Document Type : Original Article(s)


1 MSc, Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

2 Professor, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

3 Psychiatrist, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

4 Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

5 Assistant Professor, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

6 BSc, Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

7 General Practitioner, Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

8 Professor, Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran


BACKGROUND: Depression is common in patients with cardiovascular disease (CVD). Home-based cardiac rehabilitation (HBCR) is a program that alleviates depression. This study aimed to determine and compare HBCR programs and usual care (UC) effects on depression control in patients with ischemic heart disease (IHD).
METHODS: This clinical trial study was performed on 259 patients with IHD that were randomly allocated to the HBCR and UC groups for stress management. Data were collected using the "Beck Depression Inventory" (BDI) at baseline and 6 and 12 months. Generalized estimating equation (GEE) models were applied to examine the associations between times of the groups and changes in outcomes over the study times. Data analysis was done in SPSS softwareat the significance level of 0.05.
RESULTS: A total of 247 participants with a mean age of 55.22 ± 7.40 years participated in this study, and 209 (84.6%) of the study participants were men. Among patients, 128 patients in the UC program and 119 patients in the HBCR program attended at least one of the pre-determined visits (months 6 and 12). The patterns of change of the depression parameter were similar through the course of the study between the two groups (P = 0.04). In the HBCR group, the depression reduced continuously from baseline to 6 months, baseline to 12 months, and 6 to 12 months (P < 0.05). In the UC group, depression was significantly reduced from baseline to 6 months and from baseline to 12 months.
CONCLUSION: HBCR was effective in continuous reducing of depression scores in long-term follow-up of patients with IHD. These findings suggest that HBCR can alleviate depression in patients who do not participate in hospital-based cardiac rehabilitation (CR).


