Depressive symptoms in heart failure: Independent prognostic factor or marker of functional status?

Temporal evolution of anxiety and depression in chronic heart failure and its association with clinical outcome

BACKGROUND

Although anxiety and depression have been associated with adverse outcomes in chronic heart failure (HF), data on temporal evolution of these symptoms are scarce. We aimed to investigate the association between repeatedly measured depression and anxiety symptoms and clinical outcome in chronic HF patients.

METHODS

In this prospective observational study, outpatients with chronic HF were included and followed-up for a maximum of 2.5 years. The hospital anxiety and depression scale (HADS) questionnaire was conducted every six months. The primary endpoint was a composite of HF hospitalization, cardiovascular death, heart transplantation and left ventricular assist device (LVAD) implantation. Cox and joint models were used to investigate the association between the HADS score and the endpoint.

RESULTS

A total of 362 patients filled out a median (25th-75th percentile) of 3 [2-4] questionnaires each. Mean ± SD age was 63 ± 13 years, 72% were men. Anxiety scores remained relatively stable leading up to the endpoint, while depression scores increased. Higher baseline depression scores were significantly associated with the endpoint (hazard ratio [HR] 1.68 and 95% confidence interval [CI] 1.19-2.36 per log(score+1), p = 0.003), while higher baseline anxiety scores did not reach statistical significance (HR [95% CI] 1.34 [0.99-1.83], p = 0.061). When repeatedly measured, both higher anxiety (HR [95% CI] 1.57[1.07-2.30], p = 0.022) and depression (HR [95% CI] 2.04 [1.39-3.06], p < 0.001) scores were significantly associated with the endpoint.

CONCLUSION

Serial measurements of depression and anxiety symptoms identify chronic HF patients with increased risk of adverse clinical outcomes. Screening for both disorders should be considered in clinical practice.

Broken Heartstrings—Post-Traumatic Stress Disorder and Psychological Burden after Acute Mitral Regurgitation Due to Chordae Tendineae Rupture

Chordae tendineae rupture (CTR) is a potentially life-threatening cardiac event often resulting in Acute mitral regurgitation (AMR). We assessed Post-traumatic stress disorder (PTSD), depression, and anxiety symptoms in n=21 CTR patients with AMR (age 82.3 ± 4.2 years; 66.7% men) and compared them to n=23 CTR patients with Chronic mitral regurgitation (CMR) and n=35 Myocardial infraction (MI) patients. Regression analyses revealed that PTSD scores were significantly higher in CTR patients with AMR than in CTR patients with CMR or MI patients. CTR patients with CMR had the lowest levels of PTSD-symptoms. Depression and anxiety scores were elevated across all three groups. Our results suggest that psychosocial factors need to be considered in CTR patients’ care.

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.

Psychological burden and resilience factors in patients with Alveolar Echinococcosis - A cross-sectional study

BACKGROUND

Alveolar echinococcosis (AE) is a parasitic zoonosis resembling malignancy due to its clinically silent infiltrative growth, predominately in the liver. The comorbid psychological burden and fear of disease progression in AE patients have hardly been examined to date. The aim of this study was to evaluate depression, anxiety, quality of life, and fear of disease progression in AE patients.

METHODOLOGY/PRINCIPAL FINDINGS

In a cross-sectional study, n = 57 AE patients were invited to report on depression (PHQ-9), anxiety (GAD-7), somatic symptom load (SSS 8), trauma symptoms (PTSS-10), quality of life (SF-12) and on fear of disease progression (FoP-Q-SF) using validated psychometric instruments. Furthermore, attachment style was assessed (RQ-2). N = 47 patients completed the questionnaires (response rate 82.5%). Depression, anxiety, and somatic symptom load were above norm sample means, while physical quality of life was below norm sample means. Existing traumatic symptoms were comparable to those in cancer patients, while fear of disease progression even exceeded cancer patient scores. Patients with a secure attachment style showed less pronounced psychological burden than patients with other attachment styles. Adequate, guideline-based depression and anxiety treatment was very rarely installed.

CONCLUSION/SIGNIFICANCE

The present study revealed remarkable levels of psychological burden in AE patients. In our study sample, we discovered high depression and anxiety levels, a significant reduction of physical quality of life, and fear of disease progression. These results show how important it is for AE patients to be thoroughly assessed with regard to psychological symptoms and mental disorders so that those in need can receive sufficient psychosocial support and treatment according to official guidelines.

Denver Spirited Heart: Mixed-Methods Pilot Study of a Psychospiritual Intervention for Heart Failure Patients

BACKGROUND

Increased spiritual well-being is related to quality of life (QOL) in patients with heart failure (HF). However, consistent and deliberate integration of spirituality into HF patient care has received limited attention.

