a systematic review of community-based health interventions on depression for older adults with...

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A systematic review of community-based healthinterventions on depression for older adults withheart diseaseChristina D. Kang-Yi a & Zvi D. Gellis ba Department of Psychiatry, Center for Mental Health Policy and Services Research ,University of Pennsylvania School of Medicine, 3535 Market Street , 3rd Floor,Philadelphia, PA 19104, USAb Hartford Geriatric Social Work Faculty Scholar, Center for Mental Health & Aging,School of Social Policy and Practice, University of Pennsylvania, 3701 Locust Walk ,Philadelphia, PA 19104, USAPublished online: 12 Feb 2010.

To cite this article: Christina D. Kang-Yi & Zvi D. Gellis (2010) A systematic review of community-based healthinterventions on depression for older adults with heart disease, Aging & Mental Health, 14:1, 1-19, DOI:10.1080/13607860903421003

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Aging & Mental HealthVol. 14, No. 1, January 2010, 1–19

A systematic review of community-based health interventions on depression for older adults

with heart disease

Christina D. Kang-Yia* and Zvi D. Gellisb

aDepartment of Psychiatry, Center for Mental Health Policy and Services Research, University of Pennsylvania School ofMedicine, 3535 Market Street, 3rd Floor, Philadelphia, PA 19104, USA; bHartford Geriatric Social Work Faculty Scholar,Center for Mental Health & Aging, School of Social Policy and Practice, University of Pennsylvania, 3701 Locust Walk,

Philadelphia, PA 19104, USA

(Received 11 May 2009; final version received 24 September 2009)

Purpose: This systematic review examined the effectiveness of community-based heart-health interventions ondepression outcomes among homebound elderly (64 years and older) with heart disease.Design and Methods: A comprehensive literature search and meta analysis was performed to evaluate randomizedcontrolled trials examining outpatient or home-based interventions. Methodological quality was assessed bystandard criteria developed by the Cochrane Collaborative Initiative.Results: Fifteen studies met our inclusion criteria and all measured depression outcomes. Studies differed in scopeand methodological rigor and sample sizes varied widely. Problems in treatment fidelity and masking of groupassignment were noted. Great variability was found in depression outcomes due to the differences inmethodology and intervention. Five studies reported significant treatment effect on depression; three of thoseemployed home-based interventions and two were outpatient-clinic interventions. Ten studies were included inthe meta analysis and the effect sizes (ESs) ranged from �0.39 (in favor of control group) to 0.65 (in favor oftreatment group). The mean weighted ES was 0.11 and six studies showed positive ESs.Implications: Mixed evidence for community-based heart disease interventions on depression outcomes wasfound. Future research should include sub-analysis of ESs of interventions on depression outcomes by differentdemographic characteristics of the study sample, common depression outcome measures, and different follow-upperiods.

Keywords: heart disease; community-based interventions; homebound elderly; depression

Introduction

Heart disease affects an estimated 38.1 million olderadults (60 years and older) in the United States andconsumes an estimated total $475.3 billion dollars indirect and indirect health care expenditures (AmericanHeart Association, 2009; National Heart Lung andBlood Institute, 2007). It is the most common primarydiagnosis and the leading cause of death amongmedically ill homebound elderly patients (Centers forDisease Control and Prevention, 2005). The WorldHealth Organization’s (WHO) global burden of diseasestudy ranks depression second only to heart disease inburden (impact on disability-adjusted life years; WHO,2008). Depression is common and widespread amongmedically ill noninstitutionalized elderly where theprevalence rates are 13.5% for major depression(Bruce et al., 2002) and 16 to 37% for subthresholddepressive syndromes (Freedland et al., 2003; Gellis,2010; Rudisch & Nemeroff, 2003). Depression may bean independent risk factor for the onset of heart diseasesuggesting that patients are at high risk for negativeoutcomes (Nemeroff, Musselman, & Evans, 1998).

People with heart disease who are depressedhave an increased risk of death after a heart attackcompared to those who are not depressed(Frasure-Smith, Lesperance, & Talajic, 1995).

Hypertension, hypoglycemia, and coronary artery

disease can be worsened through depression (VanHout et al., 2004). Heart disease is often associatedwith increased fatigue, greater levels of chronic phys-

ical illness, increased disability, decreased psychologi-cal well-being, decreased life satisfaction and increased

healthcare costs among older adults (Glassman &Shapiro, 1998; Martin, Bishop, Poon, & Johnson,

2006; Penninx et al. 2001). Depression may alsojeopardize adherence to treatment regimens includingneeded medication.

Treatment for depression in conjunction with

heart disease may help people manage both diseases,thus enhancing survival and quality of life. Therefore,

there is a need for effective community-based inter-ventions among older adults with heart diseasecomorbid with depression (Gellis & Bruce, 2009).

Intervention research for heart disease has focusedon drug therapies, electric equipment therapies,

and community-based multidisciplinary team interven-tions as potential strategies for improving outcomes

in these patients. These multidisciplinary approachesmay also have a positive impact on the complexinteraction between medical, psychosocial, and behav-

ioral factors confronting homebound elderly with heartdisease.

*Corresponding author. Email: [email protected]

ISSN 1360–7863 print/ISSN 1364–6915 online

� 2010 Taylor & Francis

DOI: 10.1080/13607860903421003

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Caring for community-dwelling medically ill olderadults with complex needs continues to be a challengefor health care systems. In recent years,community-based care has been promoted in healthpolicies as it offers the prospect of substantialcost-savings as well as improved health outcomes(Johri, Beland, & Bergman, 2003). Currently, commu-nity care of heart disease is delivered in several ways.Large health care organizations commonly use nursecase managers in outpatient clinics to provide heartdisease management programs. Medically ill home-bound elderly may receive home health care visits ortelehealthcare using technology as a means of moni-toring and educating individuals regarding chronicmedical conditions for improved health outcomes.

This meta analysis examines the quality and effec-tiveness of community-based health care interventionson depression outcomes among non-institutionalizedolder adults diagnosed with heart disease. To ourknowledge, this is the first review that delineates a setof criteria for interpreting the validity, generalizability,and reliability of the research among selected studies ofoutpatient and home-based health care interventions aspotentially successful patient management approachesfor heart disease and depression.

Methods

A systematic review and meta analysis of the literatureon community-based healthcare interventions for olderadults diagnosed with heart disease was conducted to(1) identify the type of interventions used in nonin-stitutionalized settings and (2) determine the effective-ness of these interventions on depression outcomes.Two reviewers examined studies to determine theirselection for inclusion in the review and then assessedthe methodological quality of selected studies. Themethodology for this review was guided by theCochrane Collaboration Handbook for SystematicReviews of Interventions (Higgins & Green, 2006).

Search strategy

We conducted searches on the following electronicdatabases: Ageline, PubMed, PsycInfo, Medline,ClinialTrial.gov, Central Register of Controlled Trial,and CINAHL. Relevant treatment trials were searchedusing the following keywords: heart disease or heartfailure, and geri*, elder*, depress*, depression, ordepressive symptom. We reviewed studies ofcommunity-based health care interventions offered inthe home or in outpatient-clinic settings for olderadults diagnosed with heart disease. The search waslimited to studies published from 1998 to 2008 andclassified as randomized controlled trials investigatingan effect of an intervention. We also limited theparticipants’ mean age to 64 years or older due to thehigh prevalence rates of heart disease and depression inthe elderly population in the US.

