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A Self-Help Metacognitive Therapy for Cardiac Rehabilitation Patients (PATHWAY WS3)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
ClinicalTrials.gov Identifier: NCT03999359
Recruitment Status : Terminated (Due to COVID-19 recruitment was terminated prematurely following approval from the trial steering committee. Overall impact was minimal, study sample was reduced by four participants.)
First Posted : June 26, 2019
Last Update Posted : March 22, 2023
Greater Manchester Mental Health NHS Foundation Trust
University of Liverpool
Information provided by (Responsible Party):
Adrian Wells, University of Manchester

Brief Summary:

Depression and anxiety are highly prevalent in people with heart disease, causing immense human and economic burden. Available pharmacological and psychological interventions have limited efficacy and the needs of these patients are not being met in cardiac rehabilitation services despite emphasis in key NHS policy.

Extensive evidence shows that a particular style of thinking dominated by rumination (dwelling on the past) and worry maintains emotional distress. A psychological intervention called metacognitive therapy (MCT) that reduces this style of thinking alleviates depression and anxiety in mental health settings.

This is a single-blind feasibility randomised controlled trial of metacognitive therapy delivered in a self-help format (Home-MCT). The aim of the study is to evaluate the acceptability and feasibility of integrating Home-MCT into cardiac rehabilitation services and to evaluate the effectiveness and cost-effectiveness of Home-MCT.

Condition or disease Intervention/treatment Phase
Depression Anxiety Cardiac Rehabilitation Psychological Distress Other: Home-based Metacognitive Therapy Not Applicable

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 242 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: A Single-Blind Randomised Controlled Trial of Self-Help Metacognitive Therapy for Anxiety and Depression in the Cardiac Rehabilitation Pathway
Actual Study Start Date : May 14, 2019
Actual Primary Completion Date : August 7, 2020
Actual Study Completion Date : August 7, 2020

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
No Intervention: Control
Participants allocated to the "control" group will receive treatment as usual for cardiac rehabilitation
Active Comparator: Intervention
Participants allocated to the "intervention" group will receive treatment as usual for cardiac rehabilitation plus the home-based metacognitive therapy (Home-MCT)
Other: Home-based Metacognitive Therapy
Home-based metacognitive therapy (Home-MCT) is a facilitated self-help manual comprising six modules which participants will complete at their own pace over approximately 6 weeks. Participants will have an initial appointment with a Home-MCT trained cardiac rehabilitation staff members (face to face or by telephone). In addition, they will receive two telephone calls from trained cardiac rehabilitation staff members over the course of the intervention to offer support with completing the modules of the self-help manual.

Primary Outcome Measures :
  1. Hospital Anxiety and Depression Scale (HADS) [ Time Frame: Baseline, 4 months follow up ]
    The HADS is a 14-item self-report scale which evaluates symptoms of anxiety and depression. The HADS consists of two subscales: anxiety and depression. For each item a score is given between 0-3. Subscales scores are calculated by summing selected items on the questionnaire. Scores on each subscale range from 0-21. Scores between 0-7 are within the 'normal' range. Scores between 8- 10 are considered to be 'borderline' cases of psychological distress whilst scores of 11 or more are considered to be significant cases of psychological distress. Higher scores on the HADs indicate greater levels of anxiety or depression.

Secondary Outcome Measures :
  1. Metacognitions Questionnaire 30 (MCQ-30) [ Time Frame: Baseline, 4 months follow up ]
    The MCQ-30 is a 30-item self-report scale that assesses metacognitive beliefs across five subscales: a) Cognitive Confidence, b) Positive Beliefs about Worry, c) Cognitive Self-Consciousness, d) Negative Beliefs about Uncontrollability and Dangerousness of worry, and e) Need to Control Thoughts .Each item is rated on a 4-point Likert scale, with 1 representing "do not agree" , and with 4 indicating "agree very much." Subscale scores range from 6-24 whilst total scores range from 30-120. Subscale scores are created by summing responses to the selected items. Higher subscale scores and total scores, indicate greater dysfunctional metacognitive beliefs.

  2. Cognitive Attentional Syndrome Scale (CAS-1) [ Time Frame: Baseline, 4 months follow up ]
    The CAS-1 is a 10-item self-report measure assessing: a) the degree to which individuals have been dwelling on or worrying and/or focusing attention on threats, b) strategies used to cope with negative feelings and thoughts, and c) the degree to which individuals hold positive and negative metacognitive beliefs. Responses to these items are on 0 to 100 scale, with higher scores indicating greater use of maladaptive coping strategies and higher positive and negative metacognitive beliefs.

  3. Impact of Events Scale - Revised (IES-R) [ Time Frame: Baseline, 4 months follow up ]
    The IES-R is a 22-item self-report measure that assesses symptoms of post-traumatic stress disorder. Items are rated on a 5-point scale ranging from 0 ("not at all") to 4 ("extremely"). Total scores range from 0-88, with higher scores indicating higher levels of subjective distress caused by traumatic events.

