SACM - United Kingdom
Permanent URI for this collectionhttps://drepo.sdl.edu.sa/handle/20.500.14154/9667
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Item Restricted Does Integrating Cognitive Behavioural Therapy into Cardiac Rehabilitation Improve Depression and Quality of Life in Adults with Cardiovascular Disease? A Systematic Review.(Cardiff University, 2025) Alqahtani, Ola; Gale, NicholaDoes Integrating Cognitive Behavioural Therapy into Cardiac Rehabilitation Improve Depression and Quality of Life in Adults with Cardiovascular Disease? A Systematic Review. Background & Rationale Cardiovascular disease (CVD) is the world’s leading cause of death and disability, placing significant clinical and economic burdens on healthcare systems. While cardiac rehabilitation (CR) encompassing exercise, education, and routine psychosocial support has been shown to improve clinical outcomes, up to thirty percent of cardiac patients experience clinically meaningful depressive symptoms which reduce CR adherence and long-term success. Cognitive behavioural therapy (CBT) offers a structured approach to modifying maladaptive thoughts and behaviours, potentially addressing psychological barriers more effectively than generic psychosocial support. However, many reviews have evaluated heterogeneous ‘psychological interventions’ rather than isolating CBT’s specific impact. This systematic review set out to determine whether CBT, when integrated into CR, alleviates depression and enhances health-related quality of life (HRQoL) more effectively than CR alone. Methods A systematic literature search was conducted across five major databases (Medline, EMBASE, CINAHL, Cochrane CENTRAL, and PsycINFO) from inception to the most recent feasible date, adhering to PRISMA guidelines for study selection and reporting. Six randomised controlled trials, totalling 708 participants, satisfied the inclusion criteria by focusing on adults (≥18 years) undergoing CR for various cardiac conditions (such as myocardial infarction, heart failure, or post-cardiac surgery). Studies which integrated structured CBT sessions into standard CR were compared to CR alone or other forms of standard care. The primary outcome was the reduction in depressive symptoms, measured by validated scales (e.g., the Hamilton Rating Scale for Depression or the Hospital Anxiety and Depression Scale (HADS)). Secondary outcomes involved changes in HRQoL, assessed by either generic or cardiac-specific instruments (such as the Minnesota Living with Heart Failure Questionnaire). Quality appraisal followed the Joanna Briggs Institute guidelines and due to heterogeneity in intervention formats, population characteristics, and outcome measures, a narrative synthesis approach was applied rather than a meta-analysis. Key Findings and Discussion Although the six trials varied in terms of sample size, intervention intensity, and follow-up duration, they shared an overarching conclusion that integrating CBT within CR can lead to notable reductions in depressive symptoms and meaningful improvements in HRQoL. The degree of benefit was generally greater in patients presenting with moderate-to-severe baseline depression. Face-to-face CBT delivery typically achieved better adherence (often exceeding 75%) and larger effect sizes, whereas fully digital CBT programmes suffered from low engagement (approximately 15% module completion). These findings suggest that the personal interaction and therapeutic alliance inherent in face-to-face sessions remain critical for maximising CBT’s clinical impact in cardiac populations, particularly those facing multiple stressors related to their disease. CBT combined with exercise, in several trials, appeared to deliver synergistic benefits for depression and HRQoL, possibly through complementary behavioural (cognitive restructuring and skill-building) and physiological (improved cardiovascular function) mechanisms. The interplay between exercise encouragement and cognitive-behavioural strategies against fear-avoidance thinking also emerged as an important determinant of enhanced functional capacity and sustained improvements in mood. Limitations Several limitations may constrain the generalisability of these results. First, the overall sample predominantly comprised of male participants (approximately two-thirds were male), leaving questions regarding whether women, who often exhibit different depressive symptom profiles and a greater prevalence of depression post-myocardial infarction, would experience similar outcomes. Second, varied measures of depression and HRQoL, along with wide differences in the intervention ‘dose’ (ranging from five-session brief interventions to twelve-week combined programmes), precluded direct quantitative comparisons across studies. Some trials were also underpowered and only a few extended follow-up beyond six to twelve months. Digital CBT approaches did not yield strong results in this review but that may reflect poor adherence rather than intrinsic ineffectiveness, highlighting a need for more engaging and personalised technological platforms. Finally, these RCTs spanned multiple healthcare settings in Europe and the United States where infrastructural and cultural factors might influence both the feasibility of CBT delivery and participant engagement. Conclusions and Recommendations This review provides evidence that structured CBT, when delivered in tandem with cardiac rehabilitation, can significantly alleviate depressive symptoms and promote better quality of life. The most robust outcomes were observed in trials that targeted moderate-to-severe depression, employed face-to-face group or individual CBT sessions, and ensured consistent patient follow-up. These findings strengthen the case for systematically screening CR entrants for depressive symptoms and offering a dedicated CBT component to those above a certain severity threshold. Practical feasibility can be enhanced by training nurses, physiotherapists, or other allied professionals in CBT skills, as illustrated in studies where task shifting maintained strong