Congestive heart failure is one of the leading causes of hospitalization of older adults. An extensive literature attests to the relation between depression and congestive heart failure. Given the prevalence of congestive heart failure and the need to better characterize the rate and outcomes of concurrent depression among patients with congestive heart failure it is important to study the relationship between congestive heart failure and depression. Early studies in this subject revolved around manifestations of mental disorders such as chronic stress, anxiety and depression on the clinical course and outcome of congestive heart disease (Shabetai, 2002). In addition to its effects on the manifestations and prognosis, depression is also recognized as a risk factor for coronary heart disease. Some preliminary studies have suggested that the association of cardiac disease in general, and congestive heart failure in particular, with concurrent depression may result in adverse clinical outcomes, including higher mortality rates.
According to a study titled “Depression in Patients: with Heart Failure: Physiologic Effects, Incidence, and Relation to Mortality” (2003) by Thomas et al, heart failure affects 4.8 million people in the United States and when such patients are also depressed, it increases both morbidity and mortality. The study underlines that the incidence of depression in heart failure ranges from 13% to 77.5%. The study also reveals that men with heart failure are more likely to become depressed than the general population. Depression incidence is higher in hospitalized patients with heart failure than in stabilized outpatients. However, what is noteworthy is that this study finds that patients with heart failure, depression is associated with mortality.
The increase in mortality is mainly attributed to physiologic changes. Depression is associated with hyperactivity of the hypothalamic-pituitary-adrenocortical (HPA) and sympathoadrenal systems as well as abnormal platelet reactivity. These pathophysiologic changes associated with major depression have been postulated to mediate the increased risk for, and poor prognosis of, cardiac events in people who are depressed. The final scores of the study indicate that depression is distributed equally between the men and women and hospitalized patients with heart failure demonstrated higher incidence of depression than patients with heart failure who were outpatients at the time of the study. The study concludes that identification of hospitalized patients with depression and follow-up care at home can be important nursing contributions and that nurses have a major role in the management of patients with heart failure and can be pivotal in the detection and treatment of depression in these patients (Thomas et al, 2003).
In the study “Prognostic Value of Anxiety and Depression in Patients with Chronic Heart Failure” (2004) Jiang et al have concluded that although anxiety and depression are highly correlated in CHF patients, depression alone predicts a significantly worse prognosis for these patients. Anxiety is often present with depression and may be one of its manifestations. In this study, the researchers examined the relations among anxiety, depression, and prognosis. It stresses the fact that depression must be recognized and treated to provide good care for patients with CHF. Due to the significant impact of depression on quality of life, and its potential relation to mortality the study concludes that treatment of depression in heart failure patients needs to be improved. Given the strong correlation of anxiety and depression, this study says that caregivers must screen for depression when patients report anxiety or appear anxious (Jiang et al, 2004). This study can be considered as an extension of the study by Thomas et al. While the first study stresses that identification of depression is important in patients with congestive heart failure, this study stresses on the fact that anxiety and depression are different and patients who appear anxious must be screened for depression.
Fulop et al in their study “Congestive Heart Failure and Depression in Older Adults: Clinical Course and Health Services Use 6 Months after Hospitalization” (2003) have focused on the course of depression and the economic consequences in the 6-month period after hospitalization for congestive heart failure. The aim of this study was to examine prospectively the course of depressive disorders identified at hospital discharge in elderly medical inpatients with a diagnosis of congestive heart failure and to compare the outcomes for this group with those of non depressed elderly inpatients with congestive heart failure. According to this research, at discharge, 73 of 203 subjects (36%) were depressed according to the screening criteria of the Geriatric Depression Scale, and 44 (22%) were depressed and these depressed patients used more medical resources after discharge than non-depressed patients. In this 6-month follow-up study of older adults hospitalized for congestive heart failure, high rates of concurrent depression were observed at discharge and persistently high rates of depression were observed 1 and 6 months after discharge, Furthermore, a significant percentage of those who were not depressed at discharge were subsequently observed to be depressed.
