Depression, healthcare utilization, and death in heart failure: a community study

Uncertainty and depressive symptoms as mediators of quality of life in patients with heart failure

Uncertainty in illness is regarded as a source of stress in many chronic diseases and is negatively related to health-related quality of life (HRQoL). However, studies on the relationship between uncertainty and HRQoL in patients with heart failure are limited. This study used Mishel's theory of uncertainty in illness to investigate the mediating role of uncertainty in illness and depressive symptoms between symptom distress and HRQoL in patients with heart failure. This study used a cross-sectional correlation design. Participants were recruited by convenience sampling from outpatient services and medical wards of cardiology departments of a medical center in northern Taiwan. Data were collected for uncertainty, depressive symptoms, symptoms distress of heart failure, and HRQoL using self-report questionnaires. Demographics and clinical characteristics were analyzed with descriptive statistics. The mutual effects of disease characteristics, symptom distress, uncertainty in illness, depressive symptoms and HRQoL, as well as the overall model fitness, were analyzed by with structural equation modeling. We collected 147 qualified questionnaires. The mean score for the Mishel Uncertainty in Illness Scale for patients with heart failure was 73.5 (SD = 18.55); 65.3% of participants had a score of ≧13 on the Beck Depressive Inventory-II, indicating mild depression. Uncertainty, depressive symptoms, and HRQoL were directly related to symptom distress. Symptom distress and depressive symptoms were both mediators between uncertainty and depressive symptoms. Depressive symptoms also mediated emotional support and HRQoL. Uncertainty and depressive symptoms were important factors in the pathway between symptom distress and HRQoL for heart failure patients. We suggest providing heart failure patients with tailored interventions for effective self-management of symptoms based on Mishel's theory of uncertainty in illness, which could help control disease symptoms, alleviate uncertainty and depression as well as improve HRQoL.

Introducing nurse-led heart failure clinics in Swedish primary care settings

AIM

According to clinical guidelines, it is recommended that patients with heart failure (HF) receive structured multidisciplinary care at nurse-led HF clinics in order to optimise treatment and avoid preventable readmissions. Today, there are HF clinics with specialist-trained nurses at almost all Swedish hospitals, but HF clinics remain scarce in primary care (PC). The aim of this study was two-fold: firstly, to evaluate the effects of systematically implementing nurse-led HF clinics in PC settings with regard to hospital healthcare utilisation and evidence-based HF treatment, and secondly to explore patients' experiences of HF clinics in PC.

METHODS AND RESULTS

The study had a pre-post design. Annual measurement were done between 2010-2017 regarding in-hospital healthcare consumption and medical treatment. Data from 2011-2017 after the implementation of HF clinics in PC in one county council Sweden were compared with baseline data collected before the implementation in 2010. The implementation of HF clinics in PC significantly reduced the number of HF-related hospital admissions by 27% (P < 0.001), HF hospital days by 27.3% (P < 0.001) and HF emergency room visits by 24% (P < 0.001). Further, patients were to a higher extent medically treated according to guidelines and satisfied with the care they received at the PC HF clinic.

CONCLUSION

Nurse-led HF clinics in PC seem to be effective in reducing the need for in-hospital care and provide high quality person-centred care.

Psychosocial Distress and Health Service Utilization in Patients Undergoing Hemodialysis: A Prospective Study

BACKGROUND

End-stage renal disease is associated with significant morbidity, high-symptom burden, and health care use. Studies have not yet assessed psychosocial distress and health care utilization in this population.

OBJECTIVE

This study examines psychosocial distress and its association with hospitalization and emergency room (ER) visits in patients on maintenance hemodialysis (HD).

METHODS

The Distress Assessment and Response Tool (DART) was administered to 80 adults on HD in a single treatment center. The DART assessed for anxiety, depression, and social distress. Health care utilization data were extracted prospectively from electronic medical charts. The time between psychosocial distress and hospitalization or ER visits during 12-month follow-up was examined using Cox proportional hazard models.

RESULTS

Overall 46% of the sample reported psychosocial distress, with 33% screening above the threshold for depression, 14% for anxiety, and 36% for significant social distress. In multivariable regression adjusting for age, sex, and comorbidity, the presence of psychosocial distress was associated with shorter time to hospitalization (hazard ratio: 2.4 [1.1, 5.0], p = 0.03) during 12-month follow-up. Psychosocial distress was not significantly associated with ER visits in either univariable (hazard ratio: 1.3 [0.7, 2.3], p = 0.5) or multivariable (hazard ratio: 1.4 [0.8, 2.6], p = 0.3) analyses.

CONCLUSION

Psychosocial distress is frequent in patients undergoing maintenance HD and is associated with shorter time to hospitalization. Future longitudinal studies should examine if health service use can be reduced through routine distress screening and psychosocial distress intervention.

Depression and Coleman Care Transitions Intervention

The Coleman Care Transitions Intervention (CTI) is a "Patient Activation Model." Depression can be a barrier to activation and may challenge CTI. This study addressed whether CTI coaches modified the intervention for older adults who screened positive for depression. Over 4,500 clients in a Centers for Medicare and Medicaid Services demonstration completed screening for depression with the PHQ-9; one in five screened positive (score = 9+). Our findings suggest that coaches modified CTI and played a more directive role for clients who screened positive for depression, resulting in similar 30-day readmission rates among patients who screened positive for depression risk and those who did not. That finding stands in contrast to the widely reported higher readmission rates among people screening positive for depression.

Heart Failure Rehospitalization and Delayed Decision Making: The Impact of Self-care and Depression

BACKGROUND

Rehospitalization soon after discharge can be distressing for persons with heart failure (HF) and places a heavy burden on the healthcare system.

OBJECTIVE

We investigated and explored the association of self-care decision making variables with (1) rehospitalization within 30 days of discharge and (2) delay in seeking medical assistance (delayed decision making).

METHODS

A cross-sectional, explanatory sequential mixed methods design (quan > qual) was used to survey 127 hospitalized HF patients and interview 15 of these participants to explain their survey responses. The survey assessed rehospitalization within 30 days of discharge, delayed decision making, HF self-care, and psychosocial factors influencing self-care.

RESULTS

The likelihood of delaying the decision to be hospitalized was more than 5 times higher among those with high depressive symptoms (odds ratio, 5.33; 95% confidence interval, 2.14-13.28). Those who delayed going to the hospital were uncertain about their prognosis and did not feel their symptoms were urgent. The likelihood of being rehospitalized within 30 days was more than doubled among those with high depressive symptoms (OR, 2.31; 95% confidence interval, 1.01-5.31). Those who were rehospitalized within 30 days were less likely to consult healthcare professionals in their decision making and wanted immediate relief from their symptoms.

CONCLUSIONS

We recommend a patient-centered approach to help HF patients identify and adequately self-manage symptoms. The strong association between high depressive symptoms and rehospitalization within 30 days as well as delayed decision making highlights the critical need for clinicians to carefully assess and address depression among HF patients.

