Meta-Analysis
Copyright ©The Author(s) 2021.
World J Psychiatr. Nov 19, 2021; 11(11): 1147-1166
Published online Nov 19, 2021. doi: 10.5498/wjp.v11.i11.1147
Table 1 Characteristics of randomized controlled trials included in this meta-analysis
Ref.
Country
Sample size (I/C)
Gender: female, n (%)
Age (mean ± SD)
CHD diagnosis
Intervention
Format
Manual
Control group
Outcome
Measurement
Drop-out rate (%)
Quality of article
Barth et al[29], 2005Germany59 (27/32)I: 5 (18.50) C: 9 (28.10)I: 60.81 ± 11.06 C: 55.62 ± 10.05MI; CABG; PTCA; Unstable Angina PectorisCBT based interventionIndividualYesUC(2)BDI; HADSI: 0.00 C: 12.507 (moderate)
Beresnevaitė et al[24], 2016Lithuania150 (79/71)I: 13 (30.20) C: 14 (30.40)I: 56.70 ± 10.20 C: 59.10 ± 11.10CABG; valve replacement; valve repair surgeryCBTIndividualYesUC(3), (5)SF36I: 45.57 C: 35.214 (moderate)
Berkman et al[14], 2003United States2481 (1238/1243)I: 532 (43.00) C: 552 (44.00)I: 61.00 ± 12.60 C: 61.00 ± 12.50MICBTIndividual + groupNoUC(2)BDII: 7.51 C: NR7 (moderate)
Blumenthal et al[30], 2016United States151 (76/75)I: 31 (41.00) C: 24 (32.00)I: 61.80 ± 10.80 C: 60.40 ± 10.60ACS; stable angina; coronary revascularizationCR + SMTGroupNoCR(2), (3)BDI-II; STAI; PSS; GHQI: 3.95 C: 4.007 (moderate)
Claesson et al[31], 2006Sweden198 (101/97)I: 101 (100.00) C: 97 (100.00)I: 59.40 ± 9.30 C: 62.20 ± 7.70AMI; CABG; coronary angioplasty; angina pectorisCBT based interventionGroupNoUC(1), (2), (3), (5)ELSS; CPRS-S-AI: 23.76 C: 15.466 (moderate)
Dao et al[32], 2011United States100 (50/50)I: 11 (22.90) C: 10 (20.40)I: 62.80 ± 11.80 C: 64.20 ± 11.90A CAD diagnosis and were scheduled to undergo a first-time CABGCBTIndividualNoUC(2), (3)BDI-II; STAI SF12I: 4.00 C: 4.006 (moderate)
Freedland et al[33], 2009United States123 (41/42/40)1I: 23 (56.00) C1: 21 (50.00) C2: 17 (43.00)I: 62.00 ± 11.00 C1: 59.00 ± 10.00 C2: 61.00 ± 9.00CABGCBT + UCIndividualYesSSM+ UC; UC(2), (3)BDI; BAI PSS; SF36I: 2.44 C1: 11.90 C2: 7.507 (moderate)
Javaheri et al[34], 2020United States34 (18/16)I: 7 (38.89) C: 2 (12.50)I: 70.30 ± 10.00 C: 72.90 ± 9.20MI; coronary artery revascularization; angiographically documented stenosis of a major coronary arteryGeneral sleep education + web-based CBTIndividualNoWait-list(1), (2), (3)PHQ-8; Duke Health ProfileI: 16.67 C: 11.115 (moderate)
Koertge et al[38], 2008Sweden247 (119/128)I: 119 (100.00) C: 128 (100.00)I: 61.36 ± 9.10 C: 62.73 ± 8.72AMI; PCI; CABGCBT based interventionGroupNoUC(2)BDII: 17.65 C: 20.317 (moderate)
