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Depressive symptoms are prominent among elderly hospitalized patients
Abstract
There are limited data on the prevalence of depressive symptoms in hospitalised elderly HF patients and demographic and clinical characteristics associated with depressive symptoms are not known.
A sample of 572 HF patients (61% male; age 71+/-12 years; LVEF 34%+/-15) was recruited from 17 Dutch hospitals during HF admission. Depressive symptoms were assessed by the CES-D. Demographic, clinical variables and HF symptoms were collected from patient chart and interview.
Forty one percent of the patients had symptoms of depression with women significantly more often reporting depressive symptoms than men 48% vs. 36% (chi(2)=8.1, p<0.005). HF patients with depressive symptoms reported more clinical HF symptoms than patients without depressive symptoms. Even after deleting HF related symptoms (sleep disturbances and loss of appetite) from the CES-D scale, 36% of patients were still found to have symptoms of depression. Multivariable logistic regression analyses revealed that depressive symptoms were associated with female gender (odds 1.68, 95% CI 1.14-2.48), COPD (odds 2.11, 95% CI 1.35-3.30), sleep disturbance (odds 3.45, 95% CI 2.03-5.85) and loss of appetite (odds 2.61, 95% CI 1.58-4.33).
Depressive symptoms are prominent in elderly hospitalised HF patients especially in women. Depressive symptoms are associated with more pronounced symptomatology, despite the fact that other indices of severity of left ventricular dysfunction are similar.
... This reversal in relation to the observed trend in the general population may reflect the difficulty of younger people to accept the serious socio-economic impact of heart failure compared to older people. 11 Published studies about heart failure show a high incidence in Cyprus, roughly comparable to that described for most countries. 12 However, there are particular public health challenges that relate to significant delays in diagnosis and establishing barriers to health services, resulting in a significant increase in morbidity and a decrease in patient quality of life. ...
... The search of the studies was made in the ProQuest, PubMed, Research activity on that field has been carried out in Greece, 11,17 the Netherlands, 17 India, 16 Depression increases in patients with heart failure, with age, gender and race affecting in ways similar to those observed in the general population. In terms of age, it has been found that the higher the age, the more negatively the patient with UA is affected. ...
... Depressive symptoms are evident in elderly patients treated with heart failure, especially in women. Women have more frequent depression symptoms than men, 48% versus 36% as reported in Lesman-Leegte et al in 2006, from the Netherlands.11 ...
Introduction: Depression is one of the most common mental disorders and a serious disease that plagues many people today who end up in this through their various problems. The prevention and treatment of adolescent depression is a major issue for the society and for this reason it is important to further study this issue.Aim: This study aims to explore research studies about teenagers’ depression and its effects as well as ways to prevent and address it. Moreover, it aims to seek all cultural and historical aspects of the individual and his/her family to further understand the issue. Material and Method: This is a systematic review of research studies in the electronic databases EBSCO, MedLine, Pubmed journals and books and articles referring to the issue of teenage depression.Results: This systematic review showed that depression is a daily occurrence that affects many people and that adolescents with depression tend to multiply rather than diminish. Among the most important methods of treatment are psychotherapy and reading books.Conclusions: Young people with depression problems find difficulties in their performance in school and society and often have changes in their eating habits as they stretch their weight very often. The consequence of all the above is often suicidal behavior and suicidal tendencies or even thoughts of suicide. So the necessary prevention is needed to avoid unpleasant situations.
... This reversal in relation to the observed trend in the general population may reflect the difficulty of younger people to accept the serious socio-economic impact of heart failure compared to older people. 11 Published studies about heart failure show a high incidence in Cyprus, roughly comparable to that described for most countries. 12 However, there are particular public health challenges that relate to significant delays in diagnosis and establishing barriers to health services, resulting in a significant increase in morbidity and a decrease in patient quality of life. ...
... The search of the studies was made in the ProQuest, PubMed, Research activity on that field has been carried out in Greece, 11,17 the Netherlands, 17 India, 16 Depression increases in patients with heart failure, with age, gender and race affecting in ways similar to those observed in the general population. In terms of age, it has been found that the higher the age, the more negatively the patient with UA is affected. ...
... Depressive symptoms are evident in elderly patients treated with heart failure, especially in women. Women have more frequent depression symptoms than men, 48% versus 36% as reported in Lesman-Leegte et al in 2006, from the Netherlands.11 ...
