.78 ±36.51 4.88 ±1.07 125.00 ±12.06 83.04 ±4.94 2/23 8.7%
69.82 ±6.99 232.65 ±48.80 121.35 ±34.31 4.67 ±0.85 123.70 ±11.89 81.74 ±3.88 5/23 21.7%
70.48 ±7.19 249.52 ±65.40 132.77 ±38.62 4.93 ±1.01 124.52 ±12.44 84.05 ±4.07 5/22 22.7%
73.90 ±8.28 259.25 ±26.96 115.90 ±18.61* 4.81 ±0.88 142.75 ±14.64* 86.50 ±5.41 18/20 90.0%
72.85 ±8.17 253.00 ±23.36 113.50 ±17.40 4.73 ±0.85 138.75 ±15.38* 84.75 ±4.44 6/20 30.0%
73.05 ±7.80 254.25 ±27.30 118.51 ±31.54 4.73 ±0.90 138.50 ±14.18* 86.25 ±4.83* 9/20 45.0%
72.95 ±8.20 254.75 ±26.93 114.31 ±18.15 4.62 ±0.86 140.00 ±12.83* 86.67 ±5.15 16/20 80.0%
Control group
Statistics The Student paired and unpaired t tests were used for parametric measurements. A p < 0.05 value was ordinarily considered significant. The initial (1st month) values of the risk factors were compared with the corresponding values in the 3rd, 6th and 12th months (paired t test) separately for the two groups. The mean changes in corresponding months were compared between the groups (independent t test). Because these were multiple t tests, p < 0.01 was con sidered significant. For nonparametric values the %2 test was used. Classical formulas for correlation and regression analysis were applied as needed. Simple analysis of covariance was also used where applicable.
Results The mean values of the seven risk factors at the four time points for both groups appear in table 1. The 1st month values (the initial ones during hospitalization) do not differ signifi cantly between the two groups with the excep tion of the triglycerides which were slightly
higher in the study group (t = 2.62, p < 0.05) and the SBP which was slightly higher in the control group (t = 2.34, p < 0.05). In the study group, a decrease in the pa rameters examined was noted in all three examinations after the 1st month. This de crease was statistically significant in all in stances except for the triglycerides in the 12th month and the DBP for all months (table 2). In contrast, in the control group, the triglycer ide, uric acid, SBP and DBP values did not change significantly at any time after the ini tial measurement. Furthermore, the reduc tion in the number of smokers in the 12th month was not significant (table 2). Four patients in the study group and 2 in the control group were taking antilipidemic agents. Excluding these 6 cases, the reduction in blood cholesterol was significantly more marked in the study than in the control group (fig. 1). The reduction of cholesterol in the study group reached about 50 mg/dl in the 6th
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* p < 0.05 in a comparison between the two groups.
—I----------------------------- 1—
40
50 Age, years
Fig. 1. Scrum cholesterol values (mean ± SE) in the 1st. 3rd. 6th. and 12th months of follow-up for the study (•) and control (o) groups. Cases without antilipidemic medication only.
Fig. 2. Change in the SBP (ASBP) in the 6th month versus age, and regression line for all patients. • = Study, o = control group.
month compared to the 1st. while the maxi mal diminution of cholesterol in the control group was about 7 mg/dl in the 3rd month. No significant correlation existed between scrum cholesterol levels and age in cither group. Table 2 also shows the significance of the difference in change of all seven risk factors between the study and the control groups. The changes observed were significantly (p < 0.01) more marked in the study than the con trol group for the following variables: body weight in the 6th month; cholesterol in all 3 examinations; triglycerides in the 6th month; uric acid in the 6th month; and the number of smokers in the 12th month. Nine patients in the study group and 16 in the control group were receiving either diuret ics. P-blockers or Ca-channcl inhibitors. Thus, the observed reduction in blood pressure, and particularly that of the SBP. is not easily attributed to the psychosocial procedure, the medication or any other factor. A negative correlation existed between blood pressure re duction and patient age (fig. 2): the older the patient the greater the SBP reduction in the 6th month compared to the 1st. As seen in fig
ure 2, the majority (14/20) of the control pa tients had a blood pressure reduction above the regression line of pressure change versus age (ASBP = 5.653 - 0.2265 X age, where ASBP is the change in SBP from the 1st to the 6th month). The opposite holds for the study group (11/23 cases). Thus the mean deviation of the control cases (+2.259 ± 4.120 mm Hg) from the regression line was significantly dif ferent from that of the study group (-1.965 ± 6.120 mm Hg). A simple analysis of covar iance showed that, while there was no group effect on age (F = 2.53 for 1.41 d.fi), there was a statistically significant effect of the group on the body weight reduction (F = 5.56, p < 0.025 for 1.41 d.f.) which was more marked if the normalized change in body weight is con sidered (F = 7.74, p < 0.01 for 1,40 d.f.).
