A positive 2-item Patient Health Questionnaire depression screen among hospitalized heart failure patients is associated with elevated 12-month mortality

Associations of cumulative depressive symptoms within 1-year of discharge with subsequent mortality among patients hospitalized for acute heart failure: Findings from The China PEACE Prospective Heart Failure Study

BACKGROUND

To examine the associations between cumulative depressive symptoms and subsequent mortality among patients hospitalized for acute hear failure (AHF).

METHODS

By using data from a prospective cohort study of patients with HF, depressive symptoms were measured by using Patient Health Questionnaire-2 (PHQ-2) at admission, 1-and 12-month after discharge. Cumulative depressive symptoms were interpreted by cumulative PHQ-2 score and cumulative times of depressive symptoms. Outcomes included subsequent 3-year all-cause and cardiovascular mortality.

RESULTS

We included 2347 patients with the median follow-up of 4.4 (interquartile range [IQR]: 4.0-5.0) years. Tertile 3 of cumulative PHQ-2 score had the highest risk of all-cause (hazard ratio [HR]: 1.47, 95 % confidence interval [CI]: 1.21-1.78) and cardiovascular mortality (HR: 1.51, 95 % CI: 1.21-1.89) compared with Tertile 1; patients with≥2 times of depressive symptoms had the highest risk of all-cause (HR: 1.62, 95 % CI: 1.31-2.00) and cardiovascular mortality (HR: 1.60, 95 % CI: 1.25-2.05) compared with patients without any depressive symptom. Cumulative PHQ-2 score provided the highest level of incremental prognostic ability in predicting the risk of all-cause (C-statistics: 0.64, 95 % CI: 0.62-0.66) and cardiovascular mortality (C-statistics: 0.65, 95 % CI: 0.62-0.67) on the basis of Get With The Guidelines-Heart Failure score.

CONCLUSION

Cumulative depressive symptoms were associated with the increased risk of subsequent mortality and provided incremental prognostic ability for the outcomes among patients with HF. Repeated depressive symptom measurements could be helpful to monitor long-term depressive symptoms, identify targeted patients and perform psychological interventions and social support to improve clinical outcomes among patients with AHF.

Depression Subtypes in Systolic Heart Failure: A Secondary Analysis From a Randomized Controlled Trial

BACKGROUND

Heart failure (HF) is associated with an elevated risk of morbidity, mortality, hospitalization, and impaired quality of life. One potential contributor to these poor outcomes is depression. Yet the effectiveness of treatments for depression in patients with HF is mixed, perhaps due to the heterogeneity of depression.

METHODS

This secondary analysis applied latent class analysis (LCA) to data from a clinical trial to classify patients with systolic HF and comorbid depression into LCA subtypes based on depression symptom severity, and then examined whether these subtypes predicted treatment response and mental and physical health outcomes at 12 months follow-up.

RESULTS

In LCA of 629 participants (mean age 63.6 ± 12.9; 43% females), we identified 4 depression subtypes: mild (prevalence 53%), moderate (30%), moderately severe (12%), and severe (5%). The mild subtype was characterized primarily by somatic symptoms of depression (e.g., energy loss, sleep disturbance, poor appetite), while the remaining LCA subtypes additionally included nonsomatic symptoms of depression (e.g., depressed mood, anhedonia, worthlessness). At 12 months, LCA subtypes with more severe depressive symptoms reported significantly greater improvements in mental quality of life and depressive symptoms compared to the LCA mild subtype, but the incidence of cardiovascular- and noncardiovascular-related readmissions, and mortality was similar among all subtypes.

CONCLUSIONS

In patients with depression and systolic heart failure those with the LCA mild depression subtype may not meet full criteria for major depressive disorder, given the overlap between HF and somatic symptoms of depression. We recommend requiring depressed mood or anhedonia as a necessary symptom for major depressive disorder in patients with HF.

Sensor-Controlled Digital Game for Heart Failure Self-management: Protocol for a Randomized Controlled Trial

BACKGROUND

Heart failure (HF) is the leading cause of hospitalization among older adults in the United States. There are substantial racial and geographic disparities in HF outcomes, with patients living in southern US states having a mortality rate 69% higher than the national average. Self-management behaviors, particularly daily weight monitoring and physical activity, are extremely important in improving HF outcomes; however, patients typically have particularly low adherence to these behaviors. With the rise of digital technologies to improve health outcomes and motivate health behaviors, sensor-controlled digital games (SCDGs) have become a promising approach. SCDGs, which leverage sensor-connected technologies, offer the benefits of being portable and scalable and allowing for continuous observation and motivation of health behaviors in their real-world contexts. They are also becoming increasingly popular among older adults and offer an immersive and accessible way to measure self-management behaviors and improve adherence. No SCDGs have been designed for older adults or evaluated to test their outcomes.

OBJECTIVE

This randomized clinical trial aims to assess the efficacy of a SCDG in integrating the behavioral data of participants with HF from weight scale and activity tracker sensors to activate game progress, rewards, and feedback and, ultimately, to improve adherence to important self-management behaviors.

METHODS

A total of 200 participants with HF, aged ≥45 years, will be recruited and randomized into 2 groups: the SCDG playing group (intervention group) and sensor-only group (control group). Both groups will receive a weight scale, physical activity tracker, and accompanying app, whereas only the intervention group will play the SCDG. This design, thereby, assesses the contributions of the game. All participants will complete a baseline survey as well as posttests at 6 and 12 weeks to assess the immediate effect of the intervention. They will also complete a third posttest at 24 weeks to assess the maintenance of behavioral changes. Efficacy and benefits will be assessed by measuring improvements in HF-related proximal outcomes (self-management behaviors of daily weight monitoring and physical activity) and distal outcomes (HF hospitalization, quality of life, and functional status) between baseline and weeks 6, 12, and 24. The primary outcome measured will be days with weight monitoring, for which this design provides at least 80% power to detect differences between the 2 groups.

RESULTS

Recruitment began in the fall of 2022, and the first patient was enrolled in the study on November 7, 2022. Recruitment of the last participant is expected in quarter 1 of 2025. Publication of complete results and data from this study is expected in 2026.

CONCLUSIONS

This project will generate insight and guidance for scalable and easy-to-use digital gaming solutions to motivate persistent adherence to HF self-management behaviors and improve health outcomes among individuals with HF.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05056129; https://clinicaltrials.gov/ct2/show/NCT05056129.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45801.

Patient-reported outcome measures in cardiovascular disease

In today's medical ecosystem, it is vital to measure the outcomes that are most important to the patients. As such, patient-reported outcome measures (PROMS) can be an essential metric to deliver high-quality cardiovascular care, particularly in the subset of patients who remain disappointed with their outcomes. PROMS should be a reproducible and reflective report of what is fundamental to a patient over time and across treatments with proper standards in the analysis, interpretation, and reporting of the collected data. These reports can also be sensitive to changes, whether improvements or deteriorations in the quality of care and medical attitude, but a lack of standardization makes it difficult to draw robust conclusions and compare findings across treatments. As a research tool, PROMS can have a significant prognostic prominence, offering a powerful instrument of comparison between different treatment modalities. With the information technology (IT) abilities of today, we can leverage mobile tools and powerful computer systems to perform sophisticated data analysis using patient-derived data and randomization. This may eliminate guesswork and generate impactful metrics to better inform the decision-making process. PROMS analysed by proper standardized algorithms can avoid physician bias and be integrated into the hospital teamwork. Therefore, there is a strong need for integration of PROMS into the evaluation of cardiovascular interventions and procedures, and establishment of international standards in the analyses of patient-reported outcomes and quality of life data to address this need and develop therapeutic recommendations.

