The Effect of Holy Quran Audio Therapy on Depression and Anxiety Among Jordanian Patients Following CABG: A Randomized Control Trial

1. INTRODUCTION

The most common coronary artery disease (CAD) surgery is coronary artery bypass graft (CABG) [ 1]. Approximately 400,000 CABG surgeries are performed globally each year [ 2], with better survival rates compared to other CAD treatment modalities [ 3]. Furthermore, evidence from a meta-analysis of five clinical trials comprising 4,500 patients revealed that CABG procedures lower the risk of developing new myocardial infarctions and undergoing repeated revascularization procedures [ 4]. Nevertheless, evidence demonstrates that the positive outcomes of the CABG procedure are affected by several factors, including the patient’s psychological status, measured by the level of depression and anxiety (D&A). Anxiety among patients diagnosed with CAD predicts the occurrence of in-hospital complications, including fibrillation, recurrent ischemia, and ventricular tachycardia; indeed, it has even been associated with increased mortality [ 5]. Moreover, the literature revealed similar concerns associated with other heart diseases. For instance, a prospective observational study of 127 patients diagnosed with heart failure showed that persistent anxiety and depression predicted low quality of life [ 6].

In Jordan, the prevalence of depressive symptoms among post-CABG patients ranged from 55% [ 7] to 65.7% [ 8]. Despite these high levels of depression, almost 60% of cardiovascular physicians admitted that they did not screen or only screened less than 25% of their patients for depression [ 9]. This is important because persistent levels of depression are linked to acute myocardial infarction and prolonged length of stay post-CABG [ 7, 10]. Similarly, the impact of depressive symptoms occurring at six months post-CABG on long-term cardiac morbidity was measured at 6-36 months, during which it was found that the increment of depression levels increased the likelihood of developing a variety of morbidities such as adult respiratory distress syndrome, cardiogenic shock, cardiopulmonary arrest, new myocardial infarction, and pulmonary edema [ 11].

It is imperative for nurses to implement appropriate treatment and management for D&A, including both pharmacological and non-pharmacological solutions to improve post-CABG outcomes. Holy Quran audio therapy (QAT) is a non-pharmacological solution used to improve D&A symptoms among patients listening to the original Arabic recitation [ 12-14]. Several studies and clinical trials examined this impact among different patient populations. A randomized controlled trial (RCT) by Maziha et al. [ 15] showed that smokers who recited four chapters of the Quran ( Al-Fatihah, An-Naas, Al-Falaq, and Al-Ikhlas) over four weeks smoked a significantly lower number of cigarettes at week 12 compared to the control group. The same study reported that withdrawal symptoms, such as anxiety, anger, and cravings, were also affected by reciting the Quran. One study even supported the impact of QAT (without translation) on lowering levels of anxiety, depression, and stress among pregnant women in Iran [ 16]. Specific to patients with cardiac conditions, QAT was found to improve sleep quality after cardiac surgeries [ 17], decrease anxiety levels before the cardiac catheterization procedure [ 18], and decrease levels of depression among patients undergoing CABG [ 19]. Although the latter study examined depression after CABG, QAT was integrated with other practices in a comprehensive religious–spiritual program, including prayer and analysis of religious stories.

However, the use of QAT alone on D&A among post-CABG patients has not been explored in Arabic countries. Thus, this RCT seeks to examine the effect of QAT on D&A among Muslim, Arabic-speaking post-CABG patients.

2. MATERIALS AND METHODS

2.2. Intervention

The experimental group received QAT for ten minutes over two sessions on two days, one after the other (typically the second and third days following CABG, when patients were stable and not intubated). The daily sessions were four hours apart ( i.e., at 10 am and 2 pm). Surah Al-Rahman was chosen as it is generally regarded as one of the most rhythmic and soothing chapters of the Quran, particularly as rendered by the popular reciter Qari Abdul Basit [ 20]. The listening was undertaken using disposable headphones on an iPad. Conventional ( i.e., biomedical) care was delivered by healthcare professionals to the control group.

3. RESULTS

A total of 165 patients (82 in the intervention and 83 in the control group) participated in this trial, with a mean age of 69.1±9.6 years. More than half of the sample (N = 92, 55.8%) were male. Approximately two-thirds were married, and more than three-quarters had a history of hypertension. The intervention group had more patients with a history of hypertension than the control group (85.4% vs. 72.3%) and more former smokers (51.2% vs. 31.3%) (Table 1).

To check if the intervention affected D&A, four steps were undertaken. First, the levels of D&A between the two groups at baseline prior to initiation of the intervention were compared using an independent samples t-test to ensure no differences and avoid bias (Table 2). Second, the levels of D&A were compared between the two groups after the intervention using an independent samples t-test (Table 2). Third, the levels of D&A were compared between the pre-intervention and post-intervention in the intervention group using the paired t-test (Table 3). Fourth, the levels of D&A were compared between the baseline and follow-up measurements for the control group using the paired t-test (Table 3).