A home-based intervention was defined as treat-ment that took place at the individuals’ home and mayinclude education, counseling, exercise program, videoand/or internet-based care, or telehealth care. Anoutpatient-clinic intervention was defined as treatmentthat occurred in an outpatient healthcare setting suchas a cardiac rehabilitation or prevention clinic. If anintervention involved more than one care setting, forexample, a disease management program held at aclinic with self-management activities at home, thestudy was classified as a combined home and outpa-tient clinic-based intervention.

Two reviewers screened abstracts and full papers,and extracted data on intervention type (home-basedvs. outpatient clinic-based), sample size, participants,intervention descriptions, methodological attributes,standardized outcome measures, and key findings foreach study. After selecting papers that met the inclu-sion criteria, the reviewers assessed methodologicalquality of the interventions by independently reviewingthe full papers.

Review of methodological quality

The review criteria of methodological quality included:(a) use of random allocation methods; (b) poweranalysis conducted; (c) measures used to preventperformance and detection bias; (d) explanation oftreatment protocol provided; (e) intent-to-treat analy-sis conducted; (f) description of interventionist train-ing; and (g) explanation of measures used to collectdata on treatment fidelity. These criteria are recom-mended by the Cochrane Collaboration Review ofRandomized Controlled Trials (Higgins & Green,2006). The definitions of criteria are explained indetail elsewhere (Gellis & Kenaley, 2008). The includedstudies were graded based on the Gellis and Kenaley’s(2008) methodological quality rating scale with a rangefrom 1 to 10.

Meta analysis

Meta analysis was performed to estimate effect sizes(ESs) for mean differences in depression outcomesbetween treatment and control groups. Effect size wascalculated as standardized mean difference (Hedges) atthe most current follow-up assessment with 95%confidence intervals (CIs) between treatment andcontrol group (Hedges, 1981). Fifteen studies wereincluded in the meta analysis. However, five studieswere excluded due to missing information on meansand standard deviations of depression outcomes fortreatment and control groups.

Results

As shown in Figure 1, the search strategy initiallyyielded 59 articles. Forty-four studies were excludeddue to the following reasons: (a) a non-randomized

2 C.D. Kang-Yi and Z.D. Gellis

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controlled trial (n¼ 2), (b) intervention with partici-pants under 64 years of mean age (n¼ 17),(c) inpatient-healthcare setting intervention (n¼ 2),(d) pharmacological intervention (n¼ 9), (e) healthequipment trial (n¼ 1), (f) no standardized-depressionmeasurement included (n¼ 4), (g) study protocol only(n¼ 3), and (h) not an original study (n¼ 6). Thus, atotal of 15 studies were reviewed for the outcomes ofdepression on heart disease intervention in olderadults. The systematic review included ten studiesconducted in the US, one study in Finland, one studyin Japan, one study in Sweden, and two studies in theUK. Each study is assigned by a reference number forease of reading and is listed in Tables 1 and 2.

Methodological quality and effect size

We ranked study quality according to the method-ological scale to quantify two broad types of commu-nity interventions including home-based andoutpatient-based care. Table 1 presents the results of

the methodology review with rated quality scores, andTable 2 outlines sample sizes, outcome measures, typesof interventions, intervention descriptions, and studyfindings of the included studies.

Sample size

A total of 3545 participants were included in the 15studies, and the sample sizes greatly varied rangingfrom 32 (8) to 1173 (2). The mean sample size was 236(SD¼ 302.81). Approximately 80% (n¼ 12) of thestudies (1–4, 6, 8–12, 14, 15) had a sample size of 50participants or more.

Participants

The mean ages of the participants ranged from 64 to80. Twenty-nine percent of the studies (3, 5, 6) had100% female participants, and one study (13) had100% male participants. Among eight studies thatprovided race/ethnicity information, the proportion ofWhites was predominantly high. Minority population

Studies potentially retrieved for detailedevaluation (n = 59)

Non-randomized controlled trial studiesand studies with participants under 64years of mean age excluded (n = 19)

Eligible randomized controlled trialstudies (n = 40)

Studies with inpatient-healthcare settinginterventions excluded (n = 2)

Studies pharmacological interventionsexcluded (n = 9)

Studies of health equipment trialsexcluded (n = 1)

Studies without standardized-depressionmeasurement excluded (n = 4)

Studies with intervention protocols onlyexcluded (n = 3)

Non-original studies excluded (n = 6)

Studies included in the methodologyreview (n = 15)

Figure 1. Process of inclusion of studies for methodology review.

Aging & Mental Health 3

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Table

1.Studymethodologyquality

ofselected

studies.

Study/

Author(s)

Selection

bias

(1¼explained

method

usedfor

random

allocation;

0¼no

explanation

provided)

Sufficient

power

(3¼power

calculation

perform

ed;

2¼no

power

analysis

and

perform

ed

sample4

50;

1¼sample

550)

Perform

ance

bias

(1¼explanation

provided

that

participant/

investigator

wasunaware

ofgroup

assignment;

0¼no

explanation

provided)

Detection

bias

(1¼explanation

provided

that

follow-up

interviewer

was

unaware

ofparticipant’s

group

assignment;

0¼no

explanation

provided)

Treatm

ent

protocol

(1¼treatm

ent

provided;

0¼no

explanation

ortreatm

ent

protocol)

Intent-to-treat

(itt)analysis

(1¼itt

analysis

perform

ed;

0¼no

explanation

ofprovided)

Interventionist

training

(1¼explanation

ofinterventionist

training

provided;

0¼no

explanation

provided)

Treatm

ent

fidelity

(1¼explained

mechanisms

taken

to

ensure

treatm

ent

compliance;

0¼explana-

tion

provided)

Overall

method

quality

score

Barrow

etal.

(2007)

03

00

10

00

4

Campbell,

Thain,

Deans,

Ritchie,and

Rawles

(1998)

12

00

10

00

4

Clark

etal.

(2000)

12

11

10

10

7

Dougherty,

Lew

is,

Thompson,

Baer,and

Kim

(2004)

12

00

10

10

5

Gary

etal.

(2004)

13

00

10

00

5

Janzet

al.

(2004)

02

01

11

00

5

Jayadevappa

etal.(2007)

11

11

11

00

6

LaFramboise,

Todero,

Zim

merman,

andAgrawal

(2003)

02

00

10

00

3


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Martensson

Martensson,

Stromberg,

Dahlstrom,

Karlsson,

Fridlund

(2005)

03

00

11

10

6

Riegel

etal.

(2006)

03

00

11

00

5

Salm

inen

etal.

(2005)

02

00

10

00

3

Schwarz,Mion,

Hudock,and

Litman

(2008)

13

00

10

10

6

Seki etal.

(2003)

11

00

10

00

3

Witham

etal.

(2005)

13

11

10

00

7

Woodend

etal.

(2007)

02

00

11

00

4


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Table

2.Reference

list

ofsystem

aticreview.

Reference

number

Intervention

type

Author(s)

(year)

Participants

Intervention(s)

Outcomes

Outcomemeasures

Results

Studydesign

1Outpatient

clinic-and

home-based

intervention

Barrow

etal.

