Effects of Depression on Heart Failure Self-Care.

BACKGROUND: Depression has been identified as a barrier to effective heart failure self-care, but recent studies suggest that the relationship between depression and self-care is more complex than was previously believed. This study was designed to clarify the relationship between depression and self-care in hospitalized patients with HF. METHODS AND RESULTS: During hospitalization with a confirmed clinical diagnosis of HF, 400 patients completed a structured interview to diagnose Diagnostic and Statistical Manual, 5th edition (DSM-5) depressive disorders, the Patient Health Questionnaire (PHQ-9) depression questionnaire, the Self-Care of Heart Failure Index (SCHFI), and several psychosocial questionnaires. Multivariable models were fitted to each SCHFI scale; separate models were run with DSM-5 disorders and PHQ-9 depression scores. Higher PHQ-9 depression scores were independently associated with lower (worse) scores on the SCHFI Maintenance (P < .05), Management (P < .01), and Confidence (P < .01) scales. No independent associations with DSM-5 depressive disorders were detected. Measures of perceived stress, anxiety, and low perceived social support were also significantly associated with poor HF self-care. CONCLUSIONS: Patients with a combination of psychosocial problems, including symptoms of depression, stress, anxiety, and inadequate social support, may be more likely than other patients to display difficulties with HF self-care that can increase their risk for hospitalization. Research is needed on "broad-spectrum" psychosocial interventions for patients with HF self-care deficits.

Left Ventricular Dysfunction and Depression in Hospitalized Patients with Heart Failure.

OBJECTIVE: This study examined whether the severity of left ventricular systolic dysfunction is associated with depression in patients with heart failure (HF). Other factors were also studied to identify independent correlates of depression in HF. METHODS: The sample consisted of 400 hospitalized patients with HF. Left ventricular ejection fraction and other medical data were obtained from medical records. Depression and other psychosocial characteristics were assessed by an interview and questionnaires. Proportional odds models were used to test the relationships of these characteristics to Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) depressive disorders, and analysis of covariance was used to test relationships with continuous measures of depression in secondary models. RESULTS: The models produced no evidence of an association between left ventricular ejection fraction and depression. The adjusted odds ratio (95% confidence interval) was 1.00 (0.98-1.01; p = .87) for depression diagnosis. Analysis of covariance estimates (standard errors) were -0.01 (0.02; p = .54) for the Hamilton Rating Scale for Depression and -0.01 (0.01; p = .59) for the Patient Health Questionnaire. The odds of depression were higher in African American patients and in those with high levels of anxiety or stress. Other characteristics that have been associated with depression in previous studies, including sex and age, were not consistently associated with depression in this study. CONCLUSIONS: There is no relationship between the severity of left ventricular systolic dysfunction and depression in hospitalized patients with HF. In contrast, African American patients and those with a high level of anxiety or perceived stress are more likely than other patients to have a comorbid depressive disorder.

Major Depression and Long-Term Survival of Patients With Heart Failure.

OBJECTIVES: Previous studies have found that depression predicts all-cause mortality in heart failure (HF), but little is known about its effect on long-term survival. This study examined the effects of depression on long-term survival in patients with HF. METHODS: Patients hospitalized with HF (n = 662) at an urban academic medical center were enrolled in a prospective cohort study between January 1994 and July 1999. Depression was assessed on a structured interview during the index hospitalization and on quarterly interviews for 1 year after discharge. Patients were classified at index as having Diagnostic and Statistical Manual, Fourth Edition major depressive disorder (n = 131), minor depression (n = 106), or no depression (n = 425). Clinical data and the National Death Index were used to identify date of death or last known contact through December 19, 2014, up to 20 years after the index hospitalization. The main outcome was time from enrollment to death from any cause. RESULTS: A total of 617 (94.1%) patients died during the follow-up period. Major depressive disorder was associated with higher all-cause mortality compared with no depression (adjusted hazard ratio = 1.64, 95% confidence interval = 1.27-2.11, p = .0001). This association was stronger than that of any of the established predictors of mortality that were included in the fully adjusted model. Patients with persistent or worsening depressive symptoms during the year after discharge were at greatest risk for death. The association between minor depression and survival was not significant. CONCLUSIONS: Major depression is an independent risk factor for all-cause mortality in patients with HF. Its effect persists for many years after the diagnosis of depression.