4. DISCUSSION

Depression and anxiety are prevalent among patients undergoing cardiac surgery, and these associated conditions affect their cardiac prognosis and are intrinsic forms of mental health issues and low well-being [ 24]. Non-pharmacological interventions are generally recommended for all patients where they do not interfere with biomedical treatment, including psycho-social and spiritual care, a growing and important area of clinical practice worldwide [ 12]. Given the religious background of Jordanian people, it is clearly germane to consider the use of non-pharmacological interventions that include QAT and an intrinsic part of Islamic religious practice. Neurological studies have demonstrated the physiological impacts of this practice, and the QAT has been found to stimulate alpha brain waves that are associated with the release of endorphins, enhancement of the stress threshold, creating a sense of relaxation, and mitigating negative emotions. Therefore, this RCT was implemented to examine the effect of QAT on D&A levels among Jordanian post-CABG patients [ 12].

This was done in a four-step data analysis process. First, the levels of D&A between the intervention and control groups were contrasted before QAT implementation ( i.e., at baseline), and the results revealed that both groups of patients were experiencing high D&A levels, with no significant statistical differences. This was not unexpected since it has been reported that the prevalence of D&A after cardiovascular surgery is higher than that of the general population [ 24].

The second step of the analysis process in the current study compared the levels of D&A between the two groups after the intervention. The results revealed that the levels of D&A were significantly different among the intervention groups. The control group reported higher levels of D&A than the intervention group, indicating a positive impact of QAT on D&A levels. This finding is consistent with a previous study conducted in Iran among 108 patients who underwent cardiac surgery using the same design and intervention [ 25] as well as the general affirmation that non-pharmacological interventions tend to improve cardiovascular surgery patients’ psychological conditions.

Thirdly, the current study's findings revealed that significant differences were reported in the levels of D&A before and after the intervention among the intervention group. This is in line with a systematic review whose results revealed that QAT can function as an effective non-pharmacological solution for anxiety reduction [ 12]. Moreover, this result agreed with an experimental study finding conducted for 70 patients with myocardial infarction who listened to QAT over two days in four daily sessions and revealed that the level of anxiety was significantly lower in the experimental group compared with the control group [ 26].

Moreover, the findings of a semi-experimental study indicated that QAT was effective in reducing anxiety in patients with acute coronary syndrome [ 27]. Previous studies have demonstrated significant impacts of QAT on anxiety, blood pressure, pulse and respiratory rate reduction [ 28]; reducing D&A after open heart surgery (as a complementary therapy) [ 29]; reducing anxiety prior to and following coronary angiography [ 30]; and anxiety reduction following cardiac surgery [ 17], although the latter reported that it did not significantly affect depression.

Among other populations, QAT has been found to positively affect weaning from mechanical ventilation, decreasing anxiety levels among critically ill patients [ 31]. It has also been found to be more effective than no intervention in decreasing depression among hemodialysis patients [ 32] and pregnant women [ 16]. Additionally, another study conducted in Iran concluded that QAT is an easy-to-implement and cost-effective strategy that may be used as a supplemental treatment of depression in hemodialysis patients in resource-challenged contexts [ 33].

While exploring the causation of such effects is beyond the immediate scope of this study, there are known neurological mechanisms that are likely to be instrumental in such impacts. For example, an increase in delta brain waves occurs when reading and listening to the Quran, which stimulates growth hormones responsible for the repair and growth of cells and tissues [ 34]. Additionally, QAT increases alpha waves, directly producing a relaxing effect, and increases attention span [ 35]. Moreover, QAT was found to help improve sleep quality after cardiac surgery, which might positively affect D&A ( i.e., secondary benefits of QAT may include the beneficial impacts of improved sleep quality and duration) [ 17].

The physiological parameters indicating QAT's calming and relaxing effect are related to traditional beliefs about its impact on the human heart, expressed in the production of hormones and chemicals that relax people [ 36, 37]. Such effects are declared in the Quran itself: “Who have believed and whose hearts have rested in the remembrance of Allah. Verily in the remembrance of Allah do hearts find rest!” ( The Meaning of the Glorious Koran 1930, 13:28).

The current study showed that non-significant differences were reported in the levels of D&A between the baseline and follow-up measurements for the control group. Phillip and Baker (2012) reported that between 30% and 40% of CABG patients experience D&A disorders [ 38]. Recent studies reported that the prevalence of depressive symptoms among Jordanian post-CABG patients ranged from 55% [ 7] to 65.7% [ 8]. It is worth noting that D&A levels decreased in the current study's control and intervention groups.

However, D&A levels in the follow-up measures for both groups were still considered moderate to high, which is common in post-CABG patients, as these symptoms are notably persistent [ 39]. Both D&A appear to confer greater morbidity risks, and it is commonly hoped that psycho-social interventions might mitigate the harmful impacts of D&A [ 39]. QAT could be recommended by psychologists for improving mental health and achieving patients’ spiritual needs [ 13].

CONCLUSIONS AND RECOMMENDATIONS FOR FUTURE RESEARCH

The present study revealed that QAT significantly and positively improved D&A among post-CABG patients. Based on the findings of this study, it is particularly recommended that Muslim patients listen to QAT to improve their psychological status following CABG. Researchers can conduct further future studies to compare the effectiveness of reciting and listening to the Quran in combination with other interventions. Moreover, further studies can be conducted to evaluate its impact on different outcomes related to psychological or physiological well-being among Muslims and non-Muslims prior to (as well as following) CABG among Arab populations and those of different ethnicities.

REFERENCES