Psychological intervention to patients with coronary heart disease by e.g. type A behav ioral counseling, has been found to influence favorably the prognosis of the disease [3],
Mitsibounas/Tsouna-Hadjis/Rotas/ Sidcris
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Discussion
Table 2. Mean change ( ± SD) from the 1st month for the seven coronary risk factors Risk factor
Study group 3rd-1st month
6 th -1st month
12 th -1st month
3rd-1st month
Weight kg Cholesterol mg/dl T riglycerides mg/dl Uric acid mg/dl SBP mm Hg DBP mm Hg Smoking
—1.82a ± 1.01 —46.09a ±31.59 —16.61a ±26.25 -0 .3 3 a ±0.41 —6.30a ±7.57 -1 .7 4 ±3.57 —69.5 %a
—2.82a ±1.30 —56.04a ±43.32 —20.61a ±26.04 —0.57a ±0.69 —7.61a ±7.21 -3 .0 4 ±5.38 —56.5 %a
—1.57a ±1.91 —36.50a ±28.70 -11.57 ±35.17 —0.35a ±0.47 —7.38a ±7.85 -0.95 ±4.64 —55.5%a
-1 .0 5 3 ±1.47 —6.25ab ±7.93 -2 .4 0 ±6.15 -0 .0 9 ±0.19 -0 .8 5 ±1.87 -1.75 ±4.06 —60.0%a
Control group 6th - 1st month —0.85ab ±1.14 —5.00ab ±4.87 + 2.25» ±15.63 —0.09b ±0.26 -0.85 ±2.16 -0.25 ±3.80 —45.0%a
12th - 1st month —0.95a ±1.00 —4.50b ±9.58 -1 .1 0 ±5.25 -0.08 ±0.22 -0 .78 ±2.24 0 ±4.20 —10.0 %b
although the exact role of type A behavior in relation to coronary heart disease remains controversial [7], In this study that focuses on supportive psychosocial intervention, the number of patients was too small and the study period too short to permit an evaluation of its effects upon mortality and morbidity due to coronary heart disease. However, it did reveal a substantial improvement in the com mon risk factors of coronary heart disease. This improvement was both more profound and longer lasting in the study than in the con trol group (tables 1,2). The intervention aimed at the resolution of a psychological field of tension, personal for each patient, using group dynamics. A common scenario detected in most (16/23) patients was the following. At a young age (12-20 years) the patient was challenged by unusually unfavorable circumstances (e.g. having to support the paternal family). In order to succeed, he or she developed aggres
siveness and other features of the type A per sonality. Now mature, type A behaviour is no longer needed for success, yet aggression has become habitual and oppressive in a new environment (e.g professional or own family). An acute conflict (e.g. confrontation with an adolescent child) might actually initiate the process of acute infarction. The group, repre senting a small random sample of the popula tion with the same organic disease, showed that some of the conceivable ways out from a personal dilemma, although unacceptable to the patient, and thus impossible, were in fact quite acceptable to the group, and thus a pos sibility. While there was no objective indica tion that the field of tension had been re solved, the observed improvement in the cor onary risk factors was a mostly unexpected objective finding. The patients of the study group were signif icantly younger than those of the control group. The age difference, however, had no
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a p < 0.01, paired t test for within-group comparison. b p < 0.01, independent t test for between-groups comparison.
