de Oliveira FW, Nunes BP, Lobato FL, Schmidt MM. Psychoeducational intervention for reducing heart failure patients’ rehospitalizations and promoting their quality of life and posttraumatic growth at the 1-year follow-up: a randomized clinical trial. Psychosom Med. 2023;85(3):273-279.
To determine whether a psychoeducational intervention can reduce hospital re-admissions and improve quality of life for heart-failure (HF) patients
A 2-session intervention effectively reduced hospital readmissions by half and improved quality of life for HF patients.
Randomized, open, controlled, parallel, clinical trial
Investigators recruited 142 patients, aged 18 to 45 years, who were diagnosed with congestive HF and treated in a general hospital in Southern Brazil between July 2019 and October 2020 at baseline. The majority (68%) of participants were men; 58% were in a low-income bracket; and 67% had less than a high school education. Investigators assessed a total of 123 participants after approximately 378 days. Ten participants dropped out, and 9 participants passed away.
Investigators defined congestive HF using the American Heart Association’s definitions for stages C and D heart failure.
The control group (CG) received usual care.
The intervention group (IG) received 2 60-minute health education sessions with a registered nurse under the supervision of a psychologist. These 2 appointments were 7 days apart. Participants received a guide written at a 5th-grade reader level that provided information about heart failure, hypertension, and diabetes self-care (signs and symptoms to watch for and self-reflection on posttraumatic growth). They also received a booklet to record daily medications, fluids, and body weight. The first session included information about heart-failure warning signs and symptoms and when to seek more help; diabetes testing and treatment; and hypertension monitoring and treatment. The second session included the physical education reinforcement as well as more reflective measures.
Study Parameters Assessed
- Hospital readmission within 1 year of discharge.
- Quality-of-life scores as tracked by the WHOQoL-BREF, a questionnaire that assesses symptoms in physical, psychological, social, and environmental domains.
- Posttraumatic growth inventory (PTGI) scores 6 months after the initial intervention.
The primary outcome was rehospitalization within 1 year after initial discharge from the hospital. Readmission could be due to any cause.
At the 1-year follow-up, the overall hospital readmission rate was 24%, with 32% for the CG and 15% in the IG (P=0.018). The in-hospital mortality rate was 10% in the CG vs 3% in the IG (P=0.09). The comorbidity rate was 35% for the CG vs 16% for the IG (P=0.015).
Sex, smoking, history of coronary artery disease (myocardial infarction or coronary artery bypass graft), and having a New York Heart Association class were not associated with increased readmission rates.
Although the intervention group showed improvement in overall quality of life, the results for the individual domains were not significant. For posttraumatic growth, the intervention group showed improvements in “relating to others,” “new possibilities,” “personal strength,” and “appreciation of life.”
Practice Implications & Limitations
Clinicians often associate posttraumatic stress disorder (PTSD) with war and combat veterans, but many traumatic experiences, especially repetitive ones, may lead to PTSD with intense feelings of fear, helplessness, and/or horror. In addition to war and combat, other events that can lead to PTSD include physical, mental, or sexual assault, at home or in the workplace; the unexpected death of a loved one; an accident; or a natural disaster.1 Of all known mental and emotional disorders, PTSD is the only one with a clearly identifiable cause.2 Researchers have found that 71.9% of Korean adults3 and 89% of American adults4 have experienced at least 1 traumatic event during their lifetime. Approximately 10% to 15% of those who have experienced trauma are later diagnosed with PTSD.
Of all known mental and emotional disorders, PTSD is the only one with a clearly identifiable cause.