(2007)

Sample

size¼52

Meanage:

69

Male:81%

Fem

ale:19%

Patients

with

symptomatic

heart

failure

TaiChiChuan

andChi

Kung

exercise

Experim

ental

group,

n¼32

Controlgroup,

n¼33

16-w

eek

intervention

Changein

the

distance

walked

Changes

in

symptomsscores

andquality

of

life

indicators

Increm

entalShuttle

Walk

Test(ISWR)

Minnesota

Livingwith

Heart

Failure

Questionnaire

(MLHF)

SCL-90R

Depression

Scale

Patients

inthe

interventiongroup

showed

an

improvem

entin

symptom

scoresof

heart

failure

and

depressionscores

over

time.

Random

allocation

Power

calculationat

75%

2Outpatient

clinic-based

intervention

Campbell

etal.

(1998)

Sample

size¼1173

Meanage¼66

Male:58%

Fem

ale:42%

Patients

with

coronary

heart

disease

Secondary

prevention

clinic

Treatm

ent

group,

n¼593

Controlgroup,

n¼556

12-m

onth

intervention

Healthstatus

Chestpain

Anxiety

Depression

SF-36HealthSurvey

Questionnaire

AnginaType

Specification

HospitalAnxiety

and

DepressionScale

(HADS)

Nostatistically

significant

difference

between

treatm

entgroup

(TG)andcontrol

group(C

T)forthe

depression

outcome.

Random

allocation

Nopower

calculation

Sample4

50

3Home-

and

outpatient

clinic-based

intervention

Clark

etal.

(2000)

Sample

size¼570

Fem

ale:100%

Meanage¼72

White:

87%

Black:12%

Other

race:1%

Patients

withHeart

disease,treated

dailybyatleast

onemedication,

andseen

by

physicianeverysix

months

‘‘Women

Take

PRID

E’’

disease

managem

ent

program

Intervention

group,

n¼309

Control

group,

n¼261

12-m

onth

intervention

Physical

functioning

Symptom

experience

Psychosocial

functioning

Symptom

Impact

Profile

(SIP)

Centerfor

Epidem

iologic

Studies-

DepressionScale

(CES-D

)

MedicalOutcomes

Study(M

OS)

Depressionscore

were

notsignificantly

differentbetween

interventionand

controlgroups

over

time.

Random

allocation

Nopower

calculation

Sample4

50


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4Home-based

intervention

Dougherty

etal.

(2004)

Sample

size¼168

Meanage¼64

Male:77%

White:

89%

Black:4%

Other

race:7%

Sudden

cardiacarrest

(SCA)or

life-threatening

ventricular

arrhythmia

requiring

implantable

cardioverter

defibrillator(ICD)

implantation

Telephone

intervention

Intervention

group,

n¼84

Controlgroup,

n¼84

3-m

onth

intervention

Physicalfunction-

ing

Psychological

adjustment

Knowledge

Healthcare

use

PatientConcerns

Assessm

ent(PCA)

Short-Form

Health

Survey

(SF-12)

Centers

for

Epidem

iologic

Studies-

Depression

(CES-D

)

Sudden

Cardiac

ArrestKnowledge

Assessm

ent

Emergency

room

visit

Outpatientvisits

Hospitalization

Reported

physical

symptomswere

significantly

reducedat1

month

and

knowledgewas

improved

significantlyat3

month

of

intervention.

Random

allocation

throughrandom

number

generator

program

Nopower

calculation

Sample4

50

5Home-based

intervention

Gary

etal.

(2004)

Sample

size¼32

Meanage:

68

Fem

ale:100%

White:

63%

Black:38%

Diastolicheart

failure

(DHF)

Home-based,

low-to-

moderate

intensity

exercise

and

education

program

Treatm

ent

group,

n¼16

Educationonly

group,

n¼16

12-w

eek

intervention

Quality

ofLife

(QOL)

Depression

6Minute

Walk

Test

(6MWT)

DukeActivityStatus

Index

(DASI)

Minnesota

Livingwith

Heart

Failure

Questionnaire

(MLHFQ)

Geriatric

Depression

Scale

(GDS)

Interventiongroup

showed

greater

improvem

entthan

controlforall

outcomes

Random

allocation

90%

power

calculation

Sample5

50

6Outpatient

clinic-based

intervention

Janzet

al.

(2004)

Sample

size¼457

Meanage¼73

Fem

ale:100%

White:

87%

Non-w

hite:

13%

Cardiaccondition

Takingheart

medication

‘‘Women

Take

PRID

E’’

disease

managem

ent

program

Intervention

group,

n¼314

Controlgroup,

n¼143

6-w

eek

intervention

Stress

Psychological

distress

1-10self-report(stress)

Emotional

BehaviorCategory

oftheSickness

Impact

Profile

(SIP)

Centerfor

Epidem

iological

Studies–

DepressionScale

(CES-D

)

Interventiongroup

wasmore

likely

thanGTto

report

improvem

entfor

stress

andscore

higher

onSIP.

Random

allocation

Nopower

calculation

Sample4

50

Blindingofoutcome

measures

(continued

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Table

2.Continued.

Reference

number

Interventiontype

Author(s)

(year)

Participants

Intervention(s)

Outcomes

Outcomemeasures

Results

Studydesign

7Outpatient

clinic-based

intervention

Jayadevappa

etal.(2007)

Sample

size¼23

Meanage¼65

Male:39%

Fem

ale:61%

Black:100%

Congestiveheart

failure

(CHF)with

anejectionfrac-

tionof5

.40

Transcendental

meditation

program

Intervention

group,n¼13

Controlgroup,

n¼10

6-m

onth

intervention

Clinicaloutcome

Health-related

quality

ofcare

(HRQoL)

Rehospitalization

Six-m

inute

walk

test

HRQoL

Perceived

stress

score

(PSS)

Centerfor

Epidem

iologic

Studies

DepressionScale

(CES-D

)

Brain

natriuretic

peptide(BNP)

Cortisollevel

Number

of

hospitalizations

Treatm

entgroup

significantly

improved

onthe

depression

outcome

comparedto

CT

from

baselineto

sixmonths.

Random

allocation

Nopower

calculation

Sample5

50

8Home-based

intervention

LaFramboise

etal.(2003)

Sample

size¼90

Meanage¼70

Male:50%

White:

83%

Black:13%

Other

race:4%

Recenthospitaladmit

forheart

failure

HealthBuddy

Program

Telephonic

disease

managem

ent,

n¼26

Homehealthcare,

n¼23

HealthBuddy

(in-home

telehealth

communication

device),n¼21

HomeVisit/H

ealth

Buddy,n¼20

6-m

onth

intervention

Self-efficacy

FunctionalStatus

Depression

Quality

ofLife(Q

OL)

BarnasonEfficacy

ExpectationScale

Heart

Failure

(BEES-H

F)

Geriatric

Depression

Scale

(GDS)

6-M

inute

Walk

Test

(6MWT)

MedicalOutcomes

Study36-Item

Short-Form

HealthStatus

Survey

(SF-36)

Groupreceiving

telephonic

disease

managem

ent

showed

significantlyless

confidence

intheir

abilityto

manage

theirHF.No

other

statistically

significantdiffer-

encesamong

groups.