correlation with any of the risk factors exam ined with the exception of the reduction in SBP. Analysis of covariance showed that the more marked reduction in pressure in the study group was present even after normaliza tion of the pressure for age. The triglyceride and cholesterol values were slightly higher in the study than the control group in the 1st month. With repeated measurements a re gression to mean values could possibly be expected. However, the SBP was higher in the control than in the study group, yet no regres sion to mean values was observed and the reduction in SBP in this group was less than in the study group with the lower pressure. Any hypothesis as to how the psychological intervention affected the risk factors is almost entirely conjectural. It is possible that contact with the physician every 2 weeks for the study group but only every 4 weeks for the control group made the former patients more com pliant with treatment. Such an explanation may be valid for cigarette smoking which has a strong behavioral component. However, the
effect on serum cholesterol was profound, comparable to that of the strongest antilipidemic agents available, even when the pa tients taking medication had been exempted from the statistical evaluation. A more strict compliance with dietary orders would not ad equately explain the finding with serum cho lesterol, since diet is not known to greatly affect serum cholesterol, although its effect on body weight and serum triglycerides would be expected to be much more marked [8], On the other hand, psychological factors may ifluence the serum cholesterol level, students, e.g., having higher cholesterol values during examinations than in the period of regular classes [9], In conclusion, a group psychosocial inter vention aimed at resolving interpersonal con flicts may be associated with a substantial improvement in coronary risk factors, as in the case of serum cholesterol. However, the mechanism by which the intervention may act upon the coronary-disease risk factors re mains unknown.
References
2
Costa P. Krantz D, Blumental J. Furberg C. Rosenman R, Shckclle R: Task Force 2: Psychological risk factors in coronary artery disease. Circulation I987;76(suppl 1): 145— 149. Papageorgiou C. Anthopoulos L, Mitsibounas D, Kontou E. Vrouchos G. Benrubi M. Moulopoulos SD: Relation of personality and emotional factors to myocardial ischemia. Methodology and first ob servations. Psychothcr Psychosom 1981:36:92-97.
3
4
5
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Friedman M, Powell L. Thorescn C, Ulmer D. Price V. Gill J. Thomson L, Rabin D. Brown B. Breal I W. Levy R. Bourg E: Effects of discon tinuance of type A behavioral coun selling on type A behavior and car diac recurrence rate of post myocar dial infarction patients. Am Heart J 1987;114:483-490. Rahe R. Pugh N. Erikson J, Gardenson E, Rubin R: Cluster analyses of life changes. 1. Consistency of clus ters across large Navy samples. Arch Gen Psychiatry 1971:25:330-332. Mitsibounas D. Rotas R. Antoniou A. Tsouna-Hadjis E. Nanas S. Kontoleon P. Maliaras G. Sideris DA. Moulopoulos SD: Psychosomatic intervention following acute myo cardial infarction (a pilot study). 16th Eur Conf Psychosom Res. 1986, p 112.
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7
8
9
Razin AM: Psychosocial interven tion in coronary artery disease. A review. Psychosom Med 1982:44: 363-387. Shckellc RB. Hulley SB. Ncaton J. Billings J. et al: The MRFIT behav ior pattern study. II. Type A behav ior and incidence of coronary' heart disease. Am J Epidemiol 1985:122: 559-570. Levy R. Feinleib M: Risk factors for coronary' artery' disease and their management: in Braunwald E (ed): Heart Disease. Philadelphia. Saun ders. 1980. pp 1246-1278. Tennes K. Kryc M: Children's adre nocortical reponses to classroom ac tivity and test in elementary school. Psychosom Med 1985:47:451 —460.