Treatment of depression and inadequate self-care in patients with heart failure: One-year outcomes of a randomized controlled trial.

OBJECTIVE: Both depression and inadequate self-care are common in patients with heart failure. This secondary analysis examines the one-year outcomes of a randomized controlled trial of a sequential approach to treating these problems. METHODS: Patients with heart failure and major depression were randomly assigned to usual care (n = 70) or to cognitive behavior therapy (n = 69). All patients received a heart failure self-care intervention starting 8 weeks after randomization. Patient-reported outcomes were assessed at Weeks 8, 16, 32, and 52. Data on hospital admissions and deaths were also obtained. RESULTS: One year after randomization, Beck Depression Inventory (BDI-II) scores were - 4.9 (95% C.I., -8.9 to -0.9; p < .05) points lower in the cognitive therapy than the usual care arm, and Kansas City Cardiomyopathy scores were 8.3 (95% C.I., 1.9 to 14.7; p < .05) points higher. There were no differences on the Self-Care of Heart Failure Index or in hospitalizations or deaths. CONCLUSIONS: The superiority of cognitive behavior therapy relative to usual care for major depression in patients with heart failure persisted for at least one year. Cognitive behavior therapy did not increase patients' ability to benefit from a heart failure self-care intervention, but it did improve HF-related quality of life during the follow-up period. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02997865.

Outcomes of a tailored self-care intervention for patients with heart failure and major depression: A secondary analysis of a randomized controlled trial.

BACKGROUND: Depression is a recognized barrier to heart failure self-care, but there has been little research on interventions to improve heart failure self-care in depressed patients. OBJECTIVES: To investigate the outcomes of an individually tailored self-care intervention for patients with heart failure and major depression, and to determine whether the adequacy of self-care at baseline, the severity of depression or anxiety, or other factors affect the outcomes of this intervention. DESIGN: Secondary analysis of data from a pre-registered randomized controlled trial (NCT02997865). METHODS: Outpatients with heart failure and comorbid major depression (n = 139) were randomly assigned to cognitive behavior therapy or usual care for depression. In addition, an experienced cardiac nurse provided the tailored self-care intervention to all patients in both arms of the trial starting eight weeks after randomization. Weekly self-care intervention sessions were held between Weeks 8 and 16; the frequency was tapered to biweekly or monthly between Weeks 17 and 32. The Self-Care of Heart Failure Index (v6.2) was used to assess self-care outcomes, with scores ≥70 on each of its three scales (Maintenance, Management, and Confidence) being consistent with adequate self-care. The Week 16 Maintenance scale score was the primary outcome for this analysis. RESULTS: At baseline, 107 (77%) of the patients scored in the inadequate self-care range on the Maintenance scale. Between Weeks 8 and 16, Maintenance scores improved more in patients with initially inadequate than initially adequate self-care (11.9 vs. 3.2 points, p = .003). Sixty-six (48%) of the patients with initially inadequate Maintenance scores achieved scores in the adequate range by Week 32 (p < .0001). Covariate-adjusted predictors of better Maintenance outcomes included adequate Maintenance at baseline (p < .0001), higher anxiety at baseline (p < .05), and higher dosages of the self-care intervention (p < .0001). Neither treatment with cognitive behavior therapy nor less severe major depression predicted better self-care outcomes. CONCLUSIONS: Depressed patients with inadequate heart failure self-care are able to achieve clinically significant improvements in self-care with the help of an individually tailored self-care intervention. Further refinement and testing are needed to increase the intervention's potential for clinical implementation.

Depression and Hospital Readmissions in Patients with Heart Failure.

Depression increases the risk of mortality in patients with heart failure (HF). Less is known about whether depression predicts multiple readmissions or whether multiple hospitalizations worsen depression in patients with HF. This study aimed to test the hypotheses that depression predicts multiple readmissions in patients hospitalized with HF, and conversely that multiple readmissions predict persistent or worsening depression. All-cause readmissions were ascertained over a 2-year follow-up of a cohort of 400 patients hospitalized with HF. The Patient Health Questionnaire-9 was used to assess depression at index and 3-month intervals. At enrollment in the study, 21% of the patients were mildly depressed and 22% were severely depressed. Higher Patient Health Questionnaire-9 depression scores predicted a higher rate of readmissions (adjusted hazard ratio 1.02, 95% confidence interval 1.00 to 1.04, p = 0.03). The readmission rate was higher in those who were severely depressed than in those without depression (p = 0.0003), but it did not differ between patients who were mildly depressed and patients without depression. Multiple readmissions did not predict persistent or worsening depression, but younger patients in higher New York Heart Association classes were more depressed than other patients. Depression is an independent risk factor for multiple all-cause readmissions in patients hospitalized with HF. Severe depression is a treatable psychiatric co-morbidity that warrants ongoing clinical attention in patients with HF.