PTSD may occur immediately after an event or up to several years afterward. Some patients, for example, may not show signs of PTSD resulting from early-life trauma until their elder years.5 Several factors contribute to the onset of PTSD, including repetition of events, genetics, and female sex.6 Physical diagnoses associated with the highest incidences of PTSD include cardiovascular, digestive, and musculoskeletal disorders.7
The same set of events can lead either to PTSD or posttraumatic growth (PTG). According to the researcher Tanako Taku, PhD, associate professor of psychology at Oakland University, patients who are already resilient likely will bounce back. PTG results when “someone who has difficulty bouncing back experiences a traumatic event that challenges his or her core beliefs, endures psychological struggle (even a mental illness such as post-traumatic stress disorder), and then ultimately finds a sense of personal growth. … It’s a process that takes a lot of time, energy and struggle.”8
After a stroke, “deliberate rumination” is a key predictor of PTG. Along with rumination, actively coping and actively denying both were associated with PTG. This underlines the likelihood that all trauma patients will benefit from a therapist who can facilitate growth and well-being.9
Research looking at healthcare workers in the United Kingdom during the Covid-19 pandemic found that “positive self-reflection, black and minority ethnic status, developing new healthcare knowledge and skills, connecting with friends and family, feeling supported by senior management, feeling supported by the UK people, and feeling anxious about the personal and work-related consequences of Covid-19 each significantly independently predicted greater post-traumatic growth.”10 The same publication also found that working in community physical healthcare, in a clinical role, and in mental healthcare all reduced the likelihood of posttraumatic growth. Researchers linked an organizational focus on occupational health during a time of adversity and encouragement of personal growth, including self-reflective activities, such as mindfulness and meditation, with promoting PTG.10
As a clinician, you can offer patients support after heart failure and other traumatic events with simple and effective interventions that increase the likelihood of patients experiencing PTG rather than PTSD:
- Educating patients about posttraumatic stress disorder vs posttraumatic growth
- Telephone appointments
- Physical supports (eg, acupuncture, yoga, tai chi, qigong, forest bathing, supplements, hydrocortisone, melatonin, Silexan)
- Appropriate, state-of-the-art psychological support (eg, eye movement desensitization and retraining [EMDR], brainspotting, emotional freedom techniques, hypnosis)
Educating patients about PTSD and PTG
Providing patients information about how their experiences can catalyze either PTG or PTSD can be tremendously empowering. Instead of feeling helpless, patients can make conscious choices that support a path of growth rather than stress.
While researchers and clinicians have proposed several models to illuminate the factors that support PTG, the oblique, 5-factor model best fits the data (see below).11
Before the Covid-19 pandemic, researchers explored the benefits of phone appointments for patients with complex, chronic conditions and found that regular telephone appointments reduced repeat hospitalizations in some patient groups and reduced mortality in patients “with chronic somatic conditions.”13 Phone interventions may be a cost-effective way to support patients, particularly those who are bedridden or unable to drive after leaving the hospital.
Research demonstrates that administering a single dose (100–140 mg injected bolus) of hydrocortisone reduces the likelihood of developing PTSD by 60%.14 Lower-dose hydrocortisone also proved beneficial in preventing PTSD. In a double-blind protocol, 64 traumatic-injury patients were randomly assigned to receive either a 10-day course of hydrocortisone or placebo within 12 hours of the trauma. In interviews 1 and 3 months post trauma, participants self-reported fewer PTSD symptoms and greater improvements in health-related quality of life compared with placebo recipients. Participants who had never received prior mental health treatment had the lowest PTSD scores.15 Joseph Zohar et al posit that giving hydrocortisone mimics the natural stress response and offers protection from developing PTSD.
A murine study found that 0.1 mL peritoneal injections of melatonin daily for 2 consecutive weeks alleviated PTSD-like behavior in the mice and restored serum gamma-aminobutyric acid (GABA) and cortisol levels. A melatonin receptor 1 antagonist mediated the effects.16
Silexan is a standardized oral preparation of lavender essential oil. Fifty male and female patients with neurasthenia, PTSD, or somatization disorder received 1 80-mg caplet of Silexan daily for 6 weeks. Subjects had improvements in restlessness, depressed mood, sleep disturbance, and anxiety. Their SF-35 Mental Health Score increased by 48.2%.17
A study involving 64 women with chronic, treatment-resistant PTSD were assigned a to yoga group or a supportive women’s health education (control) group, meeting 1 hour weekly for 10 weeks. By study’s end, 52% of the yoga group no longer met the criteria for PTSD compared with 21% in the control group. The yoga group maintained their initial improvement while the control group relapsed.18
Tai chi and qigong
Survivors of refugee trauma and torture benefitted from both tai chi and qigong.19
Forest bathing (Shinrin-yoku)—visiting a forest and breathing its air—reduces salivary and serum cortisol.20 Additional benefits may include reducing blood pressure, lowering stress, lowering blood sugar levels, improving concentration and memory, lifting depression, and improving pain thresholds.21 While walking in an urban area provides many of the same benefits, only forest bathing reduces fatigue and improves vigor.21
Researchers have found an even deeper, longer-lasting effect from spending 3 days in a natural environment (“the 3-day effect”).21
Ideally patients would receive psychotherapy specifically aimed at addressing trauma. Dr Peta Stapleton, in her book The Science Behind Tapping (2019), notes that psychotherapy has evolved through 4 “waves”: first, psychoanalysis pioneered by Sigmund Freud and Carl Jung, followed by a second wave of behavior modification from which emerged 2 movements, humanistic psychology and cognitive behavioral therapy. Stapleton identifies a fourth wave of psychotherapy that emphasizes somatic therapies that yield significant results in shorter treatment windows, ie, fewer than 10 sessions. Examples of these fourth wave therapies focused specifically on trauma include eye movement desensitization reprocessing (EMDR), brainspotting, and emotional freedom techniques (EFT).
