Depression high among CHF patients

Most receive no treatment for depression

Congestive heart failure (CHF) interferes with sleep, energy, and appetite. It makes patients feel tired, unable to keep up with their normal activities, perhaps a little fuzzy in their thinking. Physicians know that, and they work to alleviate those concerns. But they might not get very far, a new study says, unless they investigate whether those symptoms are caused by depression.

In fact, 58% of the CHF patients in a recent Duke University Medical Center study1 were found to have depression. Only 44% of those with depression had received any treatment for it.

"It's hard to make the diagnosis. But we've found that if patients have these symptoms, regardless of where they're coming from, that they remain depressed even after their heart failure gets treated," says Harold Koenig, MD, director of the geriatric evaluation and treatment clinic at Duke University Medical Center in Durham, NC, and author of the study. "The error is to attribute all these symptoms, especially depressed mood and loss of interest, to the disease itself. The depression still needs treatment no matter what caused it." (For a possible solution to the diagnosis problem, see related story, above.)

Koenig's study, based on records of 542 patients age 60 and over admitted to Duke University Medical Center, found that depressed patients were no more likely than nondepressed patients to see mental health specialists. During the three months before admission, depressed patients averaged two to three times more medical visits, even after controlling for the severity of their disease. Between three and nine months after discharge, those with major depression were readmitted twice as often. And even a year after discharge, 40% remained depressed.

"It made no difference how physically healthy they were, how many medications they were on, how functionally disabled they were," Koenig says. "The only factor that predicted how fast the person resolved from their depression was the level of social support they had."

Patients with CHF have some of the highest rates of depression among those with chronic illness, Koenig says. "Slowly, this congestive heart failure leads to a constricting of the life of the person. Most people find their meaning and purpose in life through their activities and their social relationships. Congestive heart failure directly attacks both of those," he says. "All of these psychological factors together with the physical discomfort make heart failure a hard cross to bear. It's not surprising that people become depressed and have a hard time kicking it."

CHF symptoms can mimic depression

The biggest problem is in the diagnosis, Koenig says, especially since many of the symptoms of CHF are also symptoms of depression. He says all CHF patients should be screened for depression when admitted to the hospital and that physicians should consider prescribing an antidepressant when appropriate. Specific serotonin reuptake inhibitors (SSRI) are safe for heart patients and shouldn't interact with medications taken for CHF, Koenig says. In fact, a recent study2 in the Journal of the American Medical Association found that depression improved in more than half of patients taking the SSRIs paroxetine and that only 2% suffered adverse cardiac events such as increased heart rate.

The other important factor is follow-up. Physicians shouldn't prescribe an antidepressant and then forget about it, Koenig says. They need to help the patient find avenues of social support and counseling, and they should refer the patient to a specialist if those efforts don't work.

"Depression affects a person's will to live, their desire to comply with medication, their desire to go see their doctor. They lose interest, they lose energy, and they feel like they want to die," Koenig says. "My argument is it won't help to treat the heart failure if the person doesn't want to live."

What happens if depression goes untreated? Studies have shown that major depression is a strong predictor of a second heart attack, angioplasty, and coronary artery bypass surgery and that depressed patients with heart disease have increased mortality rates. Besides that, patients' quality of life is severely compromised, Koenig says. "This is a neglected population because so much effort has to be placed on keeping these patients alive given the severity of their illness."

[For more information about CHF and depression, contact Harold Koenig, MD, Duke University Medical Center, Box 3400, Durham, NC 27710. Telephone: (919) 684-3824.]

References

1. Koenig HG., Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry 1998; 20:29-43.

2. Roose S, et al. Comparison of Paroxetine and Nortriptyline in depressed patients with ischemic heart disease. JAMA 1998; 279:287-291.