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Depressive Symptoms and Risk of Functional Decline and Death in Patients With Heart Failure
Abstract
We sought to examine whether depressive symptoms are associated with poorer prognosis in patients with heart failure.
Depression is an established risk factor for poor outcome in patients with coronary heart disease (CHD). Little is known of its role in patients with heart failure.
We prospectively followed 391 patients > or =50 years of age who met criteria for decompensated heart failure on hospital admission. The outcome of the study was death or decline in activities of daily living (ADL) at six months, relative to baseline. Depressive symptoms were measured at baseline by means of the Geriatric Depression Scale, Short-Form, with 6 to 7 symptoms, 8 to 10 symptoms and > or =11 symptoms indicating mild, moderate and severe levels of depressive symptoms, respectively.
There was a strong and graded association between the severity of depressive symptoms at baseline and the rate of the combined end point of either functional decline or death at six months. After adjustment for demographic factors, medical history, baseline functional status and clinical severity, patients with > or =11 depressive symptoms, compared with those with <6 depressive symptoms, had an 82% higher risk of either functional decline or death, whereas the intermediate levels of depressive symptoms showed intermediate risk (p = 0.003 for trend). A similar graded association was found for functional decline and death separately; however, after multivariate analysis, the association with mortality was less strong and no longer statistically significant.
An increasing number of depressive symptoms is a negative prognostic factor for patients with heart failure, just as it is for patients with CHD.
... [6,31] Our study shows no difference in the sex ratio between the three groups. Some studies report that psychiatric illnesses are more common among females in patients with HF. [28,[32][33][34] However, plenty of studies show no difference in the male-female ratio in patients with HF having psychiatric illness and those without it. [32,35] The equivalent level of psychiatric disorders and symptoms among the females in our study probably nullifies the common thinking that women express their problems more than males, but as scales were administered and the diagnosis was made by a physician in our study, all the parameters were taken into consideration. ...
... Some studies report that psychiatric illnesses are more common among females in patients with HF. [28,[32][33][34] However, plenty of studies show no difference in the male-female ratio in patients with HF having psychiatric illness and those without it. [32,35] The equivalent level of psychiatric disorders and symptoms among the females in our study probably nullifies the common thinking that women express their problems more than males, but as scales were administered and the diagnosis was made by a physician in our study, all the parameters were taken into consideration. Hence, the data from other studies where psychiatric disorders are more common in females should be interpreted after seeing who has applied the scale and how or by whom the diagnosis was made. ...
... Patients with HF may report more symptoms and disability over time, even when cardiac status remains stable, which could be due to precipitation or increased severity of depression. [32,39,40] Sleep gets disturbed for patients of both HF and psychiatric illnesses. [41,42] We tried measuring sleep quality in all our enrolled patients. ...
Background
Heart failure (HF) leads to various changes including physiological (neurohormonal) changes and an increase in stress level, which can become a risk factor for the development of various psychiatric disorders, further worsening quality of life (QOL).
Methods
Patients of HF between 18 and 60 years of age attending the outpatient department of the Department of Cardiology were enrolled. Patients were screened for psychiatric illness by applying Mini International Neuropsychiatric Interview 7.0.2. The diagnosis was made through the Diagnostic and Statistical Manual of Mental Disorders-5. The severity of anxiety and depression was assessed by applying the Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale. Sleep quality was measured by applying the Pittsburgh Sleep Quality Index. Subsyndromal symptoms were assessed via SADS-CB. QOL was measured by the World Health Organization QOL-BREF. Data were statistically analyzed.
Results
Out of 70 enrolled patients, 32 patients did not have any psychiatric illness (Group A), 20 patients were in the subsyndromal group (Group B), and 18 patients had psychiatric disorders (Group C). Tobacco use and the number of risk factors of HF present were significantly higher in Group C. A significantly higher number of patients in Group C were lying in the New York Heart Association (NYHA) II class (patients lying in NYHA III and NYHA IV classes were excluded) than in other groups. In addition, sleep and QOL (especially among patients under NYHA I class) were significantly impaired in Group C.
Conclusion
Psychiatric illness is common in patients with HF. Despite guidelines to screen for them, clinicians either do not screen for them or otherwise miss the psychiatric illness. These psychiatric illnesses may further impair the outcome of heart diseases and worsen QOL.
... Uncontrolled pain stimulates the sympathetic nervous system and activates the renin-angiotensin-aldosterone system, all of which lead to increases in the haemodynamic workload, sodium and water retention and finally to HF decompensation and a higher risk of rehospitalisation (66,67). Untreated pain additionally increases the use of non-steroidal anti-inflammatory pain killers (NSAID), including those contraindicated in HF, worsens self-monitoring and self-management (risk factor of HF decompensation and hospitalization) (66,67) and increases the risk of depression (a factor limiting QoL and increasing the risk of HF related hospitalization and mortality in people with HF) (48,(68)(69)(70). ...
... Depression is up to four times more frequent in people living with HF (21.5%) than in the general population (2.6 in males and 7% in females) (70). Significant differences in the prevalence of depression exist between those who are hospitalized and outpatients with HF (13-77% vs. 13-48%, in different studies) (68,70,(127)(128)(129). The meta-analysis indicates the prevalence of depression among different groups. ...
... The meta-analysis indicates the prevalence of depression among different groups. Its prevalence rises with HF severity (11% in I NYHA class, 42% in IV NYHA class) and is an important factor limiting QoL, increasing the risk of hospitalisations, emergency room visits and death (48,(68)(69)(70). Some studies reported that anxiety, depression and psychological distress are more frequent in females than in males (64 vs. 44%), with 37% of women vs. 24% of men with advanced HF suffering from current depression (17,27,47,69,130). ...
The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.
... Elevated depressive symptoms have been found to be associated with a marked increase in adverse clinical outcomes for heart failure (HF) patients with reduced ejection fraction (HFrEF). [1][2][3] The increased risk of adverse clinical outcomes associated with elevated depressive symptoms in HFrEF patients is substantial, even in the absence of levels that denote clinical depression. [3][4][5][6] There is also evidence that depressive symptoms that increase or worsen over time may signal HF disease progression in HFrEF patients 7 and heighten the risk of subsequent adverse events. ...
... The present findings confirm that heightened depressive symptoms are associated with higher risk of adverse clinical outcomes, including cardiovascular and all-cause hospitalizations and death, over a 4 year follow-up period [1][2][3][4] Over the median 4 year follow-up period, 42 participants died and 84 had cardiovascular hospitalizations, an event rate similar to a recent report of a sample of over 2000 patients with HFrEF. 29 The association of elevated baseline depressive symptoms with adverse outcomes for HFrEF patients was robust even after controlling for the severity of HF disease, according to both BNP and EF, as well as comorbidities, medications, and device therapies. ...
Aims:
The objective of this study was to examine associations between elevated depressive symptoms and increased risk of adverse clinical events patients with heart failure and reduced ejection fraction (HFrEF), as well as the potential contribution of health behaviours.
Methods and results:
One hundred forty-two men and women with HFrEF were enrolled through heart failure (HF) clinics and followed over time. At baseline and 6 months, depressive symptoms were assessed by the Beck Depression Inventory-II (BDI-II) and HFrEF disease activity by B-type natriuretic peptide (BNP). The Self-Care of Heart Failure Index (SCHFI) was used to assess HF self-care behaviours. Proportional hazards regression models assessed the contribution of depressive symptoms and HFrEF disease biomarkers on death or cardiovascular hospitalization. Over a median follow-up period of 4 years, 42 patients (30%) died, and 84 (60%) had cardiovascular hospitalizations. A 10-point higher baseline BDI-II score was associated with a 35% greater risk of death or cardiovascular hospitalization. Higher baseline BDI-II scores were associated with poorer HF self-care maintenance behaviours (R = -0.30, P < 0.001) and fewer daily steps (R = -0.19, P = 0.04), suggesting that elevated depressive symptoms may diminish important health behaviours. Increases in plasma BNP over 6 months were associated with worse outcomes. Changes in BDI-II and plasma BNP over 6 months were positively related (R = 0.25, P = 0.004).
Conclusions:
This study confirms that elevated depressive symptoms are associated with an increased likelihood of adverse clinical outcomes in patients with HFrEF. Poor health behaviours may contribute to the adverse association of elevated depressive symptoms with the increased hazard of adverse clinical outcomes.
... Elevated depression symptoms have been found to be associated with a marked increase in adverse clinical outcomes for HF patients with reduced ejection fraction (HFrEF). [1][2][3] The increased risk of adverse clinical outcomes associated with elevated depression symptoms in HFrEF patients is substantial, even in the absence of levels that denote clinical depression. [4][5][6][7] Depression symptoms that increase or worsen over time may signal HF disease progression in HFrEF patients 8 and heightened hazard of adverse outcomes in cardiac patients. ...
... The present findings confirm that heightened symptoms of depression are associated with higher risk of adverse clinical outcomes, including cardiovascular and all-cause hospitalizations and death, over a four-year follow-up period [1][2][3]5 The association of elevated baseline depression symptoms with adverse outcomes for HFrEF patients was robust even after controlling for the severity of HF disease, according to both BNP and EF, as well as comorbidities, medications, and device therapies. The extended proportional hazards adjustment models were used to ascertain the robustness of the results from our planned models, and in all cases supported them, especially showing that higher baseline depression symptoms were associated with poorer outcomes after allowing a variety of demographic, behavioral, and medical management parameters to supplement the planned models. ...
BACKGROUND Prior studies have demonstrated an association of depression with adverse clinical outcomes in patients with HFrEF, but the possible mechanisms responsible for the association are not unserstood.
METHODS 142 men and women with HFrEF were enrolled through HF clinics and followed over time. At baseline and 6-months, depression was assessed by the Beck Depression Inventory (BDI-II) and disease activity by B-type natriuretic peptide (BNP). Proportional Hazards Regression Models assessed the contribution of depressive symptoms and HFrEF disease biomarkers on death or cardiovascular hospitalization.
RESULTS Over a median follow-up period of 4 years, 42 patients (30%) died, and 84 (60%) had cardiovascular hospitalizations. A 10-point higher baseline BDI-II score was associated with a 35% higher hazard of death or cardiovascular hospitalization. Greater baseline BDI-II scores were associated with poorer HF self-care maintenance (R=-0.30, p<0.001) and fewer daily steps (R=-0.19, p=0.04), suggesting that depression may adversely affect important health behaviors. Increases in plasma BNP over 6 months were associated with worse outcomes. Changes in BDI-II score and plasma BNP over 6 months were positively correlated (R=0.25, p=0.004).
CONCLUSIONS This study underscores the importance of elevated depression symptoms and their association with an increased likelihood of adverse clinical outcomes in patients with HFrEF. Health behaviors may play a greater role than direct biobehavioral pathways in the adverse effects of depression on the HF disease trajectory and resultant clinical outcomes.
... Aside from the physiological level of HF, several reports [4][5][6] have indicated that the primary significant risk factor for disability and death due to HF is depression. In HF patients, a three-month depressive episode doubles the risk of death and triples the likelihood of re-hospitalization within a year [7]. ...
... Additionally, people with HF who are depressed have lesser capacities for selfcare than those who are not depressed. Between 9% and 60% of people who have HF also have depression, which is a relatively high prevalence [4,5]. This high prevalence is multifactorial and may be brought on by debilitating symptoms, physical function limitations, future insecurity, lack of confidence in the ability to play personal, social, and professional roles, concerns regarding engaging in some activities, and lack of self-esteem [6]. ...
Background
About 20–40% of people with Heart failure (HF) suffer from some depression, which is 4–5% greater than the overall population. This depression can lead to undesirable outcomes, including elevated mortality rate and frequent hospitalization.
Purpose
The current study aims to evaluate the impact of cognitive behavioural therapy (CBT) on self-care and the symptoms of depression and anxiety in HF patients.
Methods
We searched PubMed, Web of Science (WOS), Scopus, and Cochrane Library till 15 October 2022. All relevant randomized controlled trials (RCTs) were included. The data were extracted and pooled using Review Manager software (RevMan 5.4). Continuous data were pooled as mean difference and 95% confidence interval (CI).
Results
Our search retrieved 1146 records, and 7 studies (611 patients) were finally included. We assessed the Beck Depression Inventory-II (BDI-II) as the primary outcome of the study. Hamilton Rating Scale for Depression (HRSD-17), Change in Beck Anxiety Inventory, Kansas City Cardiomyopathy Questionnaire (KCCQ), and Self-Care of Heart Failure Index (SCHFI) were also assessed as secondary outcomes. With CBT, BDI-II showed a significant reduction after 4 to 6 months follow-up (MD = -4.87, 95% CI: [-8.06; -1.69], P = 0.003) as well as 8 to 9 months follow-up (MD = -5.71, 95% CI: [-8.95; -2.46], P = 0.0006). But no significant difference was shown with 3 months follow-up (M.D=-4.34; 95%CI: [-10.70; 2.03], P = 0.18).
Conclusions
CBT has long-term (4–9 months) significant favorable outcomes decreasing anxiety and depression compared to non-CBT groups. No significant short-term (less than 3 months) impact on HF patients’ self-care, depression, or anxiety were shown.
... 2,3 Depression, which affects over 20% of individuals with HF, 4 appears to be an important contributor to poor outcomes in this population. 5 Specifically, among those with HF, comorbid depression is associated with impaired HRQoL, [6][7][8][9] higher distress, 7 functional decline, 10,11 nonadherence to health behaviors (e.g., to medication, diet, or exercise), [12][13][14] high rates of hospitalizations, 4,[15][16][17][18] and increased risk of mortality. 4,11,[17][18][19][20][21][22][23] Unfortunately, existing depression treatments have had limited impact in patients with HF. 2 Antidepressant medications have not impacted depressive symptoms or cardiovascular (CV) outcomes compared to placebo, 24,25 and psychotherapy interventions (e.g., cognitive behavioral therapy) have had only small effects on depressive symptoms compared to usual care (UC). ...
... 5 Specifically, among those with HF, comorbid depression is associated with impaired HRQoL, [6][7][8][9] higher distress, 7 functional decline, 10,11 nonadherence to health behaviors (e.g., to medication, diet, or exercise), [12][13][14] high rates of hospitalizations, 4,[15][16][17][18] and increased risk of mortality. 4,11,[17][18][19][20][21][22][23] Unfortunately, existing depression treatments have had limited impact in patients with HF. 2 Antidepressant medications have not impacted depressive symptoms or cardiovascular (CV) outcomes compared to placebo, 24,25 and psychotherapy interventions (e.g., cognitive behavioral therapy) have had only small effects on depressive symptoms compared to usual care (UC). 26 Similarly, depression collaborative care (CC) interventions, [27][28][29] which utilize a care manager to monitor symptoms of depression and convey treatment recommendations from a mental health specialist to existing treaters, have led to improvements of HRQoL, and mood. ...
Objective:
Heart failure (HF) is associated with an elevated risk of morbidity, mortality, hospitalization, and impaired quality of life (QoL). One potential contributor to these poor outcomes is depression. Yet the effectiveness of treatments for depression in HF patients is mixed, perhaps due to the heterogeneity of depression.
Methods:
This secondary analysis applied latent class analysis (LCA) to data from a clinical trial to classify patients with systolic HF and co-morbid depression into LCA subtypes based on depression symptom severity, and then examined whether these subtypes predicted treatment response and mental and physical health outcomes at 12-months follow-up.
Results:
In LCA of 629 participants (mean age 63.6±12.9; 43% females), we identified four depression subtypes: mild (prevalence 53%), moderate (30%), moderately severe (12%), and severe (5%). The mild subtype was characterized primarily by somatic symptoms of depression (e.g., energy loss, sleep disturbance, poor appetite), while the remaining LCA subtypes additionally included non-somatic symptoms of depression (e.g., depressed mood, anhedonia, worthlessness). At 12 months, LCA subtypes with more severe depressive symptoms reported significantly greater improvements in mental QoL and depressive symptoms compared to the LCA mild subtype, but the incidence of cardiovascular- and non-cardiovascular-related readmissions, and mortality was similar among all subtypes.
Conclusions:
In depressed patients with systolic HF, those with the LCA mild depression subtype may not meet full criteria for major depressive disorder (MDD), given the overlap between HF and somatic symptoms of depression. We recommend requiring depressed mood or anhedonia as a necessary symptom for MDD in HF patients.