Background: Depression is one of the major causes of morbidity and loss of productivity in the world. Regardless of age, ethnicity and gender, it is known that its impact increases after major stressful events. Other major causes are chronic diseases, such as heart failure. The condition shows greater frequency and prevalence today, because of the aging population, the growth of population dispersion and other risk factors like hypertension and diabetes as well as the increase in the life expectancy of sufferers, due to current therapeutic interventions. Thus, depression has become chronic and the challenge of fighting inevitably incurs psychosocial effects.Aim:This research paper (systematic review) aims to investigate the prevalence of depression in patients with heart failure in association with determinants.Method & Material: This is a systematic review. In particular, a literature search was conducted in the electronic databases ProQuest, PubMed, EBSCO and Google Scholar, using the key-words: heart failure, prevalence and depression.Results: A total of ten surveys met the selection criteria. According to the results on the prevalence of depression, a moderate to high prevalence among patients with heart failure is presented, as well as an increased risk of mortality and clinical manifestations. Depression increases in patients with heart failure, as age, gender and race affect it similarly compared to what has been observed in the general population. The NYHA class II and III in advanced age and people with a prior history of myocardial infarction show a strong positive correlation with depression, too.Conclusions: Mental health problems affect the entire sphere of activities of a patient. Management is feasible and guaranteed only in a controlled living environment. Nurses, having the privilege of close contact with patients, can promptly diagnose depression symptoms and intervene as members of an interdisciplinary team. In Cyprus, no other research studies exist concerning the assessment of the prevalence of depression in patients with heart failure.
... [7] Prevalence and incidence of the coexistence of CHF and depression in elderly patients are summarized in Table 1. [8][9][10][11][12][13][14][15][16][17][18] While it has been showed an increased prevalence of CHF in elderly patients having major depression, [8] it has been also demonstrated that CHF is an independent risk factor for incident depression in the elderly and that treating the debilitating symptoms of CHF, for example with loop diuretics, may prevent depression development. [18] More-over, some authors found a stronger relationship between the development of depression and the presence of CHF among elderly women than in elderly men. ...
... [18] More-over, some authors found a stronger relationship between the development of depression and the presence of CHF among elderly women than in elderly men. [12] In this matter the majority of studies described an increased prevalence and incidence of depression among CHF elderly patients, [9][10][11]13,14,16,17,19] especially in those with isolated systolic hypertension. [11] In particular, lower social support and hospitalization were identified as worsening factors for the development of psychological distress. ...
... Yu, et al. [14] 2004 Observational 77.1 ± 7.9 HADS Prevalence Depression is more prevalent in CHF elderly patients and correlates with lower social support Gottlieb, et al. [15] 2004 Descriptive 64 ± 12 BDI Prevalence Depression is common in patients with CHF Lesman-Leegtel, et al. [16] 2006 Observational 71 ± 12 CES-D Prevalence Depressive symptoms are prominent in hospitalized, elderly CHF patients, especially women Guallar-Castillón, et al. [17] ...
Chronic heart failure and depressive disorders have a high prevalence and incidence in the elderly. Several studies have shown how depression tends to exacerbate coexisting chronic heart failure and its clinical outcomes and vice versa, especially in the elderly. The negative synergism between chronic heart failure and depression in the elderly may be approached only taking into account the multifaceted pathophysiological characteristics underlying both these conditions, such as behavioural factors, neurohormonal activation, inflammatory mediators, hypercoagulability and vascular damage. Nevertheless, the pathophysiological link between these two conditions is not well established yet. Despite the high prevalence of depression in chronic heart failure elderly patients and its negative prognostic value, it is often unrecognized especially because of shared symptoms. So the screening of mood disorders, using reliable questionnaires, is recommended in elderly patients with chronic heart failure, even if cannot substitute a diagnostic interview by mental health professionals. In this setting, treatment of depression requires a multidisciplinary approach including: psychotherapy, antidepressants, exercise training and electroconvulsive therapy. Pharmacological therapy with selective serotonin reuptake inhibitors, despite conflicting results, improves quality of life but does not guarantee better outcomes. Exercise training is effective in improving quality of life and prognosis but at the same time cardiac rehabilitation services are vastly underutilized.
... of depression than the general population (Katon and Ciechanowski, 2002;Olver and Hopwood, 2013). However, reported estimates of the prevalence of major depression among medically hospitalized patients has varied from 5.9% to 81% (Arolt et al., 1998;Conde Martel et al., 2013;Dal Bó et al., 2011;Frazier et al., 2012;Freedland et al., 2003;Gascón et al., 2012;Helvik et al., 2012;Hosaka et al., 1999;Kok et al., 1995;Lesman-Leegte et al., 2006McCusker et al., 2005;Mendes-Chiloff et al., 2008;Michopoulos et al., 2010;Pakriev et al., 2009;Pelletier et al., 2014;Suzuki et al., 2011;Unsar and Sut, 2010;Zhang et al., 2008;Zhong et al., 2010). This extraordinarily wide, 14-fold, range (Table 1) may be related to differences in case-ascertainment methods. ...
... For example, chronic obstructive pulmonary disease has shown a higher prevalence of depression than stoke or diabetes (Olver and Hopwood, 2013). However, these comparisons usually involved different screening tools, particular subgroups (most elderly patients) and only selected diseases (Cleland et al., 2007;Conde-Martel et al., 2013;Freedland et al., 2003;Lesman-Leegte et al., 2006;Mendes-Chiloff et al., 2008;Musselman et al., 2003;Robinson, 2003)-making comparisons risky. The present study compared all ICD-10 medical conditions of medically hospitalized patients, in an effort to provide more realistic comparisons. ...