Sequential Interventions for Major Depression and Heart Failure Self-Care: A Randomized Clinical Trial.

BACKGROUND: Major depression and inadequate self-care are common in patients with heart failure (HF). Little is known about how to intervene when both problems are present. This study examined the efficacy of a sequential approach to treating these problems. METHODS: Stepped Care for Depression in HF was a single-site, single-blind, randomized controlled trial of cognitive behavior therapy (CBT) versus usual care (UC) for major depression in patients with HF. The intensive phase of the CBT intervention lasted between 8 and 16 weeks, depending upon the rate of improvement in depression. All participants received a tailored HF self-care intervention that began 8 weeks after randomization. The intensive phase of the self-care intervention ended at 16 weeks post-randomization. The coprimary outcome measures were the Beck Depression Inventory (version 2) and the Maintenance scale of the Self-Care of HF Index (v6.2) at week 16. RESULTS: One hundred thirty-nine patients with HF and major depression were enrolled; 70 were randomized to UC and 69 to CBT. At week 16, the patients in the CBT arm scored 4.0 points ([95% CI, -7.3 to -0.8]; P=0.02) lower on the Beck Depression Inventory, version 2 than those in the usual care arm. Mean scores on the Self-Care of HF Index Maintenance scale were not significantly different between the groups ([95% CI, -6.5 to 1.5]; P=0.22). CONCLUSIONS: CBT is more effective than usual care for major depression in patients with HF. However, initiating CBT before starting a tailored HF self-care intervention does not increase the benefit of the self-care intervention. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02997865.

Psychosocial Syndemics and Multimorbidity in Patients with Heart Failure †.

Heart failure (HF) is a common cause of hospitalization and mortality in older adults. HF is almost always embedded within a larger pattern of multimorbidity, yet many studies exclude patients with complex psychiatric and medical comorbidities or cognitive impairment. This has left significant gaps in research on the problems and treatment of patients with HF. In addition, HF is only one of multiple challenges facing patients with multimorbidity, stressful socioeconomic circumstances, and psychosocial problems. The purpose of this study is to identify combinations of comorbidities and health disparities that may affect HF outcomes and require different mixtures of medical, psychological, and social services to address. The syndemics framework has yielded important insights into other disorders such as HIV/AIDS, but it has not been applied to the complex psychosocial problems of patients with HF. The multimorbidity framework is an alternative approach for investigating the effects of multiple comorbidities on health outcomes. The specific aims are: (1) to determine the coprevalence of psychiatric and medical comorbidities in patients with HF (n = 535); (2) to determine whether coprevalent comorbidities have synergistic effects on readmissions, mortality, self-care, and global health; (3) to identify vulnerable subpopulations of patients with HF who have high coprevalences of syndemic comorbidities; (4) to determine the extent to which syndemic comorbidities explain adverse HF outcomes in vulnerable subgroups of patients with HF; and (5) to determine the effects of multimorbidity on readmissions, mortality, self-care, and global health.

Antidepressant use in patients with heart failure.

OBJECTIVE: There is little evidence that antidepressants are efficacious for depression in patients with heart failure (HF), and equivocal evidence that they are safe. This study identified characteristics that are associated with antidepressant use in hospitalized patients with HF. METHOD: Logistic regression models were used to identify independent correlates of antidepressant use in 400 patients hospitalized with HF between 2014 and 2016. The measure of depression in the primary analysis was a DSM-5 diagnosis based on a structured interview; this was replaced by a PHQ-9 depression score in a secondary analysis. RESULTS: In the primary analysis, there were positive associations between antidepressant use and white race, younger age, unemployment, non-ischemic HF, number of other prescribed medications, current minor depression, history of major depression, and functional impairment. In the secondary analysis, there were positive associations with white race, unemployment, number of other prescribed medications, and functional impairment; the effect of current severity of depression differed between patients with vs. without a history of major depression. CONCLUSIONS: Current depression is only one of several factors that influence the use of antidepressant medications in patients with HF. Further research is needed to ensure that these agents are being used appropriately in this patient population.