Lv et al[25], 2016China75 (38/37)I: 12 (31.58) C: 10 (27.03)I: 52.40 ± 6.30 C: 52.00 ± 6.20PCICBT + UCIndividualNoUC(2), (3)HAM-D HAM-A CROQ-PTCA-POSTI: 0.00 C: 0.006 (moderate)
Merswolken et al[36], 2011Germany62 (30/32)I: 6 (24.00) C: l8 (30.00)I: 62.50 ± 8.30 C: 59.80 ± 7.50 MI; angiographically documented CHDCBT based interventionGroupNoBlank control(2)HADSI: 16.67 C:15.635(moderate)
Murphy et al[37], 2013Australia275 (139/136)I: 15 (10.79) C: 22 (16.18)I: 58.02 ± 8.87 C: 59.92 ± 9.27MI; CABG; PCICBTGroupYesUC(1), (4), (5)6MWTI: 14.39 C: 16.917 (moderate)
Nehra et al[26], 2012India50 (25/25)NRNRMI; APCBTIndividualNoUC(2)PSSI: 0.00 C: 0.005 (moderate)
Nejati et al[27], 2020Iran51 (17/17/17)2I: 7 (41.18) C1: 4 (23.53) C2: 5 (29.41)I: 59.00 ± 10.48 C1: 57.00 ± 9.17 C2: 58.00 ± 9.77CABG; coronary angiographyCBTGGroupNoCTG; UC(2)BDI-II; DASS-21I: 0.00 C: 0.006 (moderate)
Norlund et al[38], 2018Sweden239 (117/122)I: 44 (37.60) C: 36 (29.50)I: 58.40 ± 9.00 C: 60.80 ± 7.80MIiCBTIndividualNoUC(2)HADSI: 17.95 C: 5.747 (moderate)
O’Neil et al[39], 2014Australia121 (61/60)I: 16 (26.20) C:14 (23.30)I: 61.00 ± 10.20 C: 58.90 ± 10.70ACS; unstable anginaCBT based intervention(telephone)IndividualNoUC(2), (3)PHQ-9;SF-12I: 13.11 C: 11.679 (high)
Rafanelli et al[16], 2020Italy100 (50/50)I: 19 (38.00) C: 12 (24.00)I: 57.64 ± 9.99 C: 60.02 ± 10.94MI; unstable anginaCBT + WBTIndividualNoCM(1), (2), (5)SQI: 16.00 C: 20.007 (moderate)
Schneider et al[40], 2020Canada53 (25/28)I: 12 (48.00) C: 19 (67.90)I: 56.72 ± 11.90 C: 59.29 ± 6.93MI; unstable anginaiCBTIndividualNoWait-list(2), (3)PHQ-9;GAD-7; DASS-21;SF-12I: 12.00 C: 7.147 (moderate)
Turner et al[18], 2013Australia57 (25/32)I: 6 (24.00) C: 5 (28.13)I: 61.00 ± 11.00 C: 62.00 ± 9.00ACS; PCI; CABGCBTGroupYesBI(2)BDI-II;HADS-AI: 16.00 C: 3.137 (moderate)
Turner et al[41], 2014Australia42 (21/21)I: 3 (14.29) C: 6 (28.57)I: 55.60 ± 8.80 C: 57.00 ± 11.20AMI; CABG; PCIiCBTGroupYesUC(1), (2), (4)BDI-II; HADS-A 6MWTI: 28.57 C: 23.815 (moderate)
Zeighami et al[28], 2018Iran90 (30/30/30)3I: 10 (33.33) C1: 9 (29.90) C2: 12 (40.10)47.62 ± 8.93MICBTNrNoEMDR(2)BAINR4 (moderate)
Zetta et al[42], 2011United Kingdom233 (116/117)I: 31 (28.00) C: 38 (35.00)I: 64.80 ± 10.04 C: 65.94 ± 9.96 AnginaCBT based interventionIndividualNoUC(1), (2), (3)HADS; SF-36I: 6.03 C: 6.847 (moderate)
1I = Cognitive behavioral therapy (CBT) + usual care (UC); C1 = Supportive stress management (SSM) + UC; C2 = UC.
2I = Cognitive-behavioral group intervention; C1 = Cognitive therapy in groups; C2 = UC.
3I = CBT; C1 = Eye movement desensitization reprocessing; C2 = control group.