Talking about the economic consequences of congestive heart failure, Fulop et al point out to the fact that approximately 1 million hospitalizations and more than $10 billion in direct costs annually in the United States are related to congestive heart failure, making it a costly disease for both patients and society. They also point to the fact that elderly medical inpatients are five times more likely to have major depression than elderly persons in the community. The researchers feel that treating depression concurrently with intensive medical treatment for acute exacerbation of heart failure may involve introducing another medication – a psychotropic. This has the potential for adverse events at a time of great change in the patient’s medical management plan and hence the researchers conclude that it may be more appropriate to wait a month until the patient’s congestive heart failure has stabilized and the patient has returned to a familiar environment before reevaluating the patient for depression and initiating antidepressant therapy (Fulop et al, 2003). Thus this study focuses on the treatment for depressed patients with congestive heart failure and suggests that it is best to introduce treatment for depression after the congestive heart failure has stabilized.
Another study titled “Predictors of the Onset of Depressive Symptoms in Patients with Heart Failure” by Havranek et al (2004) identified the following factors associated with the development of depressive symptoms in outpatients with heart failure: living alone, alcohol abuse, perception of medical care as being a substantial economic burden, and health status. These were independent predictors of developing depressive symptoms. For patients without these factors, 7.9% developed depression by one year. The study revealed that social factors and health status are predictive of the development of depression in outpatients with heart failure. The study recommends that clinicians should be aware of patients who are at risk for the development of depression so that these patients may be targeted for screening and potentially for psychosocial intervention.
The study is particularly important for it sets up the criteria for identifying heart failure patients who are at risk for the development of depression. There are several implications of this study. First, depression screening may be warranted for all patients with heart failure, because even among patients without any of the risk factors, about 8% developed depression over one year. However, it may be most critical to screen for depression among those the heart failure patients who have any of the risk factors identified in this study. Furthermore, patients with the depression risk factors identified in this study may be targets for psychosocial interventions, such as case management, social worker evaluation, cognitive therapy for social isolation, or alcohol abuse intervention (Havranek et al, 2004).
The study by Freedland et al titled “Prevalence of Depression in Hospitalized Patients with Congestive Heart Failure” (2003) reports the prevalence of depression in a larger sample of hospitalized patients with CHF and identifies demographic, medical, psychosocial, and methodological factors that may affect prevalence estimates. According to this study, CHF is the leading cause of hospitalization in the elderly, a leading cause of disability and death, and the only major cardiovascular disorder in which the incidence and prevalence are increasing in the United States. Freedland et al have built their argument on the basis that depression is associated with increased medical morbidity, mortality, functional impairment, and occupational disability; decreased adherence to medications and to cardiovascular risk factor interventions; and worse quality of life in these patients.
In this study major depression was significantly more common in patients less than 60 years than in older patients (29% vs. 16%). Major depression is more common in women and in patients who are disabled, who have a history of depression, or who have comorbid COPD or sleep apnea. In addition, there is a strong relationship between major depression and NYHA class. Major depression is unrelated to prior hospitalization for CHF, and medical comorbidity (Freedland et al, 2003). This study shows that there is a strong association between depression and the functional severity of heart failure, but it does not define the direction of this relationship. It is possible, however, that depression might exacerbate the symptoms of heart failure and increase the severity of functional impairment. The study concludes that depression is very common in hospitalized patients with congestive heart failure and its prevalence varies according to how depression is defined and according to the demographic, medical, and social characteristics of the patients. The findings of this study adds further weight to the findings of the study by Havranek et al “Predictors of the Onset of Depressive Symptoms in Patients with Heart Failure” who have said that there are certain factors that lead to depression among patients with congestive heart failure. However, Freedland et al have expressed that depression also depends on the way it is defined.
Gottlieb et al (2004) have studied the influence of age, gender, and race on the prevalence of depression in heart failure patients. The goal of this study was to determine the prevalence of depression in an out-patient heart failure (HF) population; its relationship to quality of life (QOL); and the impact of gender, race, and age. It was found that out of a total of 48% of the patients scored as depressed. Depressed patients tended to be younger than non-depressed patients. Women were more likely (64%) to be depressed than men (44%). Among men, blacks (34%) tended to have less depression than whites (54%).
