Effects of psychotherapy in combination with pharmacotherapy, when compared to pharmacotherapy only on blood pressure, depression, and anxiety in female patients with hypertension.

Journal ofhttp://hpq.sagepub.com/ Health Psychology

Effects of psychotherapy in combination with pharmacotherapy, when compared to pharmacotherapy only on blood pressure, depression, and anxiety in female patients with hypertension Mohammad Ahmadpanah, Somaye Jamali Paghale, Azadeh Bakhtyari, Sattar Kaikhavani, Elham Aghaei, Marzieh Nazaribadie, Edith Holsboer-Trachsler and Serge Brand J Health Psychol published online 7 October 2014 DOI: 10.1177/1359105314550350 The online version of this article can be found at: http://hpq.sagepub.com/content/early/2014/10/01/1359105314550350

Published by: http://www.sagepublications.com

Additional services and information for Journal of Health Psychology can be found at: Email Alerts: http://hpq.sagepub.com/cgi/alerts Subscriptions: http://hpq.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> OnlineFirst Version of Record - Oct 7, 2014 What is This?

Downloaded from hpq.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 26, 2014

550350 research-article2014

HPQ0010.1177/1359105314550350Journal of Health PsychologyAhmadpanah et al.

Article

Effects of psychotherapy in combination with pharmacotherapy, when compared to pharmacotherapy only on blood pressure, depression, and anxiety in female patients with hypertension

Journal of Health Psychology 1–12 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314550350 hpq.sagepub.com

Mohammad Ahmadpanah1, Somaye Jamali Paghale2, Azadeh Bakhtyari3,4, Sattar Kaikhavani5, Elham Aghaei6, Marzieh Nazaribadie3,4, Edith Holsboer-Trachsler7 and Serge Brand7,8

Abstract We investigated effects of metacognitive detached mindfulness therapy and stress management training on hypertension and symptoms of depression and anxiety, as compared to a control condition. A total of 45 female patients (mean age: M = 36.49 years) were randomly assigned to one of three conditions: metacognitive detached mindfulness therapy, stress management training, and the control condition. Blood pressure and symptoms of depression and anxiety decreased from baseline to post-test, to follow-up. Group comparisons showed that blood pressure and symptoms of depression and anxiety decreased more in psychotherapeutic groups than in the control group. Psychotherapeutic treatment of hypertension reduced blood pressure and symptoms of depression and anxiety. Positive effects were observable at follow-up 8 weeks later.

Keywords hypertension, metacognitive detached mindfulness, stress management, symptoms of depression and anxiety

1Research

Center for Behavioral Disorders and Substances Abuse, Hamadan University of Medical Sciences, Hamadan, Iran 2Department of Psychology, School of Psychology and Educational Sciences, University of Alzahra, Tehran, Iran 3Department of Clinical Psychology, School of Psychology and Educational Sciences, University of Isfahan, Iran 4Seddigheh Tahereh Research Center, Isfahan University of Medical Sciences, Isfahan, Iran 5Department of Clinical Psychology, Ilam University of Medical Sciences, Ilam, Iran

6Department

of Psychology, School of Human Sciences, Shahed University, Tehran, Iran 7Psychiatric Clinics of the University of Basel, Switzerland 8Department of Sport and Health Science, Division of Sport Science, University of Basel, Basel, Switzerland Corresponding author: Serge Brand, Center for Affective, Stress and Sleep Disorders, Psychiatric Hospital of the University of Basel, Wilhelm Klein-Strasse 27, 4012 Basel, Switzerland. Email: [email protected]


