A theory- and evidence-based approach to developing and piloting a cognitive-behavioural self-help intervention for anxiety in adults living with pulmonary hypertension

Pulmonary hypertension (PH) is a progressive and life-shortening cardiovascular disease associated with an increased risk of lower health-related quality of life (HRQoL) and psychological difficulties, including depression and anxiety. Anxiety in particular is an important issue given the prevalence, overlapping symptoms between anxiety and PH, and the physiological link between anxiety and the increased load on cardiovascular functioning. While anxiety is a normal response to distressing stimuli, it can become unhelpful and impact on daily life. There is limited research examining treatments for anxiety in PH; however, evidence demonstrates the benefits of using a form of psychological therapy known as Cognitive Behavioural Therapy (CBT). CBT aims to help people change their attitudes, beliefs and actions. CBT is recommended by the National Institute for Health and Care Excellence for anxiety and panic disorders using a stepped care model, initially providing self-help interventions progressing to more intensive treatments. The objective of the current thesis was to develop and investigate a self-help intervention for anxiety in adults with PH. Development of the intervention was guided by the Medical Research Council Framework for developing complex healthcare interventions. This involves four phases consisting of developing, piloting, evaluating and implementing the intervention. More specifically, the initial phase consists of identifying the evidence-base to inform intervention development. Therefore, a thematic synthesis was first undertaken of qualitative studies investigating adults’ experiences of living with PH. In total, the data from 19 studies involving over 1900 adults from four continents were included. Studies generally were of high quality. Four analytical themes emerged reflecting the many uncertainties associated with the disease; that PH is often experienced somatically and misunderstood by others; participants’ frustration and upset at the lack of awareness of PH; and the transitional nature of life with PH. Results highlighted the numerous challenges that this clinical group experience and, in particular, the link between PH and anxiety. A four-week self-help intervention was then developed based on the available literature and its acceptability, feasibility and preliminary effectiveness explored using a pilot randomised control trial (RCT). Individuals with PH self-reporting difficulties with anxiety were recruited from Pulmonary Hypertension Associations. Participants were randomised to the intervention (n=37) or a wait-list group (n=40). Participants were asked to complete a series of health-related measures before and after the intervention, and at one-month follow-up. Measures assessed anxiety, depression, HRQoL, dyspnoea, self-mastery and mood-related cognitions and behaviours. Participants in the intervention group were contacted part-way through and at the end of the study to investigate intervention adherence and acceptability. Overall 65/77 of participants completed the study. All participants in the self-help group agreed that the intervention was helpful. Compared to those in the control condition, participants reported a significant reduction in anxiety, depression and mood-related cognitions and behaviours. The relationship between intervention condition and change in anxiety and depression were mediated by changes in cognitions and behaviours, suggesting a mechanism of change. The intervention was acceptable and feasible. Findings support the next phase in the framework involving a definitive RCT to evaluate the intervention