Random

allocation

Nopower

calculation

Sample4

50


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9Home-based

intervention

Martensson

etal.(2005)

Sample

size¼153

Meanage¼79

Male:54%

Fem

ale:46%

Patients

withheart

failure

inprimary

healthcare

Nurse-led

intervention

aim

edat

improvingself-

managem

entof

heart

failure

Treatm

entgroup,

n¼78

Usualcare

group,

n¼75

Meanage:79years

12-m

onth

intervention

Health-relatedquality

oflife

Depression

MedicalOutcomes

Study36-Item

Short-Form

HealthStatus

Survey

(SF-36)

ZungSelf-Rating

DepressionScale

(SDS)

Interventiongroup

wassignificantly

bettermaintaining

HRQOLand

experience

of

depressionto

a

greaterextentthan

thecontrolgroup.

Random

allocation

80%

power

calculation

Sample4

50

10

Home-based

intervention

Riegel

etal.

(2006)

Sample

size¼134

Meanage¼72

Male:46%

Fem

ale:54%

Hispanic:100%

Chronic

heart

failure

(HF)

AtHomewith

Heart

Failure

telephonecase

managem

ent

Treatm

entgroup,

n¼69

Controlgroup,

n¼65

6-m

onth

intervention

Hospitalization

Quality

ofLife(Q

OL)

Depression

Minnesota

Living

withHeartFailure

Questionnaire

(MLHFQ)

EQ-5D

PatientHealth

Questionnaire,

9-item

measure

of

depressionseverity

Nostatistically

significant

differences

betweenTG

and

CTgroupsforany

oftheoutcomes.

Random

allocation

80%

power

calculation

Sample4

50

11

Outpatient

clinic-based

intervention

Salm

inen

etal.(2005)

Sample

size¼279

Meanage¼74

Male:47%

Fem

ale:53%

Adults

Heart

disease

Livingin

community

Depressivesymptoms

Health

advocacy,

counselingand

activationpro-

gram

Intervention

group,n¼116

Controlgroup,

n¼106

16-m

onth

intervention

Depression

ZungSelf-rating

DepressionScale

(SDS)

Overall,no

statistically

significant

difference

between

TG

andCT

groupsfor

depression.

However,among

male

participants

withdepression,

Intervention

outperform

edCT;

depressed

women

inTG

andCT

groupsshowed

improvem

ent.

Random

allocation

Nopower

calculation

Sample4

50

(continued

)


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Table

2.Continued.

Reference

number

Intervention

type

Author(s)

(year)

Participants

Intervention(s)

Outcomes

Outcomemeasures

Results

Studydesign

12

Home-based

intervention

Schwartz

etal.

(2008)

Sample

size¼102

Meanage¼78

Male:48%

Fem

ale:52%

White:

81%

Non-W

hite:

19%

Homecare

receiver

withhart

failure

(HF)andcare-

giver

dyads

Telem

onitoring

intervention

Telem

onitoring

group,

n¼51

Controlgroup,

n¼51

90-day

intervention

Hospital

readmission

Emergency

departmentvisit

Costsofcare

Functionalstatus

Depressive

symptoms

Quality

oflife

Caregiver

mastery

Medicalrecord

review

after

90days’

postdiscahrge

ActivitiesofDaily

Livings(A

DLs)

Independent

ActivitiesofDaily

Living(IADLs)

Centerfor

Epidem

iological

Studies

DepressionScale

(CES-D

)

Minnesota

Living

withHF

questionnaire

(MLWHF)

Philadelphia

Geriatric

CenterCaregiving

AppraisalScale

(PGCCAS)

Nosignificanteffect

oftelemonitoring

interventionwas

found.

Random

allocation

80%

power

calculation

13

Outpatient

clinic-based

intervention

Sekiet

al.

(2003)

Sample

size¼38

Meanage¼70

Male:100%

Coronary

artery

disease

(CAD)

Post

majorcoronary

event

Phase

IIcardiac

rehabiliation

program

Intervention

group,

n¼20

Controlgroup,

n¼18

6-m

onth

intervention

Quality

ofLife

(QOL)

Depression

Anxiety

MedicalOutcome

StudyShort-Form

(SF-36)

Stait-TraitAnxiety

Inventory

Questionnaire(STAI)

ZungSelf-Rating

DepressionScale

(SDS)

Interventiongroup

improved

significantlyfor

QOLandanxiety

butnotfor

depression;CT

showed

no

significant

improvem

entfor

anyoftheout-

comes.

Random

allocation

Nopower

calculation

Sample5

50

Blindingofoutcome

measures


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14

Outpatient

clinic-and

home-based

intervention

Witham

etal.

(2005)

Sample

size¼82

Meanage¼80

Male:83%

Fem

ale:17%

Chronic

heart

failure

Seatedexercise

program

Intervention

group,

n¼41

Controlgroup,

n¼41

6-m

onth

intervention

Quality

ofLife

(QOL)

Anxiety

Depression

6Minute

Walk

Test

(6MWT)

Guyattchronic

heart

failure

questionnaire

HospitalAnxiety

and

DepressionScale

(HADS)

Philadelphia

Geriatric

Morale

Scale

Functional

Lim

itations

Profile

Treatm

entgroup

showed

significant

improvem

entin

physicalactivity;

nosignificant

difference

inQOL

betweenTG

and

CT

Random

allocation

Power

at90%

Blindingofoutcome

measures

15

Home-based

intervention

Woodend

etal.

(2007)

Sample

size¼249

Meanage¼66

Male:75%

Fem

ale:25%

Cardiacdisease

Telehome

monitoring

Heart

failure

groupwith

telehome

intervention,

n¼62

Hearfailure

groupwith

usualcare,

n¼59

Anginagroup

withtele-

home

intervention,

n¼62

Anginagroup

withusual

care,n¼66

3-m

onth

intervention

Readmission,

healthcare

resourceuse,

morbidity,and

quality

oflife

Minnesota

Living

withHeart

Failure

(LiH

Fe)

forHF

patients

MedicalOutcomes

StudyShort

Form

36(SF36)for

QOLandmental

healthassessm

ent

Telem

onitoring

significantly

improved

quality

oflife

and

functionalstatus

inpatients

with

HF.

Random

allocation

Nopower

calculation

Sample4

50


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ranged from 11% to 38%. Jayadevappa et al.’s (2007)study had 100% African Americans, and Riegel,Carson, Glaser, and Romero (2006) study had 100%Hispanics.

Outcome measures

The most common measure administered to assessdepression severity was the Center for EpidemiologicStudies – Depression Scale (CES-D), followed by theZung Self-Rating Depression Scale (SDS) and theGeriatric Depression Scale (GDS). Approximately33% of the studies (3, 4, 6, 7, 12) used CES-D, 20%of the studies (9, 11, 13) used SDS, and 13% of thestudies (5, 8) used GDS. Other standardized depressionmeasures included the Hospital Anxiety andDepression Scale (HADS), the SCL-90R DepressionScale, and the Patient Health Questionnaire 9-itemmeasure of depression severity. Woodened et al. (2007)assessed mental health status using the MedicalOutcomes Study Short Form 36 (SF36).