2

Journal of Health Psychology

Introduction Hypertension (HT) is not only an important factor in chronic disability but is estimated worldwide to be the third most important cause of premature death (World Health Organization (WHO), 2006). By virtue of its slowly emerging symptoms and unpleasant complications, HT as a cardiovascular disease has been described as the “silent murderer” (Davison et al., 2004). Results showed that 25–33 percent of adults suffer from HT (Denni et al., 2005). A survey conducted in 19 different countries (N = 52,095) showed that HT was associated with psychiatric conditions such as impulsive eating, substance abuse, anxiety, and depression (Stein et al., 2014). Additionally, there is evidence that blood pressure (BP) may vary as a function of emotional state (Davison et al., 2004). More specifically, research lends support to the notion that symptoms of depression and anxiety, perceived stress, sleep disturbances (Genta-Pereira et al., 2014), job strain (Babu et al., 2014; Netterstrøm, 2014; Trudel et al., 2010), or negative emotions (Symonides et al., 2014) are causally linked to the development and maintenance of HT (Abbott et al., 2014; Petermann and Vaitl, 2009). In this regard, Meng et al. (2012) observed that the occurrence of symptoms of depression increased the risk of HT incidence. Kagee et al. (2007) observed symptoms of depression in about 20 percent of patients suffering from HT, a pattern of results also observed elsewhere (Cukrowicz et al., 2012; Stein et al., 2014; but see Ringoir et al. (2014) for opposite results). In these respects, also increased rates of anxiety (Bacon et al., 2014; Bhattacharya et al., 2014), lower quality of life (Rueda and Pérez-García, 2006; Trevisol et al., 2011), and decreased psychological well-being (Trudel-Fitzgerald et al., 2014) were observed in patients suffering from HT. Specifically, suffering from an anxiety disorder was associated with the four-fold risk of developing HT (Bacon et al., 2014). Interestingly, Khatib et al. (2014) observed that stress, anxiety, and depression were most commonly reported as factors hindering or delaying the adoption of a healthier life style in patients suffering from

HT, in that medication intake was often forgotten. In this regard, forgetting medication intake might be considered as a sign of cognitive impairments often observed with symptoms of depression (Trivedi and Greer, 2014). To treat HT, both non-pharmacological and pharmacological treatments (see below) are applied. Besides the advantages of a pharmacological treatment, several studies showed that low medication compliance is a major treatment concern (Botha et al., 2002; Cohn et al., 2012; Taylor et al., 2006; Van Wijk et al., 2008), whereas, for instance, Dusek et al. (2008) showed that relaxation treatment led to a noteworthy decrease of antihypertensive medication. As regards underlying psychophysiological mechanisms to explain HT, it has been observed that states of anxiety and depression lead to increased secretion of cortisol (Holsboer and Ising, 2010) and norepinephrine (Petermann and Vaitl, 2009), which in turn increase the arousal of the sympathetic system, and thus peripheral vasoconstriction, increased heart rate, and increased BP. Both pharmacological and non-pharmacological interventions are employed in the treatment of HT. Pharmacological treatments usually involve administration of diuretics, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors.1 However, even though the most common treatment is pharmacological, treatment compliance (see above) and side effects as described in Note 1 limit patients’ total compliance and recovery. In contrast, although non-pharmacological or psychotherapeutic treatments such as relaxation techniques (autogenic training, meditation, imagination, progressive muscle relaxation; cf. Abbott et al., 2014; Petermann and Vaitl, 2009) need instructions and time to learn, adverse side effects are virtually unknown (Davison et al., 2004). More specifically, Abbott et al. (2014) observed a reduction of stress, depression, and anxiety after a mindfulness-based intervention to treat HT, whereas the authors also summarized that results on physiological outcomes were mixed. The underlying rationale to explain the influence of psychotherapeutic interventions to treat


