The impact of internet-based cognitive behavioral therapy and depressive symptoms on self-care behavior in patients with heart failure: A secondary analysis of a randomised controlled trial

Int J Nurs Stud. 2021 Apr;116:103454. doi: 10.1016/j.ijnurstu.2019.103454. Epub 2019 Oct 31.


Background: Patients with chronic heart failure may require treatment of depressive symptoms to improve self-care behaviour.

Objectives: To investigate the impact of internet-based cognitive behavioral therapy (CBT) on self-care behaviour in heart failure patients, and to study the association between changes in depressive symptoms and changes in self-care behaviour.

Design: A secondary analysis of data collected in a pilot randomized controlled study.

Setting: 50 heart failure patients with depressive symptoms were recruited from four hospitals in Sweden.

Methods: Patients were randomized to nine weeks of internet-based CBT (n = 25) or to an active control group participating in an online discussion forum (n = 25). In week two and three, those in the internet-based CBT group worked with psychoeducation about heart failure and depression, emphasizing heart failure self-care. During the same weeks those in the on-line discussion forum specifically discussed heart failure self-care. Patient Health Questionnaire-9 was used to measure depressive symptoms at baseline and at the nine-week follow-up. The European Heart Failure Self-care Behaviour Scale-9 was used to measure self-care behaviour (i.e., the summary score and the subscales autonomous based, provider based and consulting behaviour) at baseline, and at the three-week and nine-week follow-ups.

Results: No significant differences were found in self-care between the patients in the internet-based CBT and the patients in the online discussion group at the three- and nine-week follow-up. Within-group analysis of the changes in the European Heart Failure Self-care Behaviour Scale showed that from baseline to week three, the summary score increased significantly for the online discussion group (p = 0.04), but not for the internet-based CBT group (p = 0.15). At the nine-week follow-up, these scores had decreased. Similarly, consulting behaviour improved at week three for the online discussion group (p = 0.04), but not for the internet-based CBT group (p = 0.22). Provider-based adherence at the nine-week follow-up had increased from baseline in the internet-based CBT group (p = 0.05) whereas it had decreased in the on-line discussion group. Improvement in symptoms of depression was significantly associated with improvement in autonomy-based self-care (r = 0.34, p = 0.03).

Conclusion: Improvement in depressive symptoms was associated with improved autonomous-based self-care. ICBT for depression in HF may benefit aspects of self-care that are vital to improve symptoms and prognosis.

Keywords: Cognitive behavioral therapy; Depression; Heart failure; Internet; Self-care.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Cognitive Behavioral Therapy*
  • Depression / therapy
  • Heart Failure* / therapy
  • Humans
  • Internet
  • Self Care
  • Sweden
  • Treatment Outcome