Psychosocial Intervention and Risk Factors
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1
Dimitris N. Mitsibounas E ñe D. Tsouna-Hadjis Vassilis R. Rotas Dimitris A. Sideris
Effects of Group Psychosocial Intervention on Coronary Risk Factors
Department of Clinical Therapeutics. Medical School of Athens University. Athens. Greece
Introduction Reducing the common risk factors is one of the main therapeutic approaches after an acute myocardial infarction. Diet and proper medication are the main approaches to this goal. Researchers are also concerned with psy chosocial factors which, according to a num
ber of studies [e.g. 1.2], seem to contribute to the evolution of coronary heart disease and the onset of acute myocardial infarction. Therapeutic interventions regarding the psychosocial risk factors may focus on the identification and alteration of type A person ality [3], life style change [4], or treatment of the patient's interpersonal conflicts that pre-
Dimitris N. Mitsibounas Department of Clinical Therapeutics Alexandra Hospital 80 E. Venizclou and K. Lourou Street G R -115 28 Athens (Greece)
©1992 S. Karger AG, Basel 0033-3190/92/ 0582-0097$2.75/G
Downloaded by: Kings's College London 137.73.144.138 - 10/19/2017 7:31:03 PM
KeyWords Group psychosocial intervention Myocardial infarction Coronary risk factors Cholesterol Triglycerides Smoking Blood pressure
Abstract The purpose of this study was to investigate whether a psycho social intervention approach aimed at resolving psychological conflicts could reduce the severity of risk factors for post-acute myocardial infarction patients. Twenty-three patients with a recent myocardial infarction participated in a group psychoso cial intervention program which lasted 1 year. Twenty other patients with recent myocardial infarction served as controls. Patients form both groups had regular clinical and laboratory follow-up as well as medication. Mean values for seven risk factors of coronary heart disease (smoking, S; body weight, W; serum cholesterol, C; triglycerides, T; systolic and diastolic blood pressure. SBP. DBP; scrum uric acid. U) were compared between the two groups in the 1st, 3rd, 6th and 12th months of the follow-up. The maximal mean improvements of the study versus the control group were as follows: W: -2.82 vs. -1.05 kg; C: - 56.04 vs. -6.25 mg/dl; T: -20.61 vs. -2.4 mg/dl; U: -0.57 vs. -0.9 mg/dl; S at 1 year -55.5 vs. -10% . It is concluded that group psychosocial intervention with post acute myocardial infarction patients considerably reduces some coronary-disease risk factors.
Materials and Methods Forty-three patients of both sexes with acute myo cardial infarction and no further complications were studied. All were Athenian residents. Among them 23 (19 men and 4 women) with a mean age ( ± SD) of 50.0 ± 8.9 were selected for the study group, while the remaining 20 patients (19 men and 1 woman) with an age of 56.0 ± 7.5 (t = 2.43, p < 0.05) served as the control group. The sex differences were not signifi cant. All patients were assessed on the 6th to 8th day of hospitalization for acute myocardial infarction. The assessment concerned the medical history, clinical and laboratory findings that certified the disease and an thropometric data. Exclusion criteria were an age > 70 years, the patients’ statement that they would not be able to attend regular sessions, or their refusal to par ticipate in a study that might involve open discussion of personal matters if they happened to be selected for the study group. After selection the patients were allo cated randomly to either the study or the control group. Study Group The patients selected for the study group were introduced to the psychosocial intervention groups. Before that, a semistructured personal interview re garding their psychosocial history took place, aimed at
98
identifying psychological fields of tension. A psycho logical field of tension [5] is defined as a serious psy chological conflict of the individual in his other trans action with the social environment. The individual feels that the conflict must be resolved, but is immobi lized because any way out appears unnacceptable, pro hibited or threatening. Exacerbations of fields of ten sion of varying nature were identified in 20 patients’ recent history, that is, within 1 month prior to the acute myocardial infarction. Groups of psychosocial intervention were formed with 5-7 patients in each. Overall, four such groups were formed for the 23 patients; they met with 2 psychosomatically oriented physicians and one psycholo gist every 2 weeks for 1 year in 1-hour meetings. The aim of the group meetings was to help patients realize that at least one of the alternative solutions to their conflict was socially (by the group) acceptable and therefore neither prohibited nor threatening. In the initial one or two sessions each patient was prompted to report possible conflicts with no apparent personally acceptable way-outs that had occurred to him or her up to 1 month prior to the infarction event. Group discus sion followed, aimed at finding socially acceptable alternative solutions. In subsequent sessions, similar conflicts were discussed that had occurred in the pre vious fortnight. Important events in the past history that might account for the patients' present preoccupa tions were sought and discussed. In addition, the patients were taught to regularly use relaxation tech niques. Besides group meetings, the patients had a clinical follow-up and electrocardiogram test every 2 weeks. Within 1 year, a treadmill exercise test and a 24-hour Holter monitoring were performed twice, and a coro nary arteriogram once. The values of patients’ common coronary risk fac tors [body weight, cholesterol, triglycerides, systolic and diastolic blood pressure (SBP and DBP). uric acid and smoking] were assessed at hospitalization (within the first month), and in the 3rd. 6th and 12th months. Control Group The patients of the control group had a clinical fol low-up and electrocardiogram once a month, a tread mill exercise test and 24-hour Holter monitoring twice a year, and coronary arteriography once a year. The values of the common risk factors were assessed ex actly as for the study group. The two groups were com pared regarding the values of these risk factors over a 1-year period after the myocardial infarction. Patients in both groups received medication as needed.
