The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment and blinding) and by inconsistency (variability in results across studies).
A Cochrane review included 24 studies with a total of 9 296 subjects. The review examined studies where the effect of psychological interventions could be distinguished from other components of rehabilitative treatment (e.g. exercise) in patients with coronary heart disease. There was no evidence of a statistically significant effect of the interventions on all-cause mortality (RR 0.89, 95% CI 0.75 to 1.05; 17 studies, n=6 852). For cardiac mortality there was some evidence of fewer deaths in the intervention group (RR 0.80, 95% CI 0.64 to 1.00; 5 studies, n=3 893). Interventions showed no significant effects on occurrence of revascularisation (RR 0.95, 95% CI 0.80 to 1.13; 12 studies, n=6 670), or non-fatal myocardial infarction (RR 0.87, 95% CI 0.67 to 1.13; 12 studies, n=7 535). Psychological intervention resulted in small/moderate improvements in depression (SMD -0.21, 95% CI -0.35 to -0.08; 12 studies, n=5 041, statistical heterogeneity I² = 70%), and anxiety (SMD -0.25, 95% CI -0.48 to -0.03; 8 studies, n=2 771; statistical heterogeneity I² = 72%). Meta regression analyses revealed four significant predictors of intervention effects on depression: (1) an aim to treat type-A behaviours (p=0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (p=0.03), (3) included client-led discussion and emotional support as core therapeutic components ( p<0.01), or (4) included family members in the treatment process (p<0.01) were significantly less effective.
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