outcomes. Policy-making bodies, such as national cardiac societies and health agencies, may wish to recommend CBT as a priority psychological intervention in CR programmes, particularly for patients with moderate or severe depression. Future research should further refine the optimal ‘dose’ of CBT, compare blended or stepped-care digital and in-person models, and evaluate the cost-effectiveness to guide broader adoption. By focusing on cognitive restructuring and behaviour change within the supportive framework of CR, healthcare systems can potentially improve both the mental health and functional recovery of individuals with CVD.7 0Item Restricted The Perceptions of Healthcare Professionals on Cardiac Rehabilitation for Patients with Cardiac Conditions: A Systematic Review(Queen's University Belfast, 2025-02-14) Althagafi, Abdullah; Gemma, CaughersBackground Cardiac Rehabilitation (CR) is a crucial component of secondary prevention for cardiac patients, such as those with heart failure (HF). Despite its well-documented benefits, including a 20%-25% reduction in all-cause mortality and a 38% decrease in recurrent myocardial infarctions, participation remains suboptimal. Understanding nurses’ and healthcare professionals’ (HCPs) perceptions of CR is essential to identifying barriers, facilitators, and preferred delivery models, particularly in Saudi Arabia and other low- and middle-income countries (LMICs). Aim This systematic review examines nurses’ and HCPs’ perceptions of CR, focusing on barriers, facilitators, and preferred delivery models. Methods A Mixed-Methods Systematic Review (MMSR) approach was followed to synthesise findings from seven studies conducted across Saudi Arabia, China, Iran, and Namibia. A systematic search of relevant databases was conducted, and studies were critically appraised using standardised tools. Key themes were identified through thematic analysis. Results Five key themes emerged: awareness and perceptions of CR, barriers to CR implementation, preferred modes of delivery (home-based vs. hospital-based), the role of training and professional development, and the integration of cultural factors. Institutional, professional, and patient-related barriers were identified, including limited CR facilities, staff shortages, and financial constraints. While home-based CR was preferred for accessibility, it faced compliance challenges, whereas hospital-based CR provided structured care but remained costly. Conclusion Findings underscore the need for context-specific, hybrid CR models integrating telehealth, enhanced professional training, and policy interventions to improve CR uptake. Addressing these factors is essential to ensure equitable access and improved cardiovascular outcomes globally. Future research should explore long-term CR effectiveness and culturally tailored interventions.11 0Item Restricted The Association Between Waiting Time and Starting, Completion and Outcomes in Post-Surgical Cardiac Rehabilitation Patients Following Sternotomy(2022) AlOtaibi, Kholoud; Doherty, Patrick; Harrison, AlexanderAim: Prolonged waiting times for post-surgical cardiac rehabilitation (CR) patients following median sternotomy may influence their chances of starting, completing, and potentially determine the extent by which patients benefit. This thesis aims to determine the level of association between waiting time and CR utilisation and outcomes for patients following sternotomy. Methods: A literature review was conducted in 2019 and updated in 2022 using Ovid MEDLINE, Ovid Embase and CENTRAL to identify and critically appraise eligible papers published since 2000. Overall 26 eligible papers were included and critically appraised using PEDro score and JBI tools. In reviewing the papers, key variables were identified that were included in the NACR and subsequent analysis, in addition to providing an evidential comparison for the thesis’ findings. The data collected by the National Audit of Cardiac Rehabilitation (NACR) for the period between January 2013 to December 2019 were used for in the following observational studies: • Starting CR and waiting time using a logistic regression model, employing complete case analysis, to assess the association between CR starting and waiting time, patient factors and cardiac-event factors. • CR completion and waiting time using a logistic regression model while employing multiple imputations to assess the association between CR completion and waiting time, patient factors, cardiac-event factors, pre-CR assessment factors and CR delivery factors. • CR outcomes and waiting time were used for regression analysis (9 logistics and 2 linear) as a complete case analysis to assess the association between CR outcomes of cardiovascular risk factors, psychological health and physical fitness and waiting time, patients’ factors, cardiac events factors, and CR delivery factors. Results: There were 93,869 patients post-surgery with a mean age of 67 (SD = 11) years 25% of the population were female. In accordance with clinical guidance the likelihood of post-surgical patients starting CR increased with waiting more than 6 weeks from the treatment compared to starting early and waiting up to 6 weeks by OR: 2.55 (95% CI: 2.41, 2.70). In contrast for patients who waited more than 6 weeks to start CR, their probability of completing CR decreased by OR: 0.94 (95% CI: 0.89, 0.99). Waiting longer was negatively associated with physical activity status, depression, and physical fitness measures. Conclusion: This thesis is the first to conduct observational studies of routine practice clinical data in post-sternotomy patients’ investigating waiting times and their association with CR starting, completion and outcomes. The thesis provides clinically relevant insight into waiting time and related factors that influence patients‘ chances of CR utilisation and the extent of benefit following rehabilitation. A key recommendation is that CR programmes and their patients are likely to benefit from tailoring their services according to patient factors identified as influential in this work.24 0