Mitsibounas/Tsouna-Hadjis/Rotas/ Sideris
Psychosocial Intervention and Risk Factors
Downloaded by: Kings's College London 137.73.144.138 - 10/19/2017 7:31:03 PM
ceded the infarction incidence [5]. The vari ety of approaches [6] is indicative of the inherent difficulty involved in psychological research, namely that psychological outcomes can rarely be assesseed by objective measures. On the other hand, the indirect somatic out come may be measured accurately, although it is usually difficult to prove its connection with the psychological therapeutic method applied. In this study, a group psychosocial treat ment was applied aimed at resolving patients’ interpersonal conflicts, and the change in their risk factors was estimated. The change was compared to that of a control group in which no group psychosocial intervention was applied.
Table 1. Mean values ( ± SD) for coronary risk factors at four time points Risk factor
Study group 1st month
3rd month
6th month
12th month
1st month
3rd month
6th month
12th month
Weight kg Cholesterol mg/dl Triglycerides mg/dl Uric acid mg/dl SBP mm Hg DBP mm Hg Smoking
72.64 ±7.17 288.69 ±72.51 141.96 ±53.02 5.24 ±1.29 131.30 ±17.40 84.78 ±6.30 18/23 78.2%
70.82 ±7.04 242.61 ± 49.66 126.78 ±36.51 4.88 ±1.07 125.00 ±12.06 83.04 ±4.94 2/23 8.7%
69.82 ±6.99 232.65 ±48.80 121.35 ±34.31 4.67 ±0.85 123.70 ±11.89 81.74 ±3.88 5/23 21.7%
70.48 ±7.19 249.52 ±65.40 132.77 ±38.62 4.93 ±1.01 124.52 ±12.44 84.05 ±4.07 5/22 22.7%
73.90 ±8.28 259.25 ±26.96 115.90 ±18.61* 4.81 ±0.88 142.75 ±14.64* 86.50 ±5.41 18/20 90.0%
72.85 ±8.17 253.00 ±23.36 113.50 ±17.40 4.73 ±0.85 138.75 ±15.38* 84.75 ±4.44 6/20 30.0%
73.05 ±7.80 254.25 ±27.30 118.51 ±31.54 4.73 ±0.90 138.50 ±14.18* 86.25 ±4.83* 9/20 45.0%
72.95 ±8.20 254.75 ±26.93 114.31 ±18.15 4.62 ±0.86 140.00 ±12.83* 86.67 ±5.15 16/20 80.0%
Control group
Statistics The Student paired and unpaired t tests were used for parametric measurements. A p < 0.05 value was ordinarily considered significant. The initial (1st month) values of the risk factors were compared with the corresponding values in the 3rd, 6th and 12th months (paired t test) separately for the two groups. The mean changes in corresponding months were compared between the groups (independent t test). Because these were multiple t tests, p < 0.01 was con sidered significant. For nonparametric values the %2 test was used. Classical formulas for correlation and regression analysis were applied as needed. Simple analysis of covariance was also used where applicable.
