Journal Pre-proof

The impact of internet-based cognitive behavioral therapy and

depressive symptoms on self-care behavior in patients with heart
failure. A secondary analysis of a randomised controlled trial

Peter Johansson , Tiny Jaarsma , Gerhard Andersson ,

Johan Lundgren

PII: S0020-7489(19)30261-5
DOI: https://doi.org/10.1016/j.ijnurstu.2019.103454
Reference: NS 103454

To appear in: International Journal of Nursing Studies

Received date: 24 May 2019

Revised date: 21 October 2019
Accepted date: 21 October 2019

Please cite this article as: Peter Johansson , Tiny Jaarsma , Gerhard Andersson , Johan Lundgren ,
The impact of internet-based cognitive behavioral therapy and depressive symptoms on self-care be-
havior in patients with heart failure. A secondary analysis of a randomised controlled trial, International
Journal of Nursing Studies (2019), doi: https://doi.org/10.1016/j.ijnurstu.2019.103454

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The impact of internet-based cognitive behavioral therapy and depressive
symptoms on self-care behavior in patients with heart failure. A secondary
analysis of a randomised controlled trial

Peter Johansson1,2, Tiny Jaarsma1, Gerhard Andersson3,4, Johan Lundgren1

1
Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden.
2
Department of Internal Medicine, Department of Medical and Health Sciences, Linköping
University, Norrköping, Sweden.
3
Department of Behavioural Sciences and Learning, Linköping University, Linköping,
Sweden.
4
Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

Postal address:
Peter Johansson, PhD, Professor, RN
Department of Social and Welfare Studies, Linköping University
Campus Norrköping, SE- 601 74. Norrköping, Sweden
E-mail: peter.b.johansson@liu.se
Phone: +46-11363185
Contribution of the paper

What is already known about the topic

 In patients with heart failure, depressive symptoms are common and can act as a

barrier to performing self-care behaviours. This may also be a possible explanation for

why depressive symptoms in heart failure are associated with an impaired quality of

life and a poorer prognosis in heart failure.

 There are studies reporting that psychological interventions have possible positive

short-term impact on self-care in heart failure. However, most of these studies did not

include heart failure patients who also have elevated levels of depressive symptoms.

 There is a lack of knowledge as to whether internet-based cognitive behaviour therapy

targeting depressive symptoms in patients with heart failure can improve self-care and

the different aspects autonomy-based self-care, provider-based self-care and

consulting behaviour.

What this paper adds

 Internet-based CBT targeting depressive symptoms in patients with heart failure was

not superior to an on-line discussion group, as regards self-care.

 Internet-based CBT may improve provider-based self-care behaviours such as taking

heart failure medications.

 An improvement in depressive symptoms was associated with an improvement in

autonomy-based self-care behaviours such as exercise and daily weighing.

Abstract

Background: Patients with chronic heart failure may require treatment of depressive

symptoms to improve self-care behaviour. Objectives: To investigate the impact of internet-

based cognitive behavioural therapy (CBT) on self-care behaviour in heart failure patients,

and to study the association between changes in depressive symptoms and changes in self-

care behaviour. Design: A secondary analysis of data collected in a pilot randomized

controlled study. Setting: 50 heart failure patients with depressive symptoms were recruited

from four hospitals in Sweden. Methods: Patients were randomized to nine weeks of internet-

based CBT (n=25) or to an active control group participating in an online discussion forum

(n=25). In week two and three, those in the internet-based CBT group worked with

psychoeducation about heart failure and depression, emphasizing heart failure self-care.

During the same weeks those in the on-line discussion forum specifically discussed heart

failure self-care. Patient Health Questionnaire-9 was used to measure depressive symptoms at

baseline and at the nine-week follow-up. The European Heart Failure Self-care Behaviour

Scale-9 was used to measure self-care behaviour (i.e., the summary score and the subscales

autonomous based, provider based and consulting behaviour) at baseline, and at the three-

week and nine-week follow-ups. Results: No significant differences were found in self-care

between the patients in the internet-based CBT and the patients in the online discussion group

at the three- and nine-week follow-up. Within-group analysis of the changes in the European

Heart Failure Self-care Behaviour Scale showed that from baseline to week three, the

summary score increased significantly for the online discussion group (p=0.04), but not for

the internet-based CBT group (p=0.15). At the nine-week follow-up, these scores had

decreased. Similarly, consulting behaviour improved at week three for the online discussion

group (p=0.04), but not for the internet-based CBT group (p=0.22). Provider-based adherence

at the nine-week follow-up had increased from baseline in the internet-based CBT group
(p=0.05) whereas it had decreased in in the on-line discussion group. Improvement in

symptoms of depression was significantly associated with improvement in autonomy-based

self-care (r=0.34, p=0.03).