Change in Depressive Symptoms During the First Month of Discharge and 1-Year Clinical Outcomes in Patients Hospitalized for Heart Failure

Background The patterns of depressive symptom change during the first month after discharge, as well as their prognostic implications, and predictors of persistent or new-onset depressive symptoms are not well characterized. Methods and Results We included patients hospitalized for heart failure undergoing Patient Health Questionnaire-2 before discharge and at 1 month after discharge in a multicenter prospective cohort. We characterized 4 patterns of change in depressive symptoms-persistent, new-onset, remitted depressive symptoms, and no depressive symptom-and examined the associations between the 4 patterns and 1-year clinical outcomes. We analyzed the factors associated with persistent or new-onset depressive symptoms. A total of 4130 patients were included. Among 1175 (28.5%) symptomatic patients and 2955 (71.5%) symptom-free patients before discharge, 817 (69.5%) had remission, and 366 (12.2%) had new-onset depressive symptoms, respectively. Compared with no depressive symptom, persistent depressive symptoms were associated with an increased risk of cardiovascular death (hazard ratio [HR], 2.10 [95% CI, 1.59-2.79]) and heart failure rehospitalization (HR, 1.56 [95% CI, 1.30-1.87]); new-onset depressive symptoms were associated with an increased risk of cardiovascular death (HR, 1.78 [95%CI, 1.32-2.40]) and heart failure rehospitalization (HR, 1.54 [95% CI, 1.29-1.83]). Remitted depressive symptoms were associated with a slightly increased risk of cardiovascular death but had no significant association with heart failure rehospitalization. Patients who were female or had poor socioeconomic status, stroke history, renal dysfunction, or poor health status had a higher risk of persistent or new-onset depressive symptoms. Conclusions Sex, socioeconomic status, clinical characteristics, and health status help identify patients with high risks of depressive symptoms at 1 month after discharge. Dynamic capture of depressive symptom change during this period informs long-term risk stratifications and targets patients who require psychological interventions and social support to improve clinical outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier (NCT02878811).

The Relationship Between Objectively Measured Step Count, Clinical Characteristics, and Quality of Life Among Depressed Patients Recently Hospitalized With Systolic Heart Failure

OBJECTIVE

Physical activity (PA) can improve symptoms of both depression and heart failure (HF), but objective activity data among recently hospitalized HF patients with comorbid depression are lacking. We examined PA and the relationship between daily step counts and mood, health-related quality of life (HRQoL), and heart health among patients enrolled in a clinical trial treating HF and comorbid depression.

METHODS

We screened hospitalized patients with systolic HF (left ventricular ejection fraction [LVEF] ≤45%) and New York Heart Association class II-IV symptoms for depression using the two-item Patient Health Questionnaire (PHQ-2) and telephoned screen-positive patients to administer the PHQ-9 2 weeks after discharge. If the patient scored PHQ-9 ≥10 and agreed to continue in our study, we administered our baseline assessment and mailed them an armband accelerometer. We instructed patients to wear the armbands for 7 days before returning them and classified their data as "usable" if they wore it ≥10 hours per day on ≥4 separate days.

RESULTS

We mailed accelerometers to 531 depressed HF patients, and 222 (42%) returned them with usable data. Their median age was 64 years, 54% were women, 23% were non-White, and they walked a median of 1170 steps daily. Higher median daily step counts were associated with lower New York Heart Association class and better physical- and HF-specific HRQoL, but not mood symptoms, mental HRQoL, or LVEF.

CONCLUSIONS

Patients with HF and comorbid depression are generally sedentary after hospital discharge. Although mood symptoms and LVEF were unrelated to objective PA, patients with higher step counts self-reported better HRQoL.Trial Registration:ClinicalTrials.gov identifier NCT02044211.

Efficacy of Blended Collaborative Care for Patients With Heart Failure and Comorbid Depression: A Randomized Clinical Trial

IMPORTANCE

Depression is often comorbid in patients with heart failure (HF) and is associated with worse clinical outcomes. However, depression generally goes unrecognized and untreated in this population.

OBJECTIVE

To determine whether a blended collaborative care program for treating both HF and depression can improve clinical outcomes more than collaborative care for HF only and physicians' usual care (UC).

DESIGN, SETTING, AND PARTICIPANTS

This 3-arm, single-blind, randomized effectiveness trial recruited 756 participants with HF with reduced left ventricular ejection fraction (<45%) from 8 university-based and community hospitals in southwestern Pennsylvania between March 2014 and October 2017 and observed them until November 2018. Participants included 629 who screened positive for depression during hospitalization and 2 weeks postdischarge and 127 randomly sampled participants without depression to facilitate further comparisons. Key analyses were performed November 2018 to March 2019.

INTERVENTIONS

Separate physician-supervised nurse teams provided either 12 months of collaborative care for HF and depression ("blended" care) or collaborative care for HF only (enhanced UC [eUC]).

MAIN OUTCOMES AND MEASURES

The primary outcome was mental health-related quality of life (mHRQOL) as measured by the Mental Component Summary of the 12-item Short Form Health Survey (MCS-12). Secondary outcomes included mood, physical function, HF pharmacotherapy use, rehospitalizations, and mortality.

RESULTS

Of the 756 participants (mean [SD] age, 64.0 [13.0] years; 425 [56%] male), those with depression reported worse mHRQOL, mood, and physical function but were otherwise similar to those without depression (eg, mean left ventricular ejection fraction, 28%). At 12 months, blended care participants reported a 4.47-point improvement on the MCS-12 vs UC (95% CI, 1.65 to 7.28; P = .002), but similar scores as the eUC arm (1.12; 95% CI, -1.15 to 3.40; P = .33). Blended care participants also reported better mood than UC participants (Patient-Reported Outcomes Measurement Information System-Depression effect size, 0.47; 95% CI, 0.28 to 0.67) and eUC participants (0.24; 95% CI, 0.07 to 0.41), but physical function, HF pharmacotherapy use, rehospitalizations, and mortality were similar by both baseline depression and randomization status.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of patients with HF and depression, telephone-delivered blended collaborative care produced modest improvements in mHRQOL, the primary outcome, on the MCS-12 vs UC but not eUC. Although blended care did not differentially affect rehospitalization and mortality, it improved mood better than eUC and UC and thus may enable organized health care systems to provide effective first-line depression care to medically complex patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02044211.

Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Prognostic Understanding and Preference for the Communication Process with Physicians in Hospitalized Heart Failure Patients

BACKGROUND

Heart failure (HF) is a highly prevalent, heterogeneous, and life-threatening condition. Precise prognostic understanding is essential for effective decision making, but little is known about patients' attitudes toward prognostic communication with their physicians.

