**13. Conclusion and future directions**

mortality and differential findings were reported on hospital readmissions. One found reduced odds [83], whereas another review did not when applying stringent criteria for properly randomized studies [84]. There is no trial about the role of anxiolytic drugs before or

Psychosocial interventions (psychotherapy, support, stress reduction) have been used as treatments for depression in CAD patients. The aim of these interventions is to reduce psychological distress, which in theory would ultimately improve clinical outcomes. Patients with depression often do not participate or complete cardiac rehabilitation programs after CABG and thus may form a barrier to improvements in cardiac functioning [85]. From another aspect, isolated patients may be difficult to enroll in interventions because they do feel that they have a problem. Without the experience of need, motivation to change may be low [86]. Numerous behavioural and psychological randomized controlled trial (RCT) interventions have been reported and cognitive behavioural therapy or collaborative care constitutes Class IIa evidence (i.e., it is reasonable to administer treatment, additional studies with focused objectives are needed) [85]. In one of RCT studies on brief, tailored cognitive behavioural therapy targeting preoperative depression and anxiety researchers found that intervention improved depressive and anxiety symptoms, as well as quality of life. Moreover, it reduced in-hospital length of stay [87]. In a Canadian study eight weeks prior to CABG, the treatment group received exercise training twice per week, education and reinforcement, and monthly nurse-initiated telephone calls. After surgery, participation in a cardiac rehabilitation program was offered to all patients. The intervention was not associated with differences in pre-surgery anxiety versus usual care, however length of stay differed significantly between groups. Patients who received the preoperative intervention spent 1 less day in the hospital overall and less time in the intensive care. During the waiting period, patients in the intervention group had a better quality of life than controls. Improved quality of life continued up to 6 months after surgery. Mortality rates did not differ [88]. In a prospective randomized control‐ led trial the effects of a home-based intervention program on anxiety and depression 6 months after CABG were assessed. Anxiety and depression symptoms were measured before surgery, 6 weeks after surgery, and 6 months after surgery. On 6-week and 6-month follow-ups, significant improvements in anxiety and depression symptoms were found in both groups. There was no significant difference between patients receiving interventions and not [89]. Freedland et al. compared cognitive behaviour or supportive stress management vs usual care and found significant three month depression remission rates in the treatment arms. Cognitive behaviour therapy had greater and more durable effects than supportive stress management on depression and several secondary psychological outcomes [90]. The limitation of psycho‐ social RCTs among CABG populations is that those patients experiencing significant postoperative morbidity are likely to be excluded from trial inclusion. Therefore, less is known about long term outcomes for patients who experience stroke, deep sternal wound infection, sternal dehiscence, renal failure requiring dialysis and extended length of time on mechanical ventilation, or intensive care during their hospital stay. These moribund patients are at higher risks for developing or exacerbating psychological distress. Moreover, treatment of affective

after CABG with or without concomitant depressive symptoms.

**12.2. Psychosocial Interventions**

482 Artery Bypass

Coronary artery bypass graft surgery (CABG) is a confirmed procedure to relive angina pectoris and reduce the risk from life-threatening ischaemic heart disease, besides reducing the likelihood of future heart attacks and prolonging life-expectancy. Another goal is to improve health-related quality of life and psychological well-being. After successful surgery the majority of patients can have an improved everyday life, with increased performance in physical, social and sexual functioning and decreased levels of depression, anxiety, fatigue and sleep. In some cases quality of life for patients can be disappointing, and attention has increasingly been paid to psychological difficulties following CABG surgery [92]. Psycholog‐ ical problems such as depression and anxiety are widely reported soon after CABG surgery and remain evident for around one-fifth of patients one year after surgery. Poor psychological adjustment following surgery can increase the likelihood of new coronary events, further hospitalisations and even death. According to a recent study 30% of patients have reduced health related quality of life without being clinically anxious or depressed they present with fear of activity, fear of excitement, give up enjoyed hobbies / activities. Evidence suggests that self-perceived health related quality of life, depressive symptoms and anxiety together influence the short and long term recovery following coronary bypass surgery [93]. There is also a higher risk for morbidity and mortality among the lonely and the socially isolated, they are likely to have prolonged postoperative recovery and hospital stay. Lower education and poor social background are associated with higher mortality rates related to CHD and prolonged hospital stay after CABG [93, 94]. Further research on the interaction between these disorders and social factors may improve our understandings and uncover promising ways for intervention. Most studies to date focus on depression, the role of other factors alone or investigated together warrants further research.

In conclusion, compared with community samples the prevalence of depression and anxiety disorders are significantly higher and they confer greater morbidity risks, though the behav‐ ioural and biological mechanisms are poorly understood. Researchers and clinicians hope psychosocial intervention might decrease or cease the deleterious impact of depression and anxiety on morbidity and mortality.