Conclusion: Improvement in depressive symptoms was associated with improved

autonomous-based self-care. ICBT for depression in HF may benefit aspects of self-care that

are vital to improve symptoms and prognosis.

Keywords: heart failure, depression, internet, cognitive behavioral therapy, self-care

1. BACKGROUND

Depressive symptoms are common in patients with heart failure, and studies suggest a

significantly increased risk of hospital readmissions and mortality (Gathright et al., 2017,

Ghosh et al., 2016) and impairment of quality of life (Muller-Tasch et al., 2007) for these

patients.

Poorer performance of self-care may be an underlying mechanism behind the negative effects

of depressive symptoms in heart failure (Sedlar et al., 2017). For example, studies have

reported that heart failure patients with depressive symptoms have more difficulty adhering to

prescribed medications (Goldstein et al., 2017) and a greater tendency to delay seeking

healthcare despite worsening symptoms (Johansson et al., 2011). This suggests that

interventions targeting depressive symptoms in heart failure patients may improve self-care

behaviour. A meta-analysis, including 25 randomized controlled trials (RCT), reported a

possible positive short-term impact of psychological interventions on self-care in heart failure

(Jiang et al., 2018). However a problem was that only the study by Freedland et al.

(Freedland et al., 2015) in the meta-analysis included patients who were diagnosed with

depression. In that study, six months of face-to-face cognitive behavioural therapy (CBT),

compared to enhanced standard care, improved depression but surprisingly did not improve

self-care. But self-care has more than one aspect. For example, self-care as measured by the

9-item European Heart Failure Self-care Behaviour Scale-9 (EHFScBS) (Jaarsma et al., 2009)

has been reported to consist of three different aspects of heart failure self-care (Vellone et al.,

2014): autonomy-based adherence (three items: I weigh myself every day, I limit the amount

of fluids, I exercise regularly), provider-based adherence (two items: I eat a low-salt diet, I

take my medication as prescribed), and consulting behaviour (four items: If shortness of

breath increases I contact my doctor or nurse, If my legs/feet are more swollen I contact my

doctor or nurse, If I gain weight more than two kg in seven days I contact my doctor or nurse,
If I experience fatigue I contact my doctor or nurse). Thus, instead of analysing self-care as

one concept can be of interest to explore if CBT may have a different impact on the various

aspects of self-care, such as autonomy-based adherence, provider-based adherence and

consulting behaviour, in heart failure patients with elevated levels of depressive symptom.

Regarding CBT, one problem is the low access to CBT due to a lack of psychologists.

Provision of CBT over the internet (i.e. internet-based CBT) has been proven effective in

patients with depression only (Andrews et al., 2018, Karyotaki et al., 2018). However, there is

a lack of studies that have examined whether internet-based CBT in heart failure aimed at

improving depression can also improve self-care. and different facets of self-care.

Therefore, the objectives of this explorative study including heart failure patients with

elevated levels of depressive symptoms were: (I) to investigate the impact of Internet-based

Cognitive Behaviour Therapy (ICBT) on different aspects of self-care behaviour and (II) to

study the association between changes in depressive symptoms and different aspects of self-

care behaviour.

2. METHODS

2.1 Study design and population

A secondary analysis of data collected in a RCT aimed to evaluate the impact of a nine-week

internet-based CBT programme on depressive symptoms in patients with heart failure. The

design of the RCT study has been reported in the main publication (Lundgren et al., 2016). In

brief, a total of 50 heart failure patients with at least mild depressive symptoms (i.e. Patient

Health Questionnaire-9 score >5) were recruited from four hospitals in southeastern Sweden.

They were randomized to either a nine-week internet-based CBT programme (n=25) or to an

active control group participating in a nine-week online discussion group (n=25). The

regional ethical review board of Linköping Sweden approved the study (ref. no. 2011/166-

31). The primary study is registered at clinical trials.gov (NCT01681771).