METHODS AND RESULTS

We conducted a questionnaire survey, consisting of patients' prognostic understanding, preferences for information disclosure, and depressive symptoms, among hospitalized patients with HF (92 items in total). Individual 2-year survival rates were calculated using the Seattle Heart Failure Model, and its agreement level with patient self-expectations of 2-year survival were assessed. A total of 113 patients completed the survey (male 65.5%, median age 75.0 years, interquartile range 66.0-81.0 years). Compared with the Seattle Heart Failure Model prediction, patient expectation of 2-year survival was matched only in 27.8% of patients; their agreement level was low (weighted kappa = 0.11). Notably, 50.9% wished to know "more," although 27.7% felt that they did not have an adequate prognostic discussion. Compared with the known prognostic variables (eg, age and HF severity), logistic regression analysis demonstrated that female and less depressive patients were associated with patients' preference for "more" prognostic discussion.

CONCLUSIONS

Patients' overall prognostic understanding was suboptimal. The communication process requires further improvement for patients to accurately understand their HF prognosis and be involved in making a better informed decision.

Examination of the best cut-off points of PHQ-2 and GAD-2 for detecting depression and anxiety in Italian cardiovascular inpatients

OBJECTIVE

Despite the frequent association between anxiety, depression and cardiovascular diseases (CVD), cardiovascular inpatients are not usually screened for these psychopathological conditions. To fill this gap, especially in hospital environments, there is the need of brief screening instruments that provide reliable information in a very short time. According to this need, the aim of this study was to examine the best cut-off points of two brief and easy-to-use questionnaires in a sample of Italian cardiovascular inpatients: the 2-item Patient Health Questionnaire (PHQ-2) and the 2-item Generalized Anxiety Disorder (GAD-2).

DESIGN

3500 cardiovascular inpatients were recruited and completed both the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7). PHQ-2 and GAD-2 were then obtained extracting the first two item from PHQ-9 and GAD-7.

MAIN OUTCOME MEASURES

The PHQ-2 and GAD-2 psychometric properties were calculated comparing them with PHQ-9 and GAD-7, respectively.

RESULTS

The PHQ-2 threshold of ≥ 2 and the GAD-2 threshold of ≥ 3 are the best solutions in balancing between sensitivity and specificity, also providing acceptable rates of false positives and false negatives.

CONCLUSIONS

the PHQ-2 and GAD-2 Italian versions showed good diagnostic features for measuring depression and anxiety in CVD patients.

Does a brief functional assessment in the emergency department predict outcomes of patients admitted with heart failure? The FASTER-HF study

BACKGROUND

Evaluation of patients with acute decompensated heart failure includes symptom review, biomarker measurement and comorbidity assessment. Early objective evaluation of functional status is generally not performed.

AIM

To investigate whether a simple low-impact functional assessment and measurement of sarcopenia would be safe, feasible and predictive of hospital length of stay and all-cause 30-day hospital readmission.

METHODS

We administered 3-minute bicycle ergometry and hand grip strength tests at admission and discharge to patients for whom a decision to admit for heart failure management was made in the emergency department. Associations were examined between test results and length of stay and 30-day readmission. Exclusion criteria included acute coronary syndrome, hypoxia, end-stage renal disease, dementia/delirium and inability to sit at bedside. The Kansas City Cardiomyopathy Questionnaire-12, the Patient Health Questionnaire-2 and the visual analogue scale for dyspnoea were administered at admission, the visual analogue scale at discharge and the Kansas City Cardiomyopathy Questionnaire-12 at 30 days.

RESULTS

Fifty patients were enrolled: 58% were female; the mean age was 66.2±12.5 years; 24% had heart failure with preserved ejection fraction. Bicycle ergometry variables did not correlate with outcomes. Change in handgrip strength correlated with readmission, but not after adjustment (r_partial=0.14; P=0.35). Total diuretic dose correlated with length of stay; only discharge visual analogue scale and baseline lung disease had significant adjusted correlations with readmission.

CONCLUSIONS

Functional assessment in the emergency department of patients admitted for heart failure did not predict outcomes. However, the prognostic value of these assessments for decision-making about disposition (admission or discharge) may still be warranted.

Executive dysfunction is associated with self-care confidence in patients with heart failure

AIM

To explore differences in self-care maintenance, management and confidence levels between American heart failure (HF) patients with and without executive dysfunction.

BACKGROUND

Evidence indicates some aspect of cognitive impairment is prevalent in up to 75% of the HF patient population. Moreover, cognitive impairment has been identified as a barrier to adequate self-care contributing to poor outcomes. There is limited understanding of the role executive function, a domain of cognitive performance, has on self-care behaviors for patients with HF.

METHOD

This secondary analysis examined the role of executive function, measured by the Clock Drawing Test (CDT), in relation to self-care measures. The Self Care of Heart Failure Index v6.2 (SCHFI v6.2) was used to measure self-care maintenance, management, and confidence.

RESULTS

Participants had a mean age of 75.1 ± 12.5 years, identified as male (59.4%), with New York Heart Association (NYHA) class III (57.3%). Executive function impairment was present in 28% of the sample. Comparison of self-care maintenance and management scores between the two groups were not significant. However, participants with executive dysfunction demonstrated an average self-care confidence score of 48.6 ± 23.3, while participants with no executive function impairment demonstrated a higher average self-care confidence score of 61.5 ± 18.4. Differences in self-care confidence scores between the groups were statistically significant (p = .014).

CONCLUSIONS

HF self-care confidence is considered a moderator of self-care behaviors. Understanding the influence executive function has on self-care confidence may lead to a better understanding of those needing greater support with self-care behaviors.

Blended Collaborative Care to Treat Heart Failure and Comorbid Depression: Rationale and Study Design of the Hopeful Heart Trial

OBJECTIVE

Despite numerous improvements in care, morbidity from heart failure (HF) has remained essentially unchanged in recent years. One potential reason is that depression, which is comorbid in approximately 40% of hospitalized HF patients and associated with adverse HF outcomes, often goes unrecognized and untreated. The Hopeful Heart Trial is the first study to evaluate whether a widely generalizable telephone-delivered collaborative care program for treating depression in HF patients improves clinical outcomes.

METHODS

The Hopeful Heart Trial aimed to enroll 750 patients with reduced ejection fraction (HFrEF) (ejection fraction ≤ 45%) including the following: (A) 625 patients who screened positive for depression both during their hospitalization (Patient Health Questionnaire [PHQ-2]) and two weeks following discharge (PHQ-9 ≥ 10); and (B) 125 non-depressed control patients (PHQ-2(-)/PHQ-9 < 5). We randomized depressed patients to either their primary care physician's "usual care" (UC) or to one of two nurse-delivered 12-month collaborative care programs for (a) depression and HFrEF ("blended") or (b) HrEFF alone (enhanced UC). Our co-primary hypotheses will test whether "blended" care can improve mental health-related quality of life versus UC and versus enhanced UC, respectively, on the Mental Component Summary of the Short-Form 12 Health Survey. Secondary hypotheses will evaluate the effectiveness of our interventions on mood, functional status, hospital readmissions, deaths, provision of evidence-based care for HFrEF, and treatment costs.

RESULTS

Not applicable.

CONCLUSIONS

The Hopeful Heart Trial will determine whether "blended" collaborative care for depression and HFrEF is more effective at improving patient-relevant outcomes than collaborative care for HFrEF alone or doctors' UC for HFrEF.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02044211.

