Underdiagnosed Depression, Anxiety Put Heart Failure Patients at Risk

Christopher Celano, MD

Depression and anxiety disorders affect about one-third of patients with heart failure—and these individuals are at higher risk for progressive heart disease, hospitalizations, and death. Yet anxiety and depression remain underdiagnosed and undertreated in heart failure cases, a review of research on the complex relationship among the disorders suggests.

“Diagnosing depression or anxiety disorders in patients with heart failure can be challenging, given the overlap in symptoms between these psychiatric and cardiac illnesses,” Christopher Celano, MD, of Massachusetts General Hospital, told MD Magazine®.

“Diagnosis is important, as there are safe and effective treatments—especially for depression—for patients with these illnesses,” he said.

While previous studies have linked psychiatric disorders to worse outcomes in patients with heart failure (HF), Celano and his team set out to clarify these relationships. They conducted an up-to-date review of literature on the epidemiology, mechanisms, diagnosis, and treatment of depression and anxiety disorders in a high-risk cardiac population.

The team found that clinically significant depressive symptoms affect 21.5% of HF patients. One-third of patients reported elevated depressive symptoms on questionnaires and 19% met criteria for a depressive disorder, a meta-analysis of 36 studies showed.

These percentages are double or triple those found in the general population, the researchers said.

Anxiety is also prevalent among patients with heart failure. About 13% met the diagnostic criteria for a formal anxiety disorder, usually generalized anxiety disorder (GAD). Almost 30% of heart patients showed significant levels of anxiety on a questionnaire.

“The relationships between depression/anxiety and heart failure may be mediated by both physiologic and behavioral mechanisms,” said Celano, citing inflammation and autonomic nervous system changes as examples.

Studies have shown that depression is associated with increased levels of C-reactive protein (CRP), interleukin 1 (IL-1) and interleukin 6 (IL-6), which can accompany inflammation. At the same time, depression and anxiety may make it more challenging for patients with heart disease to adhere to health behavior recommendations affecting diet, exercise, medication, and rehabilitation, the researchers noted.

Asked whether it’s fair to say that that depression can lead to the development of heart failure and that, conversely, heart failure can lead to depression and anxiety, Celano said the associations are complicated.

“The literature to date doesn’t give us a clear answer about this,” he said. While depression has clearly been linked to both the development of heart failure and worse outcomes in patients with established HF, the studies that investigate this relationship are observational.

“It is difficult to know for sure whether depression itself is causing worse cardiac outcomes or if it is a marker of something else that causes worse outcomes,” Celano explained. “Just knowing that individuals with depression are at elevated risk for heart failure or worse outcomes can be beneficial for clinicians to know.”

In contrast, very few studies have looked at the links between anxiety disorders and heart failure. Those that have been conducted have had mixed results, Celano said.

“This is certainly an area for more research,” he said. Future investigations might help define the roles that inflammation, endothelial function, autonomic function, and platelet aggregation play in the links between these psychiatric illnesses and heart failure outcomes.

Ongoing exploration might lead to new clinical approaches. “Cognitive behavioral therapy has been shown to be effective at improving psychiatric symptoms, making it a promising treatment option,” Celano said.

Selective serotonin reuptake inhibitors (SSRIs) appear safe in patients with HF, although 2 studies have not shown them to be effective at improving depressive symptoms in this population.

“Further research is needed to better understand the effectiveness of pharmacologic treatments for depression and anxiety disorders,” Celano said.

Celano’s research group is conducting a randomized, controlled trial of a “blended” collaborative care intervention. This strategy seeks to manage both psychiatric and cardiac symptoms to better identify and treat depression and anxiety disorders in patients with coronary artery disease or heart failure.

“We hope that our focus on both psychiatric and cardiac illnesses will help to improve mental and physical health and can provide a framework for future clinical interventions for this high-risk population,” Celano said.

The study, “Depression and Anxiety in Heart Failure: A Review,” was published in Harvard Review of Psychiatry.