3

Ahmadpanah et al. HT is that if HT is caused and maintained by cognitive-emotional processes such as symptoms of depression and anxiety and perceived stress, then HT should be treatable with psychotherapeutic (i.e. non-pharmacological) interventions aimed at reducing the symptoms of depression and anxiety (Beevers et al., 2001). In this regard, methods such as cognitivebehavioral therapy, stress management, relaxation, biological feedback, anger management, cognitive change, and life style change have already been used successfully (Albright et al., 1991; Davydov et al., 2012; Yung and Keller, 1996). For example, Tacon et al. (2003) assessed the effectiveness of Kabat-Zinn’s mindfulnessbased stress-reduction program and reported significant reductions in anxiety and negative affect and improvements in emotional control and coping among a group of women with heart disease. Mindfulness-based stress reduction has also induced positive physiological changes in BP, heart rate, and cardiac respiratory sinus arrhythmia (Abbott et al., 2014; Barnes et al., 2004; Ditto et al., 2006). This approach has also been integrated into a psycho-educational intervention for patients with chronic heart failure (Sullivan et al., 2009). Following a combination of mindfulness techniques, health education/ coping skills, and a support group, participants reported improvements in quality of life, physical symptoms, and psychological functioning. Given the encouraging results of these studies, and the evidence for the reduction of symptoms of depression and anxiety (Baer, 2003), stress management programs have been used effectively across a range of medical conditions including cardiovascular disease, diabetes, and cancer (Snoek et al., 2001). In contrast, Dickinson et al. (2008) were less enthusiastic about the impact of relaxation therapies for the management of primary HT in adults. They concluded that given the poor quality of trials and unexplained variation between trials, the evidence in favor of a causal association between relaxation and BP reduction was weak. Furthermore, some of the apparent benefit of relaxation was probably due to aspects of treatment unrelated to relaxation.

Taken together, however, there is reason to explore if non-pharmacological, that is, psychotherapeutic treatments of HT, may lead to a decrease in both HT and symptoms of depression and anxiety. However, to our knowledge, no study has thus far investigated the effect of a brief (8-week) group therapy program on HT and symptoms of depression and anxiety in the short and longer term. More specifically, ++this study aimed to shed more light on the effect of two new psychotherapeutic interventions, namely, metacognitive detached mindfulness therapy (MDM) and stress management training (SMT). MDM is a recent theoretical and therapeutic advance in mental health research, which offers a potentially effective approach to the treatment of emotional distress (Wells, 2006). MDM has been used with a range of problems including stress, symptoms of depression, and anxiety (Chambers et al., 2009). Moreover, mindfulness-based psychological interventions are effective in alleviating distress and in enhancing well-being (cf. Abbott et al., 2014). SMT is a broad term, and programs typically incorporate a number of techniques including relaxation training, biofeedback, cognitive restructuring, problem-solving, and time management skills training (McGinnis et al., 2005). In the context of a physical illness, individuals can be resistant to the idea of psychological intervention, whereas stress management, with perceived benefits for wellbeing more generally, is often well received (Soo and Lam, 2009). Accordingly, the aim of this study was to investigate the effectiveness of both MDM and SMT on BP among patients suffering from HT and symptoms of depression and anxiety, and to compare these data with those from a control group (CG) without psychotherapeutic intervention. The following three hypotheses were formulated. First, and following Tacon et al. (2003), and Petermann and Vaitl (2009), we expected that MDM would, compared to a CG, reduce HT over time. Second, again following Tacon et al. (2003) and Petermann and Vaitl (2009), we hypothesized that SMT would reduce HT


4


over time. Third, we expected that both MDM and SMT would have a positive impact on symptoms of depression and anxiety. Last, we anticipated that both MDM and SMT would have a positive impact in the longer term, namely, at a follow-up 8 weeks after completion of the study.

Methods Sample A total of 45 female patients (mean age in years (M) = 46.49; standard deviation (SD) = 2.33 years) suffering from HT took part in the study. They were all recruited in 2013 from the Hazrate Sedigheh Tahereh Medical Research Center in Hamadan (Islamic Republic of Iran). Patients reported to suffer from at least 5–8 years of HT. There were no differences in age between conditions (see below; MDM: M = 46.33 years (2.97); SMT: M = 46.47 years (3.78); CG: M = 46.49 years (3.53); F(2, 42) = 0.04, p = .96). The entire study was approved by the local ethics committee, and conducted in accordance with the Declaration of Helsinki. Female patients2 were included in the study if the following criteria were met: (1) diagnosis of HT (diastolic (90–110) and systolic (140– 160) BP, (2) age between 30 and 55 years, (3) upper diploma, (4) depressive symptoms (10– 17 points according to the Beck Depression Inventory (BDI), see below) and symptoms of anxiety (8–15 according to the Beck Anxiety Inventory (BAI), see below), and (5) written informed consent. Exclusion criteria were (1) not meeting inclusion criteria; (2) known physical or psychological illness discouraging participation; (3) lack of compliance (medication; group sessions); (4) after routing electrocardiogram (ECG), possible cardiac diseases; (5) suspected psychiatric disorders after a brief psychiatric screening interview (M.I.N.I.: Mini International Neuropsychiatric Interview; Sheehan et al., 1998); (6) intake of psychoactive or mood-altering substances (medication, drugs).