Symptom patterns and clinical outcomes in women versus men with systolic heart failure and depression

BACKGROUND

Depression is more common in females than in males and is 3-5 times more prevalent in patients with heart failure (HF) than in the general population. The 9-item Patient Health Questionnaire (PHQ-9) is a validated depression screening instrument; higher sum-scores predict adverse clinical outcomes. Sex- and gender differences in PHQ-9 symptom profile, diagnostic and prognostic properties, and impact on health-related quality of life (HRQOL) have not been comprehensively studied in HF patients.

METHODS AND RESULTS

This post hoc analysis from the Interdisciplinary Network Heart Failure program enrolled 852/1022 participants (67 ± 13 years, 28% female) who completed the PHQ-9 at hospital discharge after cardiac decompensation. All had a left ventricular ejection fraction ≤ 40%. Women had a higher mean PHQ-9 sum-score than men (8.4 ± 5.6 vs. 7.4 ± 5.5; p = 0.027), and higher proportions rated the following items ≥ 2 (i.e., present on ≥ 50% of days): 'feeling down, hopeless' (25.8 vs. 18.0%; p = 0.011); 'fatigue' (51.9 vs. 37.2%; p < 0.001); and 'trouble concentrating' (21.6 vs. 15.4%; p = 0.032). A PHQ-9 sum-score ≥ 10 predicted increased mortality in women [hazard ratio 1.91 (95% confidence interval 1.06-3.43); p = 0.030] and men [2.10 (1.43-3.09); p < 0.001] and was associated with worse HRQOL (p < 0.001 for all comparisons). Sum-scores ≥ 10 predicted higher re-hospitalization rates in men only [1.35 (1.08-1.69); p = 0.008].

CONCLUSIONS

Differences in several PHQ-9 items indicated sex- or gender-specific depression symptomatology in HF. For both sexes, HRQOL and survival were worse when PHQ-9 sum-score was ≥ 10, but higher sum-scores predicted higher re-hospitalization rates in men only. Considering these specific aspects might help optimize care strategies in HF.

Sex differences in depression-like behavior and neuroinflammation in rats post-MI: role of estrogens

Patients with heart failure (HF) have a high prevalence of depression associated with a worse prognosis, particularly in older women. The present study evaluated whether sex and estrogens affect depression-like behavior and associated neuroinflammation induced by myocardial infarction (MI) in rats. MI was induced by occlusion of the left anterior descending artery in young adult male and female Wistar rats or in ovariectomized (OVX) female rats without and with estrogen [17β-estradiol (E₂)] replacement. MI groups showed a comparable degree of cardiac dysfunction. Eight weeks post-MI, male rats with HF exhibited depression-like behaviors, including anhedonia and higher immobility in the sucrose preference and forced swim tests, which were not observed in female rats with HF. In the cued fear conditioning test, male but not female rats with HF froze more than sham rats. After OVX, female sham rats developed mild depression-like behaviors that were pronounced in OVX female rats post-MI and were largely prevented by E₂ replacement. Cytokine levels in the plasma and paraventricular nucleus increased in both sexes with HF, but only male rats with HF showed an increase in cytokine levels in the prefrontal cortex. OVX alone did not affect cytokine levels, but OVX-MI caused significant increases in the prefrontal cortex, which were shifted to an anti-inflammatory pattern by E₂ replacement. These results suggest that estrogens prevent depression-like behavior induced by HF post-MI in young adult female rats by inhibiting proinflammatory cytokine production and actions in the prefrontal cortex. NEW & NOTEWORTHY In contrast to male rats, female rats with heart failure after myocardial infarction do not develop depression-like behavior or increases in prefrontal cortex cytokines. However, after ovariectomy, female rats exhibit similar changes, which are prevented by 17β-estradiol replacement. Neuroinflammation in the prefrontal cortex in male subjects may contribute to depression-like behavior, whereas its estrogen-dependent absence in female subjects may protect against depression.

Walking with controlled breathing improves exercise tolerance, anxiety, and quality of life in heart failure patients: A randomized controlled trial

BACKGROUND

Patients with heart failure experience not only impaired physical condition, but also their physical activity, moods, and quality of life may be diminished.

AIMS

The purpose of this study was to investigate the effects of 12-week walking with breathing program on physical activity tolerance considering time-dependent physiological factors and time-independent interoceptive awareness, as well as psychosocial factors.

METHODS

This randomized controlled trial recruited 90 heart failure patients and randomly assigned them. The walking with breathing group received the walking and breathing intervention for 12 weeks but the control group did not. Outcomes included activity tolerance measured by 6-minute walk distance, moods assessed by the Hospital Anxiety and Depression Scale, quality of life determined by the EuroQol 5-Dimensions, oxygen saturation by pulse oximetry, and interoceptive awareness by the Multidimensional Assessment of Interoceptive Awareness scale. Data were collected before the intervention at baseline and at Weeks 2, 4 and 12.

RESULTS

The results of the generalized estimating equation showed the 6-minute walk distance in the walking with breathing group was significantly different across time ( p<0.001) compared with the control group at baseline. Oxygen saturation by pulse oximetry ( p=0.04) and Trusting on the Multidimensional Assessment of Interoceptive Awareness scale ( p=0.001) significantly and positively correlated with results of the 6-minute walk distance. There were significant between-group differences at Week 12 in anxiety ( p=0.03) and quality of life ( p=0.02) but not depression ( p=0.06).

CONCLUSIONS

Walking with breathing improved heart failure patients' tolerance of physical activity, probably because of improved oxygen saturation and trusting interoceptive awareness. Walking with breathing also improved patients' anxiety and quality of life.

Depression in Community-Dwelling Elderly Patients With Heart Failure

The present cross-sectional study discussed the relationship between comorbid depression, demographic characteristics, clinical characteristics, and dietary self-efficacy among Taiwanese community-dwelling elderly patients with heart failure (HF). Specifically, the study examined 175 community-dwelling elderly patients with HF between July 2013 and June 2014. In total, 47.13% of the patients exhibited symptoms of depression. Those without a spouse, who were currently employed, who had an ejection fraction <30%, who had been readmitted to the hospital 2 or more times, and who had a high level of HF symptom distress were significantly more likely to be depressed. Therefore, it is crucial that care programs designed for these patients include the self-management of HF symptoms, psychological consultations, cognitive behavioral therapy, and physical exercise.

The effect of exercise therapy on depressive and anxious symptoms in patients with ischemic heart disease: A systematic review

OBJECTIVE

Depressive and anxiety symptoms are associated with Ischemic Heart Disease (IHD). Exercise interventions might improve both depressive and anxiety symptoms, but an overview of the evidence is lacking. Therefore, we systematically reviewed the existing literature on the effectiveness of exercise therapy to reduce depression and anxiety symptoms specifically in patients with IHD.