2.2 Procedures

The internet-based CBT programme (Lundgren et al., 2015, Lundgren et al., 2016). consists

of seven modules: (1) Introduction; (2) Living with heart failure; (3) Depressive symptoms

and heart failure; (4) Behaviour activation – enabling change; (5) Behaviour activation –

implementing change; (6) Problem-solving – a tool for dealing with problems, and (7)

Consummation. At weeks 2 and 3, heart failure self-care was addressed in both groups,

however, using a different approach. In the internet-based CBT group by psychoeducation

and homework and in the the on-line discussion group by discussions in writing.

2.3 Measurements

2.3.1 Depressive symptoms

The Patient Health Questionnaire-9 (Spitzer et al., 1999) was used to measure depressive

symptom at baseline and at the nine-week follow-up. The Patient Health Questionnaire-9

consists of nine items to be answered on a four-point scale, and summed to a total score in the

range of 0-27, where higher numbers represent a higher level of depressive symptoms

(Kroenke et al., 2001). The Patient Health Questionnaire-9 has been found to be valid and

reliable in patients with heart failure (Hammash et al., 2013).

2.3.2 Heart failure self-care behaviour

The 9-item European Heart Failure Self-care Behaviour Scale (Jaarsma et al., 2009) was used

to measure heart failure self-care behaviour and the three sub-scales autonomy-based as

described by Vellone at al. (Vellone et al., 2014) adherence; provider-based adherence;

consulting behaviour at baseline, three weeks and at the nine-week follow-up. The items are

rated on a five-point scale between 1 (I completely agree) and 5 (I completely disagree). The
score was standardized to 0-100, and reversed so that a higher score indicated better self-care

(Vellone et al., 2014).

2.4 Statistical methods

Descriptive data are presented as percentages or mean ± SD. A Student’s t-test was used for

continuous variables and the Chi-square test was used for discrete variables. An evaluation of

differences between groups regarding the summary score of the European Heart Failure Self-

care Behaviour Scale and the three subscales scores (i.e. autonomy-based, provider-based and

consulting behaviour) at the three and nine-week follow-up was performed with Analysis of

Covariance (ANCOVA). A paired Student’s t-test was used to analyze if the changes in

European Heart Failure Self-care Behaviour Scale from baseline to three weeks, and from

three weeks to follow-up at nine weeks differed significantly within the internet-based CBT

group and the on-line discussion group. To explore possible associations between changes in

depressive symptoms and changes of European Heart Failure Self-care Behaviour Scale

summary score, as well as in the subscales of autonomy-based and provider-based adherence

and consulting behavior we did not separate data from the two groups. Since the change

scores were skewed, analyses were performed with Spearman rank correlations. A positive

correlation between the change in Patient Health Questionnaire-9 and the change in the

European Heart Failure Self-care Behaviour Scale indicates that an improvement in

depressive symptoms correlates with an improved self-care. P-values < 0.05 were considered

significant. All data were analyzed using standard software (IBM, SPSS version 24).
3. RESULTS

3.1 Population

The population has been described in detail in the main publication (Lundgren et al., 2016). In

brief, the mean age of the study population was 63 years (SD 12.8), 59% were male and 4%

were smokers. About three-quarters of the population were in New York Heart Association

Class II (40%) and III (36 %). Approximately 90 % took beta-blockers and angiotensin-

converting enzyme inhibitors or angiotensin receptor blockers. The mean score in the Patient

Health Questionnaire-9 before the start of the study did not vary between the groups (internet-

based CBT group 11.8 compared to online discussion group 11.2).

3.2 Internet-based Cognitive Behavioural Therapy and heart failure self-care

No significant differences were found in self-care between the patients in the internet-based

CBT and the patients in the online discussion group at the three- and nine-week follow-ups

(Table 1). As can be seen in Table 1, self-care behaviours increased from baseline to week

three in both groups. From week three to the end of the study at week nine, a slightly different

pattern was seen. The mean scores of the patients in the on-line discussion group decreased in

all four scales, whereas in the internet-based CBT group the scores remained stable or

increased in two of the four scales (i.e. autonomy-based and provider-based adherence).