Depressed patients scored significantly worse than non-depressed patients on all components of both the questionnaires measuring QOL. Thus, this study concludes that depression is common in patients with HF, with age, gender, and race influencing its prevalence in ways similar to those observed in the general population. The findings suggest that pharmacologic or non-pharmacologic treatment of depression might improve the QOL of HF patients (Gottlieb et al, 2004). This study implies that among the patients with congestive heart failure, women and blacks are at greater risk for developing depression. This result contradicts the finding of Thomas et al, according to which depression is distributed equally between the men and women and hospitalized patients with heart failure. Further the study shows that depressed patients with heart failure tend to have a low quality of life .
The pathophysiology of congestive heart failure is evolving in complexity, and the pace of this evolution will quicken as details of the underlying molecular changes are clarified. Many studies show that depression in patients with congestive heart failure needs to be understood and treated. Interactions between mental and cardiac health is needed at the clinical, biochemical, and molecular levels if we are to understand the interactions of these two illnesses. In the meantime, the role of the nurses has acquired greater significance. Nurses should be able to identify potential depression patients, identify existing depression in patients with congestive heart failure and understand that depression needs to be tackled in order to overcome the heart failure.
Freedland et al (2003). Prevalence of Depression in Hospitalized Patients with Congestive Heart Failure. Psychosomatic Medicine 65:119–128 (2003). http://www.psychosomaticmedicine.org/cgi/reprint/65/1/119.pdf
Fulop, George, Strain J. James and Stettin, Glen (2003). Congestive Heart Failure and Depression in Older Adults: Clinical Course and Health Services Use 6 Months After Hospitalization. Psychosomatics 2003; 44:367-373. http://psy.psychiatryonline.org/cgi/reprint/44/5/367.pdf
Gottlieb S. Stephen et al (2004). The influence of age, gender, and race on the prevalence of depression in heart failure patients. J Am Coll Cardiol, 2004; 43:1542-1549, doi:10.1016/j.jacc.2003.10.064. http://content.onlinejacc.org/cgi/content/full/43/9/1542
Havranek P. Edward, John A. Spertus, Frederick A. Masoudi, Philip G. Jones, John S. Rumsfeld (2004). Predictors of the Onset of Depressive Symptoms in Patients with Heart Failure. Journal of the American College of Cardiology. Vol. 44, No. 12, 2004 http://www.acc.org/media/releases/highlights/2004/dec04/social.pdf
Jiang, Wei, Maragatha Kuchibhatla, Michael S. Cuffe, Eric J. Christopher, Jude D. Ranga R. Krishnan and Christopher M. O’Connor Alexander, Greg L. Clary, Michael A. Blazing, Laura H. Gaulden, Robert M. Califf (2004). Prognostic Value of Anxiety and Depression in Patients with Chronic Heart Failure. Circulation: Journal of the American Heart Association. 2004;110;3452-3456
Powell, Lynda H. PhD ; Catellier, Diane; Freedland, Kenneth E. PhD d; Burg, Matthew M. PhD ; Woods, Susan L. PhD ; Bittner, Vera MD ; Calvin, James E. MD ; Blumenthal, James A. PhD (2005). Depression and heart failure in patients with a new myocardial infarction: Clinical Investigations. American Heart Journal. 149(5):851-855, May 2005. http://pt.wkhealth.com/pt/re/amhj/abstract.00000406-200505000-00016.htm;jsessionid=FnQSnnxY3y4T2SNM48ygGtlCBTL2y9prTPjhyQBWflW9CTQJ1Z3R!-1062864122!-949856145!8091!-1
Shabetai, Ralph (2002). Editorial Comment: Depression and Heart Failure. Psychosomatic Medicine 64: 13-14 (2002). http://www.psychosomaticmedicine.org/cgi/reprint/64/1/13.pdf
Thomas, Ann Sue, PhD, RN, CS-P, FAAN; Erika Friedmann, PhD; Meenakshi Khatta, MS, RN; Linda K. Cook, MS, RN, CCNS, CCRN; Anita Lippman Lann, MS, RN (2003). Depression in Patients with Heart Failure Physiologic Effects, Incidence, and Relation to Mortality. AACN Clinical Issues Volume 14, Number 1, pp. 3-12. http://www.aacn.org/pdfLibra.NSF/Files/CI1412/$file/ci140103.pdf