... In conclusion, the review of articles in this paper shows that there is a high prevalence of depression in heart failure, but it is often not recognized by doctors, there is a relationship between psychosomatic, and heart failure, non-pharmacological interventions such as psychotherapy and PENDAHULUAN Gagal jantung merupakan masalah kesehatan progresif dengan angka mortalitas dan morbiditas yang tinggi di negara maju maupun negara berkembang, termasuk Indonesia. [1][2][3][4] Gagal jantung (GJ) didefinisikan sebagai ketidakmampuan jantung memompa darah untuk memenuhi kebutuhan oksigen dan nutrisi jaringan tubuh. Penyakit jantung yang dapat mendasari keadaan gagal jantung yaitu penyakit jantung koroner (PJK), infark miokard akut (IMA), hipertensi, kelainan katup jantung, kardiomiopati, dan defek jantung kongenital. ...
... Komorbiditas depresi pada pasien dengan gagal jantung akan meningkatkan risiko luaran dan status kesehatan yang buruk, serta merupakan masalah kesehatan masyarakat yang penting. 1,2 Depresi klinis diperkirakan terjadi pada 21,5% pasien GJ dan meningkat tajam sesuai dengan peningkatan tingkat keparahan GJ. 1 Pasien GJ yang mengalami depresi mengalami penurunan fungsi fisik yang lebih cepat, kualitas hidup yang yang buruk, rawat inap yang lebih sering, dan tingkat kematian yang lebih tinggi daripada pasien GJ yang tidak mengalami depresi, terlepas dari tingkat keparahan penyakit GJ. 1,3 Tinjauan pustaka ini disusun berdasarkan kajian literatur yang didapat dari Pubmed, Google Scholar dan Scopus untuk mendapatkan gambaran mengenai depresi pada pasien GJ yang di meliputi epidemiologI, patofisiologi, diagnosis, dan manajemen. ...
... A meta-analysis reported that the prevalence of depression in patients with HF is 21.5%, with a higher prevalence in women [2]. The study also reported higher rates of mortality and rehospitalization in patients suffering from severe depression [3]. A second study recruited 391 patients with HF (age, >50 years) and found that patients with severe depression have an 82% higher risk of death or functional decline [3] (Table 1). ...
... The study also reported higher rates of mortality and rehospitalization in patients suffering from severe depression [3]. A second study recruited 391 patients with HF (age, >50 years) and found that patients with severe depression have an 82% higher risk of death or functional decline [3] (Table 1). ...
Background
Heart failure (HF) is a chronic disease affecting patients’ quality of life (QoL) and may cause depression. Recent studies reported that the prevalence of depression in patients with HF is 21.5%. Antidepressants, mainly selective serotonin reuptake inhibitors, are usually prescribed for HF patients diagnosed with depression. Some evidence supports antidepressant’s role in improving symptoms by enhancing the psychological aspect of their QoL. Depression screening and treatment are important in the multidisciplinary management; however, their survival benefits are inconsistent. In our study, we aim to investigate the prevalence of depression and the use of antidepressants in patients with HF as well as to determine the acceptance of using antidepressants in such patients.
Methods
This is a cross-sectional study conducted by interviewing HF outpatients at National Guard Hospital in Riyadh. Patients were assessed using Hamilton depression rating scale.
Results
A total of 306 patients were included, with the majority (69%) being male and aged >61 years (60%). Patients’ medical history was classified into different groups, with the largest proportion (39.9%) in the diabetic-hypertensive group, followed by a diabetic group (21.2%) and a hypertensive group (10.8%). Patients were classified according to the New York Heart Association Functional Classification, and most patients were in Class I (61.8%). Some of the patients (8.5%) had been diagnosed with depression. There was no statistically significant association between HF and depression (p > 0.05). However, 5.6% of patients had been prescribed antidepressants and 17.1% of patients believed that they required antidepressants. Moreover, there was a statically significant association between medical history and development of depression (p = 0.014).
Conclusions
The prevalence of depression in HF patients in our population was lower than reported. There was no association between HF stage, depression, and antidepressant use.
... 6 These patients also experience lower health-related quality of life (HRQoL), 7 with the largest predictor of poor HRQoL being severity of depression rather than severity of HF. 8 Moreover, compared to people without depression, patients ISSN: 1740-4398 ORIGINAL RESEARCH -Antidepressants in depression and heart failure drugsincontext.com with HF and with depression are more likely to have frequent ambulatory care and emergency department visits, 6,9 nearly four times the risk of hospital admissions, 10 a lower threshold for adverse cardiac events, 11 longer hospital stays, 12 and more readmissions. 6 Research studies have shown that depression is an independent risk factor for both cardiac-related and allcause mortality in HF patients. ...
... 6 Research studies have shown that depression is an independent risk factor for both cardiac-related and allcause mortality in HF patients. 9,12,13 Antidepressant medications are the main intervention for depression in patients with HF. In addition to their potential impact on depression and anxiety, the serotonergic antidepressants, in particular, have other pharmacological properties that may potentially benefit HF patients, including anti-inflammatory action, inhibition of platelet aggregation, and promotion of endothelial stabilization. ...
Objective:
The purpose of this paper is to review the literature on the impact of antidepressants on depressive symptom severity, quality of life (QoL), morbidity, and mortality in patients with heart failure (HF).
Methods:
Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies published from December 1969 to December 2019 that pertain to depression and HF were identified through the use of the PubMed and PsycINFO databases, using the keywords: 'antidepressant*' and 'heart failure.' Two authors independently conducted a focused analysis and reached a final consensus on 17 studies that met the specific selection criteria and passed the study quality checks.
Results:
Studies varied in types of antidepressants used as well as in study designs. Ten studies were analyzed for the impact of antidepressant medications on depressive symptom severity. Five of these were randomized controlled trials (RCTs), out of which sertraline and paroxetine showed a significant reduction in depressive symptoms despite the small samples utilized. Four of the 17 studies addressed QoL as part of their outcomes showing no difference for escitalopram (RCT), significantly greater improvements for paroxetine controlled release (RCT), statistical significance for sertraline compared to control (pilot study), and showing significant improvement before and after treatment (open-label trial) for nefazodone. Thirteen of the 17 studies included measures of morbidity and mortality. Although early analyses have pointed to an association of antidepressant use and mortality particularly with fluoxetine, the reviewed studies showed no increase in mortality for antidepressants, and secondary analyses showed improved mortality in patients who achieved remission of depressive symptoms.
Conclusion:
Out of the various antidepressants studied, which included sertraline, paroxetine, escitalopram, citalopram, bupropion, nefazodone, and nortriptyline, selective serotonin reuptake inhibitors seem to be a safe treatment option for patients with depression and HF. However, due to the variety of study designs as well as the mixed results for each antidepressant, more information for reducing depression severity, morbidity, and mortality and improving quality of life in patients with HF should be examined using robust large sample RCTs.
... Rugulies' (2002) meta-analysis found that depression predicted coronary heart disease (CHD) in previously healthy individuals, and clinical depression, relative to depressive mood, was more strongly associated with CHD, indicating a possible dose-response relationship. Higher levels of depression among individuals with heart conditions have also been associated with increased mortality and functional decline (Fan et al. 2014;Jiang et al. 2007;Sherwood et al. 2007;Vaccarino et al. 2001;Zuluaga et al. 2010). ...
Aim
Heart conditions and depression have a complex and possible bi-directional relationship. This study is an effort to provide some clarity situated within the frame of COVID-19.
Subject and methods
The relationship between chronic heart conditions and depression-related outcomes was examined before and during the COVID-19 pandemic; this included feeling depressed, not being able to get “going,” restless sleep, feeling that everything was an effort, feeling sad, keeping the mind focused, and having a poor appetite. A retrospective study was performed using the National Longitudinal Survey of Youth 97 (NLSY97) dataset, with a sample size of 645 individuals. One-way multivariate analysis of covariance (MANCOVA) analyses were conducted to examine this relationship.
Results
Before the pandemic, having a chronic heart condition was not linked with a higher risk for depressive symptoms relative to not having a heart condition. During the pandemic, having a chronic heart condition was significantly linked with a higher risk for depressive symptoms relative to not having a heart condition; this included not being able to get “going” (F (1, 645) = 5.048, p = .025, η²p = .008) and restless sleep (F (1, 645) = 15.818, p < .001, η²p = .024).
Conclusion
Targeted interventions should be advanced to address the elevated likelihood of depressive symptoms among individuals with chronic heart conditions during public health emergencies.
... In general, approximately 17-37% of patients who were hospitalized with HF have major depressive disorder while 16-22% had minor depression [3]. Several other studies report different ranges of CHF patients with depression spanning from 13 to 78% [24,42,43]. The differences in the depression prevalence in patients withCHF might be a consequence of different screening test or criteria for a diagnosis, as well as the severity of the clinical picture itself, which can mask the symptoms of depression. ...
Background
Chronic heart failure (CHF) is a severe condition, often co-occurring with depression and anxiety, that strongly affects the quality of life (QoL) in some patients. Conversely, depressive and anxiety symptoms are associated with a 2–3 fold increase in mortality risk and were shown to act independently of typical risk factors in CHF progression. The aim of this study was to examine the impact of depression, anxiety, and QoL on the occurrence of rehospitalization within one year after discharge in CHF patients.
Methods
148 CHF patients were enrolled in a 10-center, prospective, observational study. All patients completed two questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Questionnaire Short Form Health Survey 36 (SF-36) at discharge timepoint.
Results
It was found that demographic and clinical characteristics are not associated with rehospitalization. Still, the levels of depression correlated with gender (p ≤ 0.027) and marital status (p ≤ 0.001), while the anxiety values were dependent on the occurrence of chronic obstructive pulmonary disease (COPD). However, levels of depression (HADS-Depression) and anxiety (HADS-Anxiety) did not correlate with the risk of rehospitalization. Univariate logistic regression analysis results showed that rehospitalized patients had significantly lower levels of Bodily pain (BP, p = 0.014), Vitality (VT, p = 0.005), Social Functioning (SF, p = 0.007), and General Health (GH, p = 0.002). In the multivariate model, poor GH (OR 0.966, p = 0.005) remained a significant risk factor for rehospitalization, and poor General Health is singled out as the most reliable prognostic parameter for rehospitalization (AUC = 0.665, P = 0.002).
Conclusion
Taken together, our results suggest that QoL assessment complements clinical prognostic markers to identify CHF patients at high risk for adverse events. Clinical Trial Registration : The study is registered under http://clinicaltrials.gov (NCT01501981, first posted on 30/12/2011), sponsored by Charité – Universitätsmedizin Berlin.
... Negative emotional states adversely affect quality of life [18,19,20] adherences to recommended treatment [21,22,23] and physical outcomes in patients with heart failure [24,25,26,27]. ...
Heart failure is a life-threatening condition in which the heart can no longer pump enough blood to meet the metabolic needs of the body (American Heart Association, 2017). Heart failure has a broad-ranging impact, affecting almost every important aspect of patients' lives. Patients suffering from heart failure frequently feel physical suffering and anxiety. A massage provides both physical and emotional wellness. Aim of the study: to examine the effect of back massage on anxiety and physiologic responses in patients with heart failure. Setting: The study was carried out at the coronary care unit at Menoufia University Hospital. Sample: A convenient sample of 84 patients of both sexes with congestive heart failure. Design: A quasi experiment design (study/control) was utilized. Tools: A Semi Structured Demographic Questionnaire; State Anxiety Inventory Scale; New York Heart Association Classification of Heart Failure and Biophysiological Parameters Sheet were used to collect data. Results: There was a highly statistically significant decrease in the mean score of total anxiety and improvement in physiologic responses (systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate and oxygen saturation) between study and control group post intervention, P< .001.Conclusion: After back massage for 3 consecutive days, the participants' systolic and diastolic blood pressure, heart rate, and respiratory rate were significantly lower than pre intervention, while their oxygen saturation levels significantly increased. Recommendation: Massage therapy should be used to balance the vital signs and reduce anxiety level of patients with heart failure admitted to the coronary care units.
... Negative emotional states adversely affect quality of life [18,19,20] adherences to recommended treatment [21,22,23] and physical outcomes in patients with heart failure [24,25,26,27]. ...
Heart failure is a life-threatening condition in which the heart can no longer pump enough blood to meet the metabolic needs of the body (American Heart Association, 2017). Heart failure has a broad-ranging impact, affecting almost every important aspect of patients' lives. Patients suffering from heart failure frequently feel physical suffering and anxiety. A massage provides both physical and emotional wellness. Aim of the study: to examine the effect of back massage on anxiety and physiologic responses in patients with heart failure. Setting: The study was carried out at the coronary care unit at Menoufia University Hospital. Sample: A convenient sample of 84 patients of both sexes with congestive heart failure. Design: A quasi experiment design (study/control) was utilized. Tools: A Semi Structured Demographic Questionnaire; State Anxiety Inventory Scale; New York Heart Association Classification of Heart Failure and Biophysiological Parameters Sheet were used to collect data. Results: There was a highly statistically significant decrease in the mean score of total anxiety and improvement in physiologic responses (systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate and oxygen saturation) between study and control group post intervention, P< .001.Conclusion: After back massage for 3 consecutive days, the participants' systolic and diastolic blood pressure, heart rate, and respiratory rate were significantly lower than pre intervention, while their oxygen saturation levels significantly increased. Recommendation: Massage therapy should be used to balance the vital signs and reduce anxiety level of patients with heart failure admitted to the coronary care units.
... The mechanism of the effect of depression should be understood in heart patients to better understand how psychological disorders affect psychological interventions. Vaccarino et al. (35) showed that depression is effective in the outcome of heart failure patients through physiological mechanisms. Depression is associated with the activation of the sympathetic nervous system. ...
Background: Heart failure is common worldwide, and it is still expanding. Psychological factors such as depression are more effective on the consequences of this disease, which is necessary to seek a solution for controlling. Objectives: This study aimed to investigate the effect of social problem-solving skills training (SPSST) on depression in patients with heart failure. Methods: This semi-experimental study was conducted on two groups of ten male patients with heart failure in Kermanshah, Iran, randomly assigned to the intervention and control groups. In the intervention group, ten one-hour sessions of SPSST were done. The Beck depression inventory (BDI-13) was completed three times before, after, and three months after the intervention in both groups. The data were analyzed in SPSS v. 23 with t-test and ANCOVA to compare the groups. Results: There was a significant difference in the depression scores of the intervention group in the post-test (P = 0.000) and follow-up (P = 0.003) than before the intervention. However, there was no significant difference in the depression scores of the control group in all stages (P > 0.05). Conclusions: SPSST could improve the depression of patients with heart failure and prevent its complications, which is recommended for controlling the depression of heart failure patients.
... Patients with HF experience various life-limiting symptoms such as dyspnea, fatigue, edema, sleeping difficulties, chest pain, and depression [11]. Moreover, they suffer from different and significant physical, psychological, and social burdens, resulting in poor health-related quality of life (HRQOL) [12,13]. Previously published studies indicated that HRQOL in patients with HF is greatly impaired when compared with healthy populations as well as those with other chronic diseases [14][15][16]. ...
Background
Heart Failure (HF) is a chronic disease associated with life-limiting symptoms that could negatively impact patients’ health-related quality of life (HRQOL). This study aimed to evaluate HRQOL and explore the factors associated with poor HRQOL among patients with HF in Jordan.
Methods
This cross-sectional study used the validated Arabic version of the Minnesota Living with Heart Failure Questionnaire to assess HRQOL in outpatients with HF visiting cardiology clinics at two public hospitals in Jordan. Variables were collected from medical records and custom-designed questionnaires, including socio-demographics, biomedical variables, and disease and medication characteristics. Ordinal regression analysis was used to explore variables associated with poor HRQOL among HF patients.
Results
Ordinal regression analysis showed that the number of HF medications (P < 0.05) and not taking a loop diuretic (P < 0.05) significantly increased HRQOL, while the number of other chronic diseases (P < 0.05), stage III/IV of HF (P < 0.01), low monthly income (P < 0.05), and being unsatisfied with the prescribed medications (P < 0.05) significantly decreased HRQOL of HF patients.
Conclusions
Although the current study demonstrated low HRQOL among patients with HF in Jordan, HRQOL has a considerable opportunity for improvement in those patients. Variables identified in the present study, including low monthly income, higher New York Heart Association (NYHA) classes, a higher number of comorbidities, and/or taking a loop diuretic, should be considered in future intervention programs, aiming to improve HRQOL in patients with HF.