Depression and Multiple Rehospitalizations in Patients With Heart Failure.

BACKGROUND: There have been few studies of the effect of depression on rehospitalization in patients with heart failure (HF), and even fewer on its role in multiple rehospitalizations. HYPOTHESIS: Depression is an independent risk factor for multiple readmissions in patients with HF. METHODS: A cohort of 662 patients with HF who were discharged alive after hospitalization were interviewed to evaluate symptoms of depression and were followed for 1 year. All-cause readmissions were documented by chart review. A marginal proportional rates model was used to model the effect of depression on the rate of rehospitalization with adjustment for known predictors of HF outcomes. RESULTS: Depression symptoms predicted multiple readmissions (adjusted hazard ratio [HR]: 1.08, 95% confidence interval [CI]: 1.03-1.13, P = 0.0008). Compared with patients without depression, those who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression at index were at the highest risk for multiple rehospitalizations (HR: 1.51, 95% CI: 1.15-1.97, P = 0.003). CONCLUSIONS: Depression is an independent risk factor for multiple all-cause readmissions in patients with HF.

Depression and smoking in coronary heart disease.

OBJECTIVE: This review examines the relationship between depression and smoking in coronary heart disease (CHD). It summarizes relevant findings from general population and smoking cessation studies and discusses the few studies that have investigated whether smoking confounds, mediates, or moderates the effect of depression on cardiac morbidity and mortality. METHODS: Qualitative review of research literature. RESULTS: Although many studies of the prognostic importance of depression in CHD have adjusted for smoking, there is no convincing evidence that smoking actually confounds the relationship between depression and CHD. There is also no evidence that smoking moderates this relationship. There is, however, limited evidence that smoking may partially mediate the effect of depression on morbidity and mortality in CHD. CONCLUSION: We need more research on the relationship between depression and smoking in CHD to develop a more complete model of the mechanisms linking depression to cardiac morbidity and mortality.

Death takes a raincheck.

OBJECTIVE: To review the research literature on temporal variation in mortality rates around symbolically important occasions. METHODS: Qualitative literature review. RESULTS: Since the early 1970s, at least 18 studies have investigated whether death rates increase or decrease before, during, or after symbolically important occasions such as holidays and birthdays. Some studies but not others have found modest evidence of temporal effects. Methodological issues have raised questions about most of the positive findings. None of the studies provides any direct evidence that a psychophysiological mechanism enables people to postpone or hasten their own death. CONCLUSION: Research over the past 3 decades has failed to provide convincing evidence that psychological phenomena such as "giving up" or "holding on" can influence the timing of death.

Prevalence of depression in hospitalized patients with congestive heart failure.

OBJECTIVE: Prevalence estimates of depression in hospitalized patients with congestive heart failure (CHF) differ considerably across studies. This article 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. METHODS: A modified version of the Diagnostic Interview Schedule was administered to a series of 682 hospitalized patients with CHF to determine the prevalence of DSM-IV major and minor depression; 613 patients also completed the Beck Depression Inventory. Medical, demographic, and social data were obtained from hospital chart review, echocardiography, and patient interview. RESULTS: In the sample as a whole, 20% of the patients met the DSM-IV criteria for a current major depressive episode, 16% for a minor depressive episode, and 51% scored above the cutoff for depression on the Beck Depression Inventory (>or=10). However, the prevalence of major depression differed significantly between strata defined by the functional severity of heart failure, age, gender, employment status, dependence in activities of daily living, and past history of major depression. For example, the prevalence ranged from as low as 8% among patients in New York Heart Association class I failure to as high as 40% among patients in class IV. CONCLUSIONS: The prevalence of depression in hospitalized patients with CHF is similar to rates found in post-myocardial infarction patients. However, it is considerably higher in certain subgroups, such as patients with class III or IV heart failure. Further research is needed on the prognostic importance and treatment of comorbid depression in CHF.

Treatment of depression after coronary artery bypass surgery: a randomized controlled trial.