Within-group analysis (Table 1) of the changes in the European Heart Failure Self-care

Behaviour Scale shows that from baseline to week three, the summary score increased

significantly for the online discussion group (p=0.04), but not for the internet-based CBT

group (p=0.15). At the nine-week follow-up, these scores had decreased. Similarly, consulting

behaviour improved at week three for the online discussion group (p=0.04), but not for the
internet-based CBT group (p=0.22). At the nine-week follow-up, these scores had also

decreased to approximately the level found at baseline. For autonomy-based adherence, only

minor increases were found at three weeks. However, at nine weeks, the mean score in the on-

line discussion group had decreased to baseline level, whereas the score of the internet-based

CBT group was sustained. Provider-based adherence increased in the internet-based CBT

group significantly from baseline to the nine-week follow-up (p=0.05) whereas in the on-line

discussion group, the score decreased to baseline level.

3.3 Changes in symptoms of depression and changes in heart failure self-care

A significant and moderate correlation between improvement in symptoms of depression

(mean change score 0.9 SD 4.0) and improvement in autonomy-based adherence (mean

change score 1.2 SD 22.4) was found (r=0.34, p=0.03). The correlation between the

improvement in depressive symptoms and the summary score of European Heart Failure Self-

care Behaviour Scale was of the same magnitude (mean change score 2.8 SD 14.2), but not

significant (r=0.28, p=0.07). For subscales consulting behaviour (mean change score 1.8 SD

19.7), and provider-based adherence (mean change score 7.1 SD 18.3), the correlations were

weaker and not significant (r=0.18, p=0.27 and r=0.07, p=0.66). Correlational analysis in

each group did not reveal any significant associations.

4. Discussion

In this study we compared the effectiveness of internet-based CBT compared to an online

discussion group in the improvement of self-care behaviour in heart failure patients with

depressive symptoms. We could not find any beneficial effect of internet-based CBT on self-

care in depressed heart failure patients. Freedland et al. (Freedland et al., 2015) also reported

no improvements from CBT for self-care in heart failure patients. An explanation may be that

CBT interventions may not impact all aspects of self-care. We therefore undertook further
analyses to explore whether internet-based CBT could have different impact on the three

subscales in the European Heart Failure Self-care Behaviour Scale, but no beneficial effects

could be found. Another possible explanation for the lack of effects on self-care, is that in our

study and that of Freedland et al (Freedland et al., 2015), poor self-care was not a criterion for

eligibility, which limits our possibilities of detecting improvements in self-care

The within-group analyses showed that online-discussion group had a significant

improvement in the summary score at week 3, but not at week 9. This may be the result of

increased attention by way of participation in the study, thus indicating a possible digital-

placebo effect (Torous and Firth, 2016). On the other hand, the score for provider-based

adherence was significantly different than baseline (p=0.05) in the internet-based CBT group

at the nine-week follow-up. It is possible that the internet-based CBT programme was helpful

in improving provider-based adherence since content in the psycho-educative heart failure

module and the homework assignments were intended to increase the understanding of, and

the benefit of, medication and exercise. Furthermore, in the behavioural activation module of

the internet-based CBT programme, the participants could, in a structured way, plan and

implement self-care behaviours in their daily lives, such as taking medications.

We found an association between improvement in depressive symptoms and improvement in

autonomy-based adherence (exercise, weighing, fluid restriction). In this analysis we pooled

the data from the two groups to study how change in depression was related to changes in

self-care, regardless of group assignment. We realize that from this analysis, one cannot

determine whether internet-based CBT has a direct effect on self-care, or if it affects self-care

indirectly by improving depression. However, in our pilot RCT study, only patients in the

internet-based CBT group had a significant decrease in depressive symptoms (Lundgren et al.,

2016). In our internet-based CBT programme, exercise (i.e. an aspect of autonomy-based

adherence) was emphasized as a good self-care behaviour. This may indicate that

improvements in depressive symptoms may be associated with improvements in self-care

behaviours that are more endorsed by patients themselves.