Outcome: (1) Physiological factors (BMI, blood pressure, blood lipid profile: LDL-C, HDL-C, TG, TC); (2) Psychological factors (depression, anxiety, and stress symptoms); (3) QOL; (4) Exercise endurance; and (5) Cardiac rehabilitation. UC: Usual care; SSM: Supportive stress management; EMDR: Eye movement desensitization reprocessing; CBTG: Cognitive-behavioral group intervention; MI: Myocardial infarction; AMI: Acute myocardial infarction; PCI: Percutaneous coronary intervention; CABG: Coronary artery bypass grafting; ACS: Acute coronary syndrome; PTCA: Percutaneous transluminal coronary angioplasty; AP: Angina pectoris; iCBT: Internet-cognitive behavioral therapy; CR: Cardiac rehabilitation; SMT: Stress management training; WBT: Well-being therapy; CM: Clinical management; BI: No further intervention; NR: No report; BDI: Beck Depression Inventory; HADS: Hospital Anxiety and Depression Scale; SF-36: 36-Item Short Form Health Survey; BDI-II: Beck Depression Inventory II; STAI: State-Trait Anxiety Inventory; PSS: Perceived Stress Scale; GHQ: General Health Questionnaire; ELSS: The Everyday Life Stress Scale; CPRS-S-A: Comprehensive Psychopathological Rating Scale Self-Affective; SF-12: Short Form-12 Health Survey; BAI: Beck Anxiety Inventory; PHQ-8: Patient Health Questionnaire-8; HAM-D: Hamilton Depression Rating Scale; HAM-A: Hamilton Anxiety Scale; CROQ-PTCA-POST: Coronary Revascularization Outcome Questionnaire; 6MWT: 6-Minite Walk Distance Test; DASS-21: Depression Anxiety, Stress Scales; PHQ-9: Patient Health Questionnaire-9; SQ: Symptom Questionnaire; GAD-7: General Anxiety Disorder 7-Item.
Table 2 Total effect of cognitive behavioral therapy -based interventions on depression, anxiety, stress symptoms, body mass index, blood pressure, total cholesterol, high-density lipoprotein cholesterol, quality of life, and 6-min walk test distance
Index
Outcomes: Post-to pre-treatment effect
Studies, n
Participant
I2 % (P value)
Q-test
MD (95%CI)
P value
SMD (95%CI)
P value
Depression18357983 (< 0.001)102.69-2.00 (-2.83, -1.16)c< 0.001-0.42 (-0.60, -0.24)c< 0.001
Anxiety14129391 (< 0.001)142.05-2.07 (-3.39, -0.75)b0.002 -0.42 (-0.72, -0.11)b0.008
Stress536922 (0.280)5.11-3.33 (-4.23, -2.44)c< 0.001-0.62 (-0.83, -0.40)c< 0.001
BMI23770 (0.550)0.36-0.47 (-0.81, -0.13)b0.006 -0.23 (-0.43, -0.02)a0.030
Systolic pressure44371 (0.390)3.04-1.82 (-5.12, 1.49)0.280-0.10 (-0.29, 0.09)0.290
Diastolic pressure44370 (0.870)0.72-0.95 (-2.75, 0.86)0.300-0.09 (-0.28, 0.09)0.330
TC21310 (0.390)0.750.15 (-0.81, 1.12)0.7600.15 (-0.19, 0.50)0.380
HDL-C21310 (0.890)0.020.07 (-0.09, 0.23)0.3900.05 (-0.29, 0.40)0.760
Physical function766649 (0.070)11.773.36 (1.63, 5.10)c0.0000.27 (0.12, 0.43)b0.001
Mental function541952 (0.080)8.286.91 (4.10, 9.73)c< 0.0010.71 (0.41, 1.00)c< 0.001
6-minute walk test distance22790 (0.550)0.359.64 (-11.80, 31.08)0.3800.11 (-0.13, 0.34)0.380
aP < 0.05
bP < 0.01
cP < 0.001.
MD: Mean difference; SMD: Standard mean difference; BMI: Body mass index; TC: Total cholesterol; HDL-C: High-density lipoprotein cholesterol; CI: Confidence interval.