  4. Health Related Quality of Life (EQ-5D-5L) [ Time Frame: Baseline, 4 months follow up ]
    The ED-5D-5L is a standardised questionnaire for use as a measure of health status. The ED-5D-5L consists of 2 parts: a descriptive system and a visual analogue scale. The descriptive system consist of 5 separate dimensions which include mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Patients report the severity of problems they face concerning each dimension, with responses ranging from 1-5, whereby higher scores indicate more severe problems. These numbers can then be combined for each dimension to provide a 5 digit value for describing the patients' health state. The visual analogue component of the ED-5D-5L consists of the patient/participant rating their own health that day, on a scale of 0-100 with 100 indicating the best health they can imagine and 0 indicating the worst health they can imagine.

  5. Credibility questionnaire (regarding the Home-MCT intervention) [ Time Frame: From the completion of the introduction of the Home-MCT manual up to 2 weeks ]
    This is a 3-item self-report questionnaire assessing Home-MCT credibility to reduce psychological distress. Items are rated from 0 to 100, where 0 indicates less credibility of the home-MCT manual, and 100 indicates greater credibility of the home-MCT manual.

  6. Adherence questionnaire (regarding the Home-MCT intervention) [ Time Frame: From the completion of the manual up to 4 months ]
    This is a 6-item self-report questionnaire assessing adherence to Home-MCT. Items are rated on a scale from 0 (not at all easy) to 100 (extremely easy). Items assess easy of use and clarity of the manual. Greater scores indicate greater adherence to the manual.

  7. Acceptability [ Time Frame: From the completion of the manual till 4 months ]
    Acceptability of the intervention is defined as the completion of the first 4 modules of the Home-MCT manual, which includes 6 modules in total. Acceptability will be expressed as the percentage of all patients randomised to the treatment arm, minus deaths. This will be compared to the percentage of controls (minus deaths) who complete the 4-month follow up.

  8. Economic Patient Questionnaire (EPQ) [ Time Frame: Baseline, 4 months follow up ]
    The EPQ assesses the services the patients have used as part of their health and social care. Patients indicate the type and frequency of visits to in-patient, out-patient, and/or community services.

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Patients who are referred to the CR pathway who meet Department of Health (DoH) and/or British Association for Cardiovascular Prevention and Rehabilitation (BACPR) CR eligibility criteria:

    • Acute coronary syndrome used for any condition brought on by sudden, reduced blood flow to the heart
    • Following revascularisation is the restoration of perfusion to a body part or organ that has suffered ischemia
    • Stable heart failure
    • Stable angina is chest pain or discomfort that most often occurs with activity or stress
    • Following implantation of cardioverter defibrillators/cardiac resynchronisation devices
    • Heart valve repair/replacement
    • Heart transplantation and ventricular assist devices
    • Adult congenital heart disease identified in adulthood
    • Other (atypical heart presentation: nausea, dizziness, lower chest discomfort, upper abdominal pressure or discomfort that feels like indigestion and upper back pain)
  2. A score of ≥ 8 on either the depression or anxiety subscale of the Hospital Anxiety and Depression Scale
  3. Minimum of 18 years old
  4. Competent level of English language skills

Exclusion Criteria:

  1. Cognitive impairment which precludes informed consent or ability to participate
  2. Acute suicidality
  3. Active psychotic disorders (i.e., two [or more] of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour, negative symptoms).
  4. Current drug/alcohol abuse (A maladaptive pattern of drinking, leading to clinically significant impairment or distress)
  5. Concurrent psychological intervention for emotional distress that is not part of usual care
  6. Antidepressant or anxiolytic medications initiated in the previous 8 weeks
  7. Life expectancy of less than 12 months


Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03999359

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United Kingdom
Bolton NHS Foundation Trust
Bolton, United Kingdom
Aintree Liverpool NHS Foundation Trust
Liverpool, United Kingdom, L9 7AL
East Cheshire Nhs Trust
Macclesfield, United Kingdom, SK10 3BL
Pennine acute hospitals nhs trust
Manchester, United Kingdom, BL9 7TD
Manchester Foundation Trust
Manchester, United Kingdom
Sponsors and Collaborators
University of Manchester
Greater Manchester Mental Health NHS Foundation Trust
University of Liverpool
Additional Information:
Publications of Results:
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Responsible Party: Adrian Wells, Professor, University of Manchester
ClinicalTrials.gov Identifier: NCT03999359    
Other Study ID Numbers: 186990 RP-PG-1211-20011
First Posted: June 26, 2019    Key Record Dates
Last Update Posted: March 22, 2023
Last Verified: March 2023
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Additional relevant MeSH terms:
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Behavioral Symptoms