Zusammenfassung
Psychosomatisch-somatopsychische Interaktionen sind bei Koronarpatienten häufig und verlaufsrelevant. Seit den 1960er-Jahren kommen daher psychosoziale Interventionen zur Verbesserung von Befinden und Krankheitsverlauf zum Einsatz. Neben psychoedukativen und unspezifisch-supportiven Angeboten oder Entspannungsverfahren finden sich auch explizit psychotherapeutische Interventionen. Diese beabsichtigen einerseits, durch Reduktion von Stressbelastungen und Förderung gesundheitsbewusster Verhaltensweisen den Krankheitsverlauf zu verlangsamen. Zuletzt wurde zudem auch die Psychotherapie psychischer Komorbiditäten untersucht. Hier spielt die prognostisch relevante Depression eine besondere Rolle. In der größten Psychotherapiestudie bei Koronarpatienten, der ENRICHD-Studie, wurde bei 2481 Infarktpatienten mit Depression oder mangelnder sozialer Unterstützung eine maximal halbjährige kognitive Verhaltenstherapie eingesetzt. Diese führte zur deutlichen Besserung der Depressivität; bei hoher Spontanremissionsrate in der Kontrollgruppe blieb der Nettoeffekt jedoch bescheiden. Eine Lebensverlängerung wurde in der Interventionsgruppe nicht erreicht. Die Befundlage verlangt differenzielle Indikationsstellungen und behandlungstechnische Weiterentwicklungen der therapeutischen Konzepte bzw. die Erprobung anderer Therapieverfahren, erlaubt jedoch noch keine evidenzbasierte allgemeine Behandlungsempfehlung. Therapieentscheidungen stützen sich heute auf die Würdigung des Einzelfalls, auf gut belegte subjektiven Therapieeffekte, theoretische Annahmen über Stressbewältigungs- und Entspannungsverfahren sowie die an anderen Patientenkollektiven gewonnenen Wirksamkeitsnachweise psychotherapeutischer Verfahren. Dabei sind generell eine Beachtung der kardialen Situation und der typischen Problembereiche der koronaren Herzkrankheit (KHK) sowie eine gute Abstimmung mit den somatischen Behandlern wichtig.
Abstract
In patients with coronary heart disease, psychosomatic-somatopsychic interactions are frequent and clinically relevant. Starting in the 1960s, psychosocial interventions have been used to improve the patient’s well-being and disease outcomes. Besides educational and non-specific supportive interventions or relaxation trainings, more specific psychotherapeutic interventions have been reported. Many of these interventions aim at reducing distress and promoting healthy behaviors, thereby slowing down the disease process. More recently, studies have also been made on the psychotherapy for psychiatric comorbidities. In the largest psychotherapy trial in coronary patients, the ENRICHD trial, 2,481 post-myocardial infarction patients with depression or low perceived social support were randomized to receive up to six months of cognitive behavioral psychotherapy or treatment as usual. The treatment resulted in a marked reduction in depressive symptoms. However, given the high remission rate in the control group, the net treatment effect was modest. The targeted reduction in mortality was not achieved. The current state of the literature does not yet allow to give general evidence-based treatment recommendations. It rather requires the development of differential indications, the refinement of existing treatment concepts and the exploration of alternative psychotherapeutic methods. Individual treatment decisions must be based on the specific case, on the well-documented subjective benefits of psychotherapy in coronary patients as well as on theoretical assumptions about stress management and relaxation trainings and on general knowledge about the effectiveness of psychotherapy obtained in other patient groups. When working with coronary patients, psychotherapists should be aware of the cardiac condition and its typical precursors and consequences. They should also closely collaborate with the patients’ cardiologists and family physicians.
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Herrmann-Lingen, C. Psychotherapie bei Patienten mit koronarer Herzkrankheit. Psychotherapeut 50, 81–99 (2005). https://doi.org/10.1007/s00278-005-0416-3
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DOI: https://doi.org/10.1007/s00278-005-0416-3