... P<0.01), hospitalization for HF (27.4% vs. 9.2%; P = 0.01), all causes of death (27.4% vs. 7.2%; P < 0.01), and prolonged hospital stays (5)(6)(7)(8). This data leads us to consider depression as a first-order problem in terms of the comprehensive care provided to patients with HF (9,10). ...
Introduction: despite the existence of recommendations for the screening depressive symptoms in patients with cardiovascular disease and heart failure (HF), there are no comparative data regarding the performance of psychometric scales used in patients with HF. This study compares the psychometric performance of screening scales used for depressive symptoms in such patients. Methods: PRISMA declaration recommendations were used for the systematic review. MEDLINE, EMBASE, Psychology and Behavioral Sciences Collection, SCOPUS, Lilacs, Australasian Medical Index and the African Index from January 2000 to February 2016 were used for the search. The eligible articles were published in any language and they assessed the psychometric properties of screening scales for depressive symptoms in patients with HF. QUADAS-2 criteria was used for quality assessment, and a meta-analysis developed through a hierarchical model obtained the cluster estimations for sensitivity, specificity, likelihood ratio, predictive values, and diagnostic odds ratio (DOR) with 95% confidence intervals. Results: the initial search identified 1238 citations; only three gathered the inclusion criteria for quantitative assessment. The combined sensitivity and specificity was 56% (95% IC: 45-67%; T2=0.05) and 98% (95% IC: 96-99%; T2=0.01) respectively. The area under the curve was 0.92 (95% IC: 0.90-0.94). The variables related with the index test, reference test, Global QUDAS-2 score, and language predicted heterogeneity. Limitations: significant heterogeneity, small number of studies, selective cutoff report, and the lack of a cost-effectiveness analysis. Conclusions: The GDS-15, HADS-D, PHQ-9, CAT-D and PROMIS scales performed similarly with high specificity values.
... Heart failure (HF) is a complex clinical syndrome with signs and symptoms that are caused by any functional or structural impairment of ventricular filling or ejection of blood (1). Patients with HF suffer from significant physical, psychological, social burdens, and various life-limiting symptoms including dyspnea, fatigue, edema, sleeping difficulties, chest pain, depression (2)(3)(4). In 2018, it was estimated that 64.3 million patients were suffering from HF worldwide (5). ...
Background
Dyslipidemia is common among patients with heart failure, and it negatively impacts clinical outcomes. Limited data regarding the factors associated with poor lipid control in patients with HF patients. Therefore, this study aimed to evaluate lipid control and to explore the factors associated with poor lipid control in patients with HF.
Methods
The current cross-sectional study was conducted at outpatient cardiology clinics at two major hospitals in Jordan. Variables including socio-demographics, biomedical variables, in addition to disease and medication characteristics were collected using medical records and custom-designed questionnaire. Medication adherence was assessed using the validated 4-item Medication Adherence Scale. Binary logistic regression analysis was conducted to explore significant and independent predictors of poor lipid control among the study participants.
Results
A total of 428 HF patients participated in the study. Results showed that 78% of the participants had poor lipid control. The predictors that were associated with poor lipid control included uncontrolled BP (OR = 0.552; 95% CI: 0.330–0.923; P < 0.05), higher Hb levels (OR = 1.178; 95% CI: 1.013–1.369; P < 0.05), and higher WBC (OR = 1.133; 95% CI: 1.031–1.246; P < 0.05).
Conclusions
This study revealed poor lipid control among patients with HF. Future intervention programs should focus on blood pressure control in order to improve health outcomes among HF patients with dyslipidemia.
... Due to the disease and psychological pressure, experience depression may prolonged duration of illness. The prevalence of depression is significantly higher in HF patients than that in the general population (1)(2)(3). The incidence of HF combined with depression ranged from 31.0 to 77.5% (4). ...
Background
Depression is an independent factor to predict the hospitalization and mortality in the chronic HF patients. Citalopram is known as an effective drug for depression treatment. Currently, there is no specific recommendation in the HF guidelines for the treatment of psychological comorbidity. In recent years, many studies have shown that the citalopram may be safe in treating of chronic HF with depression.
Objective
To evaluate the efficacy and safety of the citalopram in the treatment of elderly chronic HF combined with depression.
Methods
PubMed, EMBASE, Cochrane, Web of Science, CNKI, VIP, CBM, and Wanfang were searched from their inception to May 2022. In the treatment of elderly chronic HF combined with depression, randomized controlled studies of the citalopram were included. Independent screening and extraction of data information were conducted by two researchers, and the quality was assessed by the Cochrane bias risk assessment tool. Review manager 5.4.1 was employed for statistical analysis.
Results
The results of meta-analysis prove that the citalopram treatment for depressed patients with chronic HF has a benefit for HAMD-24 (MD: −8.51, 95% CI: −10.15 to −6.88) and LVEF (MD: 2.42, 95% CI: 0.51 to 4.33). Moreover, the score of GDS decreases, and NT-proBNP (MD: −537.78, 95% CI: −718.03 to −357.54) is improved. However, the comparison with the control group indicates that there is no good effect on HAMD-17 (MD: −5.14, 95% CI: −11.60 to 1.32), MADRS (MD: −1.57, 95% CI: −3.47 to 0.32) and LVEDD (MD: −1.45, 95% CI: −3.65 to −0.76). No obvious adverse drug reactions were observed.
Conclusion
Citalopram treatment for depressed patients with chronic HF has a positive effect on LVEF and NT-proBNP. It can alleviate HAMD-24 and GDS, but the relative benefits for LVEDD, HAMD-17 and MADRS still need to be verified.
Systematic Review Registration : PROSPERO [CRD42021289917].
... Furthermore, mood disorders are quite frequent among HF patients, in particular depression is the most reported, and its rate is correlated with HF severity [22]. Depression is experienced by 10% of clinically asymptomatic outpatients, thereby raising to 40-70% in hospitalized NYHA III-IV subjects [23,24]. Anxiety is also very common in this setting, and at least a quarter of HF patients experience both depression and anxiety [25]. ...
Sacubitril/Valsartan (Sac-Val) has improved clinical prognosis in patients affected by heart failure (HF) with reduced ejection fraction (HFrEF). Comorbidities have a crucial impact on clinical presentation and prognosis in HF patients. Cognitive impairment (CoI) and Depression are a very common comorbidity in patients with HF and is widely recognized as a specific determinant of chronic disability, and HF patients with poor physical functional performance in Short physical performance battery (SPPB) showed a worse prognosis. The aim of the present study was to evaluate the potential effects of Sac-Val on functional, humoral, and cognitive aspects, evaluated by performing comprehensive geriatric assessment (CGA), in a cohort of elderly HFrEF. We studied 61 patients (51 men and 10 women, mean age 76.4 ± 5.1 years) suffering from HFrEF. After 6 months follow-up, we observed a significant improvement in humoral and functional parameters of CGA, renal function, NTpro-BNP levels and echocardiographic parameters. In the whole population, multivariate analysis shows that changes of Cardiac Index, NT-proBNP and Respiratory rate contributed for 26.0%, 9.7% and 4.8% to GDS variability, respectively, and the whole model accounted for a 41.1% of GDS variation; moreover changes of Global longitudinal strain, estimated glomerular filtration rate, Cardiac Index and BMI contributed for 23.9%, 11.7%, 5.4% and 4.0% to SPPB variability, respectively, and the whole model accounted for a 45% of SPPB variation. This represents the first real-world study carried out in an elderly population suffering from chronic HFrEF with numerous comorbidities, in which treatment with Sac-Val for 6 months induced important improvements in clinical, humoral, hemodynamic, and functional outcomes, without adverse effects on cognitive performance.
... A recent study found an association between self-reported anxiety symptoms as well as depressive symptoms and all-cause or cardiovascular mortality in patients with HF [7]. A graded association between depressive symptoms and functional decline in HF patients has also been reported and some may even develop major depression or commit suicide after being diagnosed with HF [1,8]. ...
Study objective
To examine first-time depression, anxiety, stress disorders or psychotropic drug prescriptions within one year after incident heart failure (HF).
Design
Nationwide Epidemiological registry study.
Setting
National patient registries.
Participants
Patients in Denmark with a first-time HF diagnosis during 2005–2015.
Interventions
None.
Main outcome measures
Incidences of depression, anxiety, stress disorders or first-time prescription of a psychotropic drug were determined.
Results
A total of 94,712 HF patients and 473,560 matched controls were included (median age 74.0 [64.0–81.0] years, 60.8 % males). At one year after incident HF, 11.9 % met the primary composite endpoint (depression, anxiety, or stress disorders or prescription of related psychotropic drugs), with 8.6 % outpatients and 13.3 % in-patients, versus 2.4 % of the controls. Starting psychotropic medication accounted for most of the composite endpoint events, as 11.6 % of the HF patients started antidepressants, anxiolytics, hypnotics, or sedative drugs (2.4 % among controls), while 0.6 % received a registered diagnosis of depression, anxiety, or stress disorder (<0.1 % among controls). The relative risk of psychotropic drug prescriptions in HF patients versus controls (standardized to the age, sex, and selected comorbidity distributions of all included subjects) was 3.85 [95 % CI 3.73–3.98]. The corresponding relative risk for one of the psychiatric diagnoses was 12.90 [95 % CI 10.60–15.19].
Conclusion
A substantial part of patients with newly diagnose heart failure started treatment with psychotropic drugs whereas only a small fraction was registered with depression, anxiety, or stress disorders within one-year follow-up. The incidences were significantly higher than in the background population.
... This suggested that presence of depressive symptoms was more common among individuals with existing health problems. In fact, the prevalence rates for HF patients in studies conducted abroad varied across a wide range, from 9% to 60% (Vaccarino et al. 2001;Pihl et al. 2005;Rutledge et al. 2006). The heterogeneity of the prevalence rates between current study and other studies could be explained by the differences in depression assessment methods (questionnaires or diagnostic interview) and diagnostic thresholds (cut-off points) being applied (Rutledge et al. 2006). ...
Heart failure (HF) patients with depression usually have poor prognosis. This study aimed to determine the prevalence of perceived depressive symptoms among outpatients with HF and its association with the New York Heart Association (NYHA) class. This was a cross-sectional survey conducted at the Heart Failure Clinic in Hospital Pulau Pinang (HPP) over 3 months period starting January 2020 using a convenience sampling method. All patients were included except patients under 18 years old, pregnant patients, diagnosed with psychiatric or depressive disorders and HF inpatients. A validated English and Malay version of Patient-Health Questionnaire-9 (PHQ-9) was used for screening of depressive symptoms. High scorers (≥ 10) were regarded as depressive. Results were reported in percentage (%) or median ± interquartile range (IQR). Fisher’s exact test with a 95% confidence interval was used. A total of 177 patients were recruited. The prevalence of perceived depressive symptoms among HF outpatients in HPP was 14.1%. The NYHA class was significantly associated with depressive status (p = 0.003). Depressive symptoms were common among these outpatients diagnosed with HF. A higher NYHA class suggested a higher depressive symptoms score. Screening for perceived depression especially patients with higher NYHA class was recommended.
... The clinical impact of depressive symptom on ADL score in elderly patients with respiratory disease decrease in physical function and functional capacity [6], and is considered to be a key factor of the decrease in quality of life (QOL) among patients with COPD [7]. Furthermore, previous research also indicated that depression decreases physical function and increases the risk of death in patients with heart failure [8]. However, the relationships between depression, physical function and activities of daily living (ADL) among elderly patients with respiratory diseases have not been thoroughly examined. ...
Ono M, Kono Y, Aoyagi Y, Tsuji Y, Ishikawa A, Sugiura T, Mori E, Tanaka Y, Kagaya H, Hirose M, Horiguchi T, Saitoh E. The clinical impact of depressive symptom on ADL score in elderly patients with respiratory disease. Jpn J Compr Rehabil Sci 2018: 9: 29-33.
Background: This study aimed to clarify the impact of depressive symptom on activities of daily living (ADL) in elderly patients with respiratory disease.
Methods: We studied 160 consecutive patients who met the criterion of no physical disability. During hospitalization, we measured physical function, respiratory function and Hospital Anxiety and Depression Scale (HADS). Firstly, we divided the patients into two groups (depression group and non-depression group) followed by presence of depressive symptom, which was defined as an HADS score of 8 points or more. Then we analyzed the association between depressive symptom and the other clinical variables mentioned above by the chi-squared test and unpaired t-test.
Results: There were 40 patients (22.7%) in the depression group. There was no statistically significant difference in age, sex, BMI, physical function or respiratory function. Although we could not find any difference in FIM motor score, the score of NRADL (The Nagasaki University Respiratory Activity of Daily Living Questionnaire), which is a disease-specific ADL score, was significantly lower in the depression group than the non-depression group (71.6 points vs 59.7 points).
Conclusion: We clarified that depressive symptom was closely related to NRADL score, but not to FIM motor score. The results also suggest that it is important to consider the impact of depressive symptom on ADL score when evaluating ADL in elderly patients with respiratory disease.
... Patients with heart failure experience various emotional as well as physical symptoms such as dyspnea, sleeping difculties, fatigue, edema, depression, and 3,4 chest pain . These symptoms limit patient's daily physical and social [5][6][7] activities and result in poor quality of life . ...
INTRODUCTION: Congestive Heart Failure is a complex physiological syndrome caused from structural or functional alterations to the myocardium. Lactate is produced by anaerobic metabolism and is secreted by the Brain-Natriuretic peptide heart ventricles in response to left ventricular stretching or wall tension. AIM: The aim of the study was to evaluate Brain-Natriuretic Peptide, Lactate levels and Blood pressure in Congestive Heart Failure patients and compared them with healthy individual. MATERIALS AND METHODS: Total 80 participants who fullled the inclusion and exclusion criteria were enrolled in the study. They were divided into two group i.e., case and control group. Case group included 40 patients of Congestive Heart Failure, age between 18-65 years and control group comprised of 40 healthy individuals with similar age range. Blood sample were drawn and analyzed for the evaluation of Serum lactate and Brain-Natriuretic Peptide. Blood Pressure was also measured in both the groups. RESULT: The present study has demonstrated that the level of Brain-Natriuretic Peptide and lactate were signicantly high in Congestive heart failure patients when compared with control group. Systolic and Diastolic blood pressure were also higher among patients group. CONCLUSION: The results of the study suggested that the levels of Lactate and Brain-Natriuretic Peptide were high in Congestive heart failure patients when compared with healthy individual. Systolic and Diastolic blood pressure were also higher among patients group. Elevated lactate and Brain-Natriuretic Peptide level can be recommended as useful indicator of poor prognosis and hence can be helpful in early identication of patients at risk.
... But it is well known that the quality of life and psychological well-being are not always tightly following the severity of the disease. The lack of relation between EF and GDS score was also observed by V Vaccarino et al. (27) In their cohort of 391 patients with HF, almost 50% were with EF>40% and the mean GDS score was not different in the various levels of EF reduction (p=0.13). The mean GDS score was almost identical to ours-7.3 vs. 7.23. ...
... H eart failure (HF) affects approximately 6.2 million people in the US and is the leading cause for hospitalizations among Medicare patients. 1 Depression is comorbid in 20% to 40% of patients with HF 2 and associated with worse health-related quality of life (HRQOL), 3,4 reduced adherence with recommended care, 5 higher levels of health services utilization, [6][7][8] and increased mortality. [9][10][11][12] Yet despite the availability of proven-effective treatments, depression is often unrecognized and untreated in patients with HF. 13 Several trials have examined the effect of treating depression as a means to improve clinical outcomes for patients with cardiovascular disease, but they reported mixed benefits on mood symptoms, [14][15][16][17][18][19] and none reduced hospital admissions or mortality. ...
Importance
Depression is often comorbid in patients with heart failure (HF) and is associated with worse clinical outcomes. However, depression generally goes unrecognized and untreated in this population.
Objective
To determine whether a blended collaborative care program for treating both HF and depression can improve clinical outcomes more than collaborative care for HF only and physicians’ usual care (UC).
Design, Setting, and Participants
This 3-arm, single-blind, randomized effectiveness trial recruited 756 participants with HF with reduced left ventricular ejection fraction (<45%) from 8 university-based and community hospitals in southwestern Pennsylvania between March 2014 and October 2017 and observed them until November 2018. Participants included 629 who screened positive for depression during hospitalization and 2 weeks postdischarge and 127 randomly sampled participants without depression to facilitate further comparisons. Key analyses were performed November 2018 to March 2019.