The relevance of depressive symptoms for the outcome of patients receiving vitamin K antagonists: results from the thrombEVAL cohort study

AIMS

Although depressive symptoms are highly prevalent in patients receiving oral anticoagulation (OAC), the relevance of depression for the outcome of anticoagulated individuals is unknown.

METHODS AND RESULTS

We analysed data from the multicentre cohort study thrombEVAL (NCT01809015) investigating the efficacy of OAC with vitamin K antagonists. There was an independent study monitoring, and an independent review panel assessed the endpoints. Out of n = 1558 participants, information about depressive symptoms, as measured by the two-item screener of the patient health questionnaire (PHQ-2), was available in n = 1405 individuals. The mean follow-up period was 28.04 months, with a standard deviation of 11.52 months. In multivariable Cox regression analysis, baseline PHQ-2 sum score was a strong and robust predictor of clinically relevant bleeding [hazard ratio (HR) 1.13, 95% confidence interval 1.03-1.24; P = 0.011] and all-cause mortality (HR 1.18, 1.08-1.28; P = 0.001) independent of age, sex, high school graduation, partnership, clinical profile, intake of serotonin reuptake inhibitors, and quality of OAC therapy. Individuals with clinically significant depressive symptoms (PHQ-2 ≥ 3) had a 57% increased risk for clinically relevant bleeding (fully adjusted HR 1.57, 1.08-2.28) and 54% greater risk for death (fully adjusted HR 1.54, 1.09-2.17). There was no association of depressive symptoms with thromboembolic events. For hospitalization, individuals with depressive symptoms (PHQ-2 ≥ 3) did not experience an elevated risk in the fully adjusted model (HR 1.08, 0.86-1.35; P = 0.52).

CONCLUSION

Assessment of depression by the PHQ-2 provided independent long-term prognostic information beyond common biomedical risk factors. These findings highlight the need for targeting depressive symptoms in the management of patients receiving OAC therapy.

Emotion regulation in patients with heart failure: Its relationship with depressive symptoms and rehospitalization

OBJECTIVE

To examine the role of emotion regulation and its relationship to mental and physical health in patients with heart failure (HF).

METHODS

Patients hospitalized with HF were screened for depressive symptoms with the two-item Patient Health Questionnaire (PHQ-2) and classified as screen-positive if endorsing ≥1 item and otherwise as screen-negative. One month after hospital discharge, the Emotion Regulation Questionnaire (ERQ) was administered to assess suppression and reappraisal as emotion regulation strategies. In all participants who completed the ERQ (N = 394), all-cause rehospitalization and depressive symptoms using the PHQ-9 were assessed at 1-, 3-, and 6-months after hospital discharge.

RESULTS

Overall, PHQ-9 scores decreased by 6-months (-0.13 points/month, p = .003), and although suppression showed a small association with depression, neither strategy modulated the slope of the decline in depressive symptoms. Multivariable-adjusted Cox models showed that reappraisal and suppression were not related to all-cause rehospitalization in the entire cohort. However, increasing reappraisal reduced rehospitalization risk by 24% for screen-positive patients (N = 311, HR = 0.76, p = .02), but increased it by 94% in screen-negative patients (N = 83, HR = 1.94, p = .009).

CONCLUSION

Suppression and reappraisal showed specific and divergent associations in patients with HF: Suppression may relate to depressive symptoms. Reappraisal was associated with rehospitalization, but differently for patients with a positive vs. negative depression screen. Further studies are needed to examine whether emotion-regulation skill training can improve mental and physical health in depressed patients with HF or ameliorate depression in those at-risk.

Patient Health Questionnaire-2 Screening for Depressive Symptoms in Japanese Outpatients with Heart Failure

Objective Depression is common in patients with heart failure (HF) and is a possible risk factor for adverse outcomes. The aim of this study was to determine the prevalence of depression assessed by the 2-item Patient Health Questionnaire (PHQ-2) and the effect of depression on outcomes in Japanese outpatients with HF. Methods This sub-analysis of a prospective observational study assessed 976 patients with HF (mean age 66±13 years; 26.7% female; 42.7% with an ischemic etiology). Depression was defined as a PHQ-2 score ≥3. The main composite outcome was death from any cause or hospitalization due to worsening HF. PHQ-2 items were extracted from the PHQ-9 results. To evaluate the association of PHQ-2 scores with outcomes, Cox proportional hazards models were evaluated. Results Fifty-seven (5.8%) patients were diagnosed with depression. During a median follow-up of 21 months, the incidence rates for death from any cause and hospitalization due to worsening HF in patients with and without depression were 2.2 vs. 0.9 per 100 person-years and 6.7 vs. 1.6, p<0.001, respectively. There was a higher incidence of the main outcome in patients with depression than in those without depression (p<0.001). After adjustment for conventional risk factors, depression (PHQ-2 ≥3) was an independent predictor of the main outcome (hazard ratio 2.41, 95% confidence interval 1.14-4.67, p=0.022), and a score for item 1 of the PHQ-2 (loss of interest or pleasure) ≥2 was also an independent risk factor (hazard ratio 3.57, 95% confidence interval 1.85-6.46, p<0.001). Conclusion Depression as assessed by the PHQ-2 was identified in 5.8% of Japanese outpatients with HF and was associated with outcomes.

A Randomized Controlled Trial Comparing Telehealth Self-Management to Standard Outpatient Management in Underserved Black and Hispanic Patients Living with Heart Failure

Background: Although the American Heart Association promotes telehealth models to improve care access, there is limited literature on its use in underserved populations. This study is the first to compare utilization and quality of life (QoL) for underserved black and Hispanic heart failure (HF) patients assigned to telehealth self-monitoring (TSM) or comprehensive outpatient management (COM) over 90 days.

Methods: This randomized controlled trial enrolled 104 patients. Outcomes included emergency department (ED) visits, hospitalizations, QoL, depression, and anxiety. Binary outcomes for utilization were analyzed using chi-square or Fisher's exact test. Poisson or negative binomial regression, repeated-measures analysis of variance, or generalized estimating equations were also used as appropriate.

Results: Of 104 patients, 31% were Hispanic, 69% black, 41% women, and 72% reported incomes of <$10,000/year. Groups did not differ regarding binary ED visits (relative risk [RR] = 1.37, confidence interval [CI] = 0.83–2.27), hospitalization (RR = 0.92, CI = 0.57–1.48), or length of stay in days (TSM = 0.54 vs. COM = 0.91). Number of all-cause hospitalizations was significantly lower for COM (TSM = 0.78 vs. COM = 0.55; p = 0.03). COM patients reported greater anxiety reduction from baseline to 90 days (TSM = 50–28%; COM = 57–13%; p = 0.05).

Conclusions: These findings suggest that TSM is not effective in reducing utilization or improving QoL for underserved patients with HF. Future studies are needed to determine whether TSM can be effective for populations facing health care access issues.

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.

Depressive symptoms prior to and after incident cardiovascular disease and long-term survival. A population-based study of older persons

BACKGROUND

Depression after a cardiovascular disease event (post-CVD) is associated with increased mortality. However, little is known about how pre-existing depression affects survival after CVD incidence.