Intervention modalities

Home-based and outpatient clinic-based interventionswere the major inclusion criterion for this review.About 47% of the studies (4, 5, 8, 9, 10, 12, 15) usedhome-based interventions, and 33% of the studies(2, 6, 7, 11, 13) used outpatient clinic-based interven-tions. Three studies (1, 3, 14) carried out interventionsthat occurred in combination at the outpatient clinicand in the patient’s home. Regarding the specificintervention components, four studies (1, 5, 13, 14)used a typical exercise protocol: three studies used awalking program, one study used Tai Chi Chuan andChi Kung exercise, and one study used a cardiacrehabilitation program. Six studies (4, 8, 9, 10, 12, 15)used telehealth interventions. Three of these studiesused self-disease management interventions including aprogram named Women Take PRIDE (3, 6) and anurse-led program (9). Other interventions includedTranscendental Meditation program (TM) for stressreduction (7) and a secondary prevention clinic (2). Allstudies provided detailed descriptions of theinterventions.

Study quality rating scale

As shown in Table 1, using Gellis and Kenaley’s (2008)study quality rating scale, we assessed the overallquality of methodology used in the reviewed studies.The average score of the overall methodology qualitywas 4.7 ranging from 3 to 7. About 60% (n¼ 15) of thestudies (3, 4, 5, 6, 7, 9, 10, 12, 14) received scores abovethe average. Jayadevappa et al.’s (2007) study thatcompared Transcendental Medication (TM) with usualcare and Martensson, Stromberg, Dahlstrom,Karlsson, and Fridlund’s (2005) study that comparedself-disease management with usual care received the

highest score. None of the included studies met thecriteria of performance bias and treatment fidelity.

Depression treatment outcomes and effect sizes ofinterventions

Overall, sample participants reported mild depressionsymptom levels at baseline. Table 3 shows thecomparisons of intervention effect on depression out-comes between treatment and control groups of thereviewed studies. Three home-based intervention stu-dies (5, 9, 15) and two outpatient clinic-based inter-vention studies (7, 11) found the treatment groups tobe significantly superior to the control groups.Salminen et al.’s study (2005) showed the longesttreatment effect (16 months) followed by Gary et al.’s(2004) exercise program and Jayadevappa et al.’s(2007) Transcendental Meditation program (6months). Barrow et al. (2007) compared the effect ofan exercise intervention to medical supervision anddrug treatment as usual care and found a significantdecrease in depression scores in the treatment group at4-month follow-up. However, their study found nooverall difference in depression outcomes betweentreatment and control groups. Salminen, Isoaho,Vahlberg, Ojanlatva, and Kivela, (2005) tested ahealth advocacy intervention to usual care, and con-ducted four different types of comparisons including(a) treatment group vs. control group for all men,(b) treatment group vs. control group for all women,(c) treatment group vs. control group for men withZSDS� 45, and (d) treatment group vs. control groupfor women with ZSDS� 45. The authors foundsignificant within-group differences in ZSDS scoresover time for both treatment and control groupsamong women with ZSDS� 45. Treatment group wassignificantly superior to control group among menwith ZSDS� 45 at 16-month follow-up.

The mean weighted effect size (ES) of the interven-tions from the meta analysis was 0.11 (Table 4). Therange of ESs was from� 0.39 (in favor of controlgroup) to 0.65 (in favor of treatment group), and sixstudies showed positive ESs. Studies with positive ESshad longer treatment periods with the final assessmentat the end of treatment. The length of treatment forthese studies (1, 2, 5, 10, 13, 14) ranged from 12 to 52weeks. The studies with negative ESs (3, 4, 12, 15) hadrelatively shorter treatment periods, but had follow-upperiods up to 11 months. Exercise interventionsshowed higher ESs that favored treatment groupsand all telehealth care interventions showed negativeESs that favored control groups except for one study.We examined the depression outcome measures chosenby the investigators and found that studies using theGeriatric Depression Scale showed the largest positiveES (ES¼ 0.65, CI¼�0.11 to 1.41) followed by theSymptom Checklist 90-R (ES¼ 0.50, CI¼ 0.01 to0.99), Patient Health Questionnaire-9 (ES¼ 0.24,CI¼�0.10 to 0.58), Hospital Anxiety and


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Depression Scale (ES¼ 0.20, CI¼�0.23 to 0.64), andSelf-Rating Depression Scale (ES¼ 0.11, CI¼�0.53 to0.75). Interventions that used the Center forEpidemiologic Studies – Depression Scale and SF-36Mental Health Scale had negative ESs favoring controlgroups. Studies with larger ESs had relatively smallersample sizes. The top three studies with the largest ESshad sample sizes ranging from 32 to 65. Attrition ratesof the studies included in the meta analysis rangedfrom 6% to 28%. Average attrition rates of the studieswith positive ESs and negative ESs were 15.8% and13.0%, respectively. The mean age, the gender mix,and the racial mix of study samples were notsignificantly different between the interventions withpositive ESs and negative ESs (Table 4).

Discussion

Based on the inclusion criteria, we selected andreviewed 15 studies of community-based health inter-ventions for older adults with heart disease andexamined intervention impact on depression outcomes.The interventions show wide variations in terms ofsample size, treatment protocol, and length of inter-vention, outcomes, and methodological quality. Whilesample sizes varied widely, outpatient clinic-based

interventions had relatively larger sample sizes com-pared to home-based interventions. Specifichome-based and/or outpatient clinic-based interven-tions include self care, exercise, rehabilitation, tele-health care, and prevention. The intervention periodacross studies also greatly differ ranging from 1 to 16months. The selected studies used seven differentdepression outcome measures including the: CES-D,GDS, SDS, HADS, the SCL-90R Depression Scale,the Patient Health Questionnaire, and SF 36Short-Form mental health scale.

The reviewed studies appear to lack rigorousmethodological approaches required for the validityand generalizability of the study findings. The averagescore of overall methodological quality was 4.7 out of apossible score of 10. Quality problems include lack ofsufficient power, detection bias, lack of intent-to-treatanalysis, lack of interventionist training, and notreatment fidelity reported. Less than 30% of thestudies met these criteria. In clinical trials, selectionbias, performance bias, detection bias, and attritionbias are all related to internal validity (Juni, Altman, &Egger, 2001), and 70% of the selected studies reviewedhave a serious internal validity problem based on theirpublished report.

Among the studies showing positive ESs, 67% ofstudies were home-based interventions or home- and

Table 3. Intervention effect on depression outcomes: treatment vs. control group comparisons.

InterventionStudy

Number

Months

BS 1 2 3 4 5 6 7 12 16

Self-disease management vs. UC 6 ns ns ns3 ns ns

Secondary prevention clinic vs. generalist practitionerclinic as UC

2 ns

Cardiac rehabilitation vs. UC in outpatient clinic 13 nsNurse-led education and counseling vs. unspecified UCNo depression 9 ns ns nsMild depression 9 ns ns nsModerate/severe depression 9 ns þ ns

Transcendental Meditation vs. health education as UC 7 ns þ þ

Exercise vs. unspecified UC 14 ns* nsExercise vs. education as UC 5 þ ns þ

Exercise vs. medical supervision and drug treatment asUC

1 ns

Telehealth care vs. unspecified UC 12 ns ns15 þ þ ns10 ns ns ns

Telehealth care vs. education as UC 4 ns nsHealth advocacy, counseling, and activation program

vs. unspecified UCMen with ZSDS� 45 vs. UC 11 þ

Women with ZSDS� 45 vs. UC 11 nsTelephonic vs.Home visit vs.Health Buddy vs.Home visit/Health Buddy 8 ns ns

Notes: Studies reported assessment periods in weeks were recalculated to months. BS¼Baseline; UC¼ usual care; ns¼ nosignificant difference between treatment and control groups; þ¼ treatment group is superior to control group on outcomes.*While this study reports significant percentage-mean-score change between treatment and control groups at 3-month follow-upassessment, it is noted as ‘‘ns’’ as the study reports no significant mean score change between the two groups.