Procedure After a thorough medical examination and assessment of the inclusion and exclusion criteria, patients were randomly assigned to one of the following conditions: MDM, SMT, or control condition. To achieve randomization and to assign 15 patients at every study condition, a total of 45 chips in three different colors were put in a ballot box and stirred. Each color represented a different condition. At the start of the study, patients drew a chip and were assigned to the corresponding condition. At baseline, patients provided background information (including age). Next, they completed two questionnaires related to symptoms of anxiety and depression. Thereafter, a study nurse measured BP. The procedure was repeated at the end of the study, that is, 8 weeks later, as well as at follow-up 8 weeks after completion of the study. During the entire study through to the follow-up, the individual HT medication was kept constant for all patients.

Interventions MDM. Mindfulness meditation practice is a form of cognitive training aimed at learning how and where to guide one’s attention (see Table 1 for more details; see also Marks, 2010). This involves maintaining awareness of attention from one moment to the next, and gently but firmly escorting it back to the initial target object when the mind becomes distracted (Kang et al., 2013). Most discussions of mindfulness include the following four elements: (1) awareness, (2) sustained attention, (3) focus on the present moment, and (4) nonjudgmental acceptance (Wells, 2006). This intervention is based on and consists of the elements set out in Table 1, and the sessions were organized and scheduled as reported in Table 1. SMT. Relaxation training and biofeedback are considered particularly beneficial in reducing physiological and related hormonal influences on HT. Initially, all techniques were taught in group sessions with patients doing follow-up


5

Ahmadpanah et al. Table 1. Metacognitive detached mindfulness therapy: sessions and description. Sessions

Session description

1.

Orientation, motivation, goal of session, fill in BDI and BAI, blood pressure measurement Explanation treatment plan, metacognitive detached mindfulness therapy, attention training techniques (ATT) Talk about home assessment, training and metacognitive leading exercise, assessment against prevented inhibition Talk about home assessment, training and association technique exercise Talk about home assessment, training and wandering mind and task oriented exercise Talk about home assessment, training and circle words and unruly child exercise Talk about home assessment, training and imagery clouds and train station exercise Review of techniques and fill in BDI and BAI, blood pressure measurement

2. 3. 4. 5. 6. 7. 8.

BDI: Beck Depression Inventory; BAI: Beck Anxiety Inventory.

work at home. The program consists of eight 1-hour sessions, each session involving 10–15 participants. The sessions consist of didactic presentations, group discussions, completion of questionnaires and forms, progressive muscle relaxation, systematic desensitization, and practical retraining. For the systematic desensitization sessions, the leader drew upon the method developed by Wolpe (1958). The program is usually evaluated when all eight sessions have been completed. The evaluation consists of both subjective and objective reports, including oral feedback, a written program evaluation, and pre-and post-administrations of the StateTrait Anxiety and depression Inventory. The technique needs a proactive approach that raises awareness of the symptoms of stress and enables individuals to develop coping skills. Training in SMT allows people to recognize the nature of stress, to identify areas that need improvement, and to ensure that risks are properly controlled. This section contains a stress management awareness training presentation and background notes. This intervention is based on and consists of the elements set out in Table 2, and the sessions were organized and scheduled as described in Table 2. Control condition. Patients assigned to the control condition came once a week to the ward. As for

the intervention group, a brief medical check was performed and BP was assessed. This ensured that all patients had comparable frequencies of social contact with the study staff, and thus, any possible bias due to variations in social contact with study staff was kept to a minimum.