AIM

To evaluate whether depressive symptoms preceding first incident CVD (pre-CVD) affects survival.

METHODS

From the Rotterdam Study, 6,932 persons aged 55+ and free of dementia and CVD completed the Center for Epidemiological Studies Depression (CES-D) scale every 4 to 5 years from 1993. CES-D subdomains were positive affect, negative affect, somatic symptoms, and interpersonal affect. Persons were followed for mortality and CVD.

RESULTS

During 15-year follow-up, 22% of participants suffered their first incident CVD. Pre-CVD depressive symptoms was not associated with mortality after adjustment for smoking status and physical function (HR per 10-point score: 1.05, 95%CI: 0.99-1.10). After first incident CVD, depressive symptoms increased. Higher post-CVD depressive symptoms was associated with increased mortality (HR: 1.13, 95%CI: 1.06, 1.22). The relation between post-CVD depressive symptoms and mortality was no longer statistically significant after adjustment for pre-CVD depressive symptoms. Pre-CVD and post-CVD measures of somatic symptoms and positive affect were associated with mortality.

CONCLUSIONS

During 15 years follow-up in community-dwelling older adults, the relation between higher depressive symptoms measured before first incident CVD and mortality was not independent of health status. Whereas, higher depressive symptoms measured after CVD was associated with increased mortality, was not independent of pre-CVD depressive symptoms. Given the associations observed between positive affect and mortality, positive affect may be the reason we observed a relation between depressive symptoms and mortality.

Repeated recall as an intervention to improve memory performance in heart failure patients

Background:

Up to 50% of heart failure patients demonstrate aspects of cognitive impairment, including memory deficit. Novel interventions are needed to address memory deficit among heart failure patients.

Aim:

The goal of this study was to evaluate the testing effect as an intervention to improve memory performance in heart failure patients.

Methods:

This was a randomized controlled clinical trial ( N=84) comparing the memory performance of heart failure patients with and without mild cognitive impairment after a repeated testing intervention. Memory performance was measured by verbal word pair associates recall scores, between attention control and experimental subjects.

Results:

Patients had a mean age of 71.7 ± 13.3 years and similar baseline memory (immediate p=.79 and delayed p=.47). Overall, there were no significant differences in memory between experimental and control subjects, respectively (67.2±18.87 vs. 61.9±22.3, verbal word pair associates, t = −1.179, p=.24). In the final hierarchical regression model, age ( p=.018) and education ( p=.006) were significant predictors of memory performance, with the intervention approaching significance ( p=.079).

Conclusions:

Although not statistically significant, the intervention group reported better memory. Age and education continue to be significant contributors to memory performance in the heart failure population. Continued development of interventions to improve memory performance in heart failure patients is indicated.

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 as Measured by PHQ-9 Versus Clinical Diagnosis as an Independent Predictor of Long-Term Mortality in a Prospective Cohort of Medical Inpatients

BACKGROUND

Depression has been associated with higher rates of mortality in medical patients. The aim of the study was to evaluate the impact of depression in medical inpatients on the rate of mortality during a prolonged follow-up period.

METHOD

This is a prospective follow-up study of a cohort of medical inpatients assessed during 1997-1998 in medical and surgical units at a tertiary university hospital in Spain and followed-up for a period ranging between 16.5 and 18 years. Eight hundred three patients were included; 420 (52.3%) were male, and the mean (SD) age was 41.7 (13.8) years. Main outcome was death for any cause during follow-up. The original full Patient Health Questionnaire (PHQ) was administered at baseline as self-report from which the PHQ-9 was derived. Depressive disorders were assessed using PHQ-9 and a structured clinical interview (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition).

RESULTS

Depressive disorders as defined by PHQ-9 were detected in 206 patients (25.7%), 122 (15.2%) of them fulfilling criteria for major depression. During follow-up, 152 patients (18.9%) died. A PHQ score indicating the presence of major depressive disorder predicted increased mortality (hazard ratio [HR], 2.44; 95% CI, 1.39-4.29), even after adjusting for important demographic and clinical variables. Similarly, the PHQ-9 score as a continuous measure of depression severity predicted increased mortality (HR, 1.06; 95% CI, 1.02-1.10). Results were similar for clinical interview diagnoses of major depression (HR, 2.07; 95% CI, 1.04-4.09).

CONCLUSIONS

Medical inpatients with a PHQ depressive disorder had a nearly 2-fold higher risk of long-term mortality, even after adjustment for several confounders. Depression severity as represented by the PHQ-9 score was also a risk factor.

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.

Identifying depression with the PHQ-2: A diagnostic meta-analysis

BACKGROUND

There is interest in the use of very brief instruments to identify depression because of the advantages they offer in busy clinical settings. The PHQ-2, consisting of two questions relating to core symptoms of depression (low mood and loss of interest or pleasure), is one such instrument.

METHOD

A systematic review was conducted to identify studies that had assessed the diagnostic performance of the PHQ-2 to detect major depression. Embase, MEDLINE, PsychINFO and grey literature databases were searched. Reference lists of included studies and previous relevant reviews were also examined. Studies were included that used the standard scoring system of the PHQ-2, assessed its performance against a gold-standard diagnostic interview and reported data on its performance at the recommended (≥3) or an alternative cut-off point (≥2). After assessing heterogeneity, where appropriate, data from studies were combined using bivariate diagnostic meta-analysis to derive sensitivity, specificity, likelihood ratios and diagnostic odds ratios.

RESULTS

21 studies met inclusion criteria totalling N=11,175 people out of which 1529 had major depressive disorder according to a gold standard. 19 of the 21 included studies reported data for a cut-off point of ≥3. Pooled sensitivity was 0.76 (95% CI =0.68-0.82), pooled specificity was 0.87 (95% CI =0.82-0.90). However there was substantial heterogeneity at this cut-off (I(2)=81.8%). 17 studies reported data on the performance of the measure at cut-off point ≥2. Heterogeneity was I(2)=43.2% pooled sensitivity at this cut-off point was 0.91 (95% CI =0.85-0.94), and pooled specificity was 0.70 (95% CI =0.64-0.76).

CONCLUSION

The generally lower sensitivity of the PHQ-2 at cut-off ≥3 than the original validation study (0.83) suggests that ≥2 may be preferable if clinicians want to ensure that few cases of depression are missed. However, in situations in which the prevalence of depression is low, this may result in an unacceptably high false-positive rate because of the associated modest specificity. These results, however, need to be interpreted with caution given the possibility of selectively reported cut-offs.