... Based on multivariate analyses, these included previous treatment with prescribed psychotropic drugs, being female, having more children, and heavy smoking (Table 4). Some previous reports also have proposed risk factors associated with depression among medically hospitalized patients, although most samples involved elderly patients with cardiac disorders (Conde-Martel et al. 2013;Freedland et al. 2003;Lesman-Leegte et al. 2006;Mendes-Chiloff et al. 2008;Zhong et al. 2010]. In these studies, identified risk factors for depression have included previous depression, female sex, advanced age, less education, poverty, being unmarried, more severe or complex medical illnesses and physical disability, as well as a history of psychological and social problems. ...
... Up to 50% to 60% report insomnia problems (ie, trouble initiating sleep, difficulties maintaining sleep, or difficulties getting enough sleep) 12,13 and/or sleep disordered breathing (SDB). 14,15 Although the direction of impact is unclear, sleep disturbances, such as insomnia, are associated with physical symptoms (ie, impaired functional performance and daytime functioning), 16Y18 mental health issues (ie, worries and/or depressive symptoms), 18,19 and poorer cognitive function. 20 Moreover, SDB has been found to be associated with cardiac readmissions. ...
... 35 We found those with continued sleep problems to have the poorest mental health. This is in line with other studies reporting a strong association between sleep problems and depression in patients with HF. 19,36 Hypothetically, it is possible that these patients are more psychologically vulnerable and perceive even minor changes of symptoms as life threatening and seek hospital care more frequently. ...
... The second step is to determine the type of sleep problem (eg, insomnia, sleep apnea) by including questions focusing on the sleep situation in the clinical assessment, as well as by using validated questionnaires (eg, the Insomnia Severity Index 37 or the Berlin Sleep Apnea Questionnaire 38 ). Because of the strong association with sleep problems, 19,36 assessment of depression at this step may also be needed. The third step is to intervene against the sleep problem. ...
Introduction: Sleep problems are common in patients with heart failure (HF) and might be associated with patient outcomes.
Aims: The aim of this study was to describe the course of sleep problems in HF patients over 1 year and the association between sleep problems and rehospitalization.
Methods: Data from 499 HF patients (mean age, 70 years) were used in this analysis. Sleep problems were assessed with the item "Was your sleep restless" from the Center for Epidemiological Studies Depression Scale during hospitalization for HF (baseline) and after 1 year.
Results: A total of 43% of patients (n = 215) reported sleep problems at baseline, and 21% of patients (n = 105), after 1 year. Among the 215 patients with problems with sleep at baseline, 30% (n = 65) continued to have sleep problems over time. Among the 284 patients without sleep problems at baseline, 14% (n = 40) reported sleep problems after 1 year. After adjustments for potential cofounders, patients with continued sleep problems had an almost 2-fold increased risk for all-cause hospitalizations (hazard ratio, 2.1; P = .002) and cardiovascular hospitalizations (hazard ratio, 2.2; P = .004).
Conclusion: One-third of HF patients with sleep problems at discharge experienced persistent sleep problems at follow-up. Continued sleep problems were associated with all-cause and cardiovascular rehospitalizations.
(C) 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
... Depression is the most common mental health condition-about 35 % of CHD patients meet criteria for clinical depression and even a greater proportion report depressive symptoms (Hemingway & Marmot, 1999;Riegel et al., 2009). Heart disease patients who are depressed tend to experience worse health status, more pronounced symptomatology, recurrent cardiac events, and higher risk of death than those who are not depressed (Lesman-Leegte et al., 2006;Riegel et al., 2009;Tully et al., 2008). ...
... On average, patients in our study experienced a decrease in depressive symptoms one month after hospital discharge compared to the two weeks prior to hospitalization; however, patients with high levels of stress during the first few days after returning home and who lacked either internal or external coping resources experienced an increase in depressive symptoms as time went on. Higher levels of depressive symptoms have negative consequences not only for patients' mental health but also for their physical health, including a more pronounced symptomatology and a higher likelihood of readmission and mortality (Lesman-Leegte et al., 2006;Riegel et al., 2009;Tully et al., 2008). Knowing which patients are particularly vulnerable to experiencing post-discharge stress and an increase in depressive symptoms as a result of this intensified stress can possibly trigger interventions prior to discharge for the patients and their caregivers that might ameliorate the prevalence of depression. ...
Little is known about the role of stress on the psychological well-being of patients after cardiac hospitalization or about factors that protect against or exacerbate the effects of stress. We use prospective data from 1542 patients to investigate the relationship between post-discharge stress and changes in depressive symptoms, and whether the level of prior depressive symptoms, health competence, and perceived social support moderate this relationship. Net of depressive symptoms in the 2 weeks prior to hospitalization, higher levels of post-discharge stress significantly increase depressive symptoms 30 days after discharge. The level of prior depressive symptoms moderates the effect of stress. On the other hand, perceived health competence and social support buffer the negative effects of post-discharge stress. Knowing which patients are particularly vulnerable to experiencing stress and a subsequent increase in depressive symptoms can help trigger interventions prior to discharge and possibly ameliorate the prevalence of depression.
