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CON 321 Health Related Research Question: Find an article that meets these criteria: Outcome evaluation of a behavioral intervention Randomized controlled trial Answer: This randomized controlled trial is conducted in order to find out the success rate of cognitive behavioral therapy on the effective management of depression in the patients who have heart disorders. It has been found that about 15% of the patients who are suffering from cardiovascular disorders and 205 of the individuals who have undergone coronary artery bypass graft (CABG) surgery experience major depression. Therefore, this paper has implications in the modern generation as it discusses the success rate of the behavioral intervention of CBT for such patients. The paper that is developed by the authors is indeed well organized and sequential with the present of various data of the statistical analysis making it easier for the readers to understand. Biasness of the language as well as use of jargons is quite. All the information had been clearly stated in details under specific headings making it easier for the readers to develop clear idea about the entire work conducted (Freedland et al. 2015). The statistical approach taken is complicated as it contains a large number of tools but the outcome has been specific helping to gain valuable and correct information. Hence, this procedure decided was apt and cannot be considered abrupt. The gaps in the literature had been clearly depicted by the authors themselves where they also mentioned about the scopes of further research on the topic. It has been found that the behavioral intervention of CBT is highly successful for mitigating the issue of depression in the heart disorder patients built they do not help in enhancing self-care strategies among the patients. It helps in reduction of the anxiety and fatigue as well as improvement in the social functioning in the patients resulting in better health-related quality of life. Therefore, healthcare professionals can use the evidences in the study for handling patients who have heart disorder along with depression and provide best treatments. However, further researches are required that would help the patients to develop motivation to conduct self-care and management successfully. Article Review Name of the article: Cognitive Behavior Therapy for Depression and Self-Care in Heart Failure Patients- A Randomized Clinical Trial First author: Kenneth E. Freedland Journal: JAMA Intern Med Year published: 2015 Abstract The abstract of the article contains a comprehensive and detailed explanation of the randomized controlled trial. Abstracts usually act as a brief for the readers to understand about a project. The abstract addressed an essential issue and contained a short explanation on the importance of the research topic. Furthermore, it contained separate headings to help readers comprehend the research objective, participants, setting, interventions, and outcomes. The authors also provided a thorough account of the results that were obtained at the end of the trial, supported by a concluding statement. Hence, it can be inferred from the abstract that CBT is effective for depressive disorder, but not for heart failure self-care. Background / introduction The background of the research provided a meticulous detail of the phenomenon being investigated. The authors clearly highlighted the associated between depression and heart failure. Time and again it has been proved by researchers that mental stress creates a negative impact on the cardiovascular health of a person (Maeda et al. 2013). According to Lossnitzer et al. (2013) unmanaged depression has also been allied with increased blood pressure, irregular heart rhythm, arterial damage, and weak immune system. The researchers based their study on these information and successfully provided an overview of the extent of connotation between the two health ailments. The theoretical framework of the study was grounded on the fact that cognitive behavioral treatments (CBT) have proved their efficacy in depression management (Naeem et al. 2014). Thus, they identified a gap in lack of adequate scholarly literature on the effects of CBT in heart failure self-care. Nonetheless, a major drawback of the background section was that the authors did not present sufficient information on review of scientific literature (Ary et al. 2018). No research hypothesis was also stated by the researchers. Methods The researchers recruited patients having suffered from heart failure from the Washington University Medical Center, for participation in the trial from January 2010-June 2013. However, they adopted convenience sampling procedure which would lead to over- or under-representation of the target population and is likely to have sampling error due to inaccuracies (Etikan, Musa and Alkassim 2016). Thus, participant recruitment strategy was incorrect. The research design was based on randomization where all participants were assigned to the intervention and control group by chance, rather than choice. Adopting single-blinding approach was beneficial as it would keep the participants deliberately ignorant of the group they were assigned to (Pocock 2013). The intervention was in accordance to standard CBT handbooks and supplemental guidelines for cardiac patients. Intervention was implemented for six months (1 hour weekly sessions). Some of the measures were depression scores, exercise capacity, physical activity, anxiety, and satisfaction with social roles and discretionary social activities. Thus, it can be stated that the researchers took into account all important measures that were imperative for determining the efficacy of CBT. Data collection encompassed use of the Beck Depression Inventory-II that is one of the most extensively used psychometric analysis for evaluating depression severity among patients (Choi et al. 2014). Use of the Self-Care of Heart Failure Index was another correct approach since it acts in the form of a realistic decision-making procedure concerning the selection of behaviors that uphold physiological stability (Vellone et al. 2013). The Kansas City Cardiomyopathy Questionnaire was also used for determining the trial outcomes owing to its validity and reliability for measuring health status of patients diagnosed with CHF (Arnold et al. 2013).   Results The researchers presented the study findings with the help of tabular representations and graphical diagrams. Following the information presented on the baseline, recruitment and retention characteristics of the participants, the researchers presented their findings under specific headings and sub-headings such as, primary outcomes, secondary outcomes, and follow-up phase, all of which were correlated to the phenomenon under investigation. They provided extensive statistical information to state that Six-month depression scores were found lower in CBT group, compared to the control arm, with the use of BDI-II (12.8 [10.6] vs 17.3 [10.7]; P = .008).  