Depression in heart failure: Intricate relationship, pathophysiology and most updated evidence of interventions from recent clinical studies

Heart failure (HF) is a burgeoning chronic health condition affecting more than 20million people worldwide. Patients with HF have a significant (17.1%) 30-day readmission rate, which invites substantial penalty in payment to hospitals from Centers for Medicare and Medicaid Services, as per the newly introduced Hospital Readmissions Reduction Program. Depression is one of the important risk factors for readmission in HF patients. It has a significant prevalence in patients with HF and contributes to the overall poor quality of life in them. Several behavioral (smoking, obesity, lack of exercise and medication noncompliance) and pathophysiological factors (hypercortisolism, elevated inflammatory biomarkers, fibrinogen, and atherosclerosis) have been found responsible for the adverse outcome in patients with HF and concomitant depression. Hippocampal volume loss noted in patients with acute HF exacerbations may contribute to the development of depressive symptoms in them. Screening for depression in HF patients continues to be challenging due to a considerable overlap in symptoms. Published trials on the use of antidepressants and cognitive behavioral therapy (CBT) have shown variable outcomes. Newer modalities like internet-based CBT have been tried in small studies, with promising results. A recent meta-analysis observed the beneficial role of aerobic exercise training in patients with HFrEF. Future long-term prospective studies may contribute to the formulation of a detailed screening and management guideline for patients with HF and depression. Our review is aimed to summarize the intricate relationship between depression and heart failure, with respect to their epidemiology, pathophysiological aspects, and optimal management approach.

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.

Depressive symptoms are associated with higher rates of readmission or mortality after medical hospitalization: A systematic review and meta-analysis

Depressive symptoms during a medical hospitalization may be an overlooked prognostic factor for adverse events postdischarge. Our aim was to evaluate whether depressive symptoms predict 30-day readmission or death after medical hospitalization. We conducted a systematic review of studies that compared postdischarge outcomes by in-hospital depressive status. We assessed study quality and pooled published and unpublished data using random effects models. Overall, one-third of 6104 patients discharged from medical wards were depressed (interquartile range, 27%-40%). Compared to inpatients without depression, those discharged with depressive symptoms were more likely to be readmitted (20.4% vs 13.7%, risk ratio [RR]: 1.73, 95% confidence interval [CI]: 1.16-2.58) or die (2.8% vs 1.5%, RR: 2.13, 95% CI: 1.31-3.44) within 30 days. Depressive symptoms were common in medical inpatients and are associated with an increased risk of adverse events postdischarge. Journal of Hospital Medicine 2016;11:373-380. © 2016 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine.

The prognostic impact and optimal timing of the Patient Health Questionnaire depression screen on 4-year mortality among hospitalized patients with systolic heart failure

OBJECTIVE

An American Heart Association (AHA) Science Advisory recommends patients with coronary heart disease undergo routine screening for depressive symptoms with the two-stage Patient Health Questionnaire (PHQ). However, little is known on the prognostic impact of a positive PHQ screen on heart failure (HF) mortality.

METHODS

We screened hospitalized patients with systolic HF (left ventricle ejection fraction≤40%) for depression with the two-item Patient Health Questionnaire (PHQ-2) and administered the follow-up nine-item Patient Health Questionnaire (PHQ-9) both immediately following the PHQ-2 and by telephone 1 month after discharge. Later, we ascertained vital status at 4-year follow-up on all patients who completed the inpatient PHQ-9 and calculated mortality incidence and risk by baseline PHQ.

RESULTS

Of the 520 HF patients we enrolled, 371 screened positive for depressive symptoms on the PHQ-2. Of these, 63% scored PHQ-9≥10 versus 24% of those who completed the PHQ-9 1 month later (P<.001). PHQ-2 positive status was an independent predictor of 4-year all-cause mortality (HR: 1.50; P=.04), and mortality incidence was similar by baseline PHQ-9 score.

CONCLUSIONS

Among hospitalized patients with systolic HF, a positive PHQ-2 screen for depressive symptoms is an independent risk factor for increased 4-year all-cause mortality. Our findings extend the AHA's Science Advisory for depression to hospitalized patients with systolic HF.

Validity of Beck Depression Inventory for the assessment of depressive mood in chronic heart failure patients

Prevalence of depression is high in patients with chronic heart failure (CHF), and depressive mood is considered as a risk factor for major cardiovascular events and mortality in CHF patients. The validity of self-administered 21-item Beck Depression Inventory (BDI) in CHF patients might be questioned. CHF actually shares overlapping symptoms with depression and such an overlap may overestimate the impact of depression on cardiac outcomes. We tested the convergent validity of the French version of BDI by reference to the interview-based Montgomery Asberg Depression Rating Scale (MADRS) in a population of 73 patients participating in the multicenter French PANIC Cohort of 321 CHF patients. Both depression scores were associated with NYHA functional class and the number of previous hospitalizations related to CHF, but not with the other indexes of cardiac severity (left ventricular ejection fraction and 6-min-walk test). MADRS scores were also associated with gender and history of depression. A strong correlation was found between BDI and MADRS scores (rho = 0.72; p < 0.001). This correlation persisted after adjustment for gender, NYHA functional class, number of previous hospitalizations and history of depression (rho = 0.68; p < 0.001). Moreover, the z score difference between standardized BDI and standardized MADRS scores was associated with none of the sociodemographic or clinical characteristics of our population, except for the depression severity at MADRS. In particular, no overestimation or underestimation of self-assessed depression was found in case of more severe CHF. These findings suggest that the BDI is a reliable instrument to assess depression in CHF patients.

Comparative potential of the 2-item versus the 9-item patient health questionnaire to predict death or rehospitalization in heart failure

BACKGROUND

Depression is common in heart failure and associated with adverse clinical outcomes. We investigated the potential of the 2-item patient health questionnaire (PHQ-2) versus that of the 9-item version (PHQ-9) to predict death or rehospitalization.

METHODS AND RESULTS

Participants of the Interdisciplinary Network for Heart Failure program were eligible, if they completed the PHQ-9 during baseline assessment. All participants were hospitalized for cardiac decompensation and had a left ventricular ejection fraction ≤40% before discharge. PHQ-2 scores were extracted from the answers to the first 2 PHQ-9 questions. To analyze associations of PHQ-2 and PHQ-9 with both, death and rehospitalization, univariable Cox regression models were used. To compare screening efficacy of both tools, c-statistics were computed. The sample consisted of 852 patients, (67.6±12.1 years; 27.7% women; 42.3% New York Heart Association class III/IV). Follow-up was 18 months (100% complete). During follow-up, 152 patients died and 482 were rehospitalized. Both, PHQ-2 and PHQ-9, predicted death in univariable analysis (hazard ratio, 1.18; 95% confidence interval, 1.09-1.29; P<0.001 and hazard ratio, 1.07; 95% confidence interval, 1.04-1.09; P<0.001, respectively), as well as rehospitalization (hazard ratio, 1.07; confidence interval, 1.01-1.21; P=0.02 and hazard ratio, 1.03; confidence interval, 1.01-1.04; P=0.001, respectively). These results were confirmed by c-statistics.

CONCLUSIONS

In univariable models and confirmed by c-statistics the potential of both PHQ-2 and PHQ-9 to predict death and hospitalization was similar. In clinical practice, PHQ-2 screening seems thus sufficiently reliable and more feasible than the time-consuming PHQ-9 to identify patients at an increased risk of adverse outcomes.

CLINICAL TRIAL REGISTRATION

URL: http://www.controlled-trials.com. Unique identifier: ISRCTN 23325295.

