The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD)
trial1 published in this issue of THE JOURNAL
is the largest controlled trial of psychotherapy ever completed. In this study,
the first multisite behavioral trial funded by the National Heart, Lung, and
Blood Institute (NHLBI), the ENRICHD investigators enrolled 2481 post–myocardial
infarction (MI) patients from 73 hospitals in 8 US cities in a 6-month course
of weekly cognitive behavior therapy (CBT) vs usual care. Three quarters of
the study patients had depression, with the remainder included because of
low perceived social support (LPSS). The goal was to determine whether treating
depression and LPSS would reduce mortality and recurrent infarction. The intervention
produced small, statistically significant decreases in depression symptoms
and small, significant increases in perceived support. These differences did
not translate into any benefit in event-free survival during a mean follow-up
of 29 months, so the study is a negative trial. However, much was learned
over the course of the ENRICHD trial, and more will be learned as the investigators
and others try to understand why results were not as expected. The study also
demonstrates that psychologists, psychiatrists, and cardiologists can successfully
collaborate to test complicated intervention protocols with large numbers
of patients from multiple sites. For these reasons, the ENRICHD trial will
remain a standard of comparison for many years.
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