These results illustrate the difficulty of finding the optimal combination of programmes in the

management of depressive symptoms in heart failure patients. It is possible that internet-based

CBT on top of exercise may be a more effective option than exercise or CBT alone. A

previous study by Gary et al. (Gary et al., 2010) showed that CBT combined with home-based

exercise had the best effect in reducing depression, increasing physical function, and

improving health-related quality of life. These data also suggest a new hypothesis regarding

the optimal components of interventions to improve self-care. Maintaining autonomy,

physical well-being and symptom relief are reported as important motivational goals for heart

failure patients (Jaarsma et al., 2017). These goals may be more associated with intrinsic

motivations, i.e. the patient performs self-care activities due to internal satisfaction, and thus

they are probably more likely to be achieved by performing autonomy-based or provider-

based self-care behaviours such as exercise, choosing healthy food, increasing control by

daily weighing, and experiencing fewer symptoms by taking heart failure medications. In our

internet-based CBT programme, participants established their own personal goals (i.e.

intrinsic goals). It is therefore hypothesized that an internet-based CBT programme could

have served as an aid to achieving self-care. This hypothesis requires testing in additional

research that explores the effects of CBT or internet-based CBT on self-care, and on different

facets of self-care behaviours and depressive symptoms in heart failure patients.

A major limitation is the fact that this was a secondary-analysis of data collected in a pilot-

RCT. Thus, the study is underpowered to detect associations and interactions between

internet-based CBT, self-care behaviours and depressive symptoms. Therefore, the results
from this study should be interpreted with caution. Another limitation is that the analysis of

self-care behaviours was self-reported. It could have been valuable if objective data regarding

self-care behaviours such as physical activity were also collected. Since this study is one of

the first internet-based CBT studies performed with heart failure patients with elevated

depressive symptoms, we believe that the results of this study, despite its limitations, are of

interest.

In conclusion, this study found improvement in depressive symptoms that were associated

with improved autonomous-based self-care adherence. More studies that evaluate whether

internet-based CBT for depression in heart failure has beneficial effects on self-care are

needed.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships

that could have appeared to influence the work reported in this paper.

Acknowledgements

This study was funded by grants from the Swedish Heart and Lung Association (grant number

E08/14), the Medical Research Council of Southeast Sweden (grant number FORSS-470121)

and the Region of Östergötland (grant number LIO-470271). The funding source had no

influence on the design, procedure, analysis or interpretation of the results in this study.
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Table 1
Table 1. Mean values at the three measurement points and analysis of changes between the internet-based CBT and the discussion group regarding the
summary score, autonomy-based adherence provider-based adherence and consulting behaviors of the European Heart-Failure Self-Care Behavior Scale. The
table also provides analysis of changes within the internet-based CBT group and the discussion group.

Summary Score Autonomy-based adherence Provider-based adherence Consulting-behavior

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Baseline W3 W9 Baseline W3 W9 Baseline W3 W9 Baseline W3 W9

ICBT-group 38.9 (17) 47.4 (21) 42.3 (17) 45.6 (19) 47.6 (26) 47.6 (31) 68.4 (25) 76.2 (23) 78.5(20) 19 (26) 33 (30) 20 (20)

Discussion- 40.5 (21) 48.1 (18) 41.8 (18) 42.5 (23) 45.8 (26) 42.2 (20) 67.4 (22) 75 (15) 69.4 (20) 25.7 (31) 36.4 (27) 27.7 (34)
group
Between-
group F(1,41)=0.20, p=0.88 F(1,41)=0.36, p=0.85 F (1,41)=0.69, p=0.79 F(1,37)=0.15, p=0.70
analysis
ANCOVAA
Between-
group F(1,37)=0.08, p=0.78 F(1,37)=0.15, p=0.69 F (1,37)=2.2, p=0.14 F(1,37)=0.28, p=0.60
analysis
ANCOVAB
Within- p=0.151 p=0.352 p=0.711 p=0.712 p=0.201 p=0.052 p=0.221 p=0.922
group
analysis
ICBT-group

Within- p=0.041 p=0.422 p=0.421 p=0.932 p=0.061 p=0.192 p=0.041 p=0.432

group
analysis
Discussion -
group
Footnote:
ANCOVAA difference between the groups a week 3
ANCOVAB difference between the groups at week 9
1
p-value for the difference between the score at baseline and the score at week 3
2
p-value for the difference between the score at baseline score and the score at week 9
Abbreviation: ANCOVA – Analysis of Covariance Internet-Based Cognitive behavioral therapy – ICBT; Standard deviation – SD; Week - W