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Gourlay GK, Plummer JL, Cherry DA, et al. Comparison of intermittent bolus with continuous infusion of epidural morphine in the treatment of severe cancer pain. Pain 1991; 47: 135-40. 21. Hogan Q, Haddox JD, Abram S, Weissman D, Taylor ML, Janjan N. Epidural opiates and local anesthetics for the management of cancer pain. Pain 1991; 46: 271-79. 22. Payne R. Role of epidural and intrathecal narcotics and peptides in the management of cancer pain. Med Clin N Am 1987; 71: 313-28. 23. McNamara P, Minton M, Twycross RG. Use of midazolam in palliative 20.

care. Palliat Med 1991; 5: 244-49. Portenoy RK. Issues in the management of neuropathic pain. In: Basbaum AI, Besson J-M, eds. Towards a new pharmacotherapy of pain. Chichester: Wiley, 1991: 393-414. 25. Dunlop RJ. Hockley JM, Tate T, Turner P. Flecainide in cancer nerve pain. Lancet 1991; 337: 1347.

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CLINICAL PRACTICE Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services

A home-based exercise programme has been found to be as useful as a hospital-based one in improving cardiovascular fitness after an acute myocardial infarction. To find out whether a comprehensive home-based programme would reduce psychological distress, 176 patients with an acute myocardial infarction were randomly allocated to a self-help rehabilitation programme based on a heart manual or to receive standard care plus a placebo package of information and informal

counselling. Psychological adjustment, as assessed by the Hospital Anxiety and Depression Scale, was better in the rehabilitation group at 1 year. They also had significantly less contact with their general practitioners during the following year and significantly fewer were readmitted to hospital in the first 6 months. The improvement was greatest among patients who were clinically anxious or depressed at discharge from hospital. The cost-effectiveness of the home-based programme has yet to be compared with that of a hospital-based programme, but the findings of this study indicate that it might be worth offering such a package to all patients with acute myocardial infarction.

lifestyle adjustments. There is increasing evidence that a comprehensive post-MI rehabilitation programme can reduce morbidity and mortality,1-4 reduce psychological distress, aid secondary prevention, and improve quality of life.5There is also evidence of the cost of not providing such help. Poor adjustment may lead to a preoccupation with physical symptoms,6,7 a general loss of confidence, and increased health-care costs because of a greater and often inappropriate use of health services.8 Around one-third of post-MI patients who have not been rehabilitated are clinically anxious or depressed a year later.9-12 These findings have led to calls for the universal provision of cardiac rehabilitation programmes. 13-16 In the UK approximately 125 000 individuals survive their MI each year; most do not receive systematic help with rehabilitation. 17,111 Traditional comprehensive rehabilitation programmes usually require a multidisciplinary staff, gymnasia, and exercise equipment. A home exercise programme has been reported to be as useful as a hospital-based one in improving cardiovascular fitnessl9-20 after MI. This paper extends the self-help approach to encompass all the elements of comprehensive rehabilitation. Instructions for the 6-week self-help programme are given in a heart manual, which has been specifically designed to

allow any general hospital or general practice to deliver post-MI rehabilitation with the minimum of disruption

ADDRESSES: Department of Clinical Psychology (B. Lewin, M.Phil, I. R. Robertson,* PhD) and Rehabilitation Medicine Unit,

Introduction A myocardial infarction (MI) is a frightening event which requires from survivors and their families psychological and

Astley Ainslie Hospital, Edinburgh EH92HL (E L Cay, PRCP); and St John’s Hospital, Livingston (J. B. Irving, FRCP, M. Campbell, MCSP). Correspondence to Mr B. Lewin

1037

and cost and with little services.

or no

demands

on

the

TABLE I-BASELINE DATA

existing

Patients and methods The heart manual The manual was developed and piloted through work with small groups of MI patients over the course of a year by one of the authors (B. L.). The final version consisted of six weekly sections that included education, a home-based exercise programme, and a tape-based relaxation and stress management programme. Specific self-help treatments were provided for intrusive and distressing thoughts, anxiety, depression, undue illness behaviour, panic disorder, and other psychological problems commonly experienced by post-MI patients. Before the patient was discharged from hospital spouses were given an audiotape that provided information and advice and were invited to take part in the programme themselves and, if possible, to encourage compliance by the patient. The manual was then assessed in a randomised controlled trial.

Subjects The study group consisted of consecutive patients admitted to the Coronary Care Unit, St Johns Hospital, Livingston, between March, 1988, and March, 1991. Criteria for entry to the study were: confirmed MI (WHO criteria); age less than 80 years; able to speak and read English; resident in the hospital catchment area; no known history of major psychiatric illness; no current psychotic symptoms; no evidence of dementia; and no continuing uncontrolled arrhythmias or heart failure (as assessed by the cardiologist

*Results given are mean (SD). tConfldence in making full recovery

Psychological outcome was assessed by postal questionnaire at 6

[J. B. I.]).

weeks, 6 months, and

1 year.

Method

Hospital Anxiety and Depression scale

3 days after the onset of MI patients were allocated to the experimental or control group by use of a written pre-determined randomisation protocol that was stratified to control for the possibility of unequal distributions of age, social class, and initial level of psychological distress. The medical secretary who held the list was blind to the purpose of the study and to the patients taking part, and the cardiologist and nursing staff were blind to which study group the patients were in. The manual was given to the patient at discharge from hospital by the facilitator (M. C.), a member of the research staff and not part of the hospital-care team. She was instructed not to divulge the results of the randomisation.