METHODS

MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials were searched until January 2016. The effectiveness of exercise was assessed within two groups: a) patients selected for study with severe depression or anxiety; and b) studies that did not exclusively targeted patients with increased levels of depression or anxiety. Secondary outcomes were mortality, cardiac events, re-hospitalizations and cardiovascular risk factors.

RESULTS

We included fourteen studies. Clinical and methodological heterogeneity precluded meta-analysis. Three studies specifically included patients with high levels of depression or anxiety and eleven studies selected patients with unclear levels of depression or anxiety. Some RCTs showed that exercise was effective in lowering severe depressive symptoms (short and long term follow-up), but for the group with unclear depressive symptoms the results were non-conclusive. In the group with elevated anxiety symptoms, exercise had a positive effect on the short term follow-up. In the group with unclear anxiety symptoms the results were inconsistent (short and long term follow-up). No differences were found regarding the secondary outcomes.

CONCLUSIONS

There is a general paucity of data on the effect of exercise, precluding firm conclusions about the effectiveness of exercise for depressive and anxiety symptoms in IHD patients.

Phosphodiesterase 1: A Unique Drug Target for Degenerative Diseases and Cognitive Dysfunction

The focus of this chapter is on the cyclic nucleotide phosphodiesterase 1 (PDE1) family. PDE1 is one member of the 11 PDE families (PDE 1-11). It is the only phosphodiesterase family that is calcium/calmodulin activated. As a result, whereas other families of PDEs 2-11 play a dominant role controlling basal levels of cyclic nucleotides, PDE1 is involved when intra-cellular calcium levels are elevated and, thus, has an "on demand" or activity-dependent involvement in the control of cyclic nucleotides in excitatory cells including neurons, cardiomyocytes and smooth muscle. As a Class 1 phosphodiesterase, PDE1 hydrolyzes the 3' bond of 3'-5'-cyclic nucleotides, cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). Here, we review evidence for this family of enzymes as drug targets for development of therapies aimed to address disorders of the central nervous system (CNS) and of degenerative diseases. The chapter includes sections on the potential for cognitive enhancement in mental disorders, as well as a review of PDE1 enzyme structure, enzymology, tissue distribution, genomics, inhibitors, pharmacology, clinical trials, and therapeutic indications. Information is taken from public databases. A number of excellent reviews of the phosphodiesterase family have been written as well as reviews of the PDE1 family. References cited here are not comprehensive, rather pointing to major reviews and key publications.

Neuroimmune Mechanisms of Depression in Adults with Heart Failure

Heart failure (HF) is a major and costly public health concern, and its prognosis is grim-with high hospitalization and mortality rates. HF affects millions of individuals across the world, and this condition is expected to become "the epidemic" of the twenty-first century (Jessup et al., 2016). It is well documented that individuals with HF experience disproportionately high rates of depression and that those who are depressed have worse clinical outcomes than their nondepressed counterparts. The purpose of this chapter is to introduce the reader to the study of depression in HF, and how psychoneuroimmunologic principles have been applied to further elucidate mechanisms (i.e., neurohormonal and cytokine activation) linking these comorbid disorders.

Utilization of psychiatric care and antidepressants among people with different severity of depression: a population-based cohort study in Stockholm, Sweden

PURPOSE

To identify how severity of depression predicts future utilization of psychiatric care and antidepressants.

METHODS

Data derived from a longitudinal population-based study in Stockholm, Sweden, include 10443 participants aged 20-64 years. Depression was assessed by Major Depression Inventory and divided into subsyndromal, mild, moderate and severe depression. Outcomes were the first time of hospitalization, specialized outpatient care and prescribed drugs obtained from national register records. The association between severity of depression and outcomes was tested by Cox regression analysis, after adjusting for gender, psychiatric treatment history and socio-environmental factors.

RESULTS

The cumulative incidences of hospitalizations, outpatient care and antidepressants were 4.0, 11.2, and 21.9% respectively. Compared to the non-depressed group, people with different severity of depression (subsyndromal, mild, moderate and severe depression) all had significantly higher risk of all three psychiatric services (all log-rank test P < 0.001). Use of psychiatric care and antidepressants increased by rising severity of depression. Although the associations between severity of depression and psychiatric services were significant, the dose relationship was not present in people with previous psychiatric history or after adjusting for gender and other factors.

CONCLUSIONS

People with subsyndromal to severe depression all have increased future psychiatric service utilization compared to non-depressed people.

General practitioners' awareness of depressive symptomatology is not associated with quality of life in heart failure patients - cross-sectional results of the observational RECODE-HF Study

BACKGROUND

Depression is a common comorbidity in patients with chronic heart failure (HF) and linked to a wider range of symptoms which, in turn, are linked to a decreased health-related quality of life (HRQOL). Treatment of depression might improve HRQOL but detecting depression is difficult due to the symptom overlap between HF and depression. Therefore, clinical guidelines recommend to routinely screen for depression in HF patients. No studies have so far investigated the treatment after getting aware of a depressive symptomatology and its correlation with HRQOL in primary care HF patients. Therefore, we examined the factors linked to depression treatment and those linked to HRQOL in HF patients. We hypothesized that GPs' awareness of depressive symptomatology was associated with depression treatment and HRQOL in HF patients.

METHODS

For this observational study, HF patients were recruited in primary care practices and filled out a questionnaire including PHQ-9 and HADS. A total of 574 patients screened positive for depressive symptomatology. Their GPs were interviewed by phone regarding the patients' comorbidities and potential depression treatment. Descriptive and regression analysis were performed.

RESULTS

GPs reported various types of depression treatments (including dialogue/counselling by the GP him/herself in 31.8% of the patients). The reported rates differed considerably between GP-reported initiated treatment and patient-reported utilised treatment regarding psychotherapy (16.4% vs. 9.5%) and pharmacotherapy (61.2% vs. 30.3%). The GPs' awareness of depressive symptomatology was significantly associated with the likelihood of receiving pharmacotherapy (OR 2.8; p < 0.001) but not psychotherapy. The patient's HRQOL was not significantly associated with the GPs' awareness of depression.

CONCLUSION

GPs should be aware of the gap between GP-initiated and patient-utilised depression treatments in patients with chronic HF, which might lead to an undersupply of depression treatment. It remains to be investigated why GPs' awareness of depressive symptomatology is not linked to patients' HRQOL. We hypothesize that GPs are aware of cases with reduced HRQOL (which improves under depression treatment) and unaware of cases whose depression do not significantly impair HRQOL, resulting in comparable levels of HRQOL in both groups. This hypothesis needs to be further investigated.

Social support, self-rated health and low mood in people on sick leave due to heart failure: a cross-sectional study

AIMS

The aim of this study was to investigate social support in relation to self-rated health and the prevalence of low mood in people on sick leave due to heart failure.

