Rebecca L. Dekker, PhD, APRN from the University of Kentucky College of Nursing recently reviewed three of the most widely used instruments for negative thinking — the Crandell Cognitions Inventory (CCI), Automatic Thoughts Questionnaire (ATQ), and Cognition Checklist-Depression (CCL-D) — in order to provide direction for the measurement of negative thinking in patients with heart failure. She concluded that a shortened version of the CCI for use in measuring negative thinking in patients with HF was needed. In this interview, she describes her research as well as the reliability and validity of the CCI short form (CCI-SF) to measure negative thinking in hospitalized patients with HF. Define negative thinking. How detrimental is negative thinking on one’s health? How does negative thinking affect depression? Negative thinking can be defined as negative thoughts about yourself, the world around you, your future, and your relationship with others. These negative thoughts can occur automatically, and sometimes you might not even be realizing you are having them. Negative thinking is a risk factor for depression. Also, if you have depression, negative thoughts will worsen your symptoms and make it less likely that treatment for depression will be successful. What percentage of heart failure (HF) patients experience depression? Do male or female HF patients experience negative thinking more often? Researchers have found that 20%, or 1 in 5 patients with HF have clinical depression. But patients with HF can also experience depressive symptoms with or without a diagnosis of clinical depression. Depressive symptoms may include depressed mood, guilt, fatigue, inability to concentrate, and a change in appetite. It’s estimated that 30% of all patients with HF have depressive symptoms, and higher rates (up to 50%) are seen in hospitalized patients. In our data, we have not seen any difference in negative thinking between males and females with HF. They have similar levels of negative thinking. However, overall, the levels of negative thinking among patients with HF are higher than the levels that have been published for normal, healthy adults. Why is it important to treat negative thinking right away? How do HF patients with depressive symptoms compare to patients without symptoms of depression, in terms of rates of mortality and rehospitalization? It is important to treat negative thinking as soon as possible, because negative thinking is a strong predictor of depressive symptoms.1 Patients with HF who have depressive symptoms are twice as likely to die and two and a half times more likely to be rehospitalized compared to patients without symptoms of depression. Perhaps more importantly, depressive symptoms lead to poorer quality of life. However, there may be important financial incentives for treating depressive symptoms and negative thinking quickly. In 2013, Medicare will stop reimbursing for HF readmissions within 30 days. Therefore, I believe we need brief interventions that target negative thinking in hospitalized patients with HF, because these patients are at high risk for readmission. Describe the three questionnaires initially chosen for review: CCI, ATQ, and CCL-D. How does each test differ? Of the three, why was the CCI most beneficial for HF patients? All three of these questionnaires have evidence for reliability and validity for measuring negative thinking. However, we felt the CCI was the best option for use in HF patients. First of all, it was originally developed with a psychiatric population — in contrast to the ATQ, which was developed with a sample of undergraduate students. Second, prior researchers had raised questions about the CCL-D’s validity among people with chronic health conditions. So that’s why we chose to look at the CCI in patients with HF.2 Why was it important to create a shortened version of the CCI? Describe how the CCI-SF test was created. The original CCI had 45 items. For a healthy adult, it might take only 3–5 minutes to fill out. However, in our research with patients with HF, we found that answering the questions on the CCI took 10–20 minutes, and the length was burdensome for the patients and impractical for clinicians and researchers. First, we wanted to make sure that the original instrument was reliable and valid before we went about shortening it. So we did psychometric testing with 179 outpatients with HF. We found that the original questionnaire was reliable and valid, but it was redundant, meaning that it didn’t need to have so many items. Then, we did a series of statistical tests to drop out the redundant items. We had several experts review the shortened scale to make sure it was appropriate for patients with HF. We then recruited a separate sample of 77 hospitalized patients with HF and did testing to see if the CCI short form (CCI-SF) had reliability and validity in this sample.3 Tell us about the components of the shortened CCI for HF patients. Give some examples of items included in the test. The CCI-SF has 12 negative thoughts, such as “It all seems so useless,” “Things really look hopeless,” and “I’m a real disappointment to my family.” Patients are asked to rate how frequently they experience each thought, from 1 (almost never) to 5 (almost always). Tell us about the HF patients that participated in the shortened CCI test. Why was this significant? The patients who were participating in the shortened CCI study were all hospitalized with HF. We used baseline data from patients who were taking part in a randomized, controlled trial testing a brief cognitive therapy intervention for depressive symptoms. (See below for more info about this randomized controlled trial). What percentage of HF patients reported having depressive symptoms? Which patients were found to have the highest level of negative thinking? Overall, these patients had high levels of depressive symptoms. About 35% had depressive symptoms. However, for the randomized, controlled trial, one of our exclusion criteria was severe depression, so the prevalence would have been higher if those patients were included. Patients who had higher levels of negative thinking also had higher levels of depressive symptoms and anxiety, as well as poorer health-related quality of life. They were also more likely to be taking an antidepressant. How does the CCI-SF test benefit HF patients? What are the best uses for this test going forward? This instrument is a valuable resource for researchers who are interested in developing interventions for depressed patients with HF. Clinicians can use this test to identify patients who may be at risk for depression. Going forward, we are conducting several studies to see if we can change negative thinking by doing brief cognitive therapy interventions with patients who are hospitalized with HF. Is there anything else you’d like to add? In a recent pilot randomized, controlled trial (the one that we took the baseline data from to shorten the CCI), we tested a 30-minute cognitive therapy session delivered by a nurse that targets negative thinking. Of the patients with depressive symptoms who received the intervention, 80% were alive without a cardiac event at three months, compared to 40% of patients with depressive symptoms who received usual care. We reported these findings at the American Heart Association Scientific Sessions in 2010,4 and we are currently submitting the manuscript. Cognitive therapy is a psychotherapeutic intervention that targets the negative thinking that worsens depression. This is an intervention that nurses can be trained to deliver. Right now we are replicating the results of the pilot study in a larger randomized controlled trial called HOPE-HF (Helping Others toward Positive Emotions in Patients with Heart Failure). For more information, please visit: http://clinicaltrials.gov/ct2/show/NCT01275742. This research was funded by the National Institutes of Nursing Research (NIH, NINR 5R01 NR 008567; NIH, NINR, P20 NR 010679) and a Philanthropic Educational Organization International.
- Dekker RL, Lennie TA, Peden AR, et al. Negative thinking: A modifiable target for the treatment of depressive symptoms in patients with heart failure. Circulation 2008;118(Suppl):976.
- Dekker RL. Measurement of negative thinking in patients with heart failure: A critical review and analysis. J Cardiovasc Nurs 2011;26:9–20.
- Dekker RL, Lennie TA, Hall LA, et al. Developing a shortened measure of negative thinking in patients with heart failure. Heart Lung 2011 Feb 14. [Epub ahead of print]
- Dekker RL, Moser DK, Peden AR, Lennie TA. A brief cognitive therapy intervention improves three-month outcomes in hospitalized patients with heart failure. Circulation 2010;122(21 Suppl):A11188.