title: The Effect of Guided Web-Based Cognitive Behavioral Therapy on Patients With Depressive Symptoms and Heart Failure: A Pilot Randomized Controlled Trial.
abstract: Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategies for depressive symptoms in patients with HF still remain to be established. Internet-based cognitive behavioral therapy (ICBT), as guided self-help CBT programs, has shown good effects in the treatment of depression. Until now, ICBT has not been evaluated in patients with HF with depressive symptoms.
  
  
  
  The aims of this study were to (1) evaluate the effect of a 9-week guided ICBT program on depressive symptoms in patients with HF; (2) investigate the effect of the ICBT program on cardiac anxiety and QoL; and (3) assess factors associated with the change in depressive symptoms.
  
  
  
  Fifty participants were randomized into 2 treatment arms: ICBT or a Web-based moderated discussion forum (DF). The Patient Health Questionnaire-9 was used to measure depressive symptoms, the Cardiac Anxiety Questionnaire (CAQ) was used to measure cardiac-related anxiety, and the Minnesota Living with Heart Failure questionnaire was used to measure QoL. Data were collected at baseline and at follow-up at the end of the 9-week intervention. Intention-to-treat analysis was used, and missing data were imputed by the Expectation-Maximization method. Between-group differences were determined by analysis of covariance with control for baseline score and regression to the mean.
  
  
  
  No significant difference in depressive symptoms between the ICBT and the DF group at the follow-up was found, [F(1,47)=1.63, P=.21] and Cohen´s d=0.26. Secondary within-group analysis of depressive symptoms showed that such symptoms decreased significantly in the ICBT group from baseline to the follow-up (baseline M=10.8, standard deviation [SD]=5.7 vs follow-up M=8.6, SD=4.6, t(24)=2.6, P=.02, Cohen´s d=0.43), whereas in the DF group, there was no significant change (baseline M=10.6, SD=5.0, vs follow-up M=9.8, SD=4.3, t(24)=0.93, P=.36. Cohen´s d=0.18). With regard to CAQ and QoL no significant differences were found between the groups (CAQ [d(1,47)=0.5, P=.48] and QoL [F(1,47)=2.87, P=.09]). In the ICBT group in the CAQ subscale of fear, a significant within-group decrease was shown (baseline M=1.55 vs follow-up M=1.35, P=.04). In the ICBT group, the number of logins to the Web portal correlated significantly with improvement in depressive symptoms (P=.02), whereas higher age (P=.01) and male sex (P=.048) were associated with less change in depressive symptoms. This study is underpowered because of difficulties in the recruitment of patients.
  
  
  
  Guided ICBT adapted for persons with HF and depressive symptoms was not statistically superior to participation in a Web-based DF. However, within the ICBT group, a statically significant improvement of depressive symptoms was detected.
  
  
  
  Clinicaltrials.gov NCT01681771; https://clinicaltrials.gov/ct2/show/NCT01681771 (Archived by WebCite at http://www.webcitation.org/6ikzbcuLN).
authors.affiliation: Division of Nursing Science, Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden. johan.lundgren@liu.se.
authors.forename: Johan Gustav
authors.identifier: 0000-0003-3964-747X
authors.initials: JG
authors.lastname: Lundgren
authors.forename: Örjan
authors.identifier: 0000-0002-3955-0443
authors.initials: Ö
authors.lastname: Dahlström
authors.forename: Gerhard
authors.identifier: 0000-0003-4753-6745
authors.initials: G
authors.lastname: Andersson
authors.forename: Tiny
authors.identifier: 0000-0002-4197-4026
authors.initials: T
authors.lastname: Jaarsma
authors.forename: Anita
authors.identifier: 0000-0002-2646-8715
authors.initials: A
authors.lastname: Kärner Köhler
authors.forename: Peter
authors.identifier: 0000-0001-7431-2873
authors.initials: P
authors.lastname: Johansson
mesh_terms: D000328:Adult; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003863:Depression / Q000628:therapy*; D005260:Female; D015438:Health Behavior; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011788:Quality of Life; D011795:Surveys and Questionnaires; D017216:Telemedicine / Q000379:methods*; D013813:Therapy, Computer-Assisted / Q000379:methods*
keywords: Internet; Internet-based cognitive behavioral therapy; cognitive behavioral therapy; depression; eHealth; heart failure