  1. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: Update From the GBD 2019 Study. J Am Coll Cardiol 2020; 76(25): 2982-3021.
  2. Jha MK, Qamar A, Vaduganathan M, Charney DS, Murrough JW. Screening and management of depression in patients with cardiovascular disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2019; 73(14): 1827-45.
  3. Whooley MA, de Jonge P, Vittinghoff E, Otte C, Moos R, Carney RM, et al. Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. JAMA 2008; 300(20): 2379-88.
  4. Myers V, Gerber Y, Benyamini Y, Goldbourt U, Drory Y. Post-myocardial infarction depression: Increased hospital admissions and reduced adoption of secondary prevention measures-a longitudinal study. J Psychosom Res 2012; 72(1): 5-10.
  5. Versteeg H, Hoogwegt MT, Hansen TB, Pedersen SS, Zwisler AD, Thygesen LC. Depression, not anxiety, is independently associated with 5-year hospitalizations and mortality in patients with ischemic heart disease. J Psychosom Res 2013; 75(6): 518-25.
  6. Sin NL, Kumar AD, Gehi AK, Whooley MA. Direction of association between depressive symptoms and lifestyle behaviors in patients with coronary heart disease: The Heart and Soul Study. Ann Behav Med 2016; 50(4): 523-32.
  7. Ghaemmohamadi MS, Behzadifar M, Ghashghaee A, Mousavinejad N, Ebadi F, Saeedi Shahri SS, et al. Prevalence of depression in cardiovascular patients in Iran: A systematic review and meta-analysis from 2000 to 2017. J Affect Disord 2018; 227: 149-55.
  8. Milani RV, Lavie CJ. Impact of cardiac rehabilitation on depression and its associated mortality. Am J Med 2007; 120(9): 799-806.
  9. Rao A, Zecchin R, Newton PJ, Phillips JL, DiGiacomo M, Denniss AR, et al. The prevalence and impact of depression and anxiety in cardiac rehabilitation: A longitudinal cohort study. Eur J Prev Cardiol 2020; 27(5): 478-89.
  10. Edwards BL, Sydeman SJ. Depression Is Associated with Reduced Outpatient Cardiac Rehabilitation Completion Rates: A systematic literature review and meta-analysis. J Cardiopulm Rehabil Prev 2019; 39(6): 365-72.
  11. Swardfager W, Herrmann N, Marzolini S, Saleem M, Farber SB, Kiss A, et al. Major depressive disorder predicts completion, adherence, and outcomes in cardiac rehabilitation: a prospective cohort study of 195 patients with coronary artery disease. J Clin Psychiatry 2010; 71(9).
  12. Resurreccion DM, Moreno-Peral P, Gomez-Herranz M, Rubio-Valera M, Pastor L, Caldas de Almeida JM, et al. Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: A systematic review of prospective cohort studies. Eur J Cardiovasc Nurs 2019; 18(1): 38-47.
  13. Snoek JA, Prescott EI, van der Velde AE, Eijsvogels TMH, Mikkelsen N, Prins LF, et al. Effectiveness of home-based mobile guided cardiac rehabilitation as alternative strategy for nonparticipation in clinic-based cardiac rehabilitation among elderly patients in Europe: A Randomized Clinical Trial. JAMA Cardiol 2021; 6(4): 463-8.
  14. Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, et al. Home-Based Cardiac Rehabilitation: A Scientific Statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation 2019; 140(1): e69-e89.
  15. Kraal JJ, Van den Akker-Van Marle ME, Abu-Hanna A, Stut W, Peek N, Kemps HM. Clinical and cost-effectiveness of home-based cardiac rehabilitation compared to conventional, centre-based cardiac rehabilitation: Results of the FIT@Home study. Eur J Prev Cardiol 2017; 24(12): 1260-73.
  16. Bravo-Escobar R, Gonzalez-Represas A, Gomez-Gonzalez AM, Heredia-Torres A. Effectiveness of e-Health cardiac rehabilitation program on quality of life associated with symptoms of anxiety and depression in moderate-risk patients. Sci Rep 2021; 11(1): 3760.
  17. Karapolat H, Demir E, Bozkaya YT, Eyigor S, Nalbantgil S, Durmaz B, et al. Comparison of hospital-based versus home-based exercise training in patients with heart failure: effects on functional capacity, quality of life, psychological symptoms, and hemodynamic parameters. Clin Res Cardiol 2009; 98(10): 635-42.
  18. Zheng X, Zheng Y, Ma J, Zhang M, Zhang Y, Liu X, et al. Effect of exercise-based cardiac rehabilitation on anxiety and depression in patients with myocardial infarction: A systematic review and meta-analysis. Heart Lung 2019; 48(1): 1-7.
  19. Bermudez T, Bierbauer W, Scholz U, Hermann M. Depression and anxiety in cardiac rehabilitation: differential associations with changes in exercise capacity and quality of life. Anxiety Stress Coping 2021; 1-15.
  20. Kachur S, Menezes AR, De Schutter A., Milani RV, Lavie CJ. Significance of comorbid psychological stress and depression on outcomes after cardiac rehabilitation. Am J Med 2016; 129(12): 1316-21.
  21. Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric properties of a Persian-language version of the Beck Depression Inventory-Second edition: BDI-II-PERSIAN. Depress Anxiety 2005; 21(4): 185-92.
  22. Okati-Aliabad H, Ansari-Moghaddam A, Roohafza H, Mohammadi M, Vakili L, Abbasi MH, et al. The effects of comprehensive home-based cardiac rehabilitation versus usual care in patients with ischemic heart disease in Iran: Study Protocol for a Multicenter Randomized Controlled Trial. Int J Prev Med 2021. [In Press].
  23. Gellis ZD, Kang-Yi C. Meta-analysis of the effect of cardiac rehabilitation interventions on depression outcomes in adults 64 years of age and older. Am J Cardiol 2012; 110(9): 1219-24.
  24. Yaman AY, Gok UH, Orak OS. Discharge education intervention to reduce anxiety and depression in cardiac surgery patients: A randomized controlled study. J Perianesth Nurs 2020; 35(2): 185-92.
  25. Cebeci F, Celik SS. Effects of discharge teaching and counselling on anxiety and depression level of CABG patients. Turkish J Thorac Cardiovasc Surg 2011; 19(2): 170-6.
  26. Sever S, Doherty P, Golder S, Harrison AS. Is improvement in depression in patients attending cardiac rehabilitation with new-onset depressive symptoms determined by patient characteristics? Open Heart 2020; 7(2): e001264.
  27. Lie I, Arnesen H, Sandvik L, Hamilton G, Bunch EH. Effects of a home-based intervention program on anxiety and depression 6 months after coronary artery bypass grafting: A randomized controlled trial. J Psychosom Res 2007; 62(4): 411-8.
  28. Gostoli S, Roncuzzi R, Urbinati S, Rafanelli C. Clinical and subclinical distress, quality of life, and psychological well-being after cardiac rehabilitation. Appl Psychol Health Well Being 2017; 9(3): 349-69.
  29. Yohannes AM, Doherty P, Bundy C, Yalfani A. The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life. J Clin Nurs 2010; 19(19-20): 2806-13.
  30. Rutledge T, Redwine LS, Linke SE, Mills PJ. A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease. Psychosom Med 2013; 75(4): 335-49.

Pinto BM, Dunsiger SI, Farrell N, Marcus BH, Todaro JF. Psychosocial outcomes of an exercise maintenance intervention after phase II cardiac rehabilitation. J Cardiopulm Rehabil Prev 2013; 33(2): 91-8.