Table 3 Subgroup analysis on the effect of cognitive behavioral therapy-based interventions on depression symptoms
Subgroups
Depressive symptom: Post- to pre-treatment effect
Studies (n)
Participants (n)
I2 % (P value)
Q-test
MD (95%CI)
SMD (95%CI)
P value (between)
Treatment form0.030
Group8258172 (0.001)24.86-0.96 (-2.16, 0.24)-0.17 (-0.32, -0.02)a
Individual10106188 (< 0.001)75.51-2.97 (-4.33, -1.62)c-0.66 (-0.97, -0.35)c
Treatment course0.200
≥ 12 wk11319481 (< 0.001)51.97-1.28 (-2.07, -0.50)b-0.34 (-0.54, -0.14)c
< 12 wk628868 (0.008)15.69-2.83 (-5.08, -0.57)a-0.54 (-1.05, -0.02)a
Duration of a session0.070
≥ 50 min11278884 (< 0.001)62.43-2.25 (-3.68, -0.81)b-0.34 (-0.55, -0.13)b
< 50 min343913 (0.320)2.30-0.86 (-1.36, -0.35)c-0.46 (-1.11, 0.19)
Number of sessions0.330
≥ 109287682 (< 0.001)43.75-1.62 (-2.76, -0.49)b-0.28 (-0.45, -0.12)c
< 10848580 (< 0.001)35.88-2.90 (-5.22, -0.59)a-0.50 (-0.92, -0.09)b
Treatment delivery way0.410
Remote547381 (0.000)20.63-2.73 (-4.78, -0.67)b-0.58 (-0.97, -0.19)b
Face to face13310685 (< 0.001)77.45-1.77 (-2.78, -0.77)c-0.37 (-0.59, -0.16)c
Manual available0.610
Yes421284 (0.000)19.24-3.27 (-9.09, 2.55)-0.39 (-1.07, 0.30)
No14336783 (< 0.001)76.32-1.76 (-2.56, -0.96)c-0.42 (-0.62, -0.23)c
Drop-out0.610
≥ 20%219734 (0.220)1.51-1.31 (-4.21, 1.59)-0.23 (-0.51, 0.05)
< 20%16338285 (< 0.001)100.58-2.10 (-3.04, -1.17)c-0.44 (-0.64, -0.24)c
Psycho-education strategies0.440
Important15336782 (< 0.001)76.48-1.78 (-2.59, -0.97)c-0.40 (-0.59, -0.21)c
Not important321292 (< 0.001)24.52-4.60 (-11.79, 2.58)-0.54 (-1.37, 0.28)
Behavioral strategies0.005
Important13331587 (< 0.001)95.77-2.48 (-3.47, -1.48)c-0.52 (-0.73, -0.31)c
Not important526411 (0.340)4.50-0.30 (-1.45, 0.85)-0.05 (-0.30, 0.20)
Cognitive strategies0.670
Important16344885 (< 0.001)99.64-2.11 (-2.99, -1.23)c-0.45 (-0.64, -0.26)c
Not important213153 (0.150)2.11-1.18 (-5.38, 3.03)-0.14 (-0.65, 0.37)
Affective strategies0.005
Important24130 (0.680)0.18-0.49 (-1.32, 0.34)-0.09 (-0.29, 0.10)
Not important16316685 (< 0.001)100.55-2.32 (-3.30, -1.33)c-0.47 (-0.68, -0.27)c
Interpersonal strategies0.230
Important4242280 (0.002)15.31-1.29 (-2.67, 0.09)-0.21 (-0.37, -0.05)b
Not important14115784 (< 0.001)80.72-2.40 (-3.55, -1.25)c-0.52 (-0.79, -0.24)c
Body directed strategies0.070
Important9287670 (0.001)26.46-1.20 (-1.91, -0.49)c-0.33 (-0.53, -0.12)b
Not important970388 (< 0.001)66.33-3.47 (-5.84, -1.10)b-0.54 (-0.92, -0.17)b
Homework assignment strategies0.890
Important6231483 (< 0.001)29.48-2.07 (-3.75, -0.38)b-0.32 (-0.60, -0.05)a
Not important12126580 (< 0.001)55.64-1.93 (-2.96, -0.90)c-0.47 (-0.74, -0.20)c
aP < 0.05.
bP < 0.01.
cP < 0.001.
MD: Mean difference; SMD: Standard mean difference; CI: Confidence interval.