CONTEXT: There has been little research on the treatment of depression after coronary artery bypass surgery. OBJECTIVE: To test the efficacy of 2 nonpharmacological interventions for depression after coronary artery bypass surgery compared with usual care. DESIGN: A 12-week, randomized, single-blind clinical trial with outcome evaluations at 3, 6, and 9 months. SETTING: Outpatient research clinic at Washington University School of Medicine, St Louis, Missouri. PATIENTS: One hundred twenty-three patients who met the DSM-IV criteria for major or minor depression within 1 year after surgery. INTERVENTION: Twelve weeks of cognitive behavior therapy or supportive stress management. Approximately half of the participants were taking nonstudy antidepressant medications. MAIN OUTCOME MEASURE: Remission of depression, defined as a score of less than 7 on the 17-item Hamilton Rating Scale for Depression. RESULTS: Remission of depression occurred by 3 months in a higher proportion of patients in the cognitive behavior therapy (71%) and supportive stress-management (57%) arms than in the usual care group (33%) (chi(2)(2) = 12.22, P = .002). Covariate-adjusted Hamilton scores were lower in the cognitive behavior therapy (mean [standard error], 5.5 [1.0]) and the supportive stress-management (7.8 [1.0]) arms than in the usual care arm (10.7 [1.0]) at 3 months. The differences narrowed at 6 months, but the remission rates differed again at 9 months (73%, 57%, and 35%, respectively; chi(2)(2) = 12.02, P = .003). Cognitive behavior therapy was superior to usual care at most points on secondary measures of depression, anxiety, hopelessness, stress, and quality of life. Supportive stress management was superior to usual care only on some of the measures. CONCLUSIONS: Both cognitive behavior therapy and supportive stress management are efficacious for treating depression after coronary artery bypass surgery, relative to usual care. Cognitive behavior therapy had greater and more durable effects than supportive stress management on depression and several secondary psychological outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00042198.

Coronary heart disease and depression: a review of recent mechanistic research.

OBJECTIVE: Both behavioural and physiological factors have been proposed as mechanisms that may explain the negative effect of depression on coronary heart disease (CHD). Our aim is to review some of the most important findings since our prior review. METHOD: We searched MEDLINE, PsycINFO, and other sources for recent studies of candidate mechanisms, with an emphasis on publications since 2002. RESULTS: Physiological pathways have received far greater attention than behavioural ones in the emerging literature. Recent studies have identified shared genetic determinants, inflammation, blood clotting, and vascular mechanisms as plausible explanatory mechanisms. CONCLUSIONS: Future research should focus on relations between behavioural and physiological mechanisms and on the effects of pharmacologic and psychotherapeutic treatments for depression on candidate mechanisms.

The Depression Interview and Structured Hamilton (DISH): rationale, development, characteristics, and clinical validity.

OBJECTIVE: The Depression Interview and Structured Hamilton (DISH) is a semistructured interview developed for the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter clinical trial of treatment for depression and low perceived social support after acute myocardial infarction. The DISH is designed to diagnose depression in medically ill patients and to assess its severity on an embedded version of Williams' Structured Interview Guide for the Hamilton Depression scale (SIGH-D). This article describes the development and characteristics of the DISH and presents a validity study and data on its use in ENRICHD. METHODS: In the validity study, the DISH and the Structured Clinical Interview for DSM-IV (SCID) were administered in randomized order to 57 patients. Trained interviewers administered the DISH, and clinicians administered the SCID. In ENRICHD, trained research nurses administered the DISH and recorded a diagnosis. Clinicians reviewed 42% of the interviews and recorded their own diagnosis. The Beck Depression Inventory (BDI) was administered in both studies. RESULTS: In the validity study, the SCID diagnosis agreed with the DISH on 88% of the interviews (weighted kappa = 0.86). In ENRICHD, the clinicians agreed with 93% of the research nurses' diagnoses. The BDI and the Hamilton depression scores derived from the DISH in the two studies correlated 0.76 (p < .0001) in the validity study and 0.64 (p < .0001) in ENRICHD. CONCLUSIONS: These findings support the validity of the DISH as a semistructured interview to assess depression in medically ill patients. The DISH is efficient in yielding both a DSM-IV depression diagnosis and a 17-item Hamilton depression score.