Instruments Depressive symptoms. To assess depressive symptoms, participants completed the BDI (Beck et al., 1961). Answers are given on 4-point rating scales with the anchor points 0 (=never) and 3 (=always), with higher sum/ mean scores reflecting greater depressive symptoms. The following cut-off ranges are proposed: 0–9 sum scores—no symptoms of depression; 10–18 sum scores—mild symptoms of depression; 19–29 sum scores—moderate to severe symptoms of depression; >30 sum scores—severe symptoms of depression. Anxiety. Symptoms of anxiety were assessed with the BAI (Beck et al., 1961). Answers are given on 4-point rating scales with the anchor points 1 (=never) and 5 (=always), with higher sum/mean scores reflecting greater symptoms of anxiety. The following cut-off ranges are proposed: 0–7—minimal level of anxiety; 8–15—mild anxiety; 16–25—moderate anxiety; 26–63—severe anxiety.


6


Table 2. Stress management training: sessions and description. Sessions

Session description

1.

About the program, stressful factors and responses, increasing relaxation of 16 muscle groups Stress effect, stress and awareness, exercise in awareness of physical signs of stress, increasing relaxation of 8 muscle groups Diaphragm breath, increasing relaxation of 4 muscle groups, imagery and relaxation, thought and emotion relation, exercise in the power of thought Diaphragm breath and imagery, passive increasing relaxation along with special image imagery, negative thought and distort cognition, negative thought and behavior, identify negative thoughts Integration relaxation, introduce self-creation training and self-creation exercise for heaviness and warmth, difference between rational and irrational self-utterance, displacement of rational thoughts Self-creation training for heart-beat, breath, stomach and front head, definition of encounter, different functional and mal-functional encounter, talk about encounter strategies Logic of self-creation training, with imagery and self-induction, sun meditation, encounter with effective steps, functional encounter exercise, soften techniques Physical conditions of meditation, exercise in mantra meditation, breath counting meditation, personal stress management schedule, measuring

2. 3. 4. 5. 6. 7. 8.

Statistical analysis. A series of four analyses of variance (ANOVAs) for repeated measures was performed with the factors Time (three conditions: baseline, post, and follow-up) and Group (three conditions: MDM, SMT, and Controls), and as dependent variables, anxiety, depression, and systolic and diastolic BP. Post hoc analyses were performed after Bonferroni–Holm correction for p values. Statistical tests were performed using Greenhouse–Geisser corrected degrees of freedom, although throughout the article, the original degrees of freedom are reported with the relevant Greenhouse–Geisser epsilon value (ε). For ANOVAs, effect sizes are indicated with the partial eta squared (η2), with 0.059 ≥ η2 ≥ 0.01 indicating small (S), 0.139 ≥ η2 ≥ 0.06 indicating medium (M), and η2 ≥ 0.14 indicating large (L) effect sizes. The level of significance was set at p ≤ .05, and all statistics were processed using SPSS® 20.0 (IBM Corporation, Armonk NY, USA) for Apple McIntosh®.

systolic and diastolic BP, separately for Time (baseline, post-test, follow-up), Group (MDM, SMT, and Controls), and for the Time × Group interaction. For all dependent variables, the pattern of results was as follows. Symptoms of depression (Figure 1) and anxiety, and systolic and diastolic BP (Figure 2) decreased significantly over time from baseline to post-assessment to follow-up. Compared to those in the control condition, participants in both intervention conditions had significantly lower scores. There were also significant Time × Group interactions. Post hoc tests after Bonferroni–Holm corrections for p values showed that mean values did not differ between groups at baseline, but did so at postassessment and at follow-up, with significantly higher scores in the control condition than in either intervention condition. No significant mean differences were found between the two intervention conditions.

Results

Discussion

Tables 3 and 4 report the descriptive and inferential statistics for the dependent variables symptoms of anxiety and depression, and

The key results of this study are that among female patients suffering from HT and symptoms of depression and anxiety, compared to a control


7

Ahmadpanah et al.