... Several studies have focused on the role of depression and suggested that depression is a possible risk factor for adverse outcomes in patients with HF [4][5][6][7]. The prevalence of depression is reported to be approximately 15-40% in patients with HF, and depression is independently associated with poor outcomes [5][6][7][8][9][10][11][12][13]. A meta-analysis showed that depression is common among patients with HF, and substantially higher rates of clinically significant depression are present among patients with more severe HF [4]. ...
... Several studies have shown that depression is an independent predictor of mortality in patients with HF [1][2][3][4][5][6][7][8][9][10][11][12][13]. In our study, depression was a risk factor in the univariate analysis but was not an independent factor after adjusting for clinical variables at discharge related to the primary outcome. ...
Anxiety is often present in patients with depression. The aim of this study was to evaluate the impact of clustered depression and anxiety on mortality and rehospitalization in hospitalized patients with heart failure (HF).
A total of 221 hospitalized patients with HF, who completed the questionnaires, were analyzed in this prospective study (mean age 62±13 years; 28% female). One-third patients had implanted cardiac devices. Depression was defined as a Zung Self-Rating Depression Scale index score of ≥60 and anxiety was defined as a State-Trait Anxiety Inventory score of ≥40 (male) or ≥42 (female). The primary outcome was the composite of death from any cause or rehospitalization due to worsened HF and refractory arrhythmia.
Of the 221 HF patients, 29 (13%) had depression alone, 80 (36%) had anxiety alone, and 46 patients (21%) had both depression and anxiety. During an average follow-up of 41±21 months, patients with depression alone and those with clustered depression and anxiety were at an increased risk of the primary outcome [hazard ratio (HR) 2.24, 95% confidence interval (CI): 1.17-4.28, p=0.01 and HR 2.75, 95% CI: 1.51-4.99, p=0.01, respectively] compared to patients with no symptoms. Multivariate analysis after adjusting for age, gender, New York Heart Association functional class, B-type natriuretic peptide, device implantation, renal dysfunction, and left ventricular dysfunction showed clustered depression and anxiety, but not depression alone or anxiety alone, was an independent predictor of the primary outcome (HR 1.96, 95% CI: 1.00-3.27, p=0.04).
Our results showed that clustered depression and anxiety were associated with worse outcomes in patients with HF.
... These findings demonstrate that depression in adults with HF is under diagnosed and under treated in LMICs, including Ethiopia, indicating a higher prevalence of depression compared to developed countries. For instance, the prevalence of depression in adults with HF was 17.3% in the USA [17], 28.6% in the UK [41], 29.7% in Spain [42], 41% in the Netherlands [43]. The higher prevalence rate in our study could be due limited access to healthcare, including mental health services [44,45], which might hinder the early identification and treatment of depression. ...
Background
Depression is a common comorbidity in adults with heart failure. It is associated with poor clinical outcomes, including decreased health-related quality of life and increased morbidity and mortality. There is a lack of data concerning the extent of this issue in Ethiopia. Consequently, this study aimed to assess the prevalence of comorbid depression and associated factors among adults living with heart failure in Ethiopia.
Methods
A hospital-based cross-sectional study was conducted at the cardiac outpatient clinics of two selected specialist public hospitals in Addis Ababa, Ethiopia: St. Paul’s Hospital Millennium Medical College and St. Peter Specialized Hospital. An interviewer-administered questionnaire was used to collect data from 383 adults with heart failure who attended the clinics and met the inclusion criteria. Depression was measured using the Patient Health Questionnaire (PHQ-9). A binary logistic regression model was fitted to identify factors associated with depression. All statistical analyses were conducted using STATA version 17 software.
Results
The mean age of the participants was 55 years. On average, participants had moderate depression, as indicated by the mean PHQ-9 score of 11.02 ± 6.14, and 217 (56.6%, 95%CI 51.53–61.68) had comorbid depression. Significant associations with depression were observed among participants who were female (AOR: 2.31, 95%CI:1.30–4.08), had comorbid diabetes mellitus (AOR: 3.16, 95%CI: 1.47–6.82), were classified as New York Heart Association (NYHA) class IV (AOR: 3.59, 95%CI: 1.05–12.30), reported poor levels of social support (AOR: 6.04, 95%CI: 2.97–12.32), and took more than five medications per day (AOR: 5.26, 95%CI: 2.72–10.18).
Conclusions
This study indicates that over half of all adults with heart failure in Ethiopia have comorbid depression, influenced by several factors. The findings have significant implications in terms of treatment outcomes and quality of life. More research in the area, including interventional and qualitative studies, and consideration of multifaceted approaches, such as psychosocial interventions, are needed to reduce the burden of comorbid depression in this population.
