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Don’t let it creep up on your patients
It usually doesn’t appear all at once, and there may not be a clear starting point where symptoms begin. But once it shows up, depression can unravel the gains you make with your CHF patients.
With treatment plans depending so much on the patients remaining motivated — to keep up with drug therapy, appointments, and tasks such as daily weighing — depression can undo a lot of the control you’re trying to get over their condition.
"The disease creeps up on people," says Sue P. Heiney, PhD, RN, CS, FAAN, a certified specialist in psychiatric nursing at the University of South Carolina in Columbia. "It’s not like dealing with an MI, where there is a clear-cut event that puts a patient in crisis."
Heiney, who specializes in working with cancer patients, says she often lectures on depression for clinicians treating patients with heart failure because of the similarities with how patients deal with lasting illness and how depression can develop.
Patients who undergo surgery face an increased risk of depression, whether they are recovering from a valve replacement, cardiac bypass, or even transplantation. And depression can develop in patients who have been dealing with CHF only. What’s needed, say experts, is to look for the situations that can lead to depression, find out if the signs are there, then go ahead and treat it.
But don’t wait for one signal to jump out at you as though someone flipped on the depression switch. CHF patients show the gradual symptoms much the way other patients do.
"It’s simple to assess, but it just gets ignored," Heiney says. "We often get so wrapped up with assessing symptoms and disease management that we miss the quality-of-life issues."
"Patients come in to get an EKG, a check of medical symptoms, heart symptoms — but doctors just need to know that the risk of depression is there," says Jim Fitzpatrick, MD, clinical assistant professor of medicine in the division of cardiology at Thomas Jefferson Medical Center in Philadelphia.
He says half of the patients that have had heart surgery show signs of depression. "In patients with heart failure, they may have had surgery for valvular repair or a bypass. After those surgeries they are in a high-risk group."
It is helpful to recognize that just being a heart patient is a roller coaster ride of emotions for most people.
"They’ve been sick. There was the anticipation of surgery. They go have it done. Then they still don’t feel well. They made it through, but instead of having a sense of relief, depression sets in," Fitzpatrick says.
The same pattern is true for patients who undergo transplantation, says Mary Amanda Dew, PhD, who is a professor of psychiatry at the University of Pittsburgh Medical Center.
Before the transplant, there is a lot of stress for patients and their families. "Nobody is really sure if they are going to make it," she says. "People live in this limbo of not going to know what’s going to happen. It goes on and on."
Dew, who works with cardiovascular patients, says she has studied depression in heart transplant patients for 10 years. The emotions can continue to work on the patient after surgery, especially after the patient’s relief that he or she survived the procedure wears off.
"After the transplant, there is disappointment. We’ve found that people come down off of a honeymoon period," she says. "People aren’t doing as well as they thought they would do."
And if the patients go on to develop depression, Dew says studies show they are more likely to develop complications like cardiac allograft disease.
"That’s something seen across the board," she says, noting it worsens the health status of transplant recipients and bypass patients alike. Complications have such a strong tie to depression, she says, that it is a powerful predictor of physical morbidity.
Heart failure symptoms can mask some indications of depression. For example, patients may have less energy and probably can’t be as active as they were when they were healthy. Those changes in a person’s life could in time lead to depression. But the signs that it’s developing, such as fatigue or difficulty sleeping, may appear to be just from the CHF itself.
"Probably, the question to ask is, How is your disease right now affecting your quality of life?’" Heiney says. "Then listen for the responses you get."
If you begin to hear about vague pain, head-aches, or sexual problems, start being suspicious. After some digging, you may determine a few of these symptoms are not indicating depression, but these are good places to start.
"Look if there are more complaints than usual," says Jeffrey E. Kelsey, MD, PhD, assistant professor of medicine and director of the Mood and Anxiety Disease Clinical Trials Program at Emory University’s department of psychiatry and behavior in Atlanta. "Where we get a lot of hits are changes in sleep, appetite, energy, concentration, or feeling blue."
"Look for clusters of symptoms that are suddenly appearing," Dew says. They can be both somatic (such as eating and sleep habits) and cognitive, such as sudden difficulty in decision making, feelings of worthlessness, or thoughts that they or their families would be better off if they died. "Some people may show one type or the other," Dew says. "Look for both."
