The observation is well made by Dr Alan Begg that there is an increasing need for cardiac rehabilitation, in spite of, and in part because of, the success of primary and secondary prevention in reducing cardiac death rates (see Guidelines in Practice, April 2002, pp. 25-34).1 The SIGN guideline gives the strongest rating to the recommendation that cardiac rehabilitation should consist of exercise training and educational and psychological support.
This is true in most areas of rehabilitation, but the psychological aspect is the one that might present the greatest practical problems, as far as providing a service in the community is concerned.
The Hospital Anxiety and Depression Scale is an easy questionnaire to administer and can be used to help identify patients who need additional psychological support.
However, in my area, clinical psychology support for rehabilitation is woefully under-resourced, and the very appropriate message about cognitive behavioural therapy (CBT) in patients with moderate to severe psychological problems would be a difficult one on which to deliver.
At present our CBT department does not offer an acute intervention service, and patients with severe problems wait for about a year to be seen.
I hope that the publicity generated by these guidelines will encourage more investment in these important integral parts of rehabilitation.
Dr Charles Sears, GP, Salisbury
In defence of IBS guidance
His comments do not suggest a careful reading of a document which, at two sides of A4, can hardly be described as a literature review.
Those GPs who peer-reviewed the guidance before publication did not come to the same conclusion as Mark did.
Dr Greg Rubin, Secretary, Primary Care Society for Gastroenterology