Interventions
Separate physician-supervised nurse teams provided either 12 months of collaborative care for HF and depression (“blended” care) or collaborative care for HF only (enhanced UC [eUC]).
Main Outcomes and Measures
The primary outcome was mental health–related quality of life (mHRQOL) as measured by the Mental Component Summary of the 12-item Short Form Health Survey (MCS-12). Secondary outcomes included mood, physical function, HF pharmacotherapy use, rehospitalizations, and mortality.
Results
Of the 756 participants (mean [SD] age, 64.0 [13.0] years; 425 [56%] male), those with depression reported worse mHRQOL, mood, and physical function but were otherwise similar to those without depression (eg, mean left ventricular ejection fraction, 28%). At 12 months, blended care participants reported a 4.47-point improvement on the MCS-12 vs UC (95% CI, 1.65 to 7.28; P = .002), but similar scores as the eUC arm (1.12; 95% CI, −1.15 to 3.40; P = .33). Blended care participants also reported better mood than UC participants (Patient-Reported Outcomes Measurement Information System–Depression effect size, 0.47; 95% CI, 0.28 to 0.67) and eUC participants (0.24; 95% CI, 0.07 to 0.41), but physical function, HF pharmacotherapy use, rehospitalizations, and mortality were similar by both baseline depression and randomization status.
Conclusions and Relevance
In this randomized clinical trial of patients with HF and depression, telephone-delivered blended collaborative care produced modest improvements in mHRQOL, the primary outcome, on the MCS-12 vs UC but not eUC. Although blended care did not differentially affect rehospitalization and mortality, it improved mood better than eUC and UC and thus may enable organized health care systems to provide effective first-line depression care to medically complex patients.
Trial Registration
ClinicalTrials.gov Identifier: NCT02044211
... 8 The prevalence of depression in conjunction with heart failure is very high, ranging from 9 to 60%. 9,10 Various studies have demonstrated that depression in patients with heart failure is multifactorial and may be due to fear and anxiety following diagnosis, debilitating symptoms, limitation in physical function, uncertainty about the future, and reduced confidence in one's ability to play personal, social, and professional roles, doubts about doing certain activities, low self-esteem, and negative self-concept. [11][12][13][14] Depression, associated with poor prognosis, is characterized by symptoms that affect the cognitive, emotional, and behavioral processes of patients with heart failure. ...
Introduction: Psychological factors including depression and anxiety are the most critical risk factors in the treatment and prognosis of heart failure which should be addressed in treatment and care programs. The purpose of this study was to examine the effect of cognitive-behavioral training (CBT) on depression severity and self-care ability of patients with heart failure.
Methods: This study was a randomized clinical trial that carried out on 80 patients with heart failure who had been hospitalized in 2018. The participants were divided into the CBT group (n= 40) and the conventional training (CT) group (n= 40), randomly. Data were collected using Beck Depression Inventory (BDI) and the Self-Care of Heart Failure Index (SCHFI) version 6.2 before and 8 weeks after the educational interventions. Data were analyzed in SPSS 21 using paired t-test, independent t-test, chi-square test, and covariance analysis.
Results: The mean score of self-care in the CBT group turned out to be significantly higher than the CT group after receiving the intervention. Also, the mean depression score of the CBT group 26.95 (5.53) after intervention was significantly lower than the CT group 36.04 (8.45).
Conclusion: Cognitive-behavioral intervention, compared with conventional training, had a greater positive impact on improving self-care and alleviating the severity of depression symptoms. Therefore, it is recommended that the principles of cognitive-behavioral therapy be integrated into routine educational programs.
... Depression severity appears to be a stronger predictor of poor HRQoL than severity of heart failure [20]. Increased severity of depressive symptoms increases risk for functional decline or death at six months among heart failure patients [21]. In a large study of outpatients with AHF, depression was found to be an independent risk factor for mortality after adjusting for confounders [22]. ...
Objectives
Heart Failure is a chronic syndrome affecting over 5.7 million in the US and 26 million adults worldwide with nearly 50% experiencing depressive symptoms. The objective of the study is to compare the effects of two evidence-based treatment options for adult patients with depression and advanced heart failure, on depressive symptom severity, physical and mental health related quality of life (HRQoL), heart-failure specific quality of life, caregiver burden, morbidity, and mortality at 3, 6 and 12-months.
Methods
Trial design. Pragmatic, randomized, comparative effectiveness trial.
Interventions. The treatment interventions are: (1) Behavioral Activation (BA), a patient-centered psychotherapy which emphasizes engagement in enjoyable and valued personalized activities as selected by the patient; or (2) Antidepressant Medication Management administered using the collaborative care model (MEDS).
Participants. Adults aged 18 and over with advanced heart failure (defined as New York Heart Association (NYHA) Class II, III, and IV) and depression (defined as a score of 10 or above on the PHQ-9 and confirmed by the MINI International Neuropsychiatric Interview for the DSM-5) selected from all patients at Cedars-Sinai Medical Center who are admitted with heart failure and all patients presenting to the outpatient programs of the Smidt Heart Institute at Cedars-Sinai Medical Center. We plan to randomize 416 patients to BA or MEDS, with an estimated 28% loss to follow-up/inability to collect follow-up data. Thus, we plan to include 150 in each group for a total of 300 participants from which data after randomization will be collected and analyzed.
Conclusions
The current trial is the first to compare the impact of BA and MEDS on depressive symptoms, quality of life, caregiver burden, morbidity, and mortality in patients with depression and advanced heart failure. The trial will provide novel results that will be disseminated and implemented into a wide range of current practice settings.
Registration
ClinicalTrials.Gov Identifier: NCT03688100 .
... A study performed in the United Kingdom found that more than 986,000 bed-days were distributed among 54,000 male patients diagnosed with HF and more than 1.37 million bed-days were distributed among 59,000 women diagnosed with HF. The increased severity of depressive symptoms was found to increase the risk for functional decline or death at six months among patients with HF. 32 After adjusting for confounders, a study of 1,017 outpatient patients with HF concluded that depression was an independent risk factor for mortality. 33 The present systematic review of published literature relating to depression in HF was performed to identify areas where future studies could elaborate further by addressing the following questions: 1) what are the instruments used to measure depression in HF, and 2) what is the impact of treatment interventions on depression in HF? ...
Objective: This paper sought to identify the instruments used to measure depression in heart failure (HF) and elucidate the impact of treatment interventions on depression in HF. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. Studies published from 1988 to 2018 covering depression and HF were identified through the review of the PubMed and PsycINFO databases using the keywords: "depres*" AND "heart failure." Two authors independently conducted a focused analysis, identifying 27 studies that met the specific selection criteria and passed the study quality checks. Results: Patient-reported questionnaires were more commonly adopted than clinician-rated questionnaires, including the Beck Depression Inventory, the Patient Health Questionnaire (PHQ-9), and the Hospital Anxiety and Depression Scale. Six common interventions were observed: antidepressant medications, collaborative care, psychotherapy, exercise, education, and other nonpharmacological interventions. Except for paroxetine, selective serotonin reuptake inhibitors failed to show a significant difference from placebo. However, the collaborative care model including the use of antidepressants showed a significant decrease in PHQ-9 score after one year. All of the psychotherapy studies included a variation of cognitive behavioral therapy and patients showed significant improvements. The evidence was mixed for exercise, education, and other nonpharmacological interventions. Conclusion: This study suggests which types of interventions are more effective in addressing depression in heart failure patients.
Inequities and gaps in palliative care access are a serious impediment to health systems especially low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions. In this paper, we present an updated methodology - SHS2.0 - building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions. Our updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. We also share detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS. We discuss the opportunities for applying SHS to future policy making, assess future research priorities particularly in light of the dearth of data from low- and middle-income countries, and share directions for future work to develop SHS 3.0.
Importance
Heart failure (HF) affects more than 6 million adults in the US and more than 64 million adults worldwide, with 50% prevalence of depression. Patients and clinicians lack information on which interventions are more effective for depression in HF.
Objective
To compare the effectiveness of behavioral activation psychotherapy (BA) vs antidepressant medication management (MEDS) on patient-centered outcomes inpatients with HF and depression.
Design, Setting, and Participants
This pragmatic randomized comparative effectiveness trial was conducted from 2018 to 2022, including 1-year follow-up, at a not-for-profit academic health system serving more than 2 million people from diverse demographic, socioeconomic, cultural, and geographic backgrounds. Participant included inpatients and outpatients diagnosed with HF and depression, and data were analyzed as intention-to-treat. Data were analyzed from 2022 to 2023.
Interventions
BA is an evidence-based manualized treatment for depression, promoting engagement in personalized pleasurable activities selected by patients. MEDS involves the use of an evidence-based collaborative care model with care managers providing coordination with patients, psychiatrists, and primary care physicians to only administer medications.
Main Outcomes and Measures
The primary outcome was depressive symptom severity at 6 months, measured using the Patient Health Questionnaire 9-Item (PHQ-9). Secondary outcomes included physical and mental health-related quality of life (HRQOL), measured using the Short-Form 12-Item version 2 (SF-12); heart failure-specific HRQOL, measured using the Kansas City Cardiomyopathy Questionnaire; caregiver burden, measured with the Caregiver Burden Questionnaire for Heart Failure; emergency department visits; readmissions; days hospitalized; and mortality at 3, 6, and 12 months.
Results
A total of 416 patients (mean [SD] age, 60.71 [15.61] years; 243 [58.41%] male) were enrolled, with 208 patients randomized to BA and 208 patients randomized to MEDS. At baseline, mean (SD) PHQ-9 scores were 14.54 (3.45) in the BA group and 14.31 (3.60) in the MEDS group; both BA and MEDS recipients experienced nearly 50% reduction in depressive symptoms at 3, 6, and 12 months (eg, mean [SD] score at 12 months: BA, 7.62 (5.73); P < .001; MEDS, 7.98 (6.06); P < .001; between-group P = .55). There was no statistically significant difference between BA and MEDS in the primary outcome of PHQ-9 at 6 months (mean [SD] score, 7.53 [5.74] vs 8.09 [6.06]; P = .88). BA recipients, compared with MEDS recipients, experienced small improvement in physical HRQOL at 6 months (mean [SD] SF-12 physical score: 38.82 [11.09] vs 37.12 [10.99]; P = .04), had fewer ED visits (3 months: 38% [95% CI, 14%-55%] reduction; P = .005; 6 months: 30% [95% CI, 14%-40%] reduction; P = .008; 12 months: 27% [95% CI, 15%-38%] reduction; P = .001), and spent fewer days hospitalized (3 months: 17% [95% CI, 8%-25%] reduction; P = .002; 6 months: 19% [95% CI, 13%-25%] reduction; P = .005; 12 months: 36% [95% CI, 32%-40%] reduction; P = .001).
Conclusions and Relevance
In this comparative effectiveness trial of BA and MEDS in patients with HF experiencing depression, both treatments significantly reduced depressive symptoms by nearly 50% with no statistically significant differences between treatments. BA recipients experienced better physical HRQOL, fewer ED visits, and fewer days hospitalized. The study findings suggested that patients with HF could be given the choice between BA or MEDS to ameliorate depression.
Trial Registration
ClinicalTrials.gov Identifier: NCT03688100.
Heart failure is a complex condition where the heart is unable to pump blood effectively because of a structural or functional abnormality. This condition is associated with a substantial human and economic burden, with a particularly high impact on patients' quality of life. However, previous research suggests that patient education, which is often delivered by nurses, can help to reduce the burden of heart failure, both for patients and healthcare services. This review aimed to assess the impact of nurse-led patient education programmes on the quality of life among patients with heart failure. Key electronic databases (MEDLINE, CINAHL, PsycINFO and Web of Science) were searched from inception to February 2022. Studies of adults with heart failure who received in-person nurse-led patient education using a quality of life assessment tool were included. Of the 2225 studies retrieved in the initial search, 18 were included in the final review, including a total of 2413 participants. Physical health was assessed across all studies, with some variation in the findings, particularly in relation to the impact of patient education on mortality rates. However, positive mental health outcomes were reported in intervention groups across selected studies, with one study reporting significant improvement at 12 months compared to a control group (P=0.038). This indicates that nurse-led patient education can improve some aspects of patients' quality of life, reinforcing the importance of this aspect of nursing care in heart failure management, while also highlighting areas in need of further research.
Background:
To discuss the effect of non-drug interventions on anxiety and depression in patients with heart failure (HF) through Bayesian network meta-analysis.
Methods:
Relevant literature was searched from PubMed, Web of Science, Embase and Medline from database establishment to October 2022 by a computer. Next, a screening was performed on randomized controlled trials (RCTs) for the effect of non-drug interventions on anxiety and depression in HF patients, followed by a collection of the related data. This meta-analysis was conducted based on Bayesian network, and the statistical analysis was conducted using R4.2 software.
Results:
A total of 23 papers were enrolled into this study. The results of Bayesian network meta-analysis showed that compared with the control group and the structured video conferencing support (SVCS) group, telephone case management (TCM) could effectively reduce the anxiety and depression of HF patients. The ranking results revealed that TCM may be the most effective intervention to lower the risk of depression in HF patients, followed by Tai Chi Chuan and Chi Kung training (TCC) and structured telephone support (STS).
Conclusion:
TCM is the most effective intervention to prevent HF patients from anxiety and depression.
Background:
Cardiac cachexia (CC) is associated with increased morbidity and mortality in persons with heart failure (HF). Compared to the biological underpinning of CC, little is known about the psychological factors. Thus, the overarching objective of this study was to determine whether depression predicts the onset of cachexia at 6 months in patients with chronic HF.
Methods:
114 participants with a mean age of 56.7 ± 13.0 years, LVEF of 33.13 ± 12.30% and NYHA class III (48.0%) were assessed for depression using the PHQ-9. Body weight was measured at baseline and at 6 months. Patients who had ≥6% non-edematous unintentional weight loss were classified as cachectic. Univariate and logistic multivariate regression were used to examine the relationship between CC and depression, controlling for clinical and demographic variables.
Results:
Cachectic patients (11.4%) had significantly higher baseline BMI levels (31.35 ± 5.70 vs. 28.31 ± 4.73; p = .038), lower LVEF (mean = 24.50 ± 9.48 vs. 34.22 ± 12.18, p = .009), and depression scores (mean = 7.17 ± 6.44 vs. 4.27 ± 3.98, p = .049) when compared to their non-cachectic counterparts. In multivariate regression analysis, depression scores (β = 1.193, p = .035) and LVEF (β = .835, p = .031) predicted cachexia after controlling for age, gender, body mass index, VO2 max, and New York Heart Association class and accounted for 49% of the variance in Cardiac cachexia. When depression was dichotomized, depression and LVEF predicted 52.6% of the variance in CC.
Conclusion:
Depression predicts CC in patients with HF. Additional studies are needed to expand the knowledge of the role of the psychological determinants of this devastating syndrome.
Among various neuropsychiatric disorders, depression and anxiety are commonly encountered in patients with heart failure (HF), reported in ≥ 50% of patients attending a HF clinic, but may frequently elude clinician’s attention. Both disorders are associated with the development and progression of HF, incurring higher rates of morbidity/mortality, probably via physiologic and behavioral mechanisms. Patients with devices and/or advanced HF are more severely affected, especially early following device receipt. In addition, various other neuropsychiatric and neuropsychological disorders and symptoms of these and other disorders occur in and impact HF patients, including sleep disorders and cognitive impairment, which further interact with and amplify depression and anxiety. Mechanisms involved in the link between neuropsychiatric/neuropsychological disorders and HF may relate to pathophysiological processes, lifestyle factors, and behavioral patterns. Among the pathophysiological factors, inflammation, autonomic dysfunction, endothelial dysfunction, thrombotic mechanisms, and dysregulation of the hypothalamic–pituitary–adrenal axis may play a significant role as they are implicated in the pathogenesis, progression, and prognosis of HF. Multimodal psychiatric management strategies with flexible approaches, using antidepressants/anxiolytics/atypical antipsychotics and various psychotherapies such as cognitive behavioral therapy combined with exercise adjusted to patients’ care and needs, appear promising in this patient group. Choosing agents with a higher efficacy/safety profile is a prudent strategy. Although depression and anxiety are risk factors for mortality in HF patients, indiscriminate use of psychiatric medications may not improve or even worsen survival when one neglects to closely monitor for potential proarrhythmic and other side effects. Newer meta-analytic data in HF patients indicate no increase in mortality for newer antidepressants, while secondary analyses show improved survival in patients who achieved remission of depressive symptoms.