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Table

4.Effectsizesforcommunity-basedhealthcare

interventionsatmost

currentfollow-upassessm

ent.

Study

Length

of

treatm

ent

Attrition

rate*(%

)Depression

scale

Latest

assessm

ent

Treatm

ent

group

Controlgroup

Favors

CG!

Favors

TG

Standardized

meandifference**

(95%

confidence

interval)

Mean(SD)

NMean(SD)

N

Gary

etal.(2004)

3Month

13

GDS

3Month

7(5.00)

16

4(4.00)

16

–1–0

.50

0.5

11.

52

0.65

(�0.06–1.36)

Barrow

etal.(2007)

4Month

20

SCL90-R

4Month

57.3(12.20)

33

51.5(10.66)

32

0.50

(0.01–0.99)

Riegel

etal.(2006)

6Month

16

PHQ-9

6Month

2(2.10)

65

1.5(2.00)

69

0.24

(�0.10–0.58)

Witham

etal.(2005)

6Month

17

HADS

6Month

5.1(3.00)

36

4.5(2.90)

32

0.20

(�0.28–0.68)

Sekiet

al.(2003)

6Month

NR

SDS

6Month

33.2(10.30)

18

32.2(7.30)

20

0.11

(�0.53–0.75)

Campbellet

al.(1998)

1Year

13

HADS

1Year

4.61(3.31)

564

4.38(3.51)

581

0.07

(�0.05–0.18)

Clark

etal.(2000)

1Month

15

CES-D

1Year

3.55(4.80)

225

3.65(4.90)

235

�0.02

(�0.20–0.16)

Doughherty

(2004)

2Month

6CES-D

3Month

8.63(8.83)

84

9.23(9.31)

84

�0.07

(�0.37–0.24)

Schwarz

etal.(2008)

3Month

18

CES-D

3Month

6.6(6.7)

40

8.2(11.20)

44

�0.17

(�0.60–0.26)

Woodendet

al.(2007)

3Month

7**

SF36MH

1Year

73.22(22.65)

36

81.3(18.06)

37

�0.39

(�0.86–0.07)

Note:*Attritionrate

forheart

failure

groupisreported.

**Effectsize

measuredasstandardized

meandifference

betweentreatm

entandcontrolgroups.

CG¼Controlgroup,TG¼Treatm

entgroup,NR¼Notreported,GDS¼Geriatric

DepressionScale,SCL-90R¼SCL-90R

DepressionScale,PHQ-9¼PatientHealthQuestionnaire,

9-item

measure

ofdepressionseverity,SDS¼ZungSelf-RatingDepressionScale,HADS¼HospitalAnxiety

andDepressionScale,CES-D¼CenterforEpidem

iologicalStudiesDepression

Scale,SF36MH¼MedicalOutcomes

StudyShort

Form

36(SF36)formentalhealthassessm

ent.


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outpatient-based interventions for older adults withheart disease. Based on these findings, home-basedinterventions may be considered as one strategy inreducing depressive symptoms in older adults withheart disease. In these patients, depression is not onlyhighly prevalent, but also characterized by symptoms(e.g. anhedonia and suicidal ideation) and condition(such as comorbid cardiovascular pulmonary diseases,cognitive impairment, and functional disability) asso-ciated with negative outcomes. Mobility limitationsalong with other disabilities are significant predictorsof depressive symptoms. Consequently, loneliness andisolation are likely to contribute to increased depres-sive symptoms. Home-based interventions can reducesocial isolation and eliminate barriers to transporta-tion, as well as meeting older adults’ care preference. Inaddition, home-based interventions may be more costeffective than outpatient clinic-based interventions.However, any general conclusions drawn from thesedata are mitigated by the limited number of rando-mized controlled studies and the varying quality andmethodological limitations of the selected studies.

Effect sizes were larger for studies with a longertreatment period than those with a shorter treatmentperiod. Nonetheless, drawing a conclusion of theassociation between length of treatment and depressionoutcome is difficult as the analysis included only themost current assessment outcomes. Higher attritionrate may inflate the treatment effect. The attrition rateof studies with positive ESs was 2.8% higher than thatof studies with negative ESs. Nonetheless, this analysisdid not lend itself to determine the influence ofattrition rates on treatment effect. Further study thatexamines if there is attrition influence on the treatmenteffect will provide more definite information. Mostinterventions included in the meta analysis recruitedparticipants with mild depression symptoms. Thus, thestudies with positive effect sizes may be, in fact,underpowered since it is difficult to demonstrate atreatment effect for those patients with mild depression(Zarit & Femia, 2008).

The studies reviewed in this article describedinterventions specifically for heart-disease manage-ment interventions and not for depression care.However, many of the components utilized in heartdisease interventions (e.g. exercise, chronic-diseasemanagement strategies, and education) are also appliedin depression care interventions. Education andchronic-disease management may reduce depressionby teaching patients how to change lifestyle andregulate symptoms (Martensson et al., 2005). TaiChi, Chi Kung, and Transcendental Meditationtechniques are designed for physical and cognitiverelaxation (Barrow et al., 2007; Jayadevappa et al.,2007), and these interventions have the potential toreduce patients’ depressive symptoms. For exerciseinterventions, attending regular programs may leadolder adults to become more active and less depressed(Gary & Lee, 2007). Group affiliations or socialsupport created through an intervention may also

play a key factor in lowering depression severity (Gary

& Lee, 2007).PRIDE, a well-known heart-disease management

program, was not associated with significant reduction

of depression. Clark et al. (2000) reported that theintentional shifts in PRIDE to emphasize physical

activity may be the reason why they did not find

significant treatment effects on depression symptoms.

Janz et al.’s (2004) study on PRIDE also showed no

significant results on depression outcomes but did findan effect on stress reduction. The authors suggest that

one of the reasons for negative findings were likely due

to the lack of sensitivity of the measurements chosen

(CES-D).Older adults with heart disease clearly have differ-

ent care management needs than younger patients.

