MONDAY, Jan. 24 (HealthDay News) -- A stress management program based on cognitive behavioral therapy may reduce the risk of heart attack, stroke and death in patients with heart disease, Swedish researchers report.

About 30 percent of heart attacks may be linked to "psychosocial factors," including chronic stressors such as poverty or emotional problems, such as depression and hostility, the authors note in the Jan. 24 issue of the Archives of Internal Medicine.

"Psychological treatment appears to prevent recurrent [cardiac] events at least as effective as many of today's established pharmacological treatments," said lead researcher Dr. Mats Gulliksson, from the Family Medicine and Clinical Epidemiology Section at Uppsala University Hospital.

For the study, Gulliksson's group randomly assigned 362 men and women with heart disease to usual care and cognitive behavioral therapy or usual care with no therapy. Patients in therapy underwent 20 two-hour sessions over a year.

Usual care included medications to lower blood pressure and cholesterol or to prevent blood clots, Gulliksson said.

The premise of CBT is that by changing the way you think about something, you can help yourself feel or behave better. The study program included five key components with specific goals -- education, self-monitoring, skills training, cognitive restructuring and spiritual development -- and focused on stress management, specifically reducing the experience of daily stress, time urgency and hostility.

Over almost eight years of follow-up, the CBT group had 23 deaths, 69 cardiovascular events, and 41 heart attacks. However, among those who did not take part in therapy, 25 died, 77 had any type of cardiovascular event and 51 suffered heart attacks, the researchers found.

That works out to 41 percent fewer deaths and heart-related events and 45 percent fewer heart attacks among those in the CBT group, compared with patients who did not receive therapy, they add.

Those who went to the most therapy sessions had a further reduction in risk, the researchers note. "The higher the attendance rates, the lower the risk," Gulliksson said.

"The psychological treatment had a clear impact beyond the already known beneficial effects of conventional treatments to prevent recurrent events," Gulliksson said. "The effects were similar for men and women," he added.

Exactly how the stress management strategies protect the heart is a question for future research, he noted.

It's possible that the better outcomes relate to long-term participation (six to 12 months at least) in a group designed to alter behavior, the authors say. Perhaps by decreasing emotional and behavioral reactivity, people can alleviate some of the burden placed on the cardiovascular system, they add.

"The positive results suggest that cognitive behavioral therapy intervention based on stress management should be added to secondary prevention programs and offered to all coronary heart disease patients," Gulliksson said. The therapy is also inexpensive and without side effects, he added.

But at least one expert remained unconvinced that the health benefits noted in the study were related to the CBT therapy.

"We know from many trials that people in intervention trials tend to get better care," said Dr. Robert Myerburg, a professor of medicine and cardiology at the University of Miami Miller School of Medicine.

What isn't clear from the study is whether the therapy patients kept to their medication regimen more consistently than the non-therapy patients, he said. For example, the study authors don't show whether blood pressure and cholesterol were better controlled in the therapy group than in the non-therapy group, Myerburg said.

"The question is, is this a direct effect or a nonspecific effect of an intervention where we know that people tend to 'behave better' in terms of their outcomes and therapies?" he said.

Despite his skepticism, Myerburg doesn't see a downside if a patient wants to try cognitive behavioral therapy.

"What I say to patients, as with all these unproven therapies, is as long as they are not doing harm I have no objection," he said.

More information

For more information on cognitive behavioral therapy, visit the U.S. National Association of Cognitive-Behavioral Therapists.