... The measurement instruments used to evaluate depression in patients with CVD include: Beck's Depression Inventory (Beck Depression Scale-BDI) (26), Center for epidemiological studies-CES D (27,28), Zung Depression Scale-ZDS (25), Hospital Anxiety Depression Index (HADI) (29), Cardiac Depression Scale-CDS (30), Geriatric Depression Scale-GDS, Hospital Anxiety and Depression Scale-HADS (31), Patient Health Questionnaire-2-PHQ-2 2, and Patient Health Questionnaire-9-PHQ-9 (32). ...
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.
... Depression is associated with higher mortality in patients with CVD [ [8], [17], [18], [19]], rehospitalisation [ [19], [20]], more days spent in hospital [20], visits to the emergency department [20] and clinical heart failure symptoms (e.g. sleep disturbance, [21]). In addition, anxiety is positively associated with mortality [ [22], [23]] and hospitalisation [24]. ...
Objective:
Positive psychology interventions (PPIs) have been found to be effective for psychiatric and somatic disorders. However, a systematic review and meta-analysis of studies examining the effectiveness of PPIs for patients with cardiovascular disease (CVD) is lacking. This systematic review and meta-analysis aims to synthesize studies examining the effectiveness of PPIs and to examine their effects on mental well-being and distress using meta-analyses.
Methods:
This study was preregistered on OSF (https://osf.io/95sjg/). A systematic search was performed in PsycINFO, PubMed and Scopus. Studies were included if they examined the effectiveness of PPIs on well-being for patients with CVD. Quality assessment was based on the Cochrane tool for assessing risk of bias. Three-level mixed-effects meta-regression models were used to analyze effect sizes of randomized controlled trials (RCTs).
Results:
Twenty studies with 1222 participants were included, of which 15 were RCTs. Included studies showed high variability in study and intervention characteristics. Meta-analyses showed significant effects for mental well-being (β = 0.33) and distress (β = 0.34) at post-intervention and the effects were still significant at follow-up. Five of the 15 RCTs were classified as having fair quality, while the remaining had low quality.
Conclusion:
These results suggest that PPIs are effective in improving well-being and distress in patients with CVD and could therefore be a valuable addition for clinical practice. However, there is a need for more rigorous studies that are adequately powered and that help us understand what PPIs are most effective for which patient.
... 40 Moreover, the studies characterizing depression and anxiety across genders in HF patients have consistently shown a higher occurrence of depression and anxiety among women vs men. 9,41 Depressive symptoms have been shown to be a strong predictor of worsening health in HF patients 42 and are associated with worse physical functioning, worse HF symptoms, increased hospitalizations, and increased mortality. 37,38 The HRQoL in the present study was assessed using MLHFQ, which is a widely used disease-specific HRQoL questionnaire validated for HF patients. ...
Purpose
To characterize symptoms, clinical burden, and health-related quality of life (HRQoL) among women and men with heart failure (HF) with a left ventricular ejection fraction (LVEF) of ≤60% in Europe.
Patients and Methods
A real-world cross-sectional study was conducted in France, Germany, Italy, Spain, and United Kingdom from June to November 2019. Patient record forms were completed by 257 cardiologists and 158 general practitioners for consecutive patients with HF. The same patients were invited to complete a questionnaire comprising patient-reported outcomes: the Minnesota Living with Heart Failure Questionnaire (MLHFQ), five-level five-dimension EuroQol questionnaire (EQ-5D-5L), Visual Analogue Scale (VAS), and Work Productivity and Activity Impairment questionnaire.
Results
The mean age of 804 patients (men, n=517; women, n=287) was 68.6 years (men, 67.8 years; women, 70.2 years; p=0.0022). The mean LVEF was 44.7% (men, 43.6%; women, 46.8%; p<0.0001). Patients reported dyspnoea when active (overall, 55.7%; men, 56.0%; women, 55.3%), fatigue/weakness/faintness (34.5%; men, 32.9%; women, 37.2%), and oedema (20.3%; men, 18.7%; women, 23.1%) as the most troublesome HF symptoms. Overall, 54.1% of patients reported low mood/depression (men, 50.8%; women, 60.1%). The overall MLHFQ mean score was higher (ie, poorer HRQoL) among women vs men (37.9 vs 34.6; p=0.0481). MLHFQ was consistently higher (ie, poorer HRQoL) for women vs men across the physical (18.6 vs 16.6; p=0.0041) and emotional (9.4 vs 7.9; p=0.0021) scoring domains. Mean EQ-5D utility (0.69 vs 0.75; p=0.0046) and VAS scores (55.4 vs 61.3; p<0.0001) were lower among women compared with men. Overall, 23.4% of patients were hospitalized owing to HF in the previous year (men, 22.7%; women, 24.6%). Patients reported 43.2% activity impairment due to HF (men, 41.6%; women, 46.4%; p=0.01).
Conclusion
HF causes a substantial burden on patients, with a greater burden among women vs men. This gender-related difference is consistent with other HF studies, warranting further research to understand the underlying reasons.