METHODS

A cross-sectional design was used, and 590 individuals on sick leave due to heart failure in Sweden responded to the postal questionnaire. The questions therein concerned received and needed functional and structural support from managers, work colleagues, families and friends. Multivariate analyses were conducted.

RESULTS

The variables of income and needed support from family contributed significantly and negatively to self-rated health. Those who perceived that they needed more support from their manager reported experiencing low mood more frequently.

CONCLUSIONS

The results showed a negative relation between manager support and low mood. Thus, support from managers and perceptions of low mood during sick leave are negatively associated, however, we do not know anything about the causality of this association. The results also indicated that needed support from family was negatively associated with self-rated health. The results also highlighted a multidimensional frailty in people with heart failure that needs to be recognized in future research as well as in clinical practice.

Economic Impact of Subsequent Depression in Patients With a New Diagnosis of Stable Angina: A Population-Based Study

Background

Depression is strongly linked to increased morbidity and mortality in patients with chronic stable angina; however, its associated healthcare costs have been less well studied. Our objective was to identify the characteristics of chronic stable patients found to have depression and to determine the impact of an occurrence of depression on healthcare costs within 1 year of a diagnosis of stable angina.

Methods and Results

In this population‐based study conducted in Ontario, Canada, we identified patients diagnosed with stable angina based on angiogram between October 1, 2008, and September 30, 2013. Depression was ascertained by physician billing codes and hospital admission diagnostic codes contained within administrative databases. The primary outcome was cumulative mean 1‐year healthcare costs following index angiogram. Generalized linear models were developed with a logarithmic link and γ distribution to determine predictors of cost. Our cohort included 22 917 patients with chronic stable angina. Patients with depression had significantly higher mean 1‐year healthcare costs ($32 072±$41 963) than patients without depression ($23 021±$25 741). After adjustment for baseline comorbidities, depression was found to be a significant independent predictor of cost, with a cost ratio of 1.33 (95% confidence interval, 1.29–1.37). Higher costs in depressed patients were seen in all healthcare sectors, including acute and ambulatory care.

Conclusions

Depression is an important driver of healthcare costs in patients following a diagnosis of chronic stable angina. Further research is needed to understand whether improvements in the approach to diagnosis and treatment of depression will translate to reduced expenditures in this population.

Factors associated with general practitioners' awareness of depression in primary care patients with heart failure: baseline-results from the observational RECODE-HF study

Background

Depression is more prevalent in patients with heart failure (HF) than in those without, but its detection is complicated by the symptom overlap between the two diseases. General practitioners (GPs) are the first point of contact for patients with HF. Therefore, this study aims to investigate GPs’ awareness of depression in their HF patients and factors associated with this awareness.

Methods

In this cross-sectional, observational study 3224 primary care patients with HF were screened for depressive symptomatology using an algorithm based on the Hospital Anxiety and Depression Scale, the 9-item subscale on Depression of the Patient Health Questionnaire, and selected items from the PROMIS Depression and Anxiety scales. The 272 GPs of all patients involved in the study were interviewed by telephone regarding their patients’ somatic and psychological comorbidities. The awareness rates of depressive symptomatology by the patients’ GPs are analyzed using descriptive statistics. Logistic regression analyses are applied to investigate the patient- and GP-based factors associated with the GPs’ awareness of depressive symptomatology.

Results

GPs were aware of their patients’ depressive symptomatology in 35% of all cases. Factors associated with the awareness of depressive symptomatology were: higher patient education levels, a history of depression known to the GP, GP-consultations due to emotional distress within the last 6 months, a higher frequency of GP-contacts within the last 6 months, a higher New York Heart Association (NYHA) classification and more severe depressive symptomatology. The GPs’ characteristics, including further education in psychology/psychiatry, were not associated with GP awareness.

Conclusions

Many aspects, including the definition of awareness and the practical issues in primary care, may contribute to the unexpectedly low awareness rates of depressive symptomatology in HF patients in primary care. Awareness rates might increase, if GPs encouraged their patients to talk about emotional distress, held detailed medical interviews including a patient’s history of depression and payed special attention to HF patients with low education levels. However, it remains to be investigated whether GPs’ judgement of depressive symptomatology is a better or worse indicator for the future prognosis and quality of life of HF patients than psychiatry based diagnostic criteria.

Two-Step Screening for Depressive Symptoms and Prediction of Mortality in Patients With Heart Failure

BACKGROUND

Comorbid depression in patients with heart failure is associated with increased risk for death. In order to effectively identify depressed patients with cardiac disease, the American Heart Association suggests a 2-step screening method: administering the 2-item Patient Health Questionnaire first and then the 9-item Patient Health Questionnaire. However, whether the 2-step method is better for predicting poor prognosis in heart failure than is either the 2-item or the 9-item tool alone is not known.

OBJECTIVE

To determine whether the 2-step method is better than either the 2-item or the 9-item questionnaire alone for predicting all-cause mortality in heart failure.

METHODS

During a 2-year period, 562 patients with heart failure were assessed for depression by using the 2-step method. With the 2-step method, results are considered positive if patients endorse either depressed mood or anhedonia on the 2-item screen and have scores of 10 or higher on the 9-item screen.

RESULTS

Screening results with the 2-step method were not associated with all-cause mortality. Patients with scores positive for depression on either the 2-item or 9-item screen alone had 53% and 60% greater risk, respectively, for all-cause death than did patients with scores negative for depression after adjustments for covariates (hazard ratio, 1.530; 95% CI, 1.029-2.274 for the 2-item screen; hazard ratio, 1.603; 95% CI, 1.079-2.383 for the 9-item screen).

CONCLUSIONS

The 2-step method has no clear advantages compared with the 2-item screen alone or the 9-item screen alone for predicting adverse prognostic effects of depressive symptoms in heart failure.

Depression increases the risk of mortality in patients with heart failure: A meta-analysis

BACKGROUND

Depression is a risk factor for mortality in cardiovascular diseases. Prior studies confirm that depression predicts adverse outcomes in patients with heart failure (HF). However, data were inconclusive regarding the effect of depression on mortality. This meta-analysis examines the relationship between depression and mortality in HF.

METHODS

Prospective studies of depression and mortality in HF published between 1999 and April 2016 were located using PubMed, PsychINFO, and MEDLINE. Comprehensive Meta-Analysis software was used to compute an aggregated effect size estimates of hazard ratios and to conduct subgroup analyses.

RESULTS

Eighteen studies met inclusion criteria. For 8 aggregated univariate and 14 multivariate estimates, depressive symptoms were related to all-cause mortality. A pooled HR of 3 multivariate analyses indicated that depressive symptoms were not linked to cardiovascular mortality. In subgroup analyses, depression predicted all-cause mortality in samples with a mean age >65. The impact of depression on all-cause mortality also differed by follow-up duration, with samples with shorter follow-up durations demonstrating a larger effect.

