Debra Moser has always been fascinated by the human heart.

Ever since she started her career as an intensive care nurse in a small northern California hospital in 1977, Moser has been intrigued with how the heart works – how it serves as the control center for the body, sending blood to every organ in the body.

As a nurse, Moser would frequently witness heart failure in patients, when the heart wasn’t strong enough to supply the rest of the body with blood. She would see the same patients in the ICU over and over again with pulmonary and cardiac distress. This triggered an epiphany in Moser; there is a link between a healthy mind and a healthy body. In order to treat the heart, you need to treat the whole body holistically.

“There's a lot we can do with medicines and surgeries,” said Moser, now a professor, assistant dean and Linda C. Gill Endowed chair of nursing in the University of Kentucky College of Nursing. “But behaviorally, all cardiac disease is driven by our lifestyle. We have a lot of behaviors that we need to attend to. We don't know how to do it very well; just telling people isn't enough, knowledge isn't enough. There have to be other motivations and engagement in your own self-care.”

In 2001, Moser came to Kentucky, a state beleaguered with cardiac disease and obesity. She switched gears from cardiac failure research to cardiovascular disease prevention. While researching factors that contribute to heart disease such as smoking and inactivity, Moser found another commonality in her subjects – depression.

According to the American Heart Association, 33 percent of people who have had a heart attack report depressive symptoms. People with depression report having a hard time and making and maintaining healthy habits, such as staying active, eating a balanced diet and quitting smoking. Depression can be harder to address in rural parts of Kentucky where not only is there a shortage of mental health providers, there is a stigma surrounding mental health.

“The stigma is common in rural areas where you know everybody,” said Moser. “If you drive your car up to the therapist's office, everybody knows your truck. Everybody sees you walking in there. There should be no stigma toward depressive symptoms. It's an illness like any other illness, but people have concerns about stigma.”

Another barrier to mental health treatment is accessibility. Cognitive-behavioral therapy, which involves in-person meetings between a therapist and the patient, is effective in patients with heart disease but is not widely available in the rural parts of eastern Kentucky. For many, traveling to see a therapist is not feasible. But with improvements to internet access in rural areas, patients now have the opportunity to meet with a therapist remotely.

For this study, Moser will determine which method of delivery for cognitive behavior therapy is more effective – real-time, face-to-face contact with a therapist via teleconferencing, or self-directed approach that patients can do on their own time. Three hundred participants with heart disease and depressive symptoms will be randomly assigned to receive one of the two types of therapy, and they will report back on their depression. Moser will also examine the rates of hospital readmissions, physical activity and medication adherence will be compared over a three, six and 12-month periods.

At a time when COVID-19 has put a number of research projects on hold, Moser’s study is unaffected because she’s examining online treatment delivery methods. But the study is not without obstacles.

“The most challenging aspect is that people who are depressed don't want to participate in projects,” said Moser. “They spend so much time worrying and being deeply depressed and paralyzed in a way of just not wanting to do things, not feeling able to do things, not feeling able to concentrate. That extends to seeking help for yourself. Convincing that people to enroll when they're feeling depressed and don't want to do anything, let alone be in a research study, can be very problematic.”

But Moser is optimistic. She’s dedicated to improving the heart health of people in rural and isolated areas. The collaborative atmosphere of UK, she says, has made significant change possible in Kentucky. Last summer, she presented her research, funded by the Patient-Centered Outcomes Research Institute (PCORI) to senators and members of the American Heart Association on Capitol Hill.

This study, funded by a $2.8 million PCORI contract, is directed by a research team of mental health experts, social workers, dieticians, nutritionists, nurses and doctors. But Moser says the most important ally in this study is the patient. Having direct, real-time feedback from them is something that is often missing in studies. Patients can see how depression impacts their activity levels and eating habits and the overall effect on their health.

“We're managing depression, also but looking at the impact on other things like medication adherence, physical activity, food and nutrition, that ultimately all feedback into depression,” said Moser. “So, if you can improve those things, depression improves. It's a nice big cycle of improvement all around.”

PCORI is an independent, nonprofit organization authorized by Congress in 2010. Its mission is to fund research that will provide patients, their caregivers and clinicians with the evidence-based information needed to make better-informed healthcare decisions. For more information about PCORI’s funding, visit www.pcori.org.