Table 3. Descriptive overview of symptoms of depression and anxiety, and blood pressure, separately for time (baseline, on completion of the study (post-test), and 8 weeks later at follow-up), and separately for the three groups (MDM, SMT, CG). Groups

MDM

BL

Post-test

FU

BL

Post-test

FU

BL

Post-test

FU

Depression

24.26 (5.12) 22.33 (5.23) 156.54 (16.88) 109.05 (12.41)

16.26 (3.83) 16.13 (3.79) 120.21 (14.18) 87.57 (8.55)

16.80 (3.26) 15.46 (3.93) 109.23 (9.49) 88.21 (8.66)

20.20 (5.12) 22.66 (3.83) 163.02 (15.12) 110.52 (11.68)

14.93 (4.29) 17.00 (4.29) 119.46 (11.63) 94.46 (10.74)

14.60 (3.50) 16.13 (3.50) 117.46 (10.74) 88.93 (6.67)

22.00 (5.53) 19.46 (4.65) 162.07 (18.66) 105.61 (9.17)

23.33 (4.88) 24.00 (5.38) 171.60 (16.17) 115.30 (9.17)

25.20 (4.95) 23.46 (5.89) 170.97 (13.45) 115.25 (7.29)

Anxiety Blood pressure (systolic; mm Hg) Blood pressure (diastolic; mm Hg)

SMT

CG

BL: baseline; FU: follow-up; MDM: metacognitive detached mindfulness therapy; SMT: stress management training; CG: control group. Values are means and, in parentheses, standard deviations.

Table 4. Inferential statistical overview of symptoms of depression and anxiety, and blood pressure, separately for Time (baseline, post-test 8 weeks later, and follow-up again 8 weeks later), and Group (MDM, SMT, CG). Factors

Time

Group

Time × Group interaction

F, partial eta2

F, partial eta2

F, partial eta2

Depression Anxiety Blood pressure 1 Blood pressure 2

59.39***, .59 50.95***, .55 129.65***, .76 31.43***, .43

10.39***, .33 4.26*, .17 28.57***, .78 19.62***, .48

41.40***, .66 78.06***, .79 48.32***, .70 30.40***, .59

Post hoc tests Greenhouse– Geisser epsilon

.83 .91 .90 .94

BL

Post

Follow-up

– – – –

Is

[Acute pharmacotherapy for anxiety symptoms in patients with depression].

Integrating pharmacotherapy and psychotherapy.

Cognitive therapy and pharmacotherapy for depression. Singly and in combination.

Combined pharmacotherapy and psychotherapy in the treatment of mild to moderate major depression?

The pharmacotherapy of depression.

Combined pharmacotherapy and psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: a preliminary report.

Effects of captopril on blood pressure and respiratory function compared to verapamil in patients with hypertension and asthma.

Pharmacotherapy of generalized anxiety disorder.

Pharmacotherapy of adolescent depression.

Pharmacotherapy of childhood anxiety disorders.

Adherence to pharmacotherapy and medication-related beliefs in patients with hypertension in Lima, Peru.

Biological measures as predictors of response to pharmacotherapy and psychotherapy.

Integrating psychotherapy and pharmacotherapy in the treatment of premature ejaculation.

The effects of blinding on the outcomes of psychotherapy and pharmacotherapy for adult depression: A meta-analysis.

Approaches to improve adherence to pharmacotherapy in patients with schizophrenia.

The pharmacotherapy of minor depression.

Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects.

Pulmonary arterial hypertension: a review in pharmacotherapy.

Pre-hypertension: rationale for pharmacotherapy.

Pharmacotherapy of generalized anxiety disorder: focus and update on pregabalin.

Effects of Pharmacotherapy on Combat-Related PTSD, Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis.

Depression, Anxiety, and Pharmacotherapy Around the Time of Pregnancy in Hawaii.

Cognitive therapy and pharmacotherapy for depression.

Mind over PMDD: A Glimpse into the Process of Pharmacotherapy-Psychotherapy Combination Treatment.