Original articleFurther development of an illness perception intervention for myocardial infarction patients: A randomized controlled trial☆
Introduction
Myocardial infarction (MI) is a major and usually sudden illness that can have serious psychological and functional impact on patients. Three months following acute MI, up to a third of patients experience significant depression [1]. Furthermore, many fail to return to work and report impaired functional ability often despite being physically able to work [2], [3]. Many patients fail to attend offered community cardiac rehabilitation classes [4].
Research based on the common-sense model of illness [5] has shown that the way patients make sense of their heart attack can strongly influence their trajectory of recovery. In this model, patients respond to symptoms and signs of illness by forming cognitive and emotional representations of the threat, which guide coping responses. The cognitive representation of the illness consists of five main domains: identity (the name and symptoms that the patient identifies as part of the illness), the cause of the illness, the timeline for the illness (how long the patient thinks it will last), the amount of control the patient perceives they have over the illness, and the perceived consequences of the illness on the patient's life [6], [7]. Later research has added illness coherence (how well the patient feels they understand the illness), perceptions of treatment control (how much treatment can help to control the illness), and the emotional representation (how much patients are emotionally affected by the illness), to assessments of illness perceptions [8].
Previous work has shown that patients' beliefs that the MI will have more serious and long-lasting consequences predict slower return to work and higher levels of disability [9]. Similarly, perceptions of greater damage to the heart predict slower return to work and greater cardiac anxiety 3 months later [10]. Causal attributions for the MI have also been linked to rate of return to work [11], [12], [13] and to lifestyle behaviors [14], [15], [16]. Patients who view their heart condition as highly symptomatic, with severe consequences, who feel that they understand their condition, feel they can control it, and who see lifestyle as a cause, are more likely to attend cardiac rehabilitation classes [17], [18].
Despite the demonstrated importance of illness perceptions to health outcomes, there has only been one randomized trial investigating whether changing illness perceptions can improve patient outcomes [19]. This brief in-hospital intervention, which targeted MI patients' perceptions of their illness, successfully changed perceptions and resulted in a quicker return to work and lower levels of chest pain for patients in the intervention group. More research is needed to further develop and test illness perception interventions with larger samples and across different illnesses [20].
The current study aimed to further develop the previous illness perception intervention and to trial it with MI patients using the new, wider definition of MI [21]. This new definition is primarily based on a rise in troponin T and has resulted in more patients being diagnosed with MI. It is not clear whether the intervention works in this broader group of patients. In order to increase generalization from the previous trial, the sample also included patients who had experienced a previous MI. The hypothesis was that, similar to the previous trial, the intervention would result in improved return to work. Return to work is an important behavioral and functional measure of recovery, with associated economic and psychological benefits [22], [23].
One of the additions to the intervention from the previous trial was a spouse session. The spouse is central to the recovery of the patient and their inclusion in the intervention may help to improve patient outcomes [24]. This paper reports the results for the patients. Another paper in this issue reports spouses results [25]. This trial enhanced the take-home written information from the previous trial by adding color diagrams and added take-home audio recordings of the intervention sessions for the patients.
Section snippets
Participants
A total of 108 consecutive patients who met the inclusion and exclusion criteria were approached and informed about the study. The inclusion criteria were that the patient had been admitted for acute MI at Auckland City Hospital, was aged less than 70, and spoke English. Exclusion criterion was the presence of a serious comorbid psychiatric or medical condition. Informed consent was gained from patients to participate. We also gained patients' consent to include their spouse/partner in the
Results
The demographics and clinical characteristics of the sample are shown in Table 1. The groups did not significantly differ on demographic variables.
Discussion
This trial further developed and tested an illness perception intervention in MI patients. The intervention significantly improved speed of return to work and a greater proportion of the intervention group had returned to full-time work at 3 months compared to the control group. The intervention lowered patient anxiety about returning to work and improved patients' understanding of the information received in hospital. Patients who received the intervention felt more prepared to leave hospital
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This research was supported by a grant from the Heart Foundation of New Zealand.