Depression in patients with heart failure: physiologic effects, incidence, and relation to mortality

Factors Associated with Depression among Heart Failure Patients at Cardiac Follow-Up Clinics in Northwest Ethiopia, 2017: A Cross-Sectional Study

Background

Depression is a comorbid disorder in patients with heart failure and it is a major public health problem worldwide. Little is known about the depression among heart failure patients in low-income countries, while, in Ethiopia, none was studied.

Objective

This study is to assess the prevalence of depression and associated factors among heart failure patients at cardiac follow-up clinics at Amhara Region Referral Hospitals, Northwest Ethiopia, 2017.

Methods

A hospital based cross-sectional study was conducted between March 30, 2017, and May 15, 2017, G.C., by using a systematic random sampling technique to select 422 of 1395 HF patients. Structured interviewer-administered questionnaires and patient card review with a checklist that incorporates the PHQ-9 tool for depression measurement were used. The collected data were checked, coded, and entered into Epi-info version 7 and exported to SPSS version 20. Bivariate logistic regression at p-value <0.2 was exported to multivariate logistic regressions and p-value <0.05 was considered statistically significant.

Results

A total of 403 were included with a response rate of 95.5%. Among the participants, 51.1% had depressive symptoms. Factors associated with depressive symptoms were poor self-care behavior 1.60 [AOR (95% CI=1.01, 2.55)], poor social support 1.90 [AOR (95% CI=1.16, 3.12)], being female 2.70 [AOR (95% CI=1.44, 5.07)], current smoking history 4.96 [AOR (95% CI=1.54, 15.98)], and duration of heart failure (>1 year) 1.64 [AOR (95% CI=1.04, 2.59)].

Conclusions

Around half of the patients were depressive. The patients who had poor self-care behavior, were females, had poor social support, had a current history of smoking, and had duration of chronic heart failure >1 year need special attention. Therefore, all referral hospitals need efforts to focus on those problems and target improvements of depressive symptoms.

Patient-reported selective adherence to heart failure self-care recommendations: a prospective cohort study: the Atlanta Cardiomyopathy Consortium

Simultaneous adherence with multiple self-care instructions among heart failure (HF) patients is not well described. Patient-reported adherence to 8 recommendations related to exercise, alcohol, medications, smoking, diet, weight, and symptoms was assessed among 308 HF patients using the Medical Outcomes Study Specific Adherence Scale questionnaire (0="never" to 5="always," maximum score=40). A baseline cumulative score of ≥32/40 (average ≥80%) defined good adherence. Clinical events (death/transplantation/ventricular assist device), resource utilization, functional capacity (6-minute walk distance), and health status (Kansas City Cardiomyopathy Questionnaire [KCCQ]) were compared among patients with and without good adherence. The mean follow-up was 2.0±1.0 years, and adherence ranged from 26.3% (exercise) to 89.9% (medications). A cumulative score indicating good adherence was reported by 35.7%, whereas good adherence with every behavior was reported by 9.1% of patients. Good adherence was associated with fewer hospitalizations (all-cause 87.8 vs 107.6; P=.018; HF 29.6 vs 43.8; P=.007) and hospitalized days (all-cause 422 vs 465; P=.015; HF 228 vs 282; P<.001) per 100-person-years and better health status (KCCQ overall score 70.1±24.6 vs 63.8±22.8; P=.011). Adherence was not associated with clinical events or functional capacity. Patient-reported adherence with HF self-care recommendations is alarmingly low and selective. Good adherence was associated with lower resource utilization and better health status.

Depression in heart failure: biobehavioral mechanisms

The etiology, predictive value, and biobehavioral aspects of depression in heart failure (HF) are described in this article. Clinically elevated levels of depressive symptoms are present in approximately 1 out of 5 patients with HF. Depression is associated with poor quality of life and a greater than 2-fold risk of clinical HF progression and mortality. The biobehavioral mechanisms accounting for these adverse outcomes include biological processes (elevated neurohormones, autonomic nervous system dysregulation, and inflammation) and adverse health behaviors (physical inactivity, medication nonadherence, poor dietary control, and smoking). Depression often remains undetected because of its partial overlap with HF-related symptoms and lack of systematic screening. Behavioral and pharmacologic antidepressive interventions commonly result in statistically significant but clinically modest improvements in depression and quality of life in HF, but not consistently better clinical HF or cardiovascular disease outcomes. Documentation of the biobehavioral pathways by which depression affects HF progression will be important to identify potential targets for novel integrative behavioral and pharmacologic interventions.

Depression and coping in heart failure patients: a review of the literature

PURPOSE

The purpose of this article is to critically evaluate the evidence related to depression and coping in heart failure patients and determine if certain types of coping are more common in heart failure patients with depression.