CONCLUSIONS

In HF, depression is related to increased all-cause mortality risk, with stronger effects in samples with shorter follow-up and in older adults. In older adults, depression may serve as a marker of more severe HF. However, this possibility is difficult to examine given inconsistent adjustment for HF severity. Additional studies may assist in determining the relationship between depression and cardiovascular mortality, as the low number of studies examining cardiovascular mortality may have precluded detection of an effect.

A functional variant of the neuropeptide S receptor-1 gene modulates clinical outcomes and healthcare utilization in patients with systolic heart failure: results from the Interdisciplinary Network Heart Failure (INH) Study

AIMS

Psychopathologies may occur in heart failure (HF) and can be associated with adverse outcomes. Amongst neuropeptide S receptor gene functional sequence variants, the T-allele [asparagine(107)isoleucine, NPSR1 rs324981] has been identified as a risk factor for increased anxiety/overinterpretation of bodily symptoms. We investigated all-cause death and re-hospitalization (composite primary endpoint, CPEP) and healthcare utilization in patients hospitalized for decompensated systolic HF with the TT vs. the AT/AA genotype.

METHODS AND RESULTS

Participants in the Interdisciplinary Network Heart Failure programme were eligible if consenting to genetic testing (n = 924) and randomization to usual care (UC, n = 464) or nurse-co-ordinated disease management (DM, n = 460). Follow-up was 180 days (100% complete). Compared with AT/AA carriers (n = 726), TT genotype carriers (n = 198) had more CPEP events [47% vs. 39%, hazard ratio (HR) 1.27, 95% confidence interval (CI) 1.01-1.61, P = 0.044] and were more frequently re-hospitalized (43% vs. 35%, HR 1.31, 95% CI 1.02-1.67, P = 0.033); mortality rate was similar in both groups (HR 1.11, 95% CI 0.68-1.81, P = 0.664). In subjects undergoing DM, CPEP and re-hospitalization occurred more often in TT (51% and 47%) than in AT/AA carriers (36% and 33%; HR 2.14, 95% CI 1.44-3.19, and HR 2.29, 95% CI 1.52-3.44, genotype/treatment interaction both P = 0.007). Furthermore, TT genotype carriers undergoing DM visited cardiologists and other specialists more often than AT/AA carriers (P = 0.009 and P = 0.005). With UC, event rates did not differ between genotype subgroups.

CONCLUSION

We identified a psychogenetic determinant of clinical outcomes and healthcare utilization after acute HF, which was modulated by the type of care. Future investigations need to clarify whether NPSR1 genotyping might further enhance the concept of 'personalized' medicine in HF.

TRIAL REGISTRATION

ISRCTN23325295.

Emotions and encounters with healthcare professionals as predictors for the self-estimated ability to return to work: a cross-sectional study of people with heart failure

OBJECTIVES

To live with heart failure means that life is delimited. Still, people with heart failure can have a desire to stay active in working life as long as possible. Although a number of factors affect sick leave and rehabilitation processes, little is known about sick leave and vocational rehabilitation concerning people with heart failure. This study aimed to identify emotions and encounters with healthcare professionals as possible predictors for the self-estimated ability to return to work in people on sick leave due to heart failure.

DESIGN

A population-based cross-sectional study design was used.

SETTING

The study was conducted in Sweden. Data were collected in 2012 from 3 different sources: 2 official registries and 1 postal questionnaire.

PARTICIPANTS

A total of 590 individuals were included.

STATISTICS

Descriptive statistics, correlation analysis and linear multiple regression analysis were used.

RESULTS

3 variables, feeling strengthened in the situation (β=-0.21, p=0.02), feeling happy (β=-0.24, p=0.02) and receiving encouragement about work (β=-0.32, p≤0.001), were identified as possible predictive factors for the self-estimated ability to return to work.

CONCLUSIONS

To feel strengthened, happy and to receive encouragement about work can affect the return to work process for people on sick leave due to heart failure. In order to develop and implement rehabilitation programmes to meet these needs, more research is needed.

Pre-Transplant Depression Is Associated with Length of Hospitalization, Discharge Disposition, and Survival after Liver Transplantation

Depression after liver transplantation has been associated with decreased survival, but the effects of pre-transplant depression on early and late post-transplant outcomes remain incompletely evaluated. We assessed all patients who had undergone single-organ liver transplantation at a single center over the prior 10 years. A diagnosis of pre-transplant depression, covariates, and the outcomes of interest were extracted from the electronic medical record. Potential covariates included demographics, etiology and severity of liver disease, comorbidities, donor age, graft type, immunosuppression, and ischemic times. In multivariable models adjusting for these factors, we evaluated the effect of pre-transplant depression on transplant length of stay (LOS), discharge disposition (home vs. facility) and long-term survival. Among 1115 transplant recipients with a median follow-up time of 5 years, the average age was 56±11 and MELD was 12±9. Nineteen percent of the study population had a history of pre-transplant depression. Pre-transplant depression was associated with longer LOS (median = 19 vs. 14 days, IRR = 1.25, CI = 1.13,1.39), discharge to a facility (36% vs. 25%, OR 1.70,CI = 1.18,2.45), and decreased survival (HR = 1.54,CI = 1.14,2.08) in this cohort, accounting for other potential confounders. In conclusion, pre-transplant depression was significantly associated with longer transplant length of stay, discharge to a facility, and mortality in this cohort.

Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

Mortality Risk Among Heart Failure Patients With Depression: A Nationwide Population-Based Cohort Study

Background

The prevalence of depression is 4‐ to 5‐fold higher in heart failure patients than in the general population. We examined the influence of depression on all‐cause mortality in patients with heart failure.

Methods and Results

Using Danish medical registries, this nationwide population‐based cohort study included all patients with a first‐time hospitalization for heart failure (1995–2014). All‐cause mortality risks and 19‐year mortality rate ratios were estimated based on Cox regression analysis, adjusting for age, sex, time period, comorbidity, and socioeconomic status. The analysis included 9636 patients with and 194 887 patients without a diagnosis of depression. Compared with patients without a history of depression, those with depression had higher 1‐year (36% versus 33%) and 5‐year (68% versus 63%) mortality risks. Overall, the adjusted mortality rate ratio was 1.03 (95% CI 1.01–1.06). Compared with no depression, the adjusted mortality rate ratios for mild, moderate, and severe depression, as defined by diagnostic codes, were 1.06 (95% CI 1.00–1.13), 1.03 (95% CI 0.99–1.08), and 1.02 (95% CI 0.96–1.09), respectively. In a subcohort of patients, the mortality rate ratios were modified by left ventricular ejection fraction, with adjusted mortality rate ratios of 1.17 (95% CI, 1.05–1.31) for ≤35%, 0.98 (95% CI 0.81–1.18) for 36% to 49%, and 0.96 (95% CI 0.74–1.25) for ≥50%. Results were consistent after adjustment for alcohol abuse and smoking.