Results The mean values of the seven risk factors at the four time points for both groups appear in table 1. The 1st month values (the initial ones during hospitalization) do not differ signifi cantly between the two groups with the excep tion of the triglycerides which were slightly
higher in the study group (t = 2.62, p < 0.05) and the SBP which was slightly higher in the control group (t = 2.34, p < 0.05). In the study group, a decrease in the pa rameters examined was noted in all three examinations after the 1st month. This de crease was statistically significant in all in stances except for the triglycerides in the 12th month and the DBP for all months (table 2). In contrast, in the control group, the triglycer ide, uric acid, SBP and DBP values did not change significantly at any time after the ini tial measurement. Furthermore, the reduc tion in the number of smokers in the 12th month was not significant (table 2). Four patients in the study group and 2 in the control group were taking antilipidemic agents. Excluding these 6 cases, the reduction in blood cholesterol was significantly more marked in the study than in the control group (fig. 1). The reduction of cholesterol in the study group reached about 50 mg/dl in the 6th
99
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* p < 0.05 in a comparison between the two groups.
—I----------------------------- 1—
40
50 Age, years
Fig. 1. Scrum cholesterol values (mean ± SE) in the 1st. 3rd. 6th. and 12th months of follow-up for the study (•) and control (o) groups. Cases without antilipidemic medication only.
Fig. 2. Change in the SBP (ASBP) in the 6th month versus age, and regression line for all patients. • = Study, o = control group.
month compared to the 1st. while the maxi mal diminution of cholesterol in the control group was about 7 mg/dl in the 3rd month. No significant correlation existed between scrum cholesterol levels and age in cither group. Table 2 also shows the significance of the difference in change of all seven risk factors between the study and the control groups. The changes observed were significantly (p < 0.01) more marked in the study than the con trol group for the following variables: body weight in the 6th month; cholesterol in all 3 examinations; triglycerides in the 6th month; uric acid in the 6th month; and the number of smokers in the 12th month. Nine patients in the study group and 16 in the control group were receiving either diuret ics. P-blockers or Ca-channcl inhibitors. Thus, the observed reduction in blood pressure, and particularly that of the SBP. is not easily attributed to the psychosocial procedure, the medication or any other factor. A negative correlation existed between blood pressure re duction and patient age (fig. 2): the older the patient the greater the SBP reduction in the 6th month compared to the 1st. As seen in fig
ure 2, the majority (14/20) of the control pa tients had a blood pressure reduction above the regression line of pressure change versus age (ASBP = 5.653 - 0.2265 X age, where ASBP is the change in SBP from the 1st to the 6th month). The opposite holds for the study group (11/23 cases). Thus the mean deviation of the control cases (+2.259 ± 4.120 mm Hg) from the regression line was significantly dif ferent from that of the study group (-1.965 ± 6.120 mm Hg). A simple analysis of covar iance showed that, while there was no group effect on age (F = 2.53 for 1.41 d.fi), there was a statistically significant effect of the group on the body weight reduction (F = 5.56, p < 0.025 for 1.41 d.f.) which was more marked if the normalized change in body weight is con sidered (F = 7.74, p < 0.01 for 1,40 d.f.).
Psychological intervention to patients with coronary heart disease by e.g. type A behav ioral counseling, has been found to influence favorably the prognosis of the disease [3],
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Discussion
Table 2. Mean change ( ± SD) from the 1st month for the seven coronary risk factors Risk factor
Study group 3rd-1st month
6 th -1st month
12 th -1st month
3rd-1st month
Weight kg Cholesterol mg/dl T riglycerides mg/dl Uric acid mg/dl SBP mm Hg DBP mm Hg Smoking
—1.82a ± 1.01 —46.09a ±31.59 —16.61a ±26.25 -0 .3 3 a ±0.41 —6.30a ±7.57 -1 .7 4 ±3.57 —69.5 %a
—2.82a ±1.30 —56.04a ±43.32 —20.61a ±26.04 —0.57a ±0.69 —7.61a ±7.21 -3 .0 4 ±5.38 —56.5 %a
—1.57a ±1.91 —36.50a ±28.70 -11.57 ±35.17 —0.35a ±0.47 —7.38a ±7.85 -0.95 ±4.64 —55.5%a
-1 .0 5 3 ±1.47 —6.25ab ±7.93 -2 .4 0 ±6.15 -0 .0 9 ±0.19 -0 .8 5 ±1.87 -1.75 ±4.06 —60.0%a
Control group 6th - 1st month —0.85ab ±1.14 —5.00ab ±4.87 + 2.25» ±15.63 —0.09b ±0.26 -0.85 ±2.16 -0.25 ±3.80 —45.0%a
12th - 1st month —0.95a ±1.00 —4.50b ±9.58 -1 .1 0 ±5.25 -0.08 ±0.22 -0 .78 ±2.24 0 ±4.20 —10.0 %b