The commonest psychiatric diagnoses attached to distressed post-MI patients are anxiety and, to a lesser extent, depression. These were quantified by use of the Hospital Anxiety and Depression Scale (HAD),22 a well-validated and widely used measure designed to identify levels of anxiety and depression that would justify pharmacological treatment in patients with concurrent physical illness.

Patients were asked not to show the heart manual to, or discuss its contents with, "anyone else who has had a heart attack". It was explained that this was important because other people might have a somewhat different problem from themselves and that the advice might therefore not be suitable for them. This statement was repeated both in the manual and on the informed consent form that the patients signed. The rehabilitation subjects, and whenever possible their spouses, were introduced to the manual by the facilitator. The control group received an equal amount of the facilitator’s time (approximately 10 min) and an extensive package of leaflets from various sources such as the British Heart Foundation, the Scottish Health Education Group, and the Flora Project for Heart Disease. This was intended to cover much the same information as that presented in the manual-ie, information about recovering from an MI, exercise, diet, cessation of smoking, and possible drug treatment. After discharge the facilitator made contact with both groups of patients at 1,3, and 6 weeks, by telephone, at a hospital clinic, or, when neither of these was possible, by brief home visits. In the case of the rehabilitation group she checked the patient’s progress with the programme, encouraged compliance with the exercises in the manual, and helped to solve any problems with the manual. These contacts were limited to approximately 10 min on each occasion; such "minimal contact" from a treatment facilitator has been shown to potentiate self-help treattnents.21 In the case of the control group she followed a similar protocol of inquiry about their recovery, gave general advice on any problem encountered, and praised and supported appropriate actions taken towards secondary prevention.

General Health Questionnaire

Many poorly adjusted post-MI patients do not have symptoms easily into the commonly used psychiatric diagnoses of or anxiety depression, so a second measure of psychological status, the 30-item General Health Questionnaire (GHQ)23 was used. This widely used and comprehensive validated psychological measure was designed for use in primary-care settings and has repeatedly been shown to be very sensitive and specific in screening for psychiatric illness;24 it measures the degree of general psychological upset, with patients scoring more than a cut-off point (5) being regarded as showing psychological "caseness". The GHQ has been useful in identifying individuals presenting with physical symptoms who have a primary psychological problem,2s and caseness has been a useful predictor of the future use of health-care resources for both that fit

mental health and non-mental-health reasons.26

Use of health services At 6 and at 12 months post discharge the patients’ general practitioners were asked about the number of contacts with the patient and whether the patient had been admitted to hospital in the preceding 6 months.

Statistical methods

Questionnaires were scored and the data entered into the statistical analysis programme by a clerical assistant based at a separate hospital who was blind both to the experimental design and to

the

patients.

Standard parametric statistical methods were employed. Group differences at individual time points were examined by use of t-tests (two tailed) and overall effects by repeated measures analysis of variance. Differences in the number of general practitioner

1038

TABLE II-ANXIETY, DEPRESSION, AND CASENESS BY GROUP AT 6 WEEKS, 6 MONTHS, AND 1 YEAR T

I

I

Fig 1-Mean anxiety scores.

Effect on anxiety,

Scores given

as mean

(SO)

consultations were tested by hospital readmissions by the

of the Mann-Whitney U test.2

use

X2

test

and

Results Recruitment

During the 3-year study period 449 patients were admitted to the coronary-care unit with acute MI. Of these 106 (24%) were not recruited because of administrative reasons (eg, holidays, discharge over weekends). Of the remainder, 75 (22%) were excluded on medical criteria, 10 (3%) on the grounds of age, 10 (3%) on residence criteria, 9 (3%) for psychiatric reasons, and 4 (1%) because of language or reading difficulties. 235 patients met the entry criteria, 26 (11%) declined to take part in the study, and 19 (8%) died before randomisation. The remaining 190 (81 %) patients were randomly allocated to the experimental or control group after giving informed consent. Of those entering the study, 14 (7%) subsequently withdrew before the first follow-up period; 7 were from the experimental and 7 from the control group. 8 withdrew voluntarily, 3 because of medical complications, and 3 because they died. These patients did not differ in baseline measures from those continuing in the study.

depression, and caseness (GHQ score) At 6 weeks questionnaires were returned by 167 (95 %) of the 176 patients available for follow-up, at 6 months by 128 (89%) of 144, and at 12 months by 110 (84%) of 131. Anxiety scores showed a significant treatment effect at 6 weeks and 1 year and a trend to significance at 6 months, (table n, fig 1), whereas depression scores did so only at 6 weeks (table 11, fig 2). Caseness was significantly lower for the rehabilitation group at 6 weeks, 6 months, and 1 year (table 11). A repeated measures analysis of variance showed a significant effect of treatment between groups across time for anxiety (p < 004) and caseness (p < 001) but not for Baseline measures were not included depression (p 0’ 11). as covariates in the analysis of variance because the =

rehabilitation group were more distressed than controls on all of the measures examined before intervention and any resulting bias would have favoured the control treatment.

Psychologically distressed group Before discharge 92 (52%) patients had HAD scores indicating clinically significant anxiety or depression (8 or above on the anxiety or depression sub-scales). Within this

Comparability of treatment groups (table I) Before intervention there were no major differences between the rehabilitation and control groups in any of the demographic or physiological measures, but the controls were less likely to be working and to have had a previous MI. There was a tendency for the rehabilitation group to be more distressed than controls on all psychological variables. Since the study was terminated before all the patients reached the 6 and 12 month follow-up points (because the funding had expired), the numbers available at these times vary. The rehabilitation group did not differ from the control group in numbers available for follow-up or in

questionnaire return rates.

v

v

yy