Conclusions

A history of depression was an adverse prognostic factor for all‐cause mortality in heart failure patients with left ventricular ejection fraction ≤35% but not for other heart failure patients.

Depression predicts mortality and hospitalization in heart failure: A six-years follow-up study

BACKGROUND

The aim of this study is to evaluate the prevalence of depressive symptoms (DS) and its relation on hospitalization for cardiovascular (CV) causes and all-cause mortality risk among outpatients with HF.

METHODS

A prospective study was conducted on 130 adult outpatients with HF. The Beck Depression Inventory Scale-second edition (BDI-II) was used to screen for DS. All-cause mortality and hospitalization for CV causes were registered over 6 years. Logistic regression and multinomial logistic regression analysis were used to evaluate the independent prognostic value of DS on mortality and hospitalization for CV causes after adjustment for clinical risk factors.

RESULTS

During a mean follow-up of 6 years, 44% of patients were classified as having DS. Sixty-two participants died for all causes, representing 61% of those with DS and 37% of those without (p=0.006); Forty-nine participants (38%) were hospitalized for CV causes, representing 49% of those with DS and 29% of those without (p=0.027). Logistic regression analysis indicated that DS predicted all-cause mortality (OR: 2.905; 95% CI:1.228-6.870; p=0.006) and multinomial logistic regression indicated that DS were predictive of hospitalization for CV causes (OR: 3.169; 95% CI: 1.230-8.164; p=0.027). These associations were independent of conventional risk factors.

LIMITATIONS

Only outpatient sample; measure of DS only at baseline; cause of death was not known.

CONCLUSION

This study, first held in a portuguese population, showed that DS are independent predictors of death and hospitalization for CV causes among HF patients and its impact persists over 6 years.

Factors to assess depression in homebound older adults

Introduction:

The number of homebound older adults is expected to increase as the elderly population grows. Many homebound older persons may be at high risk for depression, which has been associated with adverse health outcomes. The objective of this study was to identify selected factors that may predict depression in the homebound older population.

Methods:

Data from 340 homebound adults, aged 65 and older who were enrolled in Broward Meals on Wheels and who participated in a telephone survey were analyzed. Participants were asked to report demographic information, health status, medication-taking behaviors, mental health, and life satisfaction. Multiple regression analysis was used to identify predictors of depressed mood in this sample of older adults.

Results:

The majority of the sample (aged 65–95 years; mean, 77 years) were female (76.5%), white (77.1%), and living alone (52.6%). Multivariate modeling indicated that difficulty remembering the number of prescribed medications to be taken, feeling groggy after taking certain medications, poor self-reported health status, taking anxiety medications, and less satisfaction with life explained 34% (adjusted R²) of the variance in predicting depressed mood (F = 33.1, df = 5, P < .001).

Discussion:

Multiple factors related to medication use were identified that may contribute to higher levels of depressed mood in homebound older adults. These factors found in our study may be used to create a screening model to be used by pharmacists to identify homebound older adults who would benefit from further assessment for depression.

The Impact of Body Mass Index on the Link Between Depressive Symptoms and Health Outcome in Patients With Heart Failure

BACKGROUND

Depressive symptoms are predictors of shorter cardiac event-free survival, whereas increased body mass index (BMI) is associated with longer cardiac event-free survival in patients with heart failure (HF). However, the impact of BMI on the link between depressive symptoms and cardiac event-free survival is unexplored. The purpose of this study was to determine whether the relationship between depressive symptoms and cardiac event-free survival differs among HF patients stratified by BMI tertiles.

METHODS

A total of 297 outpatients with HF completed the Patient Health Questionnaire-9 to assess depressive symptoms. Body mass index was calculated as weight in kilograms divided by height in meters squared. Patients were followed for 1 year to determine cardiac event-free survival. Cox proportional hazard regression with survival curves was used to determine the relationships among depressive symptoms, BMI, and cardiac event-free survival.

RESULTS

Both depressive symptoms (P < .001) and lower BMI (P = .002) are independent predictors of shorter cardiac event-free survival after controlling for age, gender, etiology, total comorbidity scores, ejection fraction, New York Heart Association functional class, and prescribed medications. Patients with depressive symptoms had shorter cardiac event-free survival compared with patients without depressive symptoms in the lowest (P = .001) and middle (P = .036) BMI tertiles. There was no difference in cardiac event-free survival between patients with and without depressive symptoms in the highest tertile (P = .894).

CONCLUSIONS

Higher BMI has a protective role in the adverse effect of depressive symptoms on health outcomes in patients with HF.

Patient, Caregiver, and Physician Work in Heart Failure Disease Management: A Qualitative Study of Issues That Undermine Wellness

OBJECTIVE

To identify factors underlying heart failure hospitalization.

METHODS

Between January 1, 2012, and May 31, 2012, we combined medical record reviews and cross-sectional qualitative interviews of multiple patients with heart failure, their clinicians, and their caregivers from a large academic medical center in the Midwestern United States. The interview data were analyzed using a 3-step grounded theory-informed process and constant comparative methods. Qualitative data were compared and contrasted with results from the medical record review.

RESULTS

Patient nonadherence to the care plan was the most important contributor to hospital admission; however, reasons for nonadherence were complex and multifactorial. The data highlight the importance of patient education for the purposes of condition management, timeliness of care, and effective communication between providers and patients.

CONCLUSION

To improve the consistency and quality of care for patients with heart failure, more effective relationships among patients, providers, and caregivers are needed. Providers must be pragmatic when educating patients and their caregivers about heart failure, its treatment, and its prognosis.

Comorbid Depression and Heart Failure: A Community Cohort Study

Objective

To examine the association between depression and clinical outcomes in heart failure (HF) in a community cohort.

Patients and Methods

HF patients in Minnesota, United States completed depression screening using the 9-item Patient Health Questionnaire (PHQ-9) between 1^st Oct 2007 and 1^st Dec 2011; patients with PHQ-9≥5 were labelled “depressed”. We calculated the risk of death and first hospitalization within 2 years using Cox regression. Results were adjusted for 10 commonly used prognostic factors (age, sex, systolic blood pressure, estimated glomerular filtration rate, serum sodium, ejection fraction, blood urea nitrogen, brain natriuretic peptide, presence of diabetes and ischaemic aetiology). Area under the curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) compared depression as a predictor against the aforementioned factors.

Results

425 patients (mean age 74, 57.6% males) were included in the study; 179 (42.1%) had PHQ-9≥5. The adjusted hazard ratio of death was 2.02 (95% CI 1.34–3.04) and of hospitalization was 1.42 (95% CI 1.13–1.80) for those with compared to those without depression. Adding depression to the models did not appreciably change the AUC but led to statistically significant improvements in both the IDI (p = 0.001 and p = 0.005 for death and hospitalization, respectively) and NRI (for death and hospitalization, 35% (p = 0.002) and 27% (p = 0.007) were reclassified correctly, respectively).