Older adults are more likely to have lower

physical-functioning capacity than younger cohorts,

or they may be homebound due to debilitating chronicmedical conditions. More importantly, older adults are

at high risk of suffering from depression. High rates of

depression are well documented among medically ill

elderly and those confined to their homes by medical

illness and disability. Their homebound status is abarrier for access to depression care. Left untreated,

depression leads to exacerbation of medical conditions,

deterioration in functioning, and increased health

costs.It is possible to view interventions in a sample with

low levels of depressive symptoms as of the prevention

program type. In that regard, one might observe

differences over longer periods of time, with symptoms

remaining low in the treatment condition and rising in

the control condition from baseline points (Zarit &Femia, 2008). Thus, longer observation phases may be

needed to observe a treatment effect (Mittelman, Roth,

Coon, & Haley, 2004; Zarit & Femia, 2008).Psychosocial heart disease intervention studies

excluded from this review focused on quality-of-lifeimprovement and measured anxiety and/or distress

levels. These studies were also excluded because

depression outcomes were not assessed, they were not

randomized controlled trials, and the sample wasyounger than 64 years of age. The main

components of these psychosocial interventions

included education and counseling (e.g., Jaarsma et

al., 2000; Ramachandran et al., 2007). Some of the

quality-of-life interventions included an exercisecomponent as well. Since most community-based

interventions included exercise, education, and

self-management, the strength of each component

used in the intervention may have resulted in variabil-ity on depression outcomes. Identifying which compo-

nent of the intervention has a direct effect on

depression may contribute to more effective and

efficient care for older adults with heart disease.

Furthermore, evidence-based treatments for depres-sion such as cognitive behavioral therapy, interper-

sonal psychotherapy, or problem solving therapy can


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be easily integrated into heart disease interventions formedically ill elderly and be evaluated for effectiveness.

Conclusion

The strengths of this meta analytic review include theuse of a broad search strategy and standardizedinclusion and study evaluation criteria. One limitationis that quasi-experimental studies were not consideredeven when experimental designs offer more support forthe association of a causal relationship. Implementingand evaluating a randomized field trial is inherentlydifficult in ‘‘real world’’ home and community-basedsettings. The contribution of lower levels of evidenceshould not be overlooked especially when improvingaccess and quality of care for depressed medically illolder adults is critical. Another limitation is that themeta analysis was conducted using all availableoutcome data at the most current assessment. Thisexcluded other assessment outcomes during thefollow-up period.

Upon examination of the methodological quality ofthe studies and the meta analysis, we address impor-tant implications. First, depression outcome researchon community-health interventions for medically illolder adults with heart disease is needed to providefurther evidence of intervention effects on depression.Second, future intervention studies should conductmore rigorous trials that investigate its effects ondepression over longer time periods with morediversified samples of older adults with heart disease.Third, reports of randomized trial studies for heartdisease management should consider using thewell-known Consolidated Standards of ReportingTrials (CONSORT). Finally, since heart disease is acommon diagnosis in older persons and highlyassociated with depression, systematic review ofcommunity-health interventions for older adults withheart disease should be routinely conducted. In addi-tion, a larger number of studies should be included inthe systematic review and meta analysis. Interventionswith quasi experimental design could be considered aspart of inclusion criteria. Finally, future meta analysisshould consider including sub-group analyses by dif-ferent demographic characteristics of the study sample,common depression outcome measures, and assess-ment stages. This may lead to limiting the greatvariability in methodology and interventions and toprovide better understanding of the evidence. With theevidence based on sound methodological trials, clin-icians will be more knowledgeable about effectiveinterventions for community-dwelling older adultswith heart disease and depression.

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Appendix I. Reference list of other studies found

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Blumenthal, J.A., Sherwood, A., Babyak, M.A., Watkins,L.L., Waugh, R., Georgiades, A., et al. (2005). Effects of

exercise and stress management training on markers of


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cardiovascular risk in patients with ischemic heart disease.

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1626–1634.Davidson, P., Digiacomo, M., Zecchin, R., Clarke, M.,

Paul, G., Lamb, K., et al. (2008). A cardiac rehabilita-

tion program to improve psychosocial outcomes of

women with heart disease. Journal of Women’s Health,

17(1), 123–134.ENRICH Investigators (2000). Enhancing recovery in

coronary heart disease patients (ENRICHD): Study

design and methods. American Heart Journal, 139, 1–9.ENRICH Investigators (2003). Effects of treating depression

and low perceived social support on clinical events after

myocardial infarction. Journal of the American Medical

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Evangelista, L.S., Doering, L.V., Lennie, T., Moser, D.K.,

Hamilton, M.A., Fonarow, G.C., et al. (2005). Usefulness

of a home-based exercise program for overweight and

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Journal of Cardiology, 97, 886–890.Fletcher, A.E., Bulpitt, C.J., Thijs, L., Toumilehto, J.,

Antikainen, R., Bossini, A., et al. (2001). Quality of life

on randomized treatment for isolated systolic hyperten-

sion: Results from the Syst-Eur Trial. Journal of

Hypertension, 20, 2069–2079.

Frasure-Smith, N., Lesperance, F., Gravel, G., Masson, A.,

Juneau, M., & Bourassa, M.G. (2002). Long-term

survival differences among low-anxious, high-anxious

and repressive copers enrolled in the Montreal heart

attack readjustment trial. Psychosomatic Medicine, 64,

571–579.Frasure-Smith, N., Lesperance, F., & Talajic, M. (1995).

The impact of negative emotions on prognosis following

myocardial infarction: Is it more than depression? Health

Psychology, 14(5), 388–398.Gary, R. (2006). Exercise self-efficacy in older women with

diastolic heart failure: Results from a walking program

and education intervention. Journal of Gerontological

Nursing, 32(7), 31–39.Gary, R., & Lee, S. (2007). Physical function and quality of

life in older women with diastolic heart failure: Effects of a

progressive walking program on sleep patterns. Progress in

Cardiovascular Nursing, 22, 72–80.

Glassman, A.H., O’Connor, C.M., Califf, R.M.,

Swedberg, K., Schwartz, P., Bigger, J.T., et al. (2008).

Sertraline treatment of major depression in patients

with acute MI or unstable angina. Journal of American

Medical Association, 288(6), 701–709.Greenwald, B.S., Kramer-Ginsberg, E., Krishnan, K.R.R.,

Hu, J., Ashtari, M., Wu, H., et al. (2001). A controlled

study of MRI signal Hypertensities in older depressed

patients with and without hypertension. Journal of

American Geriatrics Society, 49, 1218–1225.Hamm, L.F., Kavanagh, T., Campbell, R.B., Mertens, D.J.,

Beyene, J., Kennedy, J., et al. (2004). Timeline for peak

improvements during 52 weeks of outpatient cardiac

rehabilitation. Journal of Cardiopulmonary Rehabilitation,

24, 374–382.Jaarsma, T., Halfens, R., Tan, F., Abu-Saad, H.,

Dracup., K., Diederiks, J., et al. (2000). Self-care and

quality of life in patients with advanced heart failure:

The effect of a supportive educational intervention.

Heart & Lung, 29(5), 319–330.Jerant, A., Kravitz, R., Moore-Hill, M., & Franks, P. (2008).

Depressive symptoms moderated the effect of chronic

illness self-management training on self-efficacy. Medical

Care, 46(5), 523–531.Jiang, W., O’Connor, C., Silva, S.G., Kuchibhatla, M.,

Cuffe, M.S., Callwood, D.D., et al. (2008). Safety and

efficacy of sertraline for depression in patients with CHF

(SADHART-CHF): A randomized, double-blind, pla-

cebo-controlled trial of sertraline for major depression

with congestive heart failure. American Heart Journal, 156,

437–444.Jolly, K., Lip, G.Y.H., Sandercock, J., Greenfield, S.M.,

Raftery, J.P., Mant, J., et al. (2003). Home-based versus

hospital-based cardiac rehabilitation after myocardial

infarction or revascularization: Design and rationale of

the Birmingham Rehabilitation Uptake Maximisation

Study (BRUM): A randomized controlled trail.