METHODS

A computer search of the literature from January 1996 through October 2008 was conducted. PubMed was searched using the following key search terms: congestive heart failure, heart failure, coping, and depression. Three independent reviewers met to discuss the studies, interpret findings, compare studies, and discuss recommendations.

RESULTS

Coping strategies were found to be associated with depression in patients with heart failure. Adaptive coping such as active coping, acceptance, and planning tended to be used by more patients and were associated with less depression. Those who used more maladaptive methods of coping such as denial and disengagement had higher levels of depression.

CONCLUSIONS

Further longitudinal research on depression and coping strategies and best treatment options for coping and depression in patients with heart failure are needed.

Coping and depressive symptoms in adults living with heart failure

BACKGROUND AND RESEARCH OBJECTIVE

This study used process coping theory as the basis for investigating how coping strategies are associated with depressive symptoms in individuals living with heart failure (HF). Demographic factors also were examined as correlates of depressive symptoms.

SUBJECTS AND METHODS

The convenience sample of adults living with HF (n = 75) who participated in this study ranged in age from 27 to 82 years (M = 55). Sixty-nine percent of the participants were men, 59% were married or partnered, with the majority being Caucasian and from the middle class. Subjects were recruited from a comprehensive HF program located within an academic health science center in the southeastern United States. A single wave of data collection occurred. All study questionnaires were verbally administered in a clinic room selected for privacy during a routine HF clinic visit.

RESULTS AND CONCLUSION

Individuals who used more planful problem-solving and social support seeking coping strategies had fewer depressive symptoms, whereas individuals who used more escape-avoidance coping (eg, wishful thinking) had more depressive symptoms. When demographic factors also were included in a regression analysis assessing depressive symptoms, marital status, functional impairment, and the coping strategies of planful problem-solving and escape-avoidance were all statistically significant predictors of depression. Single individuals, those who used more escape-avoidance, less planful problem-solving coping, and more functional impairment had more depressive symptoms. These results suggest that psychosocial factors, in addition to physical parameters, and the ways individuals cope with the stressors of living with heart failure may be important predictors of depressive symptoms.

Effects of Antidepressant Treatment on Cognitive Performance in Elderly Subjects With Heart Failure and Comorbid Major Depression: An Exploratory Study

Cognitive deficits are common in association with heart failure (HF), and it is possible that their severity is magnified by the concomitant presence of major depressive disorder (MDD). Using the Cambridge Mental Disorders of the Elderly Examination battery, the authors compared the cognitive performance of MDD-HF subjects (N=20), nondepressed HF subjects (N=23), and healthy control subjects (N=18). Scores were lower in both HF groups relative to control subjects. In the MDD-HF group, there were significant cognitive improvements after antidepressant treatment. Cognitive impairment is, therefore, significant in HF subjects with or without comorbid MDD, and it is important to recognize and treat MDD symptoms associated with HF.

Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality

OBJECTIVES

The Psychosocial Factors Outcome Study (PFOS) investigated the prevalence of depression and anxiety and the relationship of psychosocial factors to mortality in outpatients with heart failure (HF).

BACKGROUND

Considerable evidence links psychosocial factors to coronary heart disease mortality and sudden cardiac death (SCD). The contribution of psychosocial factors independent of disease severity to HF outpatient mortality is not well elucidated.

METHODS

Patients (N = 153) from 20 Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) sites participated in the PFOS. SCD-HeFT provided demographic, medical history, and cardiac data. Participants completed questionnaires to assess psychosocial status at PFOS entry.

RESULTS

Depression and anxiety were common in HF outpatients (36% Beck Depression Inventory-II > or = 13; 45% State Trait Anxiety Inventory > or = 40). Depression, anxiety, and social support amount did not differ in the SCD-HeFT treatment groups: implantable cardioverter defibrillator, amiodarone, and placebo medication. Fifteen (9.8%) patients died during mean follow-up at 23.6 months (SD = 8.2). In Cox regression controlling for treatment, depression, anxiety, and social isolation separately predicted mortality; perceived HF-specific functional status did not. Depression (ln) [P = .04, hazard ratio (HR) = 1.81] and social isolation (P = .04, HR = 2.25), but not anxiety, predicted mortality independent of demographics, clinical predictors, and treatment. When simultaneously including significant demographic, clinical, and psychosocial predictors and treatment groups, depression (ln) (P = .022, HR = 2.2) and social isolation (P = .094, HR = 1.75) predicted mortality. All-cause mortality was 12% for depressed patients and 9% for others.

CONCLUSION

This study finds a high prevalence of anxiety and confirms the high prevalence of depression in the HF outpatient population. Depression and social isolation predicted mortality independent of demographic and clinical status in HF outpatients.

Regional cerebral blood flow reductions, heart failure and Alzheimer's disease

OBJECTIVES

To discuss whether there are similarities between the functional brain abnormalities detectable in association with the diagnoses of heart failure (HF) and Alzheimer's disease (AD), focusing particularly on neuroimaging findings in vivo.