Conclusion

Depression is frequent among community patients with HF and associated with increased risk of hospitalizations and death. Risk prediction for death and hospitalizations in HF patients can be improved by considering depression.

Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): A multidisciplinary position statement

Background

Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide.

Methods

To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population.

Results

We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol — adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals.

Conclusions

We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF.

Healthcare and economic impact of diarrhea in patients with carcinoid syndrome

AIM: To examine healthcare resource utilization patterns and costs accrued by carcinoid syndrome (CS) patients with and without diarrhea.

METHODS: We conducted a retrospective cohort study using MarketScan^® data from 1/1/2002-12/31/2012. Newly diagnosed CS patients had 1 medical claim for CS (ICD-9-CM code 259.2) plus either ≥ 1 additional claim for CS or for carcinoid tumors (ICD-9-CM 209.x), and had no evidence of CS for 1 year prior to index CS diagnosis, in commercially-insured patients < 65 years old. Patients were required to have continuous enrollment one year prior and after index date (first claim with CS diagnosis in the ID period). We identified patients with evidence of non-infectious diarrhea (ICD-9-CM codes 564.5 and 787.91) within one year from the index date. Overall and CS-related healthcare resource utilization and costs were compared between patients with and without non-infectious diarrhea during the one year period after the index date.

RESULTS: There were 2822 newly diagnosed CS patients; 534 (18.9%) had evidence of non-infectious diarrhea. Compared to patients without non-infectious diarrhea, non-infectious diarrhea patients more commonly had at ≥ 1 CS-related hospitalization (13.7% vs 7.2%), ≥ 1 CS-related ED visit (11.0% vs 4.4%), and CS-related office visits in one year (6.9 vs 4.1; all P < 0.001). After adjusting for demographics, region, number of chronic conditions and the Charlson Comorbidity Index, the proportions of patients with any and with CS-related hospitalizations were 9.7% and 6.8% higher, respectively, among non-infectious diarrhea patients compared to those with without non-infectious diarrhea (P < 0.001). Unadjusted costs were significantly higher among non-infectious diarrhea patients vs those without non-infectious diarrhea. The non-infectious diarrhea group was also more costly, with adjusted mean annual costs of $81610, compared to $51719 in the group without non-infectious diarrhea (P < 0.001).

CONCLUSION: Diarrhea is burdensome and costly in CS patients. Reduction of CS-related healthcare expenditures may be achievable through preventive treatment and appropriate management of diarrhea in CS.

Depression and Multiple Rehospitalizations in Patients With Heart Failure

BACKGROUND

There have been few studies of the effect of depression on rehospitalization in patients with heart failure (HF), and even fewer on its role in multiple rehospitalizations.

HYPOTHESIS

Depression is an independent risk factor for multiple readmissions in patients with HF.

METHODS

A cohort of 662 patients with HF who were discharged alive after hospitalization were interviewed to evaluate symptoms of depression and were followed for 1 year. All-cause readmissions were documented by chart review. A marginal proportional rates model was used to model the effect of depression on the rate of rehospitalization with adjustment for known predictors of HF outcomes.

RESULTS

Depression symptoms predicted multiple readmissions (adjusted hazard ratio [HR]: 1.08, 95% confidence interval [CI]: 1.03-1.13, P = 0.0008). Compared with patients without depression, those who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression at index were at the highest risk for multiple rehospitalizations (HR: 1.51, 95% CI: 1.15-1.97, P = 0.003).

CONCLUSIONS

Depression is an independent risk factor for multiple all-cause readmissions in patients with HF.

Effectiveness of Motivational Interviewing in Decreasing Hospital Readmission in Adults With Heart Failure and Multimorbidity

Hospitalizations are common in heart failure (HF). Multimorbidity, defined as ≥2 comorbid conditions, drives many readmissions. The purpose of this pilot study was to test the effectiveness of motivational interviewing (MI) in decreasing these hospital readmissions. We enrolled 100 hospitalized HF patients into a randomized controlled trial, randomizing in a 2:1 ratio: intervention (n = 70) and control (n = 30). The intervention group received MI tailored to reports of self-care during one home visit and three to four follow-up phone calls. After 3 months, 34 participants had at least one hospital readmission. The proportion of patients readmitted for a condition unrelated to HF was lower in the intervention (7.1%) compared with the control group (30%, p = .003). Significant predictors of a non-HF readmission were intervention group, age, diabetes, and hemoglobin. Together, these variables explained 35% of the variance in multimorbidity readmissions. These preliminary results are promising in suggesting that MI may be an effective method of decreasing multimorbidity hospital readmissions in HF patients.

Expert Opinion-Depression in Patients with Heart Failure: Is Enough Being Done?

Depression is a major issue in heart failure (HF). Depression is present in about one in five HF patients, with about 48 % of these individuals having significant depression. There is a wide variation in reported prevalences because of differences in the cohorts studied and methodologies. There are shared pathophysiological mechanisms between HF and depression. The adverse effects of depression on the outcomes in HF include reduced quality of life, reduced healthcare use, rehospitalisation and increased mortality. Results from metaanalysis suggest a twofold increase in mortality in HF patients with compared to those without depression. Pharmacological management of depression in HF has not been shown to improve major outcomes. No demonstrable benefits over cognitive behavioural therapy and psychotherapy have been demonstrated.

Protective Effect of Regular Physical Activity on Depression After Myocardial Infarction: The HUNT Study

PURPOSE

To study if physical activity within the recommended level over time was associated with risk of developing depression after the first myocardial infarction in older adults.

METHODS

Men (n = 143) and women (n = 46) who had reached the age of 60 years in 2006-2008 who participated in the Nord-Trøndelag Health Study (HUNT1, 1984-1986; HUNT2, 1995-1997; HUNT3, 2006-2008) without any mental illness or cardiovascular disease at baseline in HUNT2 and who experienced their first myocardial infarction before HUNT3 were included. Based on the patterns of physical activity from HUNT1 to HUNT2, the sample was divided into 4 groups: persistently inactive, from active to inactive, from inactive to active, and persistently active. The primary outcome, post-myocardial infarction depression symptoms, was measured with the Hospital, Anxiety and Depression Scale in HUNT3.

RESULTS

In HUNT3, 11% of participants had depression. After multivariable adjustment, those who were persistently active had significantly lower odds of being depressed (odds ratio 0.28; 95% confidence interval, 0.08-0.98) compared with those who were persistently inactive. Additionally, a significant test for trend (P = .033) of lowering odds of depression was observed across all 4 categories of physical activity patterns at baseline.

CONCLUSIONS

In this small sample of initially healthy adults, we observed a long-term protective effect of regular physical activity on the development of depression following myocardial infarction.