Depression is a well-known risk factor for adverse cardiovascular outcomes in patients with cardiovascular diseases. The prevalence of depression in patients with cardiovascular diseases has been reported to be approximately 20 %. A two-step depression screening protocol using the 2-item Patient Health Questionnaire (PHQ-2) and the 9-item Patient Health Questionnaire (PHQ-9) is recommended for patients with cardiovascular diseases. Cardiovascular diseases and depression share a common pathology, including increased activity of the sympathetic nervous system, hyperactivity of hypothalamic-pituitary-adrenal axis, and inflammation. Psychosocial and environmental factors are also associated with depression and cardiovascular outcomes. Randomized controlled trials of antidepressant treatment for patients with depression and cardiovascular diseases have shown no advantage regarding cardiovascular outcomes. However, improvement in depressive symptoms, regardless of the method, may lead to a reduction in subsequent cardiovascular events. A collaborative approach between cardiologists and psychiatrists is recommended to manage depression in patients with cardiovascular diseases. Future research should identify more specific targets for treating patients with cardiovascular diseases, involve collaboration with professionals across fields, and establish community support systems.
Background:
Functional debility is associated with worse outcomes in the general heart failure population, but the prevalence of difficulty with activities of daily living and clinical significance once patients develop advanced heart failure requires further examination.
Methods:
This was a population-based, retrospective cohort study of Olmsted County, Minnesota adults with advanced heart failure from 2007-2018. Difficulty with 9 activities of daily living was assessed by questionnaire. Predictors of difficulty were assessed by a proportional odds model. Associations of difficulty with activities of daily living with mortality and hospitalization were examined using Cox and Andersen-Gill models.
Results:
Among 765 patients with advanced heart failure, 565 (73.9%) reported difficulty with activities of daily living at diagnosis. Of those, 257 (45%) had moderate and 148 (26%) had severe difficulty. Independent predictors of difficulty included female sex (odds ratio [OR] 1.73; 95% confidence interval [CI], 1.26-2.36; P = .001), older age (OR per 10-year increase 1.17; 95% CI, 1.05-1.31; P = .005), dementia (OR 1.85; 95% CI, 1.06-3.24; P = .031), depression (OR 1.75; 95% CI, 1.28-2.40; P = .001), and morbid obesity (OR 1.49; 95% CI, 1.04-2.13; P = .031). Estimated 2-year mortality was 61.5%, 64.2%, and 67.6% in patients with no/minimal, moderate, and severe difficulty, respectively. The adjusted hazard ratios (95% CI) for death were 1.08 (0.90-1.28) and 1.17 (0.95-1.43) for moderate and severe difficulty, respectively, vs no/minimal difficulty (P = .33). There were no statistically significant associations of difficulty with activities of daily living and hospitalization risks.
Conclusions:
Most patients with advanced heart failure have difficulty completing activities of daily living and are at high risk of mortality regardless of impairment in activities of daily living.
Objectives
The prevalence of activities of daily living (ADL) in patients with heart failure (HF) reported in current studies were inconsistent, ranging from 11.1 to 70.5%. The purpose of this study is to quantify the prevalence of ADL impairment in HF patients.Methods
PubMed, Embase, Cochrane, CINAHL, CNKI, SinoMed, VIP, and Wanfang databases were systematically searched for relevant studies (up to March 2, 2022). Cross-sectional, case-control, or cohort studies with detailed descriptions of overall ADL impairment in HF were included. Stata 16.0 was used for statistical analysis. Fixed-effect or random-effect model was adopted according to heterogeneity which was evaluated by Cochran’s Q and I2 values. Sensitivity analysis, subgroup analysis, and meta-regression were performed to investigate the sources of heterogeneity.ResultsA total of 12 studies with 15,795 HF patients were included in the meta-analysis, and the pooled prevalence of ADL impairment in patients with HF was 38.8% (95%CI: 28.2–49.3%; I2 = 99.5%, P < 0.001). No possible sources of heterogeneity were found in subgroup analysis and meta-regression. Funnel plots and Egger’s test showed no publication bias (P = 0.595).Conclusion
The prevalence of ADL impairment is relatively high in HF patients. Differences in the prevalence of ADL impairment in patients with HF may be influenced by country, region, and assessment time. We suggest that more researchers could focus on the changes of ADL impairment in HF patients during different disease periods in different regions and countries.
Context
Advanced heart failure (HF) patients often experience distressing psychological symptoms, frequently meeting diagnostic criteria for psychological disorders, including anxiety, depression, and substance use disorder. Patients with device-based HF therapies have added risk for psychological disorders, with consequences for their physiological functioning, including adverse cardiac outcomes.
Objectives
This study used natural language processing (NLP) for computer-assisted chart review to assess documentation of mental health and substance use in HF patients awaiting cardiac resynchronization therapy (CRT), a device-based HF therapy.
Methods
We applied NLP to clinical notes from electronic health records (EHR) of 965 consecutive patients, with 9,821 total clinical notes, at two academic medical centers between 2004 and 2015. We developed and validated a keyword library capturing terms related to mental health and substance use, while balancing specificity and sensitivity.
Results
Mean age was 71.6 years (SD = 11.8), 78% male, and 87% non-Hispanic White. Of the 544 patients (56.4%) with documentation of mental health history, 9.7% had their mental health assessed and 6.6% had a plan documented. Of the 773 patients (80.1%) with documentation of substance use history, 10 (1.0%) had an assessment, and 3 (0.3%) had a plan.
Conclusion
Despite clinical recommendations and standards of care, clinicians are under documenting assessments and plans prior to CRT. Future research should develop an algorithm to prompt clinicians to document this content. Such quality improvement efforts may ensure adherence to standards of care and clinical guidelines.
The occurrence of depression, anxiety, and insomnia is strikingly high in patients with heart failure and is linked to increased morbidity and mortality. However, symptoms are frequently unrecognized and the integration of mental health into cardiology care plans is not routine. This article describes the prevalence, identification, and treatment of common comorbid psychological disorders.
With advances in heart failure (HF) treatment, patients are living longer, putting further emphasis on quality of life (QOL) and the role of palliative care principles in their care. Spirituality is a core domain of palliative care, best defined as a dynamic, multidimensional aspect of oneself for which 1 dimension is that of finding meaning and purpose. There are substantial data describing the role of spirituality in patients with cancer but a relative paucity of studies in HF. In this review article, we explore the current knowledge of spirituality in patients with HF; describe associations among spirituality, QOL, and HF outcomes; and propose clinical applications and future directions regarding spiritual care in this population. Studies suggest that spirituality serves as a potential target for palliative care interventions to improve QOL, caregiver support, and patient outcomes including rehospitalization and mortality. We suggest the development of a spirituality-screening tool, similar to the Patient Health Questionnaire-2 used to screen for depression, to identify patients with HF at risk for spiritual distress. Novel tools are soon to be validated by members of our group. Given spirituality in HF remains less well studied compared with other patient populations, further controlled trials and uniform measures of spirituality are needed to understand its impact better.
Objective:
Physical activity (PA) can improve symptoms of both depression and heart failure (HF), but objective activity data among recently hospitalized HF patients with co-morbid depression is lacking. We examined PA and the relationship between daily step counts and mood, health-related quality of life (HRQoL), and heart health among patients enrolled in a clinical trial treating HF and co-morbid depression.
Methods:
We screened hospitalized patients with systolic HF (left ventricular ejection fraction [LVEF] ≤45%) and New York Heart Association (NYHA) class II-IV symptoms for depression using the 2-item Patient Health Questionnaire (PHQ-2) and telephoned screen-positive patients to administer the PHQ-9 two-weeks post-discharge. If the patient scored PHQ-9 ≥ 10 and agreed to continue in our study, we administered our baseline assessment and mailed them an armband accelerometer. We instructed patients to wear the armbands for 7 days before returning them and classified their data as "usable" if they wore it ≥10 hours per day on ≥4 separate days.
Results:
We mailed accelerometers to 531 depressed HF patients and 222 (42%) returned them with usable data. Their median age was 64 years, 54% were women, 23% were non-White, and they walked a median of 1,170 steps daily. Higher median daily step counts were associated with lower NYHA class and better physical- and heart failure-specific HRQoL, but not mood symptoms, mental HRQoL, or LVEF.
Conclusions:
Patients with HF and co-morbid depression are generally sedentary following hospital discharge. While mood symptoms and LVEF were unrelated to objective physical activity, patients with higher step counts self-reported better HRQoL.Trial registrationClinicalTrials.gov identifier NCT02044211.
Cardiovascular complications have been demonstrated in patients with anorexia nervosa (AN) in both the state of starvation and during weight restoration, however, the underlying mechanisms remain unclear. The current study aimed to assess arterial stiffness via carotid-femoral pulse wave velocity (cfPWV) in the acute and weight-restored states of AN. The study also aimed to determine the association between psychological distress and cfPWV. The sample included 37 participants; 10 participants with AN, 17 who were weight-restored (AN-WR; minimum body mass index >18.5 for at least 12 months) and 10 healthy controls (HCs). cfPWV via applanation tonometry was conducted to assess arterial stiffness. Psychological distress was assessed using the depression anxiety stress scale (DASS-21) and the state-trait anxiety inventory (STAI). Between-group comparisons were performed to determine differences between groups, a two-stage hierarchical regression model was performed to determine the contribution of physiological and psychological variables on cfPWV and correlation analyses were also performed. Vascular stiffness was significantly increased in the AN and AN-WR groups, relative to HCs. The total DASS score was the only significant predictor of cfPWV across the sample. There were positive associations between cfPWV and depression, anxiety and stress, as assessed by the DASS. Furthermore, cfPWV was positively associated with STAI trait anxiety. Arterial stiffness was increased in individuals in the acute and weight-restored states of AN, demonstrating early signs of the development of arteriosclerotic cardiovascular disease. Increased arterial stiffness was associated with increased psychological distress, which may be a contributing mechanism to the increased cardiovascular risk in AN.
Although sepsis is known to cause functional decline, the prevalence and predictors of hospital-acquired functional decline (HAFD) in patients with sepsis are unclear. The purpose of this study was to investigate the prevalence and predictors of HAFD in patients with sepsis admitted to the ICU. This study is a single-center retrospective observational study from January 2014 to December 2019. We included all consecutive patients with sepsis who received rehabilitation in our ICU. The primary outcome was HAFD, which was defined as a decrease in at least five points of the Barthel index mobility score from prehospital to hospital discharge. We described the prevalence of HAFD and investigated the predictors of HAFD using the multivariate logistic regression analysis adjusting for potential confounders. Among 134 patients, 57 patients (42.5%) had HAFD. The longer time to initial ambulation and lower prehospital walking ability were associated with HAFD (adjusted odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.10 and adjusted OR 0.79; 95% CI, 0.66-0.95, respectively). In conclusion, nearly half of the patients with sepsis who received rehabilitation developed HAFD. Lower functional status prior to hospitalization and the longer time to initial ambulation was associated with HAFD, indicating the potential importance of early ambulation among septic patients in the ICU.
Резюме. Цукровий діабет (ЦД) являє собою одну з провідних медико-соціальних проблем сучасного суспільства, що зумовлено високою захворюваністю та його поширеністю, частим виникненням ускладнень. Дослідження факторів розвитку, а саме: порушення сну, депресія, серцево-судинні захворювання (ССЗ), вивчення причини, комплексне розв’язання проблеми, наявність якої негативно позначається на якості життя людини, дозволять покращити стан здоров’я пацієнтів із ЦД 2 типу. Мета дослідження – проаналізувати літературні джерела щодо впливу тривожних, депресивних розладів на розвиток і прогресування серцево-судинних захворювань у пацієнтів із цукровим діабетом 2 типу для ранньої діагностики захворювань та їх профілактику. Матеріали і методи. При дослідженні використано дані літературних джерел та дані проведених наукових досліджень щодо причин розвитку захворювань, зокрема депресії, цукрового діабету 2 типу, розладів сну, серцево-судинних захворювань, і їх взаємозв’язок та взаємовплив. Результати. Цукровий діабет 2 типу є найпоширенішим типом діабету, що становить близько 90 % усіх випадків діабету. Це захворювання найчастіше діагностується у дорослих людей, але все частіше спостерігається у дітей, підлітків через підвищення рівня ожиріння, малорухливого способу життя, психоемоційного перевантаження, стресів. Депресія є фактором ризику виникнення цукрового діабету та негативно впливає на його перебіг, підвищуючи ризик розвитку ускладнень. Пацієнти з ЦД страждають від супутньої депресії у 2–3 рази частіше, ніж без нього. Поширеність депресивних розладів у хворих із ЦД у середньому становить близько 14 %. Приблизно у 80 % випадків у пацієнтів із ЦД 2 типу виявляється артеріальна гіпертензія. Головною причиною смертності є гострі серцево-судинні захворювання, від яких помирає 75 % хворих. За даними клінічних досліджень у 15–25 % пацієнтів з ішемічною хворобою серця (ІХС) виявляють симптоми депресії, яка в 3,7 раза підвищує несприятливий перебіг хвороби. Результати іноземних досліджень свідчать, що смертність від серцево-судинних захворювань серед людей, які сплять менше 4 год на добу на 36 % вище, ніж у тих, які сплять 4–8 год, а ризик розвитку інсульту становить 34 %. Пацієнти, які схильні до даних захворювань і спали достатню кількість часу, ризики компенсувалися і значно зменшувалися. Висновки. Основною причиною значної захворюваності та смертності від ЦД із супутніми ССЗ можна вважати високу поширеність факторів ризику і відсутність єдиного підходу до боротьби з ними. Вивчаючи чинники ризику, отримаємо можливість зрозуміти вплив мультифакторної природи на розвиток й ускладнення перебігу захворювань. Дослідження та аналіз зв’язків між депресивними порушеннями й розвитком серцево-судинної патології дозволять встановити рівень впливу цих факторів на розвиток цукрового діабету 2 типу.
Objectives
To investigate the course of depressive symptoms, and basic and instrumental activities of daily living (collectively described as, (I)ADL functioning) from acute admission until one year post-discharge, the longitudinal association between depressive symptoms and (I)ADL functioning, and to disaggregate between- and within-person effects to examine whether changes in depressive symptoms are associated with changes in (I)ADL functioning.
Methods
Prospective multicenter cohort of acutely hospitalized patients aged ≥70. Data gathered over a one-year period were assessed using validated measures of depressive symptoms (GDS-15) and physical functioning (Katz-ADL index). A Poisson mixed model analysis was used to examine the association between the courses and a hybrid model was used to disentangle between- and within-subject effects.
Results
The analytic sample included 398 patients (mean age = 79.6 years, SD = 6.6). Results showed an improvement in depressive symptoms and physical functions over time, whereby changes in depressive symptoms were significantly associated with the course of ADL function (rate ratio (RR) = 0.91, p < .001) and IADL function (RR = 0.94, p < .001), even after adjustment for confounding variables. Finally, both between- and within-person effects of depressive symptoms were significantly associated with the course of ADL function (between-person: RR = 0.85, p < .001; within-person: RR = 0.94, p < .001) and IADL function (between-person: RR = 0.87, p < .001; within-person: RR = 0.97, p < .001).
Conclusion
The course of depressive symptoms and physical functions improved over time, whereby changes in depressive symptoms were significantly associated with changes in physical functions, both at group and individual level. These changes in (I)ADL functioning lie mostly above the estimated minimally important change for both scales, implying clinically relevant changes.
Background
Congestive heart failure (CHF) is a common disease with high health care costs and high mortality rates. Knowledge of the health-related quality of life outcomes of CHF may guide decision making and be useful in assessing new therapies for this population.Methods
A prospective cohort study was conducted involving 1390 adult patients hospitalized with an acute exacerbation of severe CHF (New York Heart Association class III-IV). Demographic data and health-related quality of life were determined by interview; physiologic status and cost and intensity of care were determined from hospital charts.Results
The median (25th, 75th percentiles) age of patients was 68.0 (58.2, 76.9) years; 61.7% were male. Survival was 93.4% at discharge from the index hospitalization, 72.9% at 180 days, and 61.5% at 1 year. Of patients interviewed at 180 days, the median health rating on a scale of 0 to 100 (0 indicates death; 100, excellent health) was 60 (interquartile range, 50-80), and 59.7% were independent in their activities of daily living. Overall quality of life was reported to be good, very good, or excellent in 58.2% at 180 days. Patients with worse functional capacity were more likely to die. Health perceptions among the patients with available interview data improved at 60 and 180 days after acute exacerbation of severe CHF.Conclusions
Patients hospitalized for acute exacerbation of severe CHF have a generally poor 6-month survival, but survivors retain relatively good functional status and have good health perceptions. Furthermore, health perceptions improve after the acute exacerbation.