although the exact role of type A behavior in relation to coronary heart disease remains controversial [7], In this study that focuses on supportive psychosocial intervention, the number of patients was too small and the study period too short to permit an evaluation of its effects upon mortality and morbidity due to coronary heart disease. However, it did reveal a substantial improvement in the com mon risk factors of coronary heart disease. This improvement was both more profound and longer lasting in the study than in the con trol group (tables 1,2). The intervention aimed at the resolution of a psychological field of tension, personal for each patient, using group dynamics. A common scenario detected in most (16/23) patients was the following. At a young age (12-20 years) the patient was challenged by unusually unfavorable circumstances (e.g. having to support the paternal family). In order to succeed, he or she developed aggres
siveness and other features of the type A per sonality. Now mature, type A behaviour is no longer needed for success, yet aggression has become habitual and oppressive in a new environment (e.g professional or own family). An acute conflict (e.g. confrontation with an adolescent child) might actually initiate the process of acute infarction. The group, repre senting a small random sample of the popula tion with the same organic disease, showed that some of the conceivable ways out from a personal dilemma, although unacceptable to the patient, and thus impossible, were in fact quite acceptable to the group, and thus a pos sibility. While there was no objective indica tion that the field of tension had been re solved, the observed improvement in the cor onary risk factors was a mostly unexpected objective finding. The patients of the study group were signif icantly younger than those of the control group. The age difference, however, had no
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a p < 0.01, paired t test for within-group comparison. b p < 0.01, independent t test for between-groups comparison.
correlation with any of the risk factors exam ined with the exception of the reduction in SBP. Analysis of covariance showed that the more marked reduction in pressure in the study group was present even after normaliza tion of the pressure for age. The triglyceride and cholesterol values were slightly higher in the study than the control group in the 1st month. With repeated measurements a re gression to mean values could possibly be expected. However, the SBP was higher in the control than in the study group, yet no regres sion to mean values was observed and the reduction in SBP in this group was less than in the study group with the lower pressure. Any hypothesis as to how the psychological intervention affected the risk factors is almost entirely conjectural. It is possible that contact with the physician every 2 weeks for the study group but only every 4 weeks for the control group made the former patients more com pliant with treatment. Such an explanation may be valid for cigarette smoking which has a strong behavioral component. However, the
effect on serum cholesterol was profound, comparable to that of the strongest antilipidemic agents available, even when the pa tients taking medication had been exempted from the statistical evaluation. A more strict compliance with dietary orders would not ad equately explain the finding with serum cho lesterol, since diet is not known to greatly affect serum cholesterol, although its effect on body weight and serum triglycerides would be expected to be much more marked [8], On the other hand, psychological factors may ifluence the serum cholesterol level, students, e.g., having higher cholesterol values during examinations than in the period of regular classes [9], In conclusion, a group psychosocial inter vention aimed at resolving interpersonal con flicts may be associated with a substantial improvement in coronary risk factors, as in the case of serum cholesterol. However, the mechanism by which the intervention may act upon the coronary-disease risk factors re mains unknown.
References
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Razin AM: Psychosocial interven tion in coronary artery disease. A review. Psychosom Med 1982:44: 363-387. Shckellc RB. Hulley SB. Ncaton J. Billings J. et al: The MRFIT behav ior pattern study. II. Type A behav ior and incidence of coronary' heart disease. Am J Epidemiol 1985:122: 559-570. Levy R. Feinleib M: Risk factors for coronary' artery' disease and their management: in Braunwald E (ed): Heart Disease. Philadelphia. Saun ders. 1980. pp 1246-1278. Tennes K. Kryc M: Children's adre nocortical reponses to classroom ac tivity and test in elementary school. Psychosom Med 1985:47:451 —460.
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