Eye Movement Desensitization and Reprocessing (EMDR)
This therapy recognizes that trauma often is imprinted through visual stimulation and aims to disrupt and reprocess that information in the brain. Several international health organizations recommend EMDR for treating trauma.22,1
Brainspotting utilizes a fixed eye focus and does not employ cognitive restructuring, which is a feature of EMDR.23 Although brainspotting yields faster effects than EMDR, due to streamlined sessions (not incorporating cognitive restructuring), EMDR may have longer-lasting effects.
Emotional freedom techniques (EFT)
Commonly referred to as “tapping,” this therapeutic modality relies on self-stimulation of selected acupuncture points to resolve emotional trauma. Researchers have found that EFT is effective for many groups suffering with PTSD, including victims of sexual violence, war veterans, motor vehicle accident survivors, prisoners, hospital patients, adolescents, and survivors of both natural and humanmade disasters. A course of treatment involves 4 to 10 sessions and could be offered effectively in a group setting. Researchers have also found that patients can have both physiological and psychological improvements; more than 1 condition can be treated (eg, anxiety and depression); and benefits persist over time.24
Hypnosis helped improve sleep for PTSD patients undergoing cognitive processing therapy. Sleep disorders associated with PTSD tend to persist, despite psychotherapy treatment. Although hypnotherapy helped improve sleep, it did not augment the gains associated with PTSD treatment.25
A recent meta-analysis demonstrated that acupuncture outperformed pharmacotherapy for several disorders, and acupuncture outperformed pharmacotherapy for SCL-90 somatization for PTSD.26
A review study of integrative therapies (mindfulness, nutrition, yoga, exercise, acupuncture, qigong, tai chi, and art therapy) for veterans suggests many therapies effectively treat veterans with PTSD, but the researchers also note these studies lack evidence to conclude that these therapies alone will address PTSD.27
Posttraumatic Stress Disorder vs Posttraumatic Growth
As noted above, patients experiencing trauma may take 1 of 2 divergent pathways when responding to a stressful event or events: posttraumatic stress or posttraumatic growth. The bigger the trauma, the greater the potential for growth.28 Both pathways are available, so what are other recommendations that clinicians can offer to encourage patients to follow the path of “growth” rather than the path of “stress disorder”?
In 1996, researchers Tadeschi and Calhoun identified 5 factors that all contribute to taking the PTG pathway. Although referred to as “steps,” these factors do not necessarily follow a specific chronology. They include:
- appreciation of life,
- relationship with others,
- new possibilities in life,
- personal strength, and
- spiritual change.29
Kelly et al (2018) identify “deliberate rumination” as 1 of the strongest predictors that someone will take the growth pathway after the trauma of having a stroke.9
Social support is an integral part of “relationship with others” in promoting posttraumatic growth, according to Danhauer et al (2013).28
Clinicians should also screen traumatized patients for symptoms of depression. Addressing depression early can help resolve depression more quickly and can improve both clinical and disability outcomes.40
PTG for Other Illnesses
Although the study under review here explores the aftermath of heart failure, examining other chronic illnesses (eg, breast cancer) may provide clues about how to support PTG. The following factors are all predictors of PTG in women with breast cancer:28
- education level (except beyond college graduate)
- time since diagnosis
- baseline level of illness intrusiveness (the bigger the trauma, the greater the likelihood of PTG)
- spirituality–meaning and peace
- use of active–adaptive coping strategies
- greater increases in social support
Danhauer et al’s study (2013)28 was the first to demonstrate that increases in social support are associated with PTG, primarily via the “Relating to Others” domain of the Post Trauma Growth Index (PTGI). The researchers theorized that social support promotes PTG by allowing disclosure about the highly stressful event.
Clinicians can be a key support for patients after heart failure (and for other traumatized patients) by evaluating them for posttraumatic growth using the Post Traumatic Growth Inventory (free version: https://www.careinnovations.org/wp-content/uploads/Post-Traumatic-Growth-Inventory.pdf). Assess them for depression as well, and if indicated, begin treatment as soon as possible. In addition to screening patients, you can offer physical support—ie, specific supplementation (hydrocortisone, melatonin, and/or Silexan) and physically based therapies (acupuncture, tai chi, qigong, forest bathing). Refer patients for appropriate psychotherapy, ideally an approach developed specifically to address trauma. “Fourth wave” therapies likely will provide faster, longer-lasting results than older forms of psychoanalysis. Befriend time; continue to be an ally for your patient over time, offering support for each PTG factor as it emerges in your patient’s life.