Cardiac autonomic activity, as assessed by heart rate variability, has been found to be associated with postmyocardial infarction
mortality, sudden death, and all-cause mortality. However, the association of heart rate variability and the incidence of
coronary heart disease (CHD) is not well described. The authors report on the association of baseline cardiac autonomic activity
(1987–1989) with incident CHD after 3 years (1990–1992) of follow-up of the Atherosclerosis Risk in Communities Study cohort
selected from four study centers in the United States by using a case-cohort design. The authors examined 137 incident cases
of CHD and a stratified random sample of 2, 252 examinees free of CHD at baseline. Baseline, supine, resting beat-to-beat
heart rate data were collected. High- (0.16–0.35 Hz) and low- (0.025–0.15 Hz) frequency spectral powers and high-/low-frequency
power ratio, estimated from spectral analysis, and standard deviation of all normal R-R intervals, calculated from time domain
analysis, were used as the conventional indices of cardiac parasym-pathetic, sympatho-parasympathetic, and their balance,
respectively. Incident CHD was defined sis hospitalized myocardial infarction, fatal CHD, or cardiac revascularization procedures
during 3 years of follow-up. The age, race, gender, and other CHD risk factor-adjusted relative risks (and 95% confidence
intervals) of incident CHD comparing the lowest quartile with the upper three quartiles of high-frequency power, low-frequency
power, high-/low-frequency power ratio, and standard deviation of R-R intervals were 1.72 (95% confidence interval (CI) 1.17–2.51),
1.09 (95% CI 0.72–1.64), 1.25 (95% CI 0.84–1.86), and 1.39 (95% CI 0.94–2.04), respectively. The findings from this population-based,
prospective study suggest that altered cardiac autonomic activity, especially lower parasympathetic activity, is associated
with the risk of developing CHD. Am J Epidemiol 1997; 145: 696–706.
The measurement of physical disability as an indication of the impact of disease is commonly seen in research. However, these measures often do not clearly differentiate between functional limitations and daily performance of an activity.
We measured the differences between self-reported disability and observed functional limitations in six activities of daily living tasks among community-dwelling elders. The value of functional limitations vs disability measures in determining risk factors for disablement was ascertained.
Systematic differences were found among the 1453 participants. At least 89% of the time when a difference was identified, the subjects ranked disability greater than the functional limitations observed. For those who were cognitively impaired, discrepancies occurred up to 11% of the time. In determining risk factors for disablement, we found that neurological impairments were associated with both functional limitations and disability, while sociocultural factors were associated with disability only.
Our findings suggest that physical functional limitations and disability in the elderly are two distinct concepts and that the measure of choice should be determined by research objectives and the type of population being studied.
Although enhanced efferent cardiac sympathetic nervous activity has been proposed as an important factor in the genesis of ventricular arrhythmias and sudden cardiac death, direct clinical evidence has been lacking.
We measured the rates of total and cardiac norepinephrine spillover into the plasma, which reflect respectively overall and cardiac sympathetic nervous activity, in 12 patients who had recovered from a spontaneous, sustained episode of ventricular tachycardia or ventricular fibrillation outside the hospital 4 to 48 days earlier. The results were compared with those from three age-matched reference groups without a history of ventricular arrhythmias: 12 patients with coronary artery disease, 6 patients with chest pain but normal coronary arteries, and 12 healthy, normal subjects.
The patients who had had ventricular arrhythmias had reduced left ventricular ejection fractions, as compared with the patients with coronary artery disease or chest pain (mean [+/- SE], 46 +/- 3 percent vs. 58 +/- 4 percent and 69 +/- 5 percent, respectively; P less than 0.003). The rates of total norepinephrine spillover into the plasma were similar in the three reference groups, but 80 percent higher in the patients with ventricular arrhythmias (P less than 0.005). The rate of cardiac norepinephrine spillover was 450 percent higher in these patients (176 +/- 39 pmol per minute, as compared with 32 +/- 8 pmol per minute in the normal subjects; P less than 0.001), a disproportionate increase relative to the increase in total spillover, which indicated selective activation of the cardiac sympathetic outflow. This increase in cardiac norepinephrine spillover was probably caused by a reduction in left ventricular function.
These results suggest that in some patients major ventricular arrhythmias are associated with and perhaps caused by sustained and selective cardiac sympathetic activation. We speculate that depressed ventricular function was present before the ventricular arrhythmia occurred, and that this resulted in reflex cardiac sympathetic activation, which in turn contributed to the genesis of the arrhythmia.
This paper describes 6-year rates and correlates of functional change in the elderly, as well as associated hospital use.
The Longitudinal Study on Aging (n = 7527) and matched Medicare claims were used to calculate 6-year functional status transition rates and hospital use rates. A hierarchical measure that incorporated activities of daily living, instrumental activities of daily living, and competing risks of institutionalization and death was used to assess functional status. Multinomial logistic regression was used to predict 1990 status.
The functional status of 12% of men and women 70 to 79 years of age who were initially impaired in instrumental activities of daily living improved, and about half of the initially independent people in that age group remained so. Multivariate analyses revealed that age, baseline functioning, self-rated health, and comorbidity predicted 1990 status. Both baseline functioning and functional change were related to hospitalization.
This study supports others that have shown some long-term functional improvement, but more commonly decline, in the elderly. Furthermore, it documents the link between functional decline and increased hospital use.
The impact of three sociodemographic, two cognitive, two affective, and four personality measures on the discrepancies between self-reported and performance-based ADL in a sample of 753 frail elderly is studied by means of multiple regression analyses. Underestimation (i.e., lower self-reported levels of ADL compared to performance-based levels) occurs, in particular, among subjects with low perceptions of physical competence and mastery or personal control, and high levels of depressive symptomatology. In contrast, the role of cognitive functioning and sociodemographic variables in the discrepancies is a minor one. Although self-report ADL measures are easier to administer and less sensitive to nonresponse than performance-based ADL measures, the confounding effects of perceived physical competence, mastery, and depressive symptomatology on self-reported ADL should be considered in any application of self-report measures of ADL among frail elderly.
Introduction: The aim of this study was to evaluate the association between heart rate turbulence (HRT) parameters and clinical characteristics of coronary artery disease patients as well as to identify clinical features of patients with abnormal values of HRT. Material and methods: In 146 patients (29 women, 117 men; aged 62 ± 9 years) with angiographically documented coronary artery disease, 24-hour Holter monitoring with HRT analysis was performed to evaluate turbulence onset (TO) and turbulence slope (TS). Results: HRT parameters showed broad spectrum of values, TO ranging from -8.3% to +4.45% (-1.29% ± 1.63) and TS ranging from 0.42 to 54.7 ms/RR (11.3 ± 10.3 ms/RR). According to quartile values TO ≥ -0.37% and TS ≥ 4.25 ms/RR were considered as abnormal. Average values of TS were higher and TS lower in patients over 60 years, with past myocardial infarction and in those with left ventricular ejection fraction < 40%. Considering pharmacotheraphy, higher values of TS were observed in patients on statins, nitrates and beta-blockers while lower TS values were noted in patients on calcium channel blockers Patients with abnormal parameters of HRT compared to group with normal HRT values were older and characterized by feature of more advanced coronary artery disease: age over 60 yrs (77% vs. 49%), past myocardial infarction (75% vs. 64%) and ejection fraction < 40% (25% vs. 3%). Multivariate analysis revealed that abnormal HRT parameters are significantly and independently associated with age (OR 1.27; p = 0.002) and ejection fraction < 40% (OR 1.39; P = 0.001). Conclusions: HRT parameters are dependent on clinical characteristics of studied patients and on pharmacotherapy. Older age and left ventricular dysfunction are independently associated with abnormal heart rate turbulence.
Background: Later-life depressive disorders are a major public health problem in primary care settings. A validated screening instrument might aid in the recognition of depression. However, available findings from younger patients may not generalize to older persons, and existing studies of screening instruments in older patient samples have suffered substantial methodological limitations. Methods: One hundred thirty patients 60 years or older attending 3 primary care internists' practices participated in the study. Two screening scales were used: the Center for Epidemiologic Studies—Depression Scale (CES-D) and the Geriatric Depression Scale (GDS). The Structured Clinical Interview for the Diagnostic and statistical Manual of Mental Disorders, Third Edition, Revised , was used to establish "gold standard" diagnoses including major and minor depressive disorders. Receiver operating curve analysis was used to determine each scale's operating characteristics. Results: Both the CES-D and the GDS had excellent properties in screening for major depression. The optimum cutoff point for the CES-D was 21, yielding a sensitivity of 92% and a specificity of 87%. The optimum cutoff point for the GDS was 10, yielding a sensitivity of 100% and a specificity of 84%. A shorter version of the GDS had a sensitivity of 92% and a specificity of 81% using a cutoff point of 5. All scales lost accuracy when used to detect minor depression or the presence of any depressive diagnosis. Conclusions: The CES-D and the GDS have excellent properties for use as screening instruments for major depression in older primary care patients. Because the GDS's yes or no format may ease administration, primary care clinicians should consider its routine use in their practices. Arch Intern Med. 1997;157:449-454
Objective
The present study was undertaken in order to evaluate the relationship between depressed mood (depression, emotional distress) and disease-specific subjective health symptoms upon mortality risk among patients with congestive heart failure (CHF).
Methods and Results
Proportional hazard models were used to evaluate the effects of selected biomedical, subjective health and psychological variables on mortality among 119 clinically stable patients (71.4% men; mean age 65.7 years +/− 9.6) with symptomatic heart failure, recruited from an outpatient cardiology practice. Twenty deaths were registered during the twenty-four-month period of data collection, all from cardiac causes. Results indicated that depressed mood was a significant predictor of mortality with a hazard ratio of 1.9, p .002. In contrast, subjective health was not a significant predictor of mortality in a Cox regression model that included depressed mood. The hazard ratio for a 1-point increase in Zung Depression Scale score was equal to 1.08 based on the multivariate model.
Conclusions
Results indicate that depressed mood is significantly related to increased mortality risk among heart failure patients. This finding is of concern to clinicians and should have implications for treatment of patients with congestive heart failure.
The total resting plasma catecholamine concentration from 13 drugfree, depressed patients was found to be significantly elevated over concentrations from 47 normal controls. Differential determinations of epinephrine and norepinephrine revealed that both catecholamine components were elevated in the Patients. The literature on norepinephrine concentrations in brain, spinal fluid, and urinary excretion was reviewed and indicated that rather than being decreased, norepinephrine has been found to be either unchanged or increased in depressed patients.
Background:
To determine whether elevations of plasma norepinephrine (NE) in major depression represent increased sympathetic nervous system (SNS) activity and to assess the effects of desipramine hydrochloride on sympathetic function.Methods:
SNS activity was assessed in depressed patients and controls by an isotope-dilution, plasma NE Kinetic technique using mathematical modeling and compartmental analysis. This approach provided estimates of the rate of NE appearance into an extravascular compartment, which is the site of endogenous NE release from SNS nerves, the corresponding rate of NE appearance into plasma, and the rate of NE clearance from plasma.Results:
Norepinephrine appearance into the extravascular and vascular compartments was significantly elevated in 17 depressed patients compared with that in 36 controls. The rate of NE clearance from plasma was similar in both groups. This is compatible with increased SNS activity in major depression. Desipramine, given for 2 days, significantly reduced the concentration of NE in plasma of patients and controls by markedly suppressing the rates of extravascular and vascular NE appearance, compatible with a short-term reduction in SNS activity. Desipramine prolonged the rate of NE clearance from plasma, consistent with a blockade of NE re-uptake into SNS nerve terminals. The initial suppression of SNS activity by desipramine was reversed by long-term (28 days) treatment of patients, with extravascular and vascular NE appearance rates returning to approximately basal levels. An associated rise in plasma NE concentrations compared with the baseline was attributable to a progressive reduction in plasma NE clearance.Conclusion:
Sympathetic nervous system activity is elevated in major depression and is suppressed by short-term desipramine administration. The demonstration of SNS reactivation occurring with prolonged desipramine treatment is compatible with the theory that long-term treatment desensitizes CNS α2-adrenergic receptors and emphasizes the value of examining the temporal course of responses to pharmacological challenges of neuroendocrine systems. Previously reported elevations of plasma NE during prolonged administration of tricyclic antidepressants are probably the result of a reduction in plasma NE clearance, not an increase in SNS activity.
• Considerable evidence suggests that the acute effects of antidepressant treatments on brain norepinephrine (NE) and serotonin (5-HT) systems cannot account fully for their delayed therapeutic action. This review evaluates the effects of long-term antidepressant treatment on biogenic amine metabolism and on various indexes of presynaptic and postsynaptic receptor function. In contrast to variable effects on NE and 5-HT turnover and on presynaptic receptor sensitivity, almost all long-term antidepressant treatments produce consistent alterations in a number of measures of postsynaptic amine receptor sensitivity. Longterm treatment has been found to reduce β-adrenergic sensitivity while enhancing responses to serotonergic and α-adrenergic stimulation, suggesting that modulation of receptor sensitivity may be a mechanism of action common to tricyclic antidepressants, "atypical" antidepressants, monoamine oxidase inhibitors, and electroconvulsive therapy. These findings provide support for hypotheses of amine receptor abnormalities in depression and indicate the need for expanded studies of amine receptor function in patients.
Background: Older patients often have poor health status outcomes after hospitalization. Symptoms of depression are common in hospitalized older persons and may be a risk factor for these poor outcomes. Objective: To determine whether symptoms of depression predict worse health status outcomes in acutely ill, older medical patients, independent of health status and severity of illness at hospital admission. Design: Prospective cohort study. Setting: Medical service of a teaching hospital. Patients: 572 hospitalized medical patients older than 70 years of age. Measurements: 15 symptoms of depression, health status, and severity of illness were measured at admission. The main outcome was dependence in basic activities of daily living at discharge and 30 and 90 days after discharge. Other outcome measures were dependence in instrumental activities of daily living, fair or poor global health status, and poor global satisfaction with life. Results: The median number of symptoms of depression on admission was 4. Patients with 6 or more symptoms on admission (n = 196) were more likely than patients with 0 to 2 symptoms (n = 181) to be dependent in basic activities of daily living (odds ratio, 2.47 [95% Cl, 1.58 to 3.86]) after controlling for demographic characteristics and severity of illness. At each subsequent time point, patients with more symptoms of depression on admission were more likely to be dependent in basic activities of daily living. This association persisted after adjustment for dependence in basic activities of daily living, severity of illness, and demographic characteristics on admission. The odds ratios comparing patients who had 6 or more symptoms with those who had 0 to 2 symptoms were 3.23 (Cl, 1.76 to 5.95) at discharge, 3.45 (Cl, 1.81 to 6.60) 30 days after discharge, and 2.15 (Cl, 1.15 to 4.03) 90 days after discharge. At each time point, patients with 6 or more symptoms of depression were more likely to have more dependence in instrumental activities of daily living, worse global health status, and less satisfaction with life. Conclusions: Symptoms of depression identified a vulnerable group of hospitalized older persons. The health status of patients with more symptoms of depression was more likely to deteriorate and less likely to improve during and after hospitalization. This association was not attributable to health status or severity of illness on admission. The temporal sequence and magnitude of this association, its consistency over time with different measures, and its independence from the severity of the somatic illness strongly support a relation between symptoms of depression on admission and subsequent health status outcomes.