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Karlsson, M.R., Edstrom-Plu¡¡ss, C., Held, C.,

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social status in coronary artery disease with focus on

type D characteristics. Journal of Behavioral Medicine,

30, 253–261.Koertge, J., Janszky, I., Sundin, O., Blom, M.,

Georgiades, A., Laszlo, K.D., et al. (2007). Effects of

a stress management program in vital exhaustion and

depression in women with coronary heart disease: A

randomized controlled intervention study. Journal of

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intervention on patients’ long-term adjustment to the

ICD: A prospective . study. PACE, 23(Part I), 450–456.Koukouvou, G., Kouidi, E., Lacovides, A., Konstantinidou,

E., Kaprinis, G., & Deligiannis, A. (2004). Quality of life,

psychological and physiological changes following exercise

training in patients with chronic heart failure. Journal of

Rehabilitation Medicine, 36(1), 36–41.

Krishnan, K.R., Doraiswamy, P.M., & Clary, C.M. (2001).

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depression associated with vascular disease: A pooled

analysis of two multicenter trials with sertraline. Progress

in Neuro-Psychopharmacology and Biological Psychiatry,

25, 347–361.Kulcu, D.G., Kurtais, Y., Tur, B.S., Gulec, G., & Seckin, B.

(2007). The effect of cardiac rehabilitation on

quality of life, anxiety and depression in patients

with congestive heart failure: A randomized controlled

trial, short-tern results. Europa Medicophysica, 43(4),

489–497.Lacey, E.A., Musgrave, R.J., Freeman, J.V., Tod, A.M., &

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infarction in an area of deprivation in the UK: Evaluation

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Luskin, F., Reitz, M., Newell, K., Quinn, T.G., &

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management training of elderly patients with congestive

heart failure. Preventive Cardiology, 5, 168–176.

Marchionni, N., Fattirolli, F., Fumagalli, S., Oldridge, N.,

Lungo, F., Bonechi, F., et al. (2000). Determinants of

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48(2), 146–153.Mittag, O., China, C., Hoberg, E., Juers, E., Kolenda, K.,

Richardt, G., et al. (2006). Outcomes of cardiac


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rehabilitation with versus without a follow-up intervention

rendered by telephone (Luebeck follow-up trial): Overall

and gender-specific effects. International Journal of

Rehabilitation Research, 29(4), 295–302.Nuyen, J., Spreeuwenberg, P.M., Beekman, A.T.F.,

Groenewegen, P.P., Bos, G.A.M., & Schellevis, F.G.

(2007). Cerebrovascular risk factors and subsequent

depression in older general practice patients. Journal of

Affective Disorders, 99, 73–81.Oslin, D.W., Ten Have, T.R., Streim, J.E., Datto, C.J.,

Weintraub, D., DiFilippo, S., et al. (2003). Probing the

safety of medications in the frail elderly: Evidence from a

randomized clinical trial of sertraline and venlafaxine in

depressed nursing home residents. Journal of Clinical

Psychiatry, 64(8), 875–882.Peter-Klimm, F., Muller-Tasch, T., Shellberg, D., Gensichen,

J., Muth, C., Herzog, W., et al. (2007). Rationale, design

and conduct of a randomized controlled trial evaluating a

primary care-based complex interventions to improve the

quality of life of heart failure patients: HICMan

(Heidelberg Integrated Case Management).

Cardiovascular Disorders, 7(25), 1471–2261.

Peters, R., Beckett, N., Nunes,M., Fletcher, A., Forette, F., &

Bulpitt, C. (2006). A substudy protocol of the hypertension

in the very elderly trial assessing cognitive decline and

dementia incidence (HYVET-COG). Drugs Aging, 23(1),

83–92.Ramachandran, K., Husain, N., Muikhuri, R., Seth, S.,

Vij, A., Kumar, M., et al. (2007). Impact of a

comprehensive telephone-based disease management pro-

gramme on quality-of-life in patients with heart failure.

The National Medical Journal of India, 20(2), 67–73.Riegel, B., Carlson, B., Glaser, D., & Romero, T. (2003).

Changes over 6-month in health-related quality of life in a

matched sample of Hispanics and non-Hispanics with

heart failure. Quality of Life Research, 12, 689–698.Santos, F.S., & Velasco, I.T. (2005). Clinical features of

elderly patients submitted to coronary artery bypass graft.

Gerontology, 51(4), 234–241.Schneiderman, N., Saab, P.G., Catellier, D.J., Powell, L.H.,

Debusk, R.F., Williams, R.B., et al. (2004). Psychosocial

treatment within sex by ethnicity subgruops in the

enhancing recovery in coronary heart disease clinical

trial. Psychosomatic Medicine, 66, 476–483.

Sheikh, J.I., Cassidy, E.L., Doraiswamy, P.M., Salomon,R.M., Hornig, M., Holland, P.J., et al. (2004). Efficacy,

safety, and tolerability of sertraline in patients with late-life depression and comorbid mental illness. Journal ofAmerican Geriatrics Society, 52, 86–92.

Shuldham, C.M., Fleming, S., & Goodman, H. (2002). The

impact of pre-operative education on recovery followingcoronary artery bypass surgery. European Heart Journal,23, 666–674.

Sneed, N.V., Paul, S., Michel, Y., VanBakel, A., &Hendrix, G. (2001). Evaluation of 3 quality of lifemeasurement tools in patients with chronic heart failure.

Heart & Lung, 30, 332–340.Southard, B.H., Southard, D.R., & Nuckolls, J. (2003).Clinical trial of an internet-based case managementsystem for secondary prevention of heart disease. Journal

of Cardiopulmonary Rehabilitation, 23, 341–348.Swenson, J.R., O’Connor, C.M., Barton, D., Van Zyl, L.T.,Swedberg, K., Forman, L.M, et al. (2003). Influence of

depression and effect of treatment with sertraline onquality of life after hospitalization for acute coronarysyndrome. American Journal of Cardiology, 92(1),

1271–1276.Wakefield, B.J., Bylund, C.L., Holman, J.E., Ray, A.,Scherubel, M., Kienzle, M.G., et al. (2008).

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Witham, M.D., Argo, I.S., Johnston, D.W., Struthers, A.D.,& McMurdo, M.E.T. (2007). Long-term follow-up of veryolder heart failure patients enrolled in a trial exercise

training. American Journal of geriatric cardiology, 16(4),423–248.

Woodened, A.K., Sherrard, H., Fraser, M., Stuewe, L.,

Cheung, T., & Struthers, C. (2007). Telehome monitoringin patients with cardiac disease who are at high risk ofremission. Heart & Lung, 37, 36–45.

Zwisler, A., Soja, A., Rasmussen, S., Frederiksen, M.,Abadini, S., Appel, J., et al. (2008). Hospital-basedcomprehensive cardiac rehabilitation versus usual careamong patients with congestive heart failure, ischemic

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a systematic review of community-based health interventions on depression for older adults with...

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