Kelsey notes that elderly people tend to complain more about physiological symptoms than psychological ones. But that doesn’t mean that psychological ones aren’t there. In these cases, it may help to talk with the patient’s spouse or another family member to see if they have noticed problems such as increased irritability or changes in sleeping or eating habits.
(See handout for caregivers, p. 20.)
Fitzpatrick says he had a patient’s wife come to him to ask what could be wrong with her husband. She said her husband seemed so down after his surgery.
The patient went through the surgery well and made no complaints himself. His wife, however, told Fitzpatrick he wasn’t sleeping well. He also had lost his appetite and had anhedonia, or no sense of pleasure in anything. With that information, Fitzpatrick started the patient on antidepressant medication, and he responded well.
Dew has one more note about the patient’s household caregivers: Keep an eye on the patient’s family. You may need to assess if they are showing signs of depression, too. If so, they may need to be directed to get help from their physicians.
"The caregiver and the patient tend to feed off of one another," she says. It’s a big problem to your case when caregivers, who are usually under a lot of strain themselves, are the one who give the patient daily medication. "If they get depressed, they may not be able to do what they used to do."
(See related story on another factor doctors can use to help CHF patients, p. 21.)
So the physician is asking questions about quality of life, eating, sleeping, and overall mood — and a patient shows signs that depression could be a problem. "Chances are, you’ll want to take a clinical history and evaluate specifically for depression," Heiney says.
The basics include asking about previous history with depression, suicide attempts (personal or family members), persistence of feeling down all day long and every day, and not enjoying their usual activities. Most doctors are familiar with this drill for patients who are not suffering chronic disease, but it is still valid to CHF patients as well.
"The yeses you get from these questions are a major red flag," she says. Then once the physician establishes the cause for depression and determines depression does exist, patients can be treated.
"Whenever you see signs of depression, go ahead and treat it," Kelsey advises. Some treatment begins at looking at the medication the patient is taking already. Some drugs can cause depression as a side effect, particularly ones that have a long half life and tend to accumulate in the body over time.
Examples of drugs that could cause problems are Benzodiazepines such as Valium, Dalmane and Librium. If there are questions about drug interactions, it’s a good idea to consult a pharmacist or a psychiatrist, he says.
"It used to be thought that beta-blockers could cause depression," Kelsey adds. "That’s probably not the case." If depression is not a result of the medicine the patient is receiving, medication and counseling can be prescribed.
Heiney says the data show half of the patients who suffer from depression are treated effectively with antidepressants alone. The other half may need a combination of antidepressants and psychotherapy.
According to Dew, studies show, in most cases, that psychotherapy or support groups alone are not enough to fight depression. Medication is needed as well.
"Without that," Fitzpatrick adds, "treatment is not going to be as successful."
Dew notes patients usually can tolerate the newer medications, such as Paxil, because of their lower profile for causing side effects. The older medications, however, such as tricyclic antidepressants such as Elavil (amitriptyline) often are contraindicated for heart patients.
In order to guide patients on where to go for support, Heiney points out, it’s a good idea to know about what’s going on in your particular area. Find the support groups and where patients can go for more information. Keep up on the hospital-hosted patient programs, the groups that meet there, and how to get your patients involved.
Local chapters of national organizations such as the American Heart Association also can put patients in contact with information and support. She says the United Way agencies often act as a clearinghouse for information as well. Get on their mailing lists, too.
"A lot of people may not know they have help right at their own back door," Heiney adds.
Also, take a look at what is available on-line. If you go to http://www.healthfinder.gov, you can find a wealth of information. It’s a search engine available through the Department of Health and Human Services. Type in "depression," and you will find clinical guides and general depression brochures that have been made available through the Internet. (See list of helpful resources, p. 22.)
The clinician’s quick reference guide works through either an interactive table of contents or direct searching. The table of contents takes you to a list of options: purpose and scope, guideline highlights, a bibliography, and tables and figures. The entire guide can be downloaded.
Note that the guideline is written to address primary care settings in general and not specifically for CHF patients. Heiney notes, however, it is a good outline to have.
The healthfinder site also includes links to Web sites for organizations like the National Institute of Health’s National Institute of Mental Health and the National Foundation for Depressive Illness Inc., in New York City.
If you direct patients to this search engine to get printouts of information, be aware that they may try to get some on their condition as well. Typing in "congestive heart failure" summons a lot of materials, but not all of it may be useful for patient information.
In fact, patients may be shocked at how bluntly death from heart failure can be described. A word (or two) of caution to them may be helpful.