Background
Major depression is associated with increased mortality, but it is not known whether patients who report depressive symptoms have greater mortality.Subjects and Methods
We performed a prospective cohort study of 7518 white women 67 years of age or older who were recruited from population-based listings in Baltimore, Md, Minneapolis, Minn, Portland, Ore, and the Monongahela Valley, Pa. Participants completed the Geriatric Depression Scale (short form) and were considered depressed if they reported 6 or more of 15 possible symptoms of depression. Women were followed up for an average of 6 years. If a participant died, we obtained a copy of the official death certificate and hospital records, if available, and used International Classification of Diseases, Ninth Revision, codes to classify death attributable to cardiovascular, cancer, or noncancer, noncardiovascular cause.Results
Mortality during 7-year follow-up varied from 7% in women with no depressive symptoms to 17% in those with 3 to 5 symptoms to 24% in those with 6 or more symptoms of depression (P<.001). Of 473 women (6.3%) with 6 or more depressive symptoms at baseline, 24% died (111 deaths in 2610 woman-years of follow-up) compared with 11% of women who reported 5 or fewer symptoms of depression (760 deaths in 41460 woman-years of follow-up) (P<.001). Women with 6 or more depressive symptoms had a 2-fold increased risk of death (age-adjusted hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.75-2.61; P<.001) compared with those who had 5 or fewer depressive symptoms. This association remained strong after adjusting for potential confounding variables, including history of myocardial infarction, stroke, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, smoking, perceived health, and cognitive function (HR, 1.47; 95% CI, 1.14-1.88; P =.003). Depressive symptoms were associated with an increased adjusted risk of death from cardiovascular diseases (HR, 1.8; 95% CI, 1.2-2.5; P=.003), and noncancer, noncardiovascular diseases (HR, 1.8; 95% CI, 1.2-2.7; P=.01), but were not associated with deaths from cancer (HR, 1.0; 95% CI, 0.6-1.7; P=.93).Conclusions
Depressive symptoms are a significant risk factor for cardiovascular and noncancer, noncardiovascular mortality but not cancer mortality in older women. Whether depressive symptoms are a marker for, or a cause of, life-threatening conditions remains to be determined.
• Among 140 depressed and control subjects, there were significant positive correlations between indexes of noradrenergic activity in cerebrospinal fluid (CSF), plasma, and urine. Among the depressed patients, CSF levels of the norepinephrine (NE) metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG) and urinary outputs of NE and its metabolites normetanephrine, MHPG, and vanillylmandelic acid correlated significantly with plasma cortisol levels in relation to dexamethasone administration. Also, CSF levels of MHPG were significantly higher among patients who were cortisol nonsuppressors than among either patients who were cortisol suppressors or controls. Urinary outputs of NE and normetanephrine were significantly higher among patients who were cortisol nonsuppressors than among controls. Patients who were cortisol suppressors had indexes of NE metabolism similar to those of controls. These results in the depressed patients extend recent observations suggesting that dysregulation of the noradrenergic system and hypothalamic-pituitary-adrenal axis occur together in a subgroup of depressed patients.
Objective.
—To determine if the diagnosis of major depression in patients hospitalized following myocardial infarction (Ml) would have an independent impact on cardiac mortality over the first 6 months after discharge.Design.
—Prospective evaluation of the impact of depression assessed using a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. Cox proportional hazards regression was used to evaluate the independent impact of depression after control for significant clinical predictors in the data set.Setting.
—A large, university-affiliated hospital specializing in cardiac care, located in Montreal, Quebec.Patients.
—All consenting patients (N=222) who met established criteria for Ml between August 1991 and July 1992 and who survived to be discharged from the hospital. Patients were interviewed between 5 and 15 days following the MI and were followed up for 6 months. There were no age limits (range, 24 to 88 years; mean, 60 years). The sample was 78% male.Primary Outcome Measure.
—Survival status at 6 months.Results.
—By 6 months, 12 patients had died. All deaths were due to cardiac causes. Depression was a significant predictor of mortality (hazard ratio, 5.74; 95% confidence interval, 4.61 to 6.87; P=.0006). The impact of depression remained after control for left ventricular dysfunction (Killip class) and previous Ml, the multivariate significant predictors of mortality in the data set (adjusted hazard ratio, 4.29; 95% confidence interval, 3.14 to 5.44; P=.013).Conclusion.
—Major depression in patients hospitalized following an Ml is an independent risk factor for mortality at 6 months. Its impact is at least equivalent to that of left ventricular dysfunction (Killip class) and history of previous Ml. Additional study is needed to determine whether treatment of depression can influence post-MI survival and to assess possible underlying mechanisms.(JAMA. 1993;270:1819-1825)
Administered a structured interview designed to diagnose current major depressive episodes to 60 hospitalized patients (aged 70+ yrs) with congestive heart failure (CHF) to estimate the point prevalence of major depression. Overall, 17% of the Ss met Diagnostic and Statistical Manual of Mental Disorders-III—Revised (DSM-III—R) criteria for major depressive episode during their index admission for CHF. Whereas the rate was 24% for White Ss, none of the Black Ss was found to be depressed. There were trends toward an increased number of inpatient days at 3 mo and higher mortality among the depressed Ss (50%) than among nondepressed patients (29%) at 1 yr. Major depression appears to be highly prevalent among elderly patients with CHF, and screening for depression should become a routine part of medical evaluation in this group. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The objectives of this study were to examine the prevalence of depression in hospitalized, medically ill, older patients with and without congestive heart failure (CHF), and examine correlates, course, predictors of outcome, and treatment of depression in patients with CHF. A consecutive sample of 542 patients age 60 or over admitted to inpatient services of Duke University Medical Center were systematically screened by a psychiatrist for depression using the Diagnostic Interview Schedule; 342 depressed cases and nondepressed controls were identified. Of these, 107 had a primary or secondary diagnosis of CHF. Among patients with CHF, major depression was identified in 36.5%, a rate that was significantly higher than for patients without CHF (25.5%); the difference was largely explained by low rates of major depression in cardiac patients without CHF (17.0%) who had less severe physical illness. Minor depression was also present in 21.5% of CHF patients, but was not more prevalent than in patients without CHF (17.0%). Compared with nondepressed CHF patients, those with depression were more likely to have comorbid psychiatric disorder, severe medical illness, and severe functional impairment. Depressed patients used more outpatient and inpatients medical services, although this was largely due to the severity of their health problems. Patients often remained depressed for a prolonged period, and over 40% failed to remit during the year following discharge. Factors predicting slower remission included nonhealth-related, stressful life events and low social support; physical health factors at baseline had little effect. The majority of depressed CHF patients did not receive treatment for their depression with either antidepressants or psychotherapy, and did not see mental health specialists any more frequently than did the nondepressed. These findings are of concern and have important implications for the diagnosis and treatment of depression in older patients with heart failure.
OBJECTIVES: To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF).
DESIGN: Prospective cohort study.
PARTICIPANTS: A total of 519 patients, aged > or = 65, who were discharged alive after a hospitalization for CHF (DRG = 127).
MEASUREMENTS: Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge.
RESULTS: The 205 men were, on average, younger (77 +/- 7 vs 80 +/- 8, P < .001), wealthier (46% vs 21% earned > or = $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values > or = .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0-6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge.
CONCLUSIONS: Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).
Congestive heart failure is a frequent and important manifestation of cardiovascular disease, but no uniform clinical criteria are available for use in epidemiologic studies. To develop diagnostic criteria, we related pertinent clinical findings to physiologic measures of left ventricular function in patients with coronary artery disease. When left ventricular end diastolic pressure or arteriovenous oxygen difference was used as the physiologic criterion, the following variables contributed significant (P less than 0.01) information: heart volume, ventricular gallop, heart rate, and blood pressure. The most reliable and valid set of descriptors determined in one group was tested in a second group of 1306 patients who had been followed for 6 to 36 months after initial evaluation. The validity of the descriptors was confirmed, and patients identified as having heart failure by these criteria experienced a worse survival rate (P less than 0.001). These criteria characterize patients likely to have impaired left ventricular function and a greater risk of death.
Because physicians have traditionally considered heart failure to be a hemodynamic disorder, they have described the syndrome of heart failure using hemodynamic concepts and have designed treatment strategies to correct the hemodynamic derangements of the disease. However, although hemodynamic abnormalities may explain the symptoms of heart failure, they are not sufficient to explain the progression of heart failure and, ultimately, the death of the patient. Therapeutic interventions may improve the hemodynamic status of patients but adversely affect their long-term outcome. These findings have raised questions about the validity of the hemodynamic hypothesis and suggest that alternative mechanisms must play a primary role in advancing the disease process. Several lines of evidence suggest that neurohormonal mechanisms play a central role in the progression of heart failure. Activation of the sympathetic nervous system and renin-angiotensin system exerts a direct deleterious effect on the heart that is independent of the hemodynamic actions of these endogenous mechanisms. Therapeutic interventions that block the effects of these neurohormonal systems favorably alter the natural history of heart failure, and such benefits cannot be explained by the effect of these treatments on cardiac contractility and ejection fraction. Conversely, pharmacologic agents that adversely influence neurohormonal systems in heart failure may increase cardiovascular morbidity and mortality, even though they exert favorable hemodynamic effects. These observations support the formulation of a neurohormonal hypothesis of heart failure and provide the basis for the development of novel therapeutic strategies in the next decade.
To compare the accuracy of self-ratings with informant-ratings of physical functional capacity in the elderly, 150 elderly patients attending a geriatric day hospital (GDH) and their formal and informal community carers were administered a questionnaire about their ability to perform activities of daily living (ADL). Direct observation of the patients' performance by therapists at the GDH was used as a standard, after the reliability and validity of this approach had been evaluated. Self-ratings were shown to be more accurate and less biased than informant-ratings, both for individual ADL and overall functional capacity. The accuracy of all ratings tended to be greater for less complex or physically demanding ADL, and informants tended to consistently underestimate functional capacity. The concurrent validity of the adapted Barthel Index in a self-report format was also demonstrated. Wherever possible, information concerning the physical functional capacity of an elderly subject should in the first instance be sought from the subject himself, as the quality of such information may be superior to that of his carers.
The study was designed to determine the prevalence and mortality rate of congestive heart failure in noninstitutionalized men and women in the U.S.
Congestive heart failure is a serious condition with significant morbidity and mortality. Earlier epidemiologic descriptions of congestive heart failure were constructed from small surveys, limited data, hospital records or death certificates. No nationally representative data from noninstitutionalized persons have been examined.
Data collected from the National Health and Nutrition Examination Survey (NHANES-I, 1971 to 1975) were used to determine the prevalence of heart failure on the basis of both self-reporting and a clinical definition. Mortality data were derived from the NHANES-I Epidemiologic Follow-up Study (1982 to 1986).
The prevalence of self-reported congestive heart failure approximates 1.1% of the noninstitutionalized U.S. adult population; the prevalence of congestive heart failure based on clinical criteria is 2%. These estimates suggest that between 1 and 2 million adults are affected. Mortality at 10 and 15 years for those persons with congestive heart failure increases in graded fashion with advancing age, with men more likely to die than women. In the group greater than or equal to 55 years old, the 15-year total mortality rate was 39.1% for women and 71.8% for men.
Congestive heart failure is a common problem in the U.S., with significant prevalence and mortality, both of which increase with advancing age. As the population of the U.S. becomes older, the health care impact of congestive heart failure will probably grow.
The frequency of ventricular premature complexes and the degree of impairment of left ventricular ejection fraction are major predictors of cardiac mortality and sudden death in the year after acute myocardial infarction. Recent studies have implicated psychosocial factors, including depression, the interaction of social isolation and life stress, and type A-B behavior pattern, as predictors of cardiac events, controlling for known parameters of disease severity. However, results tend not to be consistent and are sometimes contradictory. The present investigation was designed to test the predictive association between biobehavioral factors and clinical cardiac events. This evaluation occurred in the context of a prospective clinical trial, the Cardiac Arrhythmia Pilot Study (CAPS). Five-hundred two patients were recruited with greater than or equal to 10 ventricular premature complexes/hour or greater than or equal to 5 episodes of nonsustained ventricular tachycardia, recorded 6 to 60 days after a myocardial infarction. Baseline behavioral studies, conducted in approximately 66% of patients, included psychosocial questionnaires of anxiety, depression, social desirability and support, and type A-B behavior pattern. In addition, blood pressure and pulse rate reactivity to a portable videogame was assessed. The primary outcome was scored on the basis of mortality or cardiac arrest. Results indicated that the type B behavior pattern, higher levels of depression and lower pulse rate reactivity to challenge were significant risk factors for death or cardiac arrest, after adjusting statistically for a set of known clinical predictors of disease severity. The implication of these results for future research relating behavioral factors to cardiac endpoints is discussed.
Self reported physical function was assessed in telephone interviews approximately 3 weeks apart for a sample of 193 persons aged 69 or older. Three measures of physical function were used: a modified Activities of Daily Living scale, three items proposed by Rosow and Breslau, and five items from among those used by Nagi. Agreement between first and second interviews was very good; most subjects reported no impairment in function at either interview. Among those who reported some impairment, the degree of limitation within the specific activities reported as limited and the total number of activities with any degree of limitation agreed exactly for most and within one level for almost all subjects. There was no evidence to suggest that age or cognitive impairment affected the variability of the responses, and reported declines and improvements in function were about equally common.
A new clinical index of dyspnea and fatigue has been applied to rate the condition of patients with congestive heart failure. The index has 3 components, each rated on a scale from 0 to 4, for the magnitude of the task that evokes dyspnea or fatigue, the magnitude of the pace (or effort) with which the task is performed and the associated functional impairment in general activities. The ratings for each component are added to form an aggregated score, which can range from 0, for the worst condition, to 12, for the best. Because dyspnea and fatigue are prime symptoms and sources of clinical distress, the index helps reflect the quality of life in patients with congestive heart failure. In double-blind trials of therapy, changes in the index showed good correlations with patients' self-selected ratings of improvement. The posttherapeutic changes in the index ratings were significantly higher with a new active agent (lisinopril) than with placebo or another active agent (captopril).
Mickey, R. M. (Dept of Mathematics and Statistics, U. of Vermont, Burlington, VT 05405) and S. Greenland. The impact of confounder selection criteria on effect estimation. Am J Epidemiol 1989;129:125–37.
Much controversy exists regarding proper methods for the selection of variables in confounder control. Many authors condemn any use of significance testing, some encourage such testing, and others propose a mixed approach. This paper presents the results of a Monte Carlo simulation of several confounder selection criteria, including change-in-estimate and collapsibility test criteria. The methods are compared with respect to their Impact on Inferences regarding the study factor's effect, as measured by test size and power, bias, mean-squared error, and confidence Interval coverage rates. In situations in which the best decision (of whether or not to adjust) is not always obvious, the change-in-estimate criterion tends to be superior, though significance testing methods can perform acceptably If their significance levels are set much higher than conventional levels (to values of 0.20 or more).
Fifty-two patients undergoing cardiac catheterization and subsequently found to have significant coronary artery disease (CAD) were given structured psychiatric interviews before catheterization. Nine of these patients met criteria for major depressive disorder. All 52 patients were contacted 12 months after catheterization, and the occurrence of myocardial infarction, angioplasty, coronary bypass surgery and death was determined. Results of the study show that major depressive disorder was the best predictor of these major cardiac events during the 12 months following catheterization. The predictive effect was independent of the severity of CAD, left ventricular ejection fraction, and the presence of smoking. Furthermore, with the exception of smoking, there were no statistically significant differences between those patients with major depressive disorder and the remaining patients on any variable studied. The possible mechanisms relating major depressive disorder to subsequent cardiac events are discussed. It is concluded that major depressive disorder is an important independent risk factor for the occurrence of major cardiac events in patients with CAD.
The effects of antidepressant treatment on noradrenergic function were studied in 27 patients with a major affective disorder. Twenty-four-hour urinary excretion of 6-hydroxymelatonin and "whole-body norepinephrine (NE) turnover," ie, 24-hour urinary output of NE and its major metabolites 3-methoxy-4-hydroxyphenylglycol, vanillylmandelic acid, and normetanephrine, were measured before and after treatment with the tricyclic desipramine hydrochloride, the aminoketone bupropion hydrochloride, the nonselective monoamine oxidase (MAO) inhibitor tranylcypromine sulfate, and the specific MAO type A inhibitor clorgiline. 6-Hydroxymelatonin excretion increased following antidepressant treatment, while at the same time whole-body NE turnover was reduced. These findings support the hypothesis that antidepressant therapy increases noradrenergic "efficiency," in that functional output, as measured by 6-hydroxymelatonin, is maintained while total NE production is decreased.
