***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: A multicenter clinical trial was conducted to evaluate the effects on compliance of a group counseling program for cardiac patients and spouses . The sample comprised 58 couples in which one of the partners had documented atherosclerotic heart disease and was enrolled in an outpatient cardiac rehabilitation program . The experimental intervention involved a ten-week series of group sessions based on symbolic interactionist role theory . The research used a quasi-experimental , three-group , time-series design : Experimental group 1 consisted of 17 patients and their spouses who participated in group counseling ; experimental group 2 consisted of 22 patients and their spouses , but only the patients participated in the group series ; the control group consisted of 19 patients and their spouses who did not participate in the experimental program .  Data were collected at baseline , ten weeks , and six months on four cardiac risk factors : weight loss , blood pressure , exercise , and smoking . Repeated measures analysis of variance showed a significant difference ( P less than 0.01 ) in mean body fat among treatment groups , with experimental group 2 having the greatest decrease over time . Patients in both experimental groups demonstrated lowered blood pressure , with a significant decrease ( P less than 0.05 ) in systolic blood pressure . Again , the largest decrease was in experimental group 2 . Changes in weekly exercise level were not significantly different among groups , although the highest compliance was reported by experimental group 1 patients . Results support the efficacy of group counseling based on an interactionist role theory framework to increase compliance . The anticipated effect of spouse participation was not confirmed Abstract Objectives : To examine the association between self perceived psychological stress  and cardiovascular disease in a population where stress was not associated with social disadvantage . Design : Prospect i ve observational study with follow up of 21 years and repeat screening of half the cohort 5 years from baseline . Measures included perceived psychological stress , coronary risk factors , self reported angina , and ischaemia detected by electrocardiography . Setting : 27 workplaces in Scotl and . Participants : 5606 men ( mean age 48 years ) at first screening and 2623 men at second screening with complete data on all measures Main outcome measures : Prevalence of angina and ischaemia at baseline , odds ratio for incident angina and ischaemia at second screening , rate ratios for cause specific hospital admission , and hazard ratios for cause specific mortality . Results : Both prevalence and incidence of angina increased with increasing perceived stress ( fully adjusted odds ratio for incident angina , high versus low stress 2.66 , 95 % confidence interval 1.61 to 4.41 ; P for trend < 0.001 ) . Prevalence and incidence of ischaemia showed weak trends in the opposite direction . High stress was associated with a higher rate of admissions to hospital generally and for admissions related to cardiovascular disease and psychiatric disorders ( fully adjusted rate ratios for any general hospital admission 1.13 , 1.01 to 1.27 , cardiovascular disease 1.20 , 1.00 to 1.45 , and psychiatric disorders 2.34 , 1.41 to 3.91 ) . High stress was not associated with increased admission for coronary heart disease ( 1.00 , 0.76 - 1.32 ) and showed an inverse relation with all cause mortality , mortality from cardiovascular disease , and mortality from coronary heart disease , that was attenuated by adjustment for occupational class ( fully adjusted hazard ratio for all cause mortality 0.94 , 0.81 to 1.11 , cardiovascular mortality 0.91 , 0.78 to 1.06 , and mortality from coronary heart disease 0.98 , 0.75 to 1.27 ) . Conclusions : The relation between higher stress , angina , and some categories of hospital admissions probably result ed from the tendency of participants reporting higher stress to also report more symptoms . The lack of a corresponding relation with objective indices of heart disease suggests that these symptoms did not reflect physical disease . The data suggest that associations between psychosocial measures and disease outcomes reported from some other studies may be spurious . What is already known on this topic Higher psychological stress has predicted coronary heart disease in several observational studies Exposure to stress and heart disease outcomes were often based on self report so that a general tendency to negative perceptions may have generated a spurious association between higher perceived stress and heart disease symptoms What this study adds Perceived stress was strongly related to subjective symptoms of heart disease , including those leading to hospital admission However , stress showed a weakly inverse relation to all objective indices of heart disease : socially advantaged men perceived themselves to be most stressed , and the “ protective ” effect of stress was probably attributable to residual confounding Suggestions that psychological stress is an important determinant of heart disease may be OBJECTIVE To determine the efficacy of a psychoeducational nursing intervention in patients who receive coronary artery bypass graft and valve repair surgery . DESIGN A cluster-r and omized controlled trial design . SETTING Two hospitals in the western United States -- a large community hospital with an active cardiovascular