OBJECTIVE

The aim of this study was to evaluate the feasibility, acceptability, and preliminary evidence regarding the efficacy of a resource-sparing psychospiritual intervention to improve QOL in HF patients.

METHODS

A 12-week mail-based intervention addressing spirituality, stress, coping, and adjusting to illness was developed and tested using a mixed-methods, 1-group pretest-posttest pilot study design. A convenience sample of patients with HF completed prestudy and poststudy questionnaires, including the Kansas City Cardiomyopathy Questionnaire, Patient Health Questionnaire, Meaning in Life Questionnaire, and Functional Assessment of Chronic Illness Therapy-Spiritual. Research staff conducted semistructured interviews with program completers. Interviews were coded and analyzed using conventional content analysis.

RESULTS

Participants (N = 33; 82% male; mean age, 61 years) completed 87% of baseline data collection, an average of 9 intervention modules, and 55% of poststudy questionnaires. Participants rated all the modules as at least moderately helpful, and qualitative themes suggested that patients found the intervention acceptable and beneficial. Most participants believed spirituality should continue to be included, although they disagreed on the extent to which religion should remain. Participants who completed the intervention reported evidence suggesting increased QOL (Kansas City Cardiomyopathy Questionnaire; effect size [ES], 0.53), decreased depressive symptoms (Patient Health Questionnaire-9; ES, 0.62), and less searching for meaning (Meaning in Life Questionnaire; ES, 0.52).

CONCLUSIONS

Results indicate that a module-based program integrating spirituality and psychosocial coping strategies was feasible and acceptable and may improve QOL. This preliminary study suggests that clinicians be open to issues of spirituality as they may relate to QOL in patients with HF. Future research will test a revised intervention.

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.

Post-surgical depressive symptoms and long-term survival in non-metastatic breast cancer patients at 11-year follow-up

BACKGROUND

Mild to moderate depressive symptoms are common during treatment for non-metastatic breast cancer. The goal of this secondary analysis was to determine if depressive symptoms predict clinical outcomes at long-term follow-up.

METHODS

From 1998 to 2005, we interviewed 231 women with the Hamilton Rating Scale for Depression who were participating in a psychosocial study 2-10weeks post-surgery for non-metastatic breast cancer (Stage 0-IIIb). We conducted Kaplan Meier (K-M) curves and Cox proportional hazards (PH) models to examine associations between depressive symptoms, overall survival, and disease-free survival at 8-15-year follow-up.

RESULTS

A total of 95 women (41.1%) scored in the mild-moderately depressed range. Non-depressed women had longer overall survival (M=13.56years; SE=0.26) than those in the mild/moderate depressed group (M=11.45years; SE=0.40), Log-rank χ2(1)=4.41, p=0.036. Cox PH models, adjusting for covariates, showed comparable results: mild/moderate depressive symptoms hazard ratio=2.56, [95% CI, 1.11 to 5.91], p=0.027. Similar results were observed in a subsample with invasive disease (n=191). Depression category did not predict disease-free survival in the overall or invasive sample.

CONCLUSIONS

Screening and referrals for treatment of depressive symptoms, even at subclinical levels, is important early in treatment. A randomized trial is warranted to determine effects of depressive symptoms on clinical outcomes.

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.

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.

Association between depression severity and cardiac autonomic modulation

OBJECTIVE

Changes in autonomic modulation are found in depressive patients. QT dispersion is a convenient measure of cardiac autonomic modulation (CAM). As both QT dispersion and depression are related to changes in CAM, this study aimed to examine if there was an association between depression severity and QT dispersion.

METHODS

The selected sample (n=60) derived from 236 women who were recruited via a campaign for breast cancer prevention. The women selected to participate were all non-smokers and were not taking any drug that could interfere with the results. After applying inclusion and exclusion criteria, 60 women were selected. QT dispersion (QTd) and rate-corrected QTd (QTcD) were calculated in 37 physically and mentally healthy women and 23 nontreated depressive women. Univariate ANOVA(s) were used to test group differences. The 17-item Hamilton Depression Rating Scale (HDRS17) was scored to measure depression severity. The relationship between depression severity and cardiac autonomic modulation was analyzed by the best curve that fit the raw data of the HDRS17 scores and the QT dispersion variables.

RESULTS

The QTd and QTcD were significantly smaller in non-depressed in relation to the depressed women. The best curve that fit the raw data of depression severity (HDRS17) and the two measurements of cardiac autonomic modulation (QTd and QTcD) was a cubic equation for both QTd and QTcD. An increase in QTd and QTcD were observed until the HDRS17 score reached 20 points.

CONCLUSION

There is a significant positive relationship between depression severity and cardiac autonomic modulation in mild and moderate depression.