Among 140 depressed and control subjects, there were significant positive correlations between indexes of noradrenergic activity in cerebrospinal fluid (CSF), plasma, and urine. Among the depressed patients, CSF levels of the norepinephrine (NE) metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG) and urinary outputs of NE and its metabolites normetanephrine, MHPG, and vanillylmandelic acid correlated significantly with plasma cortisol levels in relation to dexamethasone administration. Also, CSF levels of MHPG were significantly higher among patients who were cortisol nonsuppressors than among either patients who were cortisol suppressors or controls. Urinary outputs of NE and normetanephrine were significantly higher among patients who were cortisol nonsuppressors than among controls. Patients who were cortisol suppressors had indexes of NE metabolism similar to those of controls. These results in the depressed patients extend recent observations suggesting that dysregulation of the noradrenergic system and hypothalamic-pituitary-adrenal axis occur together in a subgroup of depressed patients.
Although an estimate of the odds ratio adjusted for other covariates can be obtained by logistic regression, until now there has been no simple way to estimate other interesting parameters such as the risk ratio and risk difference multivariately for prospective binomial data. These parameters can be estimated in the generalized linear model framework by choosing different link functions or transformations of binomial or binary data. Macros for use with the program GLIM provide a simple method to compute parameters other than the odds ratio while adjusting for confounding factors. A data set presented previously is used as an example.
The Index of Independence in Activities of Daily Living (ADL), now in frequent use in rehabilitation settings, has application for prevention of disability and maintenance of rehabilitation gains in the aging person in all settings. Since the Index is sensitive to changes in meaningful self-care functions, uses well-defined criteria, and can be broadly taught to non-professionals, it has considerable practical value as a longitudinal measure of change and predictor of adaptive capacity in terms of community residences and congregate living facilities.
Considerable evidence suggests that the acute effects of antidepressant treatments on brain norepinephrine (NE) and serotonin (5-HT) systems cannot account fully for their delayed therapeutic action. This review evaluates the effects of long-term antidepressant treatment on biogenic amine metabolism and on various indexes of presynaptic and postsynaptic receptor function. In contrast to variable effects on NE and 5-HT turnover and on presynaptic receptor sensitivity almost all long-term antidepressant treatments produce consistent alterations in a number of measures of postsynaptic amine receptor sensitivity. Long-term treatment has been found to reduce beta-adrenergic sensitivity while enhancing responses to serotonergic and alpha-adrenergic stimulation, suggesting that modulation of receptor sensitivity may be a mechanism of action common to tricyclic antidepressants, "atypical" antidepressants, monoamine oxidase inhibitors, and electroconvulsive therapy. These findings provide support for hypotheses of amine receptor abnormalities in depression and indicate the need for expanded studies of amine receptor function in patients.
The authors found that patients with major affective disorder had higher levels of plasma norepinephrine and higher pulse rates (tachycardia) than healthy control subjects, but their blood pressures were normal. These measurements were similar in all three subgroups of patients with affective disorder--manic, bipolar depressed, and unipolar. Because norepinephrine is the primary neurotransmitter of the sympathetic nervous system, these data suggest sympathetic hyperactivity in the major affective disorders. This conclusion is compatible with recent speculation based on the effect of antidepressants on noradrenergic receptors and a failure of alpha-receptors to downregulate normally in patients with major affective disorder.
To improve the clinical measurement of dyspnea, we developed a baseline dyspnea index that rated the severity of dyspnea at a single state and a transition dyspnea index that denoted changes from that baseline. The scores in both indexes depend on ratings for three different categories: functional impairment; magnitude of task, and magnitude of effort. At the baseline state, dyspnea was rated in five grades from 0 (severe) to 4 (unimpaired) for each category. The ratings for each of the three categories were added to form a baseline focal score (range, 0 to 12). At the transition period, changes in dyspnea were rated by seven grades, ranging from -3 (major deterioration), to +3 (major improvement). The ratings for each of the three categories were added to form a transition focal score (range, -9 to +9). In 38 patients tested with respiratory disease, interobserver agreement was highly satisfactory for both indexes. The baseline focal score had the highest correlation (r = 0.60; P less than 0.001) with the 12-minute walking distance (12 MW), while significant, but lower, correlations existed for lung function. For the transition focal score, there was a significant correlation only with the 12 MW (r = 0.33; p = 0.04). These results indicate that dyspnea can receive a direct clinical rating that provides important information not disclosed by customary physiologic tests.
We previously reported that major depression in patients in the hospital after a myocardial infarction (MI) substantially increases the risk of mortality during the first 6 months. We examined the impact of depression over 18 months and present additional evidence concerning potential mechanisms linking depression and mortality.
Two-hundred twenty-two patients responded to a modified version of the National Institute of Mental Health Diagnostic Interview Schedule (DIS) for a major depressive episode at approximately 7 days after MI. The Beck Depression Inventory (BDI), which measures depressive symptomatology, was also completed by 218 of the patients. All patients and/or families were contacted at 18 months to determine survival status. Thirty-five patients met the modified DIS criteria for major in-hospital depression after the MI. Sixty-eight had BDI scores > or = 10, indicative of mild to moderate symptoms of depression. There were 21 deaths during the follow-up period, including 19 from cardiac causes. Seven of these deaths occurred among patients who met DIS criteria for depression, and 12 occurred among patients with elevated BDI scores. Multiple logistic regression analyses showed that both the DIS (odds ratio, 3.64; 95% confidence interval [CI], 1.32 to 10.05; P = .012) and elevated BDI scores (odds ratio, 7.82; 95% CI, 2.42 to 25.26; P = .0002) were significantly related to 18-month cardiac mortality. After we controlled for the other significant multivariate predictors of mortality in the data set (previous MI, Killip class, premature ventricular contractions [PVCs] of > or = 10 per hour), the impact of the BDI score remained significant (adjusted odds ratio, 6.64; 95% CI, 1.76 to 25.09; P = .0026). In addition, the interaction of PVCs and BDI score marginally improved the model (P = .094). The interaction showed that deaths were concentrated among depressed patients with PVCs of > or = 10 per hour (odds ratio, 29.1; 95% CI, 6.97 to 122.07; P < .00001).
Depression while in the hospital after an MI is a significant predictor of 18-month post-MI cardiac mortality. Depression also significantly improves a risk-stratification model based on traditional post-MI risks, including previous MI, Killip class, and PVCs. Furthermore, the risk associated with depression is greatest among patients with > or = 10 PVCs per hour. This result is compatible with the literature suggesting an arrhythmic mechanism as the link between psychological factors and sudden cardiac death and underscores the importance of developing screening and treatment programs for post-MI depression.
The objective of this study was to compare two methods of measuring physical function in subjects with a broad range of abilities and to evaluate the effects of cognitive, social, educational, and age factors on the relationship between the two methods.
Multiple regression analysis was used to compare self-perceived (dependent variables) with performance measures (independent variables). Covariates included age, gender, Mini-Mental State Exam score, education, living status, and depression score.
Five community-dwelling and two nursing home sites.
417 community-dwelling subjects and 200 nursing home residents aged 62-98 years.
Self-perceived physical function was assessed with the physical dimension summary score of the Sickness Impact Profile, which comprises three subscales: ambulation, mobility, and body care and movement. Physical performance was evaluated by self-selected gait speed, chair-stand time, maximal grip strength, and a balance score.
Nursing home residents and community-dwellers were significantly different (P < .0001) in all variables except age and gender. Self-perceived and performance-based measures were moderately correlated, with a range from r = -.194 to r = -.625 (P < .05). Gait speed was the strongest independent predictor of self-perceived physical function in both groups. Symptoms of depression were also an independent predictor of self-perceived function in nursing home residents; subjects who had such symptoms report more self-perceived dysfunction than would be predicted based on performance tests.
Self-selected gait speed is a global indicator of self-perceived physical function over a broad range of abilities. External determinants (depressive symptoms, cognitive function, marital status, etc.) affect self-perceived function in both groups, but gait speed is the greatest single predictor of self-perceived function. In nursing home residents depressive symptomatology is related to self-perceived.
To compare case-finding tools for depression in the nursing home setting and to evaluate effects of subject function, cognition, and disease number on test performance.
Cross-sectional survey.
One academic and four community homes.
One hundred thirty-four randomly selected, mildly cognitively impaired, functionally dependent residents.
The Geriatric Depression Scale (GDS), Short Geriatric Depression Scale (SGDS), Center for Epidemiologic Studies Depression Scale (CES-D), and Brief Carrol Depression Rating Scale (BCDRS) were administered. The Structured Clinical Interview for DSM-III-R diagnoses was administered independently,. Operating characteristics and the effects of subject characteristics on test performance were evaluated using McNemar's test and logistic regression. Selection of "optimal" threshold scores was guided by Kraemer's quality indices and clinical judgment.
Thirty-five subjects (26%) had major depression. No differences were found among the instruments in sensitivity (range 0.74-0.89), specificity (range 0.62-0.77), or area under the receiver operating curve (ROC) (range 0.85-0.91). Resident characteristics did not affect test performance. Quality indices showed the GDS and BCDRS met criteria for moderate to substantial agreement with the criterion standard, whereas the SGDS and the CES-D achieved only fair agreement. No change in threshold scores was warranted.
The GDS and BCDRS performed well in the nursing home. As the GDS can serve as a both a case-finding and severity instrument, it is preferred. Use of brief, interviewer-administered tools may improve detection of depression in the nursing home.
To determine whether elevations of plasma norepinephrine (NE) in major depression represent increased sympathetic nervous system (SNS) activity and to assess the effects of desipramine hydrochloride on sympathetic function.
SNS activity was assessed in depressed patients and controls by an isotope-dilution, plasma NE kinetic technique using mathematical modeling and compartmental analysis. This approach provided estimates of the rate of NE appearance into an extravascular compartment, which is the site of endogenous NE release from SNS nerves, the corresponding rate of NE appearance into plasma, and the rate of NE clearance from plasma.
Norepinephrine appearance into the extravascular and vascular compartments was significantly elevated in 17 depressed patients compared with that in 36 controls. The rate of NE clearance from plasma was similar in both groups. This is compatible with increased SNS activity in major depression. Desipramine, given for 2 days, significantly reduced the concentration of NE in plasma of patients and controls by markedly suppressing the rates of extravascular and vascular NE appearance, compatible with a short-term reduction in SNS activity. Desipramine prolonged the rate of NE clearance from plasma, consistent with a blockade of NE re-uptake into SNS nerve terminals. The initial suppression of SNS activity by desipramine was reversed by long-term (28 days) treatment of patients, with extravascular and vascular NE appearance rates returning to approximately basal levels. An associated rise in plasma NE concentrations compared with the baseline was attributable to a progressive reduction in plasma NE clearance.
Sympathetic nervous system activity is elevated in major depression and is suppressed by short-term desipramine administration. The demonstration of SNS reactivation occurring with prolonged desipramine treatment is compatible with the theory that long-term treatment desensitizes CNS alpha 2-adrenergic receptors and emphasizes the value of examining the temporal course of responses to pharmacological challenges of neuroendocrine systems. Previously reported elevations of plasma NE during prolonged administration of tricyclic antidepressants are probably the result of a reduction in plasma NE clearance, not an increase in SNS activity.
To determine if the diagnosis of major depression in patients hospitalized following myocardial infarction (MI) would have an independent impact on cardiac mortality over the first 6 months after discharge.
Prospective evaluation of the impact of depression assessed using a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. Cox proportional hazards regression was used to evaluate the independent impact of depression after control for significant clinical predictors in the data set.
A large, university-affiliated hospital specializing in cardiac care, located in Montreal, Quebec.
All consenting patients (N = 222) who met established criteria for MI between August 1991 and July 1992 and who survived to be discharged from the hospital. Patients were interviewed between 5 and 15 days following the MI and were followed up for 6 months. There were no age limits (range, 24 to 88 years; mean, 60 years). The sample was 78% male.
Survival status at 6 months.
By 6 months, 12 patients had died. All deaths were due to cardiac causes. Depression was a significant predictor of mortality (hazard ratio, 5.74; 95% confidence interval, 4.61 to 6.87; P = .0006). The impact of depression remained after control for left ventricular dysfunction (Killip class) and previous MI, the multivariate significant predictors of mortality in the data set (adjusted hazard ratio, 4.29; 95% confidence interval, 3.14 to 5.44; P = .013).
Major depression in patients hospitalized following an MI is an independent risk factor for mortality at 6 months. Its impact is at least equivalent to that of left ventricular dysfunction (Killip class) and history of previous MI. Additional study is needed to determine whether treatment of depression can influence post-MI survival and to assess possible underlying mechanisms.
Packer, M (Division of Circulatory Physiology, Columbia University, College of Physicians and Surgeons, New York, USA). New concepts in the pathophysiology of heart failure: beneficial and deleterious interaction of endogenous haemodynamic and neurohormonal mechanisms (Minisymposium: Heart failure). J Intern Med 1996; 239: 327–33.
During most of the last 50 years, physicians have viewed heart failure primarily as an oedematous disorder, in which fluid retention occurs because the heart cannot pump adequate quantities of blood to the kidneys. This conceptual model led to the successful utilization of diuretics for heart failure, but it failed to permit physicians to recognize that heart failure is a chronic progressive disorder that impairs both the quality and quantity of life, even when oedema is adequately controlled.
To accommodate this new understanding, a new model has been developed, in which the development and progression of heart failure is viewed as resulting from the interplay of haemodynamic and neurohormonal mechanisms. Both mechanisms support the inotropic state of the heart following an injury to the myocardium, but when sustained for long periods, their ability to augment cardiac contractility wanes, and, instead, these same mechanisms act to enhance ventricular wall stress, thereby impairing ventricular performance. As the heart-failure state evolves, endogenous mechanisms that are normally activated to control wall stress become exhausted, and peripheral vasoconstriction and sodium retention develop. Unopposed activation of haemodynamic stresses and neurohormonal systems leads to further destruction of the myocardium and progression of the underlying disease.
The acceptance of this haemodynamic– neurohormonal model has led to the development of vasodilators and neurohormonal antagonists that have been shown to be useful alone, or when added to diuretics, in the treatment of heart failure.
Previous research has established that patients with coronary artery disease (CAD) have an increased risk of death if they are depressed at the time of hospitalization. Follow-up periods have been short in these studies; therefore, the present investigation examined this phenomenon over an extended period of time. Patients with established CAD (n = 1,250) were assessed for depression with the Zung Self-Rating Depression Scale (SDS) and followed for subsequent mortality. Follow-up ranged up to 19.4 years. SDS scores were associated with increased risk of subsequent cardiac death (p = 0.002) and total mortality (p < 0.001) after controlling for initial disease severity and treatment. Patients with moderate to severe depression had a 69% greater odds of cardiac death and a 78% greater odds of mortality from all causes than nondepressed patients. Increased risk was not confined to the initial months after hospitalization. Patients with high SDS scores at baseline still had a higher risk of cardiac death > 5 years later (p < 0.005). Compared with the nondepressed, patients with moderate to severe depression had an 84% greater risk 5 to 10 years later and a 72% greater risk after > 10 years. Patients with mild depression had intermediate levels of risk in all models. The heightened long-term risk of depressed patients suggests that depression may be persistent or frequently recurrent in CAD patients and is associated with CAD progression, triggering of acute events, or both.
Later-life depressive disorders are a major public health problem in primary care settings. A validated screening instrument might aid in the recognition of depression. However, available findings from younger patients may not generalize to older persons, and existing studies of screening instruments in older patient samples have suffered substantial methodological limitations.
One hundred thirty patients 60 years or older attending 3 primary care internists' practices participated in the study. Two screening scales were used: the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Geriatric Depression Scale (GDS). The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised, was used to establish "gold standard" diagnoses including major and minor depressive disorders. Receiver operating curve analysis was used to determine each scale's operating characteristics.
Both the CES-D and the GDS had excellent properties in screening for major depression. The optimum cutoff point for the CES-D was 21, yielding a sensitivity of 92% and a specificity of 87%. The optimum cutoff point for the GDS was 10, yielding a sensitivity of 100% and a specificity of 84%. A shorter version of the GDS had a sensitivity of 92% and a specificity of 81% using a cutoff point of 5. All scales lost accuracy when used to detect minor depression or the presence of any depressive diagnosis.
The CES-D and the GDS have excellent properties for use as screening instruments for major depression in older primary care patients. Because the GDS's yes or no format may ease administration, primary care clinicians should consider its routine use in their practices.