Screening can uncover depression in heart failure patients

Screening can successfully identify factors associated with the development of depression in patients with heart failure, according to a recent study in the Journal of the American College of Cardiology (2004;44:2333-2338). In the study, four social and environmental factors were found to contribute significantly to the onset of depression in heart failure.

The investigators, led by Edward P. Havranek, MD, studied 245 outpatients with heart failure who did not have depressive symptoms at baseline. They were evaluated at baseline and at 1 year using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and a clinical evaluation that included social and economic status. The KCCQ is a

23-item instrument for measuring symptoms, physical functioning, social functioning, self-efficacy, and quality of life that is specific to heart failure. The overall score ranges from 0 to 100, with higher scores indicative of better health status.

At the 1-year follow-up, four risk factors were significantly and independently associated with depressive symptoms in multivariate an-alysis: living alone (P = .015), the perception of medical care being a substantial burden (P = .003), a

history of alcohol abuse (P = .013), and impaired health status as measured by the KCCQ (P < .001). The mean KCCQ scores were 59.7 in patients who developed significant depressive symptoms and 71.1 in those who did not develop depressive symptoms.

The likelihood of depression at 1 year was 7.9% for patients with none of these four risk factors, 15.5% for those with one risk factor, 36.2% for those with two risk factors, and 69.2% for those with three risk factors. No patients had all four of the identified risk factors.

There was no difference between the depressed and nondepressed group with respect to a history of treated depression.

The factors associated with depressive symptoms in this study were similar to those in studies of patients following myocardial infarction and in studies of general populations, except, unlike previous studies, the current one found that female gender was not associated with development of depression.

These findings are important because patients with heart failure who develop depression have higher mortality, more heart failure hospitali-zations, worsening of heart failure symptoms, and worse functional status and quality of life than heart failure patients without depression. As such, “depression screening may be warranted for all patients with heart failure,” write the authors. They recommend serial screening because of the elevated risk of depression in patients with heart failure. Future studies should address whether targeted psychosocial intervention for at-risk patients can reduce the incidence of depression and improve outcomes, they believe.

“Although there is no evidence that a systematic depression screening program for heart failure patients will improve outcomes, if a heart failure patient is identified as having depression, we strongly support the use of standard treatment for that patient,” Dr. Havranek, staff cardiologist at Denver Health Medical Center, told Cardiology Review in an e-mail interview. “We think the available evidence suggests that selective serotonin reuptake inhibitor antidepressants are safe in patients with heart failure. Cognitive/behavioral therapy may also be of benefit. Referral for treatment to a psychiatrist or to the patient’s primary care physician may also be of benefit.”