... 19,24 After adjusting for relevant variables, patients with depression and HF have reported lower mental and physical health scores. 25 Other studies have concluded a negative impact on the psychosocial and physical health ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE April-June 2020 • Volume 17 • Number 4-6 R E V I E W of caregivers, due to their feelings of being unprepared for their caregiving responsibilities in addition to being inadequately supported by their given healthcare team. 26 Spouses of patients with HF have reported feeling a signi cant reduction in well-being and feeling burdened in the caregiving role. ...
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.
... We predict that these relay neurons represent a bottleneck node for integrating convergent excitation by PVH and HSD2 neurons (hunger-reducing, dysphoria-promoting) with inhibition by AgRP neurons (hunger-promoting, dysphoria-reducing), and other inputs that in aggregate tilt the balance of activity in this forebrain network toward a state of dysphoria and anorexia (PVH and/or HSD2 active; AgRP quiet) or hunger (PVH and HSD2 quiet; AgRP active). This testable model, with FoxP2+ pLC/PBcL neurons as a nodal choke point, may provide mechanistic insights to what are at present phenomenological links between appetite and mood dysregulation and disease states with excess aldosterone, such as heart failure (Lesman-Leegte et al. 2006;Rutledge et al. 2006). ...
Sodium deficiency elevates aldosterone, which in addition to epithelial tissues acts on the brain to promote dysphoric symptoms and salt intake. Aldosterone boosts the activity of neurons that express 11-beta-hydroxysteroid dehydrogenase type 2 (HSD2), a hallmark of aldosterone-sensitive cells. To better characterize these neurons, we combine immunolabeling and in situ hybridization with fate mapping and Cre-conditional axon tracing in mice. Many cells throughout the brain have a developmental history of Hsd11b2 expression, but in the adult brain one small brainstem region with a leaky blood–brain barrier contains HSD2 neurons. These neurons express Hsd11b2, Nr3c2 (mineralocorticoid receptor), Agtr1a (angiotensin receptor), Slc17a6 (vesicular glutamate transporter 2), Phox2b, and Nxph4; many also express Cartpt or Lmx1b. No HSD2 neurons express cholinergic, monoaminergic, or several other neuropeptidergic markers. Their axons project to the parabrachial complex (PB), where they intermingle with AgRP-immunoreactive axons to form dense terminal fields overlapping FoxP2 neurons in the central lateral subnucleus (PBcL) and pre-locus coeruleus (pLC). Their axons also extend to the forebrain, intermingling with AgRP- and CGRP-immunoreactive axons to form dense terminals surrounding GABAergic neurons in the ventrolateral bed nucleus of the stria terminalis (BSTvL). Sparse axons target the periaqueductal gray, ventral tegmental area, lateral hypothalamic area, paraventricular hypothalamic nucleus, and central nucleus of the amygdala. Dual retrograde tracing revealed that largely separate HSD2 neurons project to pLC/PB or BSTvL. This projection pattern raises the possibility that a subset of HSD2 neurons promotes the dysphoric, anorexic, and anhedonic symptoms of hyperaldosteronism via AgRP-inhibited relay neurons in PB.
... A similar prevalence was reported in the hospitalized HF patients in other studies. 38 The levels of anxiety measured with the HADS in this study were similar 34,36 or slightly higher than those reported in previous studies. 15,17,18 Anxiety and depression may reduce a patient's independence or their motivation to be active. ...
Background:
Symptoms of anxiety, depression, and cognitive impairment are common in heart failure (HF) patients, but there are inconsistencies in the literature regarding their relationship and effects on exercise capacity.
Objectives:
The aim of this study was to explore the relationships between exercise capacity and anxiety, depression, and cognition in HF patients.
Methods:
This was a secondary analysis on the baseline data of the Italian subsample (n = 96) of HF patients enrolled in the HF-Wii study. Data was collected with the 6-minute walk test (6MWT), Hospital Anxiety and Depression Scale, and Montreal Cognitive Assessment.
Results:
The HF patients walked an average of 222 (SD 114) meters on the 6MWT. Patients exhibited clinically elevated anxiety (48%), depression (49%), and severe cognitive impairment (48%). Depression was independently associated with the distance walked on the 6MWT.
Conclusions:
The results of this study reinforced the role of depression in relation to exercise capacity and call for considering strategies to reduce depressive symptoms to improve outcomes of HF patients.
... OAB may be a component of a neurohormonal phenomenon that includes HF, fatigue, and depression [10]. Emerging evidence in the fields of neurocardiology and behavioral cardiology exists to suggest that HF and depression share signs such as decreased heart rate variability and symptoms including low mood and fatigue, and researchers suggest they may also share the same mechanism [23,24]. An association between depression and urge incontinence has been reported with depression in 60% of those who have idiopathic urge incontinence [25]. ...