Table 4 Subgroup analysis on the effect of cognitive behavioral therapy-based interventions on anxiety symptoms
Subgroups
Anxiety symptom: Post- to pre-treatment effect
Studies (n)
Participant (n)
I2 % (P value)
Q-test
MD (95%CI)
SMD (95%CI)
P value (between)
Treatment form0.100
Group532050 (0.090)7.96-1.24 (-2.63, 0.15)-0.27 (-0.57, 0.04)
Individual891394 (< 0.001)123.83-3.25 (-5.17, -1.32)b-0.62 (-1.05, -0.18)b
Treatment course0.280
≥ 12 wk893573 (0.001)25.76-0.73 (-1.69, 0.23)-0.16 (-0.40, 0.08)
< 12 wk526190 (< 0.001)38.38-2.47 (-5.48, 0.54)-0.63 (-1.37, 0.12)
Duration of session0.050
≥ 50 min965289 (< 0.001)71.35-2.49 (-4.88, -0.09)a-0.43 (-0.86, -0.00)
< 50 min23180 (0.540)0.38-0.12 (-0.35, 0.11)-0.13 (-0.35, 0.09)
Number of session0.150
≥ 10661779 (0.000)23.89-0.98 (-2.77, 0.80)-0.18 (-0.54, 0.18)
< 10745892 (< 0.001)70.66-3.50 (-6.42, -0.58)a-0.66 (-1.23, -0.10)a
Treatment delivery way0.390
Remote438394 (< 0.001)51.28-0.59 (-4.68, 3.51)-0.29 (-1.17, 0.59)
Face to face1091090 (< 0.001)88.49-2.54 (-4.17, -0.90)b-0.47 (-0.78, -0.16)b
Manual available0.200
Yes421450 (0.110)6.03-0.86 (-2.73, 1.02)-0.19 (-0.52, 0.13)
No10107993 (< 0.001)135.85-2.48 (-4.12, -0.84)b-0.52 (-0.91, -0.12)a
Psycho-education strategies0.140
Important10102193 (< 0.001)128.71-2.71 (-4.29, -1.13)c-0.57 (-0.95, -0.19)b
Not important427277 (0.004)13.30-0.14 (-3.14, 2.86)-0.03 (-0.54, 0.48)
Behavioral strategies0.003
Important999894 (< 0.001)134.13-3.46 (-5.33, -1.60)c-0.67 (-1.07, -0.27)b
Not important529547 (0.110)7.570.13 (-1.27, 1.54)0.05 (-0.26, 0.36)
Cognitive strategies0.020
Important11110293 (< 0.001)134.22-2.84 (-4.37, -1.31)c-0.57 (-0.91, -0.22)b
Not important319172 (0.030)7.261.06 (-1.95, 4.06)0.16 (-0.37, 0.69)
Interpersonal strategies0.190
Important239046 (0.180)1.84-0.59 (-2.50, 1.32)-0.09 (-0.31, 0.13)
Not important1290392 (< 0.001)140.01-2.30 (-4.01, -0.59)b-0.48 (-0.86, -0.10)a
Body directed strategies0.150
Important569467 (0.020)12.22-0.64 (-1.51, 0.22)-0.19 (-0.43, 0.05)
Not important959991 (< 0.001)87.09-2.73 (-5.43, -0.02)-0.50 (-1.01, 0.00)
Homework assignment strategies0.640
Important552991 (< 0.001)45.80-2.60 (-5.42, 0.23)-0.61 (-1.17, -0.04)a
Not important976491 (< 0.001)84.86-1.79 (-3.62, 0.04)-0.31 (-0.72, 0.09)
aP < 0.05.
bP < 0.01.
cP < 0.001.
MD: Mean difference; SMD: Standard mean difference; CI: Confidence interval.
Table 5 Egger's regression analysis on publication bias
Variables
T
P value
95%CI
Depression symptom-0.750.467-2.60, 1.25
Anxiety symptom-1.370.196-7.36, 1.68
Stress symptom-4.420.021-9.65, -1.57
BMI---
Systolic pressure0.780.516-4.71, 6.80
Diastolic pressure-0.240.836 -3.48, 3.12
Total cholesterol---
HDL---
Physical function-0.230.829-5.76, 4.83
Mental function2.030.135-3.83, 17.40
6-min walk distance---
BMI: Body mass index; HDL: High-density lipoprotein; CI: Confidence interval.