Furthermore, the researchers also stated that variations were observed in the remission rates on the Hamilton Depression Scale (51% vs 20%; NNT = 3.29; 95% CI, 3.15-3.43; P < .001), and the BDI-II (46% vs 19%; number needed to treat [NNT] = 3.76; 95% CI, 3.62-3.90; P < .001). The tabular information also made the researchers state that no significant differences were observed between the intervention and control group, in terms of the Self-Care Maintenance and/or Confidence subscales. Furthermore, low mean SD in the BDI-II scores, six months following randomization were found in CBT group T (12.8 [10.6]), in comparison to the usual care group (17.3 [10.7]), P = .008. Besides the tabular representation, the graphs also explained the outcomes in all subgroups, defined by their high vs. low baseline scores. The results section usually contains a detailed report of the findings based on the research methodology adopted by the investigators, for gathering essential information. Hence, it can be stated that the researchers were able to arrange their results in a logical manner, without any bias. Discussion The purpose of research discussion is to infer and define the implication of the results in light of what had been previously known about the phenomenon being investigated, and to clarify any new insight or understanding about the condition, after the researchers have taken the findings into their consideration. The discussion section of this scholarly literature was able to connect the readers to the introduction and background of the study by associating the results obtained with the research question that has been explored. The researchers provided a comprehensive analysis of the fact that remission rates of depression were found to be greater in CBT, when compared to the participants who were subjected to usual care. This made the researchers suggest that CBT acts as a superior form of treatment to usual care for effective management of depression among patients who have had heart failure. Hence, the discussion elucidated this reassuring result in light of the undesirable conclusions of the MOOD-HF and SADHART-CHF antidepressant trials (Angermann et al. 2016). Furthermore, the researchers also explained their results and stated that the intervention (CBT) failed to demonstrate its efficacy in self-care maintenance, confidence for heart failure, which was considered as the co-primary outcome of the trial. Every research has its limitations and clarifying these allow the readers to gain a sound understanding of the conditions under which the results should be inferred. Thus, the researchers were correct in illustrating the limitations of the trial. Certain limitations were allied with the recruitment strategy, lack of double-blinding provisions, and assessment of treatment fidelity by therapists, and diversity of secondary outcomes. In general It can be suggested that the research was well written and did not contain any medical jargon that could not be interpreted by a reader. At instances where abbreviations were used for different data collection tools, the researchers displayed a correct approach in expanding them for a better understanding. Furthermore, this was the first research of its kind that aimed to bring about an alteration in heart failure self-care amid patients who are clinically depressed. The article headings and subheadings were also correctly organized and summarized, and did not contain any language that indicated biasness of the researchers. Additionally, the investigators also suggested future implications of the practice by explaining the potential of the intervention in reducing rates of re-hospitalization among heart failure patients who had been diagnosed with clinical depression. Thus, the article was able to prove the efficacy of CBT for management of depression among heart failure patients. Suggestions Caution must maintained in future while determining the association between rates of hospitalization and mortality, with the intervention among heart failure patients. Further research should also aim at exploring the predictors that create an influence on self-care behavior among heart failure patients. References Angermann, C.E., Gelbrich, G., Störk, S., Gunold, H., Edelmann, F., Wachter, R., Schunkert, H., Graf, T., Kindermann, I., Haass, M. and Blankenberg, S., 2016. Effect of escitalopram on all-cause mortality and hospitalization in patients with heart failure and depression: the MOOD-HF randomized clinical trial. Jama, 315(24), pp.2683-2693. Arnold, S.V., Spertus, J.A., Lei, Y., Allen, K.B., Chhatriwalla, A.K., Leon, M.B., Smith, C.R., Reynolds, M.R., Webb, J.G., Svensson, L.G. and Cohen, D.J., 2013. Use of the Kansas City Cardiomyopathy Questionnaire for monitoring health status in patients with aortic stenosis. Circulation: Heart Failure, 6(1), pp.61-67. Ary, D., Jacobs, L.C., Irvine, C.K.S. and Walker, D., 2018. Introduction to research in education. Cengage Learning. Choi, S.W., Schalet, B., Cook, K.F. and Cella, D., 2014. Establishing a common metric for depressive symptoms: Linking the BDI-II, CES-D, and PHQ-9 to PROMIS Depression. Psychological assessment, 26(2), p.513. Etikan, I., Musa, S.A. and Alkassim, R.S., 2016. Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and Applied Statistics, 5(1), pp.1-4. Freedland, K.E., Carney, R.M., Rich, M.W., Steinmeyer, B.C. and Rubin, E.H., 2015. Cognitive behavior therapy for depression and self-care in heart failure patients: a randomized clinical trial. JAMA internal medicine, 175(11), pp.1773-1782. Kahan, B.C., Rehal, S. and Cro, S., 2015. Risk of selection bias in randomised trials. Trials, 16(1), p.405. Lossnitzer, N., Herzog, W., Störk, S., Wild, B., Müller-Tasch, T., Lehmkuhl, E., Zugck, C., Regitz-Zagrosek, V., Pankuweit, S., Maisch, B. and Ertl, G., 2013. Incidence rates and predictors of major and minor depression in patients with heart failure. International journal of cardiology, 167(2), pp.502-507. Maeda, U., Shen, B.J., Schwarz, E.R., Farrell, K.A. and Mallon, S., 2013. Self-efficacy mediates the associations of social support and depression with treatment adherence in heart failure patients. International journal of behavioral medicine, 20(1), pp.88-96. Naeem, F., Sarhandi, I., Gul, M., Khalid, M., Aslam, M., Anbrin, A., Saeed, S., Noor, M., Fatima, G., Minhas, F. and Husain, N., 2014. A multicentre randomised controlled trial of a carer supervised culturally adapted CBT (CaCBT) based self-help for depression in Pakistan. Journal of affective disorders, 156, pp.224-227. Pocock, S.J., 2013. Clinical trials: a practical approach. John Wiley & Sons. Vellone, E., Riegel, B., Cocchieri, A., Barbaranelli, C., D'Agostino, F., Antonetti, G., Glaser, D. and Alvaro, R., 2013. Psychometric testing of the self?care of heart failure index version 6.2. Research in nursing & health, 36(5), pp.500-511.

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