The prevalence of Heart failure (HF) is expected to increase worldwide with the aging population trend. The numerous symptoms of and repeated hospitalizations for HF negatively affect the patient's quality of life and increase the patient's economic burden. Up to 50% of patients with HF suffer from urinary incontinence (UI) and an overactive bladder (OAB). However, there are limited data about the relationship between UI, OAB, and HF. The association between HF and urinary symptoms may be directly attributable to worsening HF pathophysiology. A comprehensive literature review was conducted for all publications between January 2000 and November 2017 using the PubMed, Embase, and Cochrane databases. HF represents a major and growing public health problem, with an increased risk of UI and an OAB as comorbidities. Possible effects of HF on urinary problems may be mediated by the prescription of medications for symptomatic relief. Although diuretics are typically used to relieve congestion, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve survival, these classes of drugs have been suggested to worsen urinary symptoms in the presence of HF. Further research is required to understand the impact of UI and an OAB on the HF illness trajectory.
... WHO educational program on depression, founded depression is 33% among patients with ischemic heart [17]. Leegte IL et al. [18] founded 41% percent of Netherlands sample had depression. Whooley MA (20%) [19]. ...
Background: Depression and ischemic heart disease present a major comorbidity.
Objective: To determine the prevalence and to estimate the severity of depression, and some of sociodemographic
variables among patients with ischemic heart disease.
Methods: A cross-sectional study conducted in Baghdad Teaching Hospital, Baghdad, Iraq. Study included all
patients with ischemic heart disease excluding those with unstable medical illness. Socio-demographic variables,
history of comorbid illnesses and complications were compiled. Self-Reporting Questionnaire (SRQ-20) to identify
mental illnesses; DSM-IV criteria for depression and Hamilton-17 Scale for severity of depression, were used.
Results: A total of 271 patients were approached; 94.1% responded. About a half was having myocardial
infarction (50.6%), stable angina (31.4%), and (18%) unstable angina. 45.1% had depression; 14.9% mild, 20%
moderate, 7.06% sever, and 3.14% very severe depression. Depressed was significantly associated with age
(P=0.008), sex (P=0.000), marital status (P=0.026), occupation (P=0.000), education (P=0.005), income (P=0.000),
duration of ischemia (P=0.001), comorbidity with other illnesses (P=0.000), cardiac surgery (P=0.025), and stressful
life events (P=0.000).
Conclusion: Depression is high among ischemic heart disease patients, significantly associated with
demographic variables. Treating physicians and cardiologists need to be aware of this co-morbidity.
... 24,26,27 CES-D has been validated in cancer outpatients as well as hospitalized patients with serious illness. [28][29][30][31][32] Patients also completed the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp) scale, which measures the extent to which medical patients experienced aspects of spiritual well-being in the past week on a 5-point ordinal scale ranging from 0 to 4. 33 Last, we reviewed charts in November 2014 to assess the presence of advance directives, use of hospice services, and rate of death in the hospital after the index admission. ...
Background:
Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer.
Objective:
To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs.
Design:
Prospective cohort study and long-term follow-up.
Setting/subjects:
From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year.
Measurements:
We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes.
Results:
Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p < 0.0001), controlling for tumor type, education, and spiritual well-being. Physicians correctly estimated death within one year in 101 (69%) cases, yet only 37 patients (25%) used hospice, and 4 (2.7%) received a palliative care consult; 89 (60.5%) had a do-not-resuscitate order, and 63 (43%) died in the hospital.
Conclusions:
The surprise question identifies inpatients with advanced solid or hematologic cancers having poor QOL and frequent depressive symptoms. Although physicians expected death within a year, EOL quality outcomes were poor. Hospitalized patients with advanced cancer may benefit from palliative care interventions to improve mood, QOL, and EOL care, and the surprise question is a practical method to identify those with unmet needs.
... Because of an increasing body of research on HR-QoL, more knowledge of how to improve HR-QoL is available. Previous research has focused mainly on medical and physical factors related to HR-QoL (Flynn et al., 2009;Mommersteeg et al., 2009;Rahimi et al., 2010;Hoekstra et al., 2011;Kraai et al., 2012;Hoekstra et al., 2013); however, emotional factors (Guyatt et al., 1993) such as depressive symptoms are also highly prevalent in patients with HF (Lesman-Leegte et al., 2006;Lesman-Leegte et al., 2009b) and are related to HR-QoL (Schowalter et al., 2013). HF patients with a comorbid depressive disorder, for example, have a lower HR-QoL compared with HF patients without a comorbid depressive disorder. ...
Objectives
Health-related quality of life (HR-QoL) of patients with heart failure (HF) is low despite the aim of HF treatment to improve HR-QoL. To date, most studies have focused on medical and physical factors in relation to HR-QoL, few data are available on the role of emotional factors such as dispositional optimism. This study examines the prevalence of optimism and pessimism in HF patients and investigates how optimism and pessimism are associated with different patient characteristics and HR-QoL.
Methods
Dispositional optimism was assessed in 86 HF patients (mean age 70 ± 9 years, 28% female, mean left ventricular ejection fraction 33%) with the Revised Life Orientation Test (LOT-R). HR-QoL was assessed with the Minnesota Living with Heart Failure Questionnaire and the EuroQol.