Assessment of Coping Strategies and Their Associations With Health Related Quality of Life in Patients With Chronic Heart Failure: the Brief COPE Restructured

Background

Individuals with chronic heart failure (CHF) need to cope with both the physical limitations and the psychological impacts of the disease. Since some coping strategies are beneficial and others are linked to increased mortality and worse health-related quality of life (HRQoL), it is important to have a reliable and valid instrument to detect different coping styles. Brief COPE, a self-reporting questionnaire, has been previously used in the context of CHF. There is, however, currently a lack of consensus about the theoretical or empirical foundations for grouping the multiple coping strategies assessed by Brief COPE into higher order categories of coping. The main purpose of this study was to examine the structure of Brief COPE, founded on the higher order grouping of its subscales in order to establish an assessment model supported by theoretical considerations. Furthermore, the associations between these higher order categories of coping and HRQoL were examined to establish the predictive validity of the selected model in the context of CHF.

Method

One hundred eighty-three patients diagnosed with CHF were recruited at a heart failure outpatient clinic or at a cardiac ward. Self-reported questionnaires were filled in to measure coping strategies and HRQoL. Confirmatory factor analyses were performed to investigate different hierarchical structures of Brief COPE found in the literature to assess coping strategies in patients with CHF. Regression analyses explored associations of aggregated coping strategies with HRQoL.

Results

A four factorial structure of Brief COPE displayed the most adequate psychometric properties, consisting of problem focused coping, avoidant coping, socially supported coping and emotion focused coping. Avoidant coping was associated with worse HRQoL in CHF.

Conclusions

This study provides support for a four-factor model of coping strategies in patients with CHF. This could facilitate assessment of coping both in clinical and research settings.

Relevance of depression for anticoagulation management in a routine medical care setting: results from the ThrombEVAL study program

BACKGROUND

Depressive symptoms have detrimental effects on quality of life and mortality. Poor adherence to a treatment regimen is a potential mechanism for the increased risk of adverse medical events associated with depression. Regarding oral anticoagulation with vitamin K antagonists, adherence is crucial for the outcome. Little is known about the clinical relevance of current depressiveness for anticoagulation treatment.

OBJECTIVES

To examine the impact of current depressiveness on anticoagulation treatment in regular medical care.

PATIENTS/METHODS

We examined the association between clinically significant depressiveness as assessed by the Patient Health Questionnaire-2 ≥ 2 (PHQ-2 ≥ 2) with the percentage of time in the therapeutic range (TTR), self-rated compliance, several aspects of health literacy, anticoagulation side-effects and treatment satisfaction in a cross-sectional study of 1790 oral anticoagulation outpatients.

RESULTS

Seven hundred and sixteen participants (40.0%) had clinically significant depressive symptoms. Depressed persons reported lower compliance with intake of prescribed medication and regular visits for control of anticoagulation, more unspecific side-effects (e.g. pruritus) and lower satisfaction with the anticoagulation treatment and their doctors' expertise and empathy. Depressed as compared with non-depressed individuals had a lower TTR (-4.67; 95% CI, -8.39 to -0.95). Increasing severity of depressiveness was related with decreasing TTR. However, depressiveness lost its significant impact on TTR after multivariable adjustment (-3.11; 95% CI, -6.88 to 0.66).

CONCLUSIONS

Clinically significant depressiveness was highly prevalent and impaired several aspects of anticoagulation treatment. Depressiveness should be regarded as a clinically significant condition that needs to be addressed in the management of anticoagulation patients.

Depression after heart failure and risk of cardiovascular and all-cause mortality: a meta-analysis

OBJECTIVES

The aim of this study is to investigate whether depression after heart failure (HF) was a predictor for subsequent cardiovascular and all-cause mortality in prospective observational studies.

METHODS

Pubmed, Embase, and PsycInfo databases were searched for prospective studies reported depression after HF and subsequent risk of cardiovascular or all-cause mortality (prior to May 2013). Pooled adjust hazard ratio (HR) and corresponding 95% confidence intervals (CI) were calculated separately for categorical risk estimates.

RESULTS

Nine studies with 4012 HF patients were identified and analyzed. Pooled HR of all-cause mortality was 1.51 (95% CI 1.19-1.91) for depression compared with non-depressive patients. Subgroup analyses showed that major depression significantly increased all-cause mortality (HR=1.98, 95% CI 1.23-3.19), but not mild depression (HR=1.04, 95% CI 0.75-1.45). Pooled HR of cardiovascular mortality was 2.19 (95% CI 1.46-3.29) for depression compared with non-depressive patients.

CONCLUSION

Major depression after HF was a predictor for subsequent all-cause mortality, but not mild depression. More well-designed studies are needed to explore the influence of depression and antidepressant medication use on cardiovascular and all-cause mortality in HF patients.

Recognition of depression and anxiety and their association with quality of life, hospitalization and mortality in primary care patients with heart failure - study protocol of a longitudinal observation study

BACKGROUND

International disease management guidelines recommend the regular assessment of depression and anxiety in heart failure patients. Currently there is little data on the effect of screening for depression and anxiety on the quality of life and the prognosis of heart failure (HF). We will investigate the association between the recognition of current depression/anxiety by the general practitioner (GP) and the quality of life and the patients' prognosis.

METHODS/DESIGN

In this multicenter, prospective, observational study 3,950 patients with HF are recruited by general practices in Germany. The patients fill out questionnaires at baseline and 12-month follow-up. At baseline the GPs are interviewed regarding the somatic and psychological comorbidities of their patients. During the follow-up assessment, data on hospitalization and mortality are provided by the general practice. Based on baseline data, the patients are allocated into three observation groups: HF patients with depression and/or anxiety recognized by their GP (P+/+), those with depression and/or anxiety not recognized (P+/-) and patients without depression and/or anxiety (P-/-). We will perform multivariate regression models to investigate the influence of the recognition of depression and/or anxiety on quality of life at 12 month follow-up, as well as its influences on the prognosis (hospital admission, mortality).

DISCUSSION

We will display the frequency of GP-acknowledged depression and anxiety and the frequency of installed therapeutic strategies. We will also describe the frequency of depression and anxiety missed by the GP and the resulting treatment gap. Effects of correctly acknowledged and missed depression/anxiety on outcome, also in comparison to the outcome of subjects without depression/anxiety will be addressed. In case results suggest a treatment gap of depression/anxiety in patients with HF, the results of this study will provide methodological advice for the efficient planning of further interventional research.

Medication adherence, depressive symptoms, and cardiac event-free survival in patients with heart failure

BACKGROUND

Medication nonadherence and depressive symptoms predict hospitalization and death in patients with heart failure (HF). Depressed patients have lower medication adherence than nondepressed patients. However, the predictive power of the combination of medication adherence and depressive symptoms for hospitalization and death has not been investigated in patients with HF.

OBJECTIVE

The aim of this study was to explore the combined influence of medication adherence and depressive symptoms for prediction of cardiac event-free survival in patients with HF.

METHODS AND RESULTS

We monitored medication adherence in 216 HF patients who completed the Patient Health Questionnaire-9 (PHQ-9) at baseline. Medication adherence was measured objectively with the use of the Medication Event Monitoring System (MEMS). Patients were followed for up to 3.5 years to collect data on cardiac events. Survival analyses were used to compare cardiac event-free survival among groups. The risk of experiencing a cardiac event for patients with medication nonadherence and depressive symptoms was 5 times higher than those who were medication adherent without depressive symptoms. The risk of experiencing a cardiac event for patients with only 1 risk factor was 1.2-1.3 times that of those with neither risk factor.