Promotora assisted depression care among predominately Hispanic patients with concurrent chronic illness: Public care system clinical trial design

Depression frequently negatively affects patient overall self-care and social stress management within United States safety net care systems. Rates of major depression are significantly high among low-income predominantly Hispanic/Latino with chronic illness, such as diabetes and heart disease. The study design of the A Helping Hand to Activate Patient-Centered Depression Care among Low-income Patients (AHH) randomized clinical trial aims to enhance patient depression care receipt and overall bio-psychosocial self-care management. The AHH trial is conducted in collaboration with three Los Angeles County Department of Health Services (DHS) safety net clinics that provide Patient-Centered Medical Home (PCMH) care. The study compares AHH intervention (AHH) in which community-based bilingual promotoras provide in-person or telephone patient engagement and intervention aimed to reduce the burden and strain on patients, families, and care providers by assessing, enhancing, and facilitating patient depression and co-morbid illness self-care management skill, and activating patient communication with clinic medical providers versus DHS PCMH team usual care (PCMHUC). AHH independent bilingual recruiters screened 1957 and enrolled 348 predominantly Hispanic/Latino patients, of whom 296 (85%) had diabetes, 14 (4%) with heart disease, and 38 (11%) with both diseases. Recruiters identified depressed patients by baseline Patient Health Questionnaire-9 scores of 10 or more, completed baseline assessments, and randomized patients to either AHH or PCMHUC study group. The comprehensive assessments will be repeated at 6 and 12months by an independent bilingual follow-up interviewer. Baseline and outcome data include mental health assessment and treatment receipt, co-morbid illness self-care, social relationships, and environmental stressor assessments.

Psychosocial characteristics and outcomes in patients with left ventricular assist device implanted as destination therapy

BACKGROUND

Psychosocial factors impact survival in patients undergoing cardiac transplantation, but it is unclear whether they affect outcomes in patients undergoing left ventricular assist device (LVAD) implantation as destination therapy (DT).

METHODS

Patients undergoing DT LVAD at the Mayo Clinic in Rochester, MN, from February 2007 to December 2013 were included. Psychosocial characteristics at the time of LVAD implantation were abstracted from the medical record. Andersen-Gill and Cox models were used to examine the association between psychosocial characteristics and all-cause readmission and death, respectively. Patients were censored at death or last follow-up through September 2014.

RESULTS

Among 136 patients (mean age. 64 years; 17% female), most were married/living with a partner (82%), half (55%) had post-high school education, and a history of depression was common (32%). Although most patients were former tobacco users (60%) only a small proportion were current tobacco users (10%) and had a history of alcohol abuse (16%) or illegal drug use (7%). After a mean follow-up of 2.2 ± 1.8 years, 78% of patients had been readmitted (range, 0-14 per person) and 49% had died. There were no statistically significant differences in the risk of death according to psychosocial characteristics. However, current tobacco users had lower risk of readmission (adjusted HR, 0.57; 95% CI, 0.38-0.88), while illegal drug use (HR, 1.55; 95% CI, 1.01-2.35) and depression (HR, 1.77; 95% CI, 1.40-2.22) were associated with higher readmission risk.

CONCLUSIONS

Psychosocial characteristics are not significant predictors of death but are associated with readmission risk after DT LVAD.

Cognitive Behavior Therapy for Depression and Self-Care in Heart Failure Patients: A Randomized Clinical Trial

IMPORTANCE

Depression and inadequate self-care are common and interrelated problems that increase the risks of hospitalization and mortality in patients with heart failure (HF).

OBJECTIVE

To determine the efficacy of an integrative cognitive behavior therapy (CBT) intervention for depression and HF self-care.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial with single-blind outcome assessments. Eligible patients were enrolled at Washington University Medical Center in St Louis between January 4, 2010, and June 28, 2013. The primary data analyses were conducted in February 2015. The participants were 158 outpatients in New York Heart Association Class I, II, and III heart failure with comorbid major depression.

INTERVENTIONS

Cognitive behavior therapy delivered by experienced therapists plus usual care (UC), or UC alone. Usual care was enhanced in both groups with a structured HF education program delivered by a cardiac nurse.

MAIN OUTCOMES AND MEASURES

The primary outcome was severity of depression at 6 months as measured by the Beck Depression Inventory. The Self-Care of Heart Failure Index Confidence and Maintenance subscales were coprimary outcomes. Secondary outcomes included measures of anxiety, depression, physical functioning, fatigue, social roles and activities, and quality of life. Hospitalizations and deaths were exploratory outcomes.

RESULTS

One hundred fifty-eight patients were randomized to UC (n = 79) or CBT (n = 79). Within each arm, 26 (33%) of the patients were taking an antidepressant at baseline. One hundred thirty-two (84%) of the participants completed the 6-month posttreatment assessments; 60 (76%) of the UC and 58 (73%) of the CBT participants completed every follow-up assessment (P = .88). Six-month depression scores were lower in the CBT than the UC arm on the Beck Depression Inventory (BDI-II) (12.8 [10.6] vs 17.3 [10.7]; P = .008). Remission rates differed on the BDI-II (46% vs 19%; number needed to treat [NNT] = 3.76; 95% CI, 3.62-3.90; P < .001) and the Hamilton Depression Scale (51% vs 20%; NNT = 3.29; 95% CI, 3.15-3.43; P < .001). The groups did not differ on the Self-Care Maintenance or Confidence subscales. The mean (SD) Beck Depression Inventory scores 6 months after randomization were lower in the CBT (12.8 [10.6]) than the UC arm (17.3 [10.7]), P = .008. There were no statistically significant differences between the groups on the Self-Care Maintenance or Confidence subscale scores or on physical functioning measures. Anxiety and fatigue scores were lower and mental- and HF-related quality of life and social functioning scores were higher at 6 months in the CBT than the UC arm, and there were fewer hospitalizations in the intervention than the UC arm.

CONCLUSIONS AND RELEVANCE

A CBT intervention that targets both depression and heart failure self-care is effective for depression but not for HF self-care or physical functioning relative to enhanced UC. Additional benefits include reduced anxiety and fatigue, improved social functioning, and better health-related quality of life.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01028625.

[Prevalence and prognostic meaning of comorbidity in heart failure]

Heart failure (HF) predominantly affects elderly individuals and has a significant impact on the health systems of developed countries. Comorbidities are present in most patients with HF by acting as the cause, the consequence or a mere coincidence. In addition to their high prevalence, they have considerable relevance because they can mask symptoms, impede the diagnosis and treatment, contribute to progression and negatively influence the prognosis of HF. Most of the associated comorbidities result in a greater number of hospitalisations, poorer quality of life and increased mortality. Given that many of these comorbidities are underdiagnosed, their detection could improve the outcome and quality of life of patients with HF. This article reviews the prevalence and prognostic meaning of the most prevalent comorbidities associated with HF.