Results
The (mean ± SD) total score on the LOT-R was 14.6 ± 2.9 (theoretical range 0–24) and the scores on the subscales optimism and pessimism were 8.1 ± 1.9 and 5.5 ± 2.5, respectively. Higher age was related to more optimism ( r = 0.22, p < 0.05), and optimism was associated with higher generic HR-QoL (B = 0.04, p < 0.05).
Significance of results
The association found between optimism and generic HR-QoL of HF patients can lead to promising strategies to improve HF patients’ HR-QoL, particularly because the literature has indicated that optimism is a modifiable condition.
... Symptoms of depression are suitable for interventions. These findings correspond with other studies that have demonstrated that depressive symptoms constitute a barrier for nutrition intake [40,41]. As depression can be a barrier for performing adequate nutritional self-care activities, health care professionals could routinely screen for and treat depressive symptoms among HIV patients under ART [42]. ...
... In heart failure patients, certain symptoms such as exhaustion, loss of hunger, feeling of tiredness and sleeplessness are common [7,8]. One study indicates that hospitalized elderly patients show 41 % depressive symptoms with heart failure, and it is comparable to another study which reported 14 -77 % [9]. In a few North American general hospitals, up to 5 % of all admissions are referred to a psychiatrist [10]. ...
Purpose: To assess the level of anxiety and depression in hospitalized cardiac patients in Faisalabad
Institute of Cardiology, Faisalabad, Pakistan.
Methods: The study was conducted on hospitalized cardiac patients at Faisalabad Institute of
Cardiology (FIC), Faisalabad. Aga Khan University Anxiety and Depression Scale (AKUADS) was
applied to estimate the occurrence of depression and anxiety in selected participants. This study
involved 400 diagnosed hospitalized cardiac patients and another 400 participants without cardiac
disease as control group.
Results: The anxiety and depression level in hospitalized cardiac patient’s was 79.5% (318), compared
with 68.25 % (273) of the control group. Female patients were also more prone to depression than male
patients. Psychological suffering was 1.80 times more in the hospitalized cardiac patients (OR = 1.804,
95 %CI = 1.308 - 2.488, p = 0.0001). The results showed that gender was the leading factor in the
occurrence of co-morbidities such as depression and anxiety.
Conclusion: Depression symptoms are more common among hospitalized patients than in those
without cardiac disease. Close monitoring is required and patients with psychiatric illness should be
referred for appropriate treatment to overcome this risk.
... Symptoms of depression are suitable for interventions. These findings correspond with other studies that have demonstrated that depressive symptoms constitute a barrier for nutrition intake [40,41]. As depression can be a barrier for performing adequate nutritional self-care activities, health care professionals could routinely screen for and treat depressive symptoms among HIV patients under ART [42]. ...
Background: The study explored the association between the depressive symptoms, loss of appetite and under nutrition among treated HIV patients in Goma, a post conflict setting.
Methodology: This was a cross-sectional survey carried out from February 1st to March 3rd, 2016. The prevalence of depressive symptoms and loss of appetite were estimated. A logistic regression model was used to identify the associations between under nutrition, loss of appetite and depressive symptoms, adjusted for other covariates.
Results: The proportion of participants with depressive symptoms was 21.3% (95% CI: 17.1 – 25.5). The prevalence of loss of appetite was 50.1% (95% CI: 45 – 55%). Depressive symptoms (AOR: 2.19; 95%CI: 1.27 – 3.79), smoking (AOR: 2.97; 95%CI: 1.03 – 8.58) and low socio-economic status (AOR: 1.74; 95%CI: 1.05 – 2.88) were associated with loss of appetite. Loss of appetite (AOR: 3.29; 95% CI: 1.92 – 5.64) and receiving efavirenz (AOR: 2.13; 95% CI: 1.24 – 3.66) were significantly associated with under nutrition.
Conclusion: The fact that about one-fifth hand half of the sample reported having respectively depressive symptoms and the lack of appetite demonstrates the magnitude of the problems. There is a need for longitudinal studies to elucidate the pathways linking depressive symptoms, appetite and under nutrition.
Keywords: Depressive Symptoms; Loss of Appetite; Under Nutrition; HIV; Antiretroviral
... A substantial literature has demonstrated the association between depression and chronic heart failure (CHF), with a prevalence ranging from 30% to 51% in these patients (Jiang et al., 2007;Parissis et al., 2008;Sherwood et al., 2007;Lesman-Leegte et al., 2006;Freedland et al., 2003;Jiang et al., 2001). This large variability might be related to the diversity of methods used to measure depressive symptoms (Rutledge et al., 2006). ...
... Samband mellan depression och fysisk funktionsnedsättning har även konstaterats i grupper av medelålders patienter med svår hjärtsvikt (Sullivan, Levy, Russo, & Spertus, 2004;Dracup m.fl., 2003) och bland äldre män med