Ghassan Mourad dissertation



Friday the 4th of December 2015 was the day I had been preparing for…for several year. This was the day for my dissertation. The day when I had to defend all the work I had performed during my doctoral studies. It was with mixed emotions that I looked forward to this day. From being far away it was suddenly time to roll up my sleeves and tackle the trickiest part of the doctoral studies.

The faculty opponent, Siv Söderberg, and the grading committee did a great job and made me feel that I had done a great piece of work. I really enjoyed discussing my thesis with all of them and I felt a bit disappointed when time was over…not really what I thought that I would feel. Off-course, passing this exam felt great and was a huge success. Looking back at it, dissertation day was a really good day that ended with a great party. I shared it with close friends and colleagues. This day was filled with a lot of nice speeches, song and dance performances, and I received a lot of nice gifts. It was a real ego boost hearing a lot of nice words about yourself, wow I could do that again!

Here is a short summary of my thesis:

This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. In study I, 267 patients participated. Out of these, 199 patients participated in study II. Participants in these studies were predominantly male (about 60 %) with a mean age of 67 years. Study III had a cross-sectional explorative and descriptive design including 552 patients (51 % women, mean age 64 years). Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years. The intervention group received a four-session guided Internet-delivered cognitive behavioural therapy (CBT) and the control group received usual care.

The overall aim of this thesis was to improve care for patients with non-cardiac chest pain (NCCP) by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention.

The specific aims for the four studies were:

Aim I: To compare depressive symptoms and healthcare utilization in patients admitted for later proven NCCP, compared to patients with ischemic heart disease presenting with acute myocardial infarction (AMI) and angina pectoris (AP) during a 1-year follow-up after an acute chest pain event.

Aim II: To present a detailed description of the costs of patients with NCCP compared to patients with AMI and AP from a societal perspective.

Aim III: To explore the prevalence of depressive symptoms, cardiac anxiety, and fear of body sensations in patients who were admitted to hospital because of chest pain and discharged with a NCCP diagnosis. Further, we aimed to describe how depressive symptoms, cardiac anxiety and fear of body sensations are related to each other and to healthcare-seeking behavior.

Aim IV: To test the feasibility of a short guided Internet-delivered CBT intervention and the effects on chest pain, cardiac anxiety, fear of body sensations, and depressive symptoms in patients with NCCP compared to usual care.

The main findings were that patients with NCCP experienced recurrent and persistent chest pain and psychological distress in terms of depressive symptoms, cardiac anxiety and fear of body sensations. The prevalence and severity of depressive symptoms in patients with NCCP did not differ from patients with AMI and patients with AP. NCCP was significantly associated with healthcare utilization and patients had similar amount of primary care and outpatient clinic contacts as patients with AMI. The estimated cumulative annual national societal cost for patients with NCCP was more than double that of patients with AMI and patients with AP, due to a larger number of patients with NCCP. Depressive symptoms, cardiac anxiety and fear of body sensations were related to increased healthcare utilization, but cardiac anxiety was the only variable independently associated with healthcare utilization. The short guided Internet-delivered CBT program seemed to be feasible and was perceived as easy to manage, with comprehensible language, adequate and varied content, and manageable homework assignments. Patients improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but this did not differ from the patients in the control group who received usual care. These findings imply that screening and treatment of psychological distress should be considered for implementation in the care of patients with NCCP. By reducing cardiac anxiety, patients may be better prepared to handle chest pain.

You can access the whole framework at Please do not hesitate to contact me in case of any queries.

Thank you for your attention.

Ghassan Mourad, PhD, RN