METHODS

Using an electronic database (Medline), we reviewed imaging studies that have evaluated resting cerebral blood flow (CBF), resting glucose metabolism or amyloid deposition in groups of subjects suffering AD or HF compared with healthy controls.

RESULTS

Single photon emission computed tomography (SPECT) investigations have reported global CBF reductions in HF groups compared with controls. In one recent SPECT study using modern voxel-based methods for image analysis, regional CBF deficits in the pre-cuneus and posterior cingulate gyrus were detected in a sample of HF sufferers relative to controls. The regional distribution of functional deficits in the latter study was similar to that found in many positron emission tomography (PET) investigations of glucose metabolism at early AD stages, as well as in recent PET investigations of amyloid deposition in AD.

DISCUSSION

Imaging studies have rarely investigated whether there are localized functional brain deficits in association with HF. Recent regional CBF SPECT data provide preliminary anatomic support to a view that AD-like brain changes may develop in HF patients, possibly as a consequence of chronic CBF reductions. Additional studies of larger HF samples are needed to confirm this possibility, preferably using PET measures that have afforded greater sensitivity and specificity to identify brain functional abnormalities associated with the diagnosis of AD, such as indices of glucose metabolism and amyloid deposition.

Somatic Symptoms Explain Differences in Psychological Distress in Heart Failure Patients vs a Comparison Group

Psychological distress is common among patients with heart failure (HF); however, somatic symptoms are also common and may confound its assessment. Understanding the contributions of symptoms to psychological distress may assist in focusing treatment. The purpose of this study was to evaluate differences between HF patients and a non-HF comparison group on psychological distress (anxiety and depression); the association of anxiety and depression with common somatic symptoms of HF (fatigue, sleep disturbance, dyspnea, and excessive daytime sleepiness); and the extent to which somatic symptoms and HF diagnosis explain psychological distress. In this cross-sectional study, 61 stable systolic HF outpatients and a comparison group of 57 persons recruited from the community completed the Centers for the Epidemiological Studies of Depression Scale, Profile of Mood States-Short Form, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Multidimensional Assessment of Fatigue Scale, and the Multidimensional Assessment of Dyspnea Scale. The HF patients scored higher on depression, as measured by the Centers for the Epidemiological Studies of Depression Scale, but not on the other depression or anxiety scales. Group-related differences in depression were explained by sleep disturbance, fatigue, and excessive daytime sleepiness, after accounting for the effects of age, sex, minority status, comorbidity, and physical function.

Psychological and Social Factors That Correlate With Dyspnea in Heart Failure

Dyspnea is a common symptom of heart failure frequently relied upon to assess clinical functioning. The purpose of this study is to explore a broad range of medical, psychological, and social factors that correlate with dyspnea in heart failure patients. Seventy-six participants ranged from well-compensated, ambulatory subjects to those with recent hospitalization for acutely decompensated heart failure. The sample was predominantly male, mean age of 63.5 years, with mild depressive symptoms in 25%. Correlation analysis revealed that dyspnea significantly correlated with depression, fatigue, and overall health perception. Standard regression analyses indicated that depression, fatigue, and overall health perception uniquely contributed to dyspnea, explaining 38.0% of the total variance. The present study confirms that dyspnea is multifactorial, with links to psychological distress and overall health perception.

Evidenced-based Factors in Readmission of Patients with Heart Failure

The purpose of this project was to organize the variables associated with the hospital readmission of patients with heart failure (HF) into a usable framework to inform clinical practice and facilitate administrative decision making. An integrated, systematic review of the literature was used as the research approach. A content analysis of the sample (31 research reports from the years 1986-2004) yielded multiple factors associated with the hospital readmission of HF patients. Factors and their definitions were extracted, grouped into like categories, and eventually classified into 5 domains-demographic, physiologic, psychosocial, patient functioning, and resource utilization. The resulting framework has clinical, research, and administrative implications in the delivery of care to HF patients.

Depression and Anxiety in Heart Failure

BACKGROUND

Although common among patients with heart failure, depression and anxiety have been relatively neglected by researchers and practitioners. Both depression and anxiety have been implicated in contributing independently to the poor outcomes seen in patients with heart failure. Emphasis in the literature is on physical symptom recognition and management, in contrast to the patient's perspective of the effects of heart failure on his or her daily life.

METHODS AND RESULTS

This review summarizes and integrates research findings on anxiety and depression and translates these findings to clinical practice. Depression and anxiety are prevalent among patients with heart failure and require assessment and intervention. Short-term nonpharmacologic approaches, in conjunction with drug therapy, hold promise for successful management of patients who are depressed or anxious.

CONCLUSION

Carefully designed clinical trials that are tailored to individual needs, yet are embedded within a systemic framework, are needed to inform clinicians regarding optimal practices for the treatment of patients with heart failure who suffer from depression or anxiety.