Metacognitive therapy improves depression, anxiety in CVD patients

Metacognitive therapy (MCT), when incorporated in cardiac rehabilitation (CR), is useful for managing depression and anxiety in patients with cardiovascular disease (CVD), according to the results of the PATHWAY study. This approach also confers benefits for trauma symptoms, beliefs about thinking, and unhelpful thinking styles.

“The benefits appeared to be stable over a 12-month follow-up period… The effect sizes were medium to large, compare favourably with the best reported outcomes for depression, and are better for anxiety than those obtained in earlier CVD studies,” the investigators said. [Cochrane Database Syst Rev 2017;4:CD002902; JAMA Intern Med 2014;174:927-935; JAMA Intern Med 2013;173:997-1004]

Furthermore, group MCT was safe and did not negatively affect clinic attendance for CR. There were no reports of adverse events, such as increased suicidality, death, or self-injury. 

A theory-based, structured treatment approach, MCT does away with an in-depth analysis and “cognitive challenging” (ie, challenging of patients' beliefs in the accuracy of their thoughts) that are often required in cognitive behavioural therapy. This is viewed as an advantage since the worries of patients in the CVD context are said to be “often realistic.” [Front Psychol 2018;9:2288]

“Depression and anxiety in CVD are significant, contributing to poor prognosis… MCT focuses on enabling patients to regulate repetitive negative thinking cycles such as worry and rumination and other unhelpful behaviours that research shows maintain anxiety and depression,” the investigators said.

“CR services may be particularly interested in implementing MCT rather than other approaches because it is brief, is highly structured, and can be delivered in groups irrespective of the nature of psychological problems. Delivering such an intervention within CR services has the added value of availability of specialist cardiac knowledge while avoiding delay and potential stigma associated with a secondary mental health referral,” they pointed out.

MCT adds value to CR

In PATHWAY, the investigators examined whether adding group MCT to usual CR was more effective than CR alone in alleviating symptoms of anxiety and depression in patients with CVD. They randomized 332 CR patients (mean age 60.3 years, 65.7 percent female) to undergo (n=163, 49.1 percent) or forgo (n=169, 50.9 percent) MCT.

The primary outcome of Hospital Anxiety and Depression Scale (HADS) total score at 4 months favoured MCT+CR (adjusted difference, –3.24, 95 percent confidence interval [CI], –4.67 to –1.81; p<0.001; standardized effect size, 0.52). This difference between MCT+CR and CR alone remained significant at 12 months (adjusted difference, –2.19, 95 percent CI, –3.72 to –0.66; p=0.005; standardized effect size, 0.33). [Circulation 2021;144:23-33]

When assessed separately, MCT+CR likewise produced greater reductions in both depression and anxiety symptoms compared with CR alone. Secondary outcomes were also better with MCT+CR, with medium to high effect sizes for psychological mechanisms of metacognitive beliefs and repetitive negative thinking.

“[A]n unexpected finding was that MCT+CR demonstrated lower rates of statistically reliable deterioration compared with CR at 4 months. However, the reliable change index sets a high bar with its criteria of statistically significant change within an individual, and possibly underestimates the numbers experiencing a clinically meaningful change,” the investigators noted.

“Nonetheless, [the observed] effects suggest two areas of benefit. First, the provision of MCT lowered both anxiety and depression symptom severity. Second, the provision of MCT might also reduce the risk of psychological deterioration,” they added.

CR sessions were conducted weekly over a period of 8 to 10 weeks. Meanwhile, MCT consisted of six once-weekly group sessions, each lasting 60–90 minutes. In MCT sessions, participants first identified triggering thoughts that led to worry, rumination, and other unhelpful coping behaviours. Then, they were trained in specific techniques to help them discover flexibility and control over such patterns of extended negative thinking. 

One notable limitation of the study was that the MCT sessions were delivered by CR staff—who nevertheless had received training, supervised practice, and additional workshop—rather than specialists in psychological therapies. The relatively inexperienced cardiac staff and the shorter treatment duration might explain the smaller effects of MCT seen in PATHWAY as compared with those observed among patients with primary mental health disorders in previous studies. [BJPsych Open 2018;4:393-400; Sci Rep 2020;10:7878; Front Psychol 2018;9:2211]

“The present study did not aim to test cardiac event outcomes, and therefore we have tempered our consideration of implications of the study in this respect. However, our results suggest that … group MCT has the potential to significantly improve psychological outcomes in patients with CVD and offer added value over standard CR,” according to the investigators.