CONCLUSIONS

Medication nonadherence and depressive symptoms had a negative synergistic effect on cardiac event-free survival in patients with HF.

Feasibility and utility of screening for depression and anxiety disorders in patients with cardiovascular disease

BACKGROUND

Depression and anxiety in patients with cardiac disease are common and independently associated with morbidity and mortality. We aimed to explore the use of a 3-step approach to identify inpatients with cardiac disease with depression, generalized anxiety disorder (GAD), or panic disorder; understand the predictive value of individual screening items in identifying these disorders; and assess the relative prevalence of these disorders in this cohort.

METHODS AND RESULTS

To identify depression and anxiety disorders in inpatients with cardiac disease as part of a care management trial, an iterative 3-step screening procedure was used. This included an existing 4-item (Coping Screen) tool in nursing data sets, a 5-item screen for positive Coping Screen patients (Patient Health Questionnaire-2 [PHQ-2], GAD-2, and an item about panic attacks), and a diagnostic evaluation using PHQ-9 and the Primary Care Evaluation of Mental Disorders anxiety disorder modules. Overall, 6210 inpatients received the Coping Screen, 581 completed portions of all 3 evaluation steps, and 210 received a diagnosis (143 depression, 129 GAD, 30 panic disorder). Controlling for age, sex, and the other screening items, PHQ-2 items independently predicted depression (little interest/pleasure: odds ratio [OR]=6.65, P<0.001; depression: OR=5.24, P=0.001), GAD-2 items predicted GAD (anxious: OR=4.09, P=0.003; unable to control worrying: OR=10.46, P<0.001), and the panic item predicted panic disorder (OR=49.61, P<0.001).

CONCLUSIONS

GAD was nearly as prevalent as depression in this cohort, and GAD-2 was an effective screening tool; however, panic disorder was rare. These results support the use of 2-step screening for depression and GAD beginning with a 4-item scale (GAD-2 plus PHQ-2).

CLINICAL TRIAL REGISTRATION

Unique Identifier: NCT01201967. URL: http://www.clinicaltrials.gov/ct2/show/NCT01201967.

Depression and cardiac disease: epidemiology, mechanisms, and diagnosis

In patients with cardiovascular disease (CVD), depression is common, persistent, and associated with worse health-related quality of life, recurrent cardiac events, and mortality. Both physiological and behavioral factors—including endothelial dysfunction, platelet abnormalities, inflammation, autonomic nervous system dysfunction, and reduced engagement in health-promoting activities—may link depression with adverse cardiac outcomes. Because of the potential impact of depression on quality of life and cardiac outcomes, the American Heart Association has recommended routine depression screening of all cardiac patients with the 2- and 9-item Patient Health Questionnaires. However, despite the availability of these easy-to-use screening tools and effective treatments, depression is underrecognized and undertreated in patients with CVD. In this paper, we review the literature on epidemiology, phenomenology, comorbid conditions, and risk factors for depression in cardiac disease. We outline the associations between depression and cardiac outcomes, as well as the mechanisms that may mediate these links. Finally, we discuss the evidence for and against routine depression screening in patients with CVD and make specific recommendations for when and how to assess for depression in this high-risk population.

Effect of psychosocial interventions on quality of life in patients with chronic heart failure: a meta-analysis of randomized controlled trials

BACKGROUND

Patients with chronic heart failure (CHF) usually experience poor quality of life (QoL). Psychosocial interventions tend to affect QoL in CHF. The aim of this study was to explore: 1) the effectiveness of psychosocial interventions on patients' QoL; 2) the magnitude of this effect; and 3) factors that appear to moderate the reported effect on QoL.

METHODS AND RESULTS

Meta-analysis of the data of 1,074 intervention patients and 1,106 control patients from 16 randomized controlled trials (RCTs) that reported QoL measures in treatment and control groups before and after a psychosocial intervention. Subgroup analyses were conducted between: 1) face-to-face versus telephone interventions; 2) interventions that included only patients versus those that included patients and their caregivers; and 3) interventions conducted by a physician and a nurse only, versus those conducted by a multidisciplinary team. Psychosocial interventions improved QoL of CHF patients (standardized mean difference 0.46, confidence interval [CI] 0.19-0.72; P < .001). Face-to-face interventions showed greater QoL improvement compared with telephone interventions (χ(2) = 5.73; df = 1; P < .02). Interventions that included caregivers did not appear to be significantly more effective (χ(2) = 1.12; df = 1; P > .29). A trend was found for multidisciplinary team approaches being more effective compared with nonmultidisciplinary approaches (χ(2) = 1.96; df = 1; P = .16).

CONCLUSIONS

A significant overall QoL improvement emerged after conducting psychosocial interventions with CHF patients. Interventions based on a face-to-face approach showed greater benefit for patients' QoL compared with telephone-based approaches. No significant advantage was found for interventions conducted by a multidisciplinary team compared with a physician and nurse approach, or for psychosocial interventions which included patients' caregivers compared with patient-only approaches.

Cardiac Depression Scale: Mokken scaling in heart failure patients

Background

There is a high prevalence of depression in patients with heart failure (HF) that is associated with worsening prognosis. The value of using a reliable and valid instrument to measure depression in this population is therefore essential. We validated the Cardiac Depression Scale (CDS) in heart failure patients using a model of ordinal unidimensional measurement known as Mokken scaling.

Findings

We administered in face-to-face interviews the CDS to 603 patients with HF. Data were analysed using Mokken scale analysis. Items of the CDS formed a statistically significant unidimensional Mokken scale of low strength (H<0.40) and high reliability (Rho>0.8).

Conclusions

The CDS has a hierarchy of items which can be interpreted in terms of the increasingly serious effects of depression occurring as a result of HF. Identifying an appropriate instrument to measure depression in patients with HF allows for early identification and better medical management.

Risk factors for positive depression screens in hospitalized cardiac patients

BACKGROUND

Depression is common in patients with cardiac illness and is independently associated with elevated morbidity and mortality. There are screening guidelines for depression in cardiac patients, but the feasibility and cost-effectiveness of screening all cardiac patients is controversial. This process may be improved if a subset of cardiac patients at high risk for depression could be identified using information readily available to clinicians and screened.

OBJECTIVE

To identify risk factors for a positive depression screen at the time of admission in hospitalized cardiac patients.

METHODS

A total of 561 consecutively screened cardiac inpatients underwent the Patient Health Questionnaire-2 (PHQ-2). A prospective chart review was performed to assess potential risk factors for depression that would be readily available to front-line clinicians. Rates of risk factors were compared between patients with positive and negative PHQ-2 depression screens, and multivariate logistic regression was performed to assess whether specific risk factors were independently associated with positive screens.

RESULTS

Of the 561 patients screened, 13.5% (n=76) had a positive depression screen (PHQ-2≥2). In the univariate analyses, several variables were associated with a positive depression screen. On multivariate analysis, an elevated white blood cell (WBC) count (>10×10(9) cells per liter) and prescription of an antidepressant on admission were independently associated with a positive depression screen, while current smoking showed a trend toward significance.

CONCLUSION

Information on these three identified risk factors (WBC count, antidepressant use, and smoking) is readily available to clinicians, and patients with these diagnoses may represent a cohort who would benefit from targeted depression screening in certain settings.