surgery practice and a health-sciences research center . SUBJECTS 156 patients between 25 and 75 years of age , 125 ( 81.1 % ) men , and 31 ( 19.9 % ) women , all with primary care givers . OUTCOME MEASURES Self-efficacy expectations , activities ( behavior performance ) , quality of life , mood state . INTERVENTION Supplemental in-hospital education followed by telephone contact from discharge to eighth week after discharge . RESULTS Patients in the experimental group reported significantly greater self-efficacy expectations for walking and behavior performance for walking , lifting , climbing stairs , general exertion and , where applicable , for working . CONCLUSION This trial suggests that a low-intensity psychoeducational nursing intervention can promote self-efficacy expectations for walking in recovery and is associated with more self-reported walking and lifting behavior after cardiac surgery An education and group discussion program administered to a r and omly selected group of post myocardial infa rct ion subjects failed to produce any differences in a large number of behavioral and psychological measures . These included smoking behavior , health status , social and recreational status , family and marital life and vocational activities , as well as measures of anxiety , depression , and health locus of control . Treated subjects were slower to return to work than controls and were less likely to have returned to work by the end of the study . More individuals in the treatment group were receiving compensation and this may have been a factor in delaying return to work . Since the majority of our subjects had a very optimistic attitude toward their eventual recovery , there was limited room for improvement . We suggest that cardiac rehabilitation be directed only at those patients with " negative " attitudes , and with more than usual anxiety and depression BACKGROUND Several studies have found that depression is an independent predictor of poor outcome after the onset of clinical coronary artery disease . There are few data concerning depression as a risk factor for the development of coronary artery disease . OBJECTIVE To determine if clinical depression is an independent risk factor for incident coronary artery disease . PATIENTS AND METHODS The Johns Hopkins Precursors Study is a prospect i ve , observational study of 1190 male medical students who were enrolled between 1948 and 1964 and who continued to be followed up . In medical school and through the follow-up period , information was collected on family history , health behaviors , and clinical depression . Cardiovascular disease end points have been assessed with review s of annual question naires , National Death Index search es , medical records , death certificates , and autopsy reports . RESULTS The cumulative incidence of clinical depression in the medical students at 40 years of follow-up was 12 % . Men who developed clinical depression drank more coffee than those who did not but did not differ in terms of baseline blood pressure , serum cholesterol levels , smoking status , physical activity , obesity , or family history of coronary artery disease . In multivariate analysis , the men who reported clinical depression were at significantly greater risk for subsequent coronary heart disease ( relative risk [ RR ] , 2.12 ; 95 % confidence interval [ CI ] , 1.24 - 3.63 ) and myocardial infa rct ion ( RR , 2.12 ; 95 % CI , 1.11 - 4.06 ) . The increased risk associated with clinical depression was present even for myocardial infa rct ions occurring 10 years after the onset of the first depressive episode ( RR , 2.1 ; 95 % CI , 1.1 - 4.0 ) . CONCLUSION Clinical depression appears to be an independent risk factor for incident coronary artery disease for several decades after the onset of the clinical depression This paper critically examines three str and s of evidence that concern the relationship between type A behaviours and coronary heart disease ; prospect i ve epidemiological studies of healthy population s , studies of those at high risk for coronary heart disease , and angiographic studies of atherosclerosis . The first of these would seem to provide the strongest test . Method ological and conceptual issues mean that the results of studies using the other methods should be interpreted with care . It is concluded that there is relatively strong evidence of an association between Type A behaviour as measured by  Structured Interview and coronary heart disease . Hostility and anger appear to be the most powerful determinants of CHD . However , it is likely that they interact with other type A behaviours and related environmental factors in determining risk 
    Output:
    
Combining the results of all trials showed no strong evidence of effect on total or cardiac mortality , or revascularisation .
Provision of any psychological intervention or SM intervention caused small reductions in anxiety and depression .
Few trials reported modifiable cardiac risk factors or quality of life .
REVIEW ERS ' CONCLUSIONS Overall psychological interventions showed no evidence of effect on total or cardiac mortality , but did show small reductions in anxiety and depression in patients with CHD .
Similar results were seen for SM interventions when considered separately .
However , the poor quality of trials , considerable heterogeneity observed between trials and evidence of significant publication bias make the pooled finding of a reduction in non-fatal myocardial infa rct ion insecure