The Effect of a Telephone Counseling Intervention on Self-Rated Health of Cardiac Patients KARA ZIVIN BAMBAUER,PHD, ONESKY AUPONT, MD, PHD, PETER H. STONE, MD, STEVEN E. LOCKE, MD, MARIQUITA G. MULLAN,PHD, JANE COLAGIOVANNI, AND THOMAS J. MCLAUGHLIN,SCD Objective: The objective of this study was to evaluate the effectiveness of a telephone-based intervention on psychological distress among patients with cardiac illness. Methods: We recruited hospitalized patients surviving an acute coronary syndrome with scores on the Hospital and Anxiety Depression Scale (HADS) indicating mild to severe depression and/or anxiety at 1 month postdischarge. Recruited patients were randomized into either an intervention or control group. Intervention patients received up to six 30-minute telephone-counseling sessions focused on identifying cardiac-related fears. Control patients received usual care. For both groups, we collected patients’ responses to the HADS and to the Global Improvement (CGI-I) subscale of the Clinical Global Impressions (CGI) Scale at baseline and at 2, 3, and 6 months postbaseline using Interactive Voice Recognition (IVR) technologies. We used mixed-effects analysis to estimate patients’ changes in CGI-I measures over the three time points of data collection postbaseline. Results: We enrolled 100 patients, and complete CGI-I measures were collected for 79 study patients. The mean age was 60 years (standard deviation = 10), and 67% of the patients were male. A mixed-effects analysis confirmed that patients in the intervention group had significantly greater improvements in self-rated health (SRH) between baseline and month 3 than the control group (p = .01). Between month 3 and month 6, no significant differences in SRH improvements were observed between the control and intervention groups. Conclusions: Study patients reported greater SRH improvement resulting from the telephone-based intervention compared with control subjects. Future research should include additional outcome measures to determine the effect of changes in SRH on patients with comorbid physical and emotional disorders. Key words: adjustment to chronic disease, cardiac disease, psychological distress, randomized controlled trial, self-rated health, telephone counseling. ACS = acute coronary syndrome; ADL = activities of daily living; CAD = coronary artery disease; CGI = Clinical Global Impressions Scale; CGI-I = Global Improvement subscale of the Clinical Global Impressions (CGI) Scale; ENRICHD = Enhancing Recovery in Heart Disease Patients trial; HADS = Hospital and Anxiety Depres- sion Scale; HTS = Healthcare Technology Systems; ICD-9 = International Classification of Diseases, Ninth Edition; IRB = Insti- tutional Review Boards; IVR = interactive voice recognition; MI = myocardial infarction; SADHART = the Sertraline Antidepressant Heart Attack Randomized Trial; SRH = self-rated health. INTRODUCTION S elf-rated health (SRH) has been shown repeatedly to be an important predictor of morbidity and mortality (1–7) and a major component of quality of life (7–11). Both physical and mental diseases can influence SRH (7). In addition to the impact that mental and physical disorders separately have on SRH, comorbid physical and mental diseases cause increased morbidity and mortality compared with either disease alone (12,13). For example, patients who struggle with both depres- sion and coronary artery disease (CAD) have worse health prognosis and outcomes than patients with either depression or CAD alone (14 –18). Major depression, minor depressive disorders, and anxiety are all independent risk factors for mortality and diminished quality of life in cardiac patients (19 –32). After myocardial infarction (MI), mood disorders appear to slow recovery, and have a negative impact on social functioning and capacity to perform activities of daily living (ADL) (17,33). Depressive disorders are associated with in- creased costs, in part as a result of higher rates of hospital readmission and inpatient procedures such as angiography and catheterization (17,27,30,34 –36). Both pharmacological and psychosocial treatments for mood disorders among patients with CAD can improve pa- tients’ prognosis and quality of life (22,34,37,38). Several studies also have demonstrated that psychosocial treatments focusing on social support (30,39,40), self-efficacy (41), af- fect (42), and coping style (30,43) appear to be components of an effective intervention for reducing depressive symp- toms in cardiac patients. Although research results have not agreed on a mortality-reducing effect of depression treat- ment among cardiac patients, treatments to alleviate de- pression in patients with an acute coronary syndrome (ACS) may improve SRH and quality of life (44). There- fore, a key remaining question is whether psychosocial treat- ment for mental distress among patients with CAD might improve self-rated health. The present study used a telephone-based counseling intervention to treat psychological distress among patients recently hospitalized for ACS. In contrast to traditional psychotherapy, this intervention focused not on underlying psychopathology, but on the patients’ adjustment to the effects of chronic illness (45). The goal is to help patients adjust successfully to illness by strengthening existing coping mech- anisms and mobilizing resources (45). This longitudinal study examined whether a telephone counseling intervention im- proved patient SRH. From Harvard Medical School (K.Z.B., O.A., P.H.S., S.E.L., T.J.M.), Harvard Pilgrim Health Care (K.Z.B., O.A., M.G.M., J.C., T.J.M.), Beth Israel Deaconess Medical Center (S.E.L.), and Brigham and Women’s Hos- pital (P.H.S.), Boston, Massachusetts. Address correspondence and reprint requests to Thomas J. McLaughlin, ScD, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215. E-mail: thomas_mclaughlin@hms.harvard.edu This work was supported by the National Institute of Mental Health’s (T.J.M.) Mental Health Services Research Program in Managed Care (RISP), MH-56217-05, 1997; the Robert Wood Johnson Foundation’s (T.J.M.) Effec- tiveness of Telephone Counseling in Managing Depression Associated with Chronic Medical Illness, grant 038765, 2001; and the National Institute of Mental Health’s (K.Z.B.) Relationship Between Depression and Diabetes Self-Care, F31MH0608041-01, 2002. Received for publication September 21, 2004; revision received January 26, 2005. DOI: 10.1097/01.psy.0000171810.37958.61 539 Psychosomatic Medicine 67:539 –545 (2005) 0033-3174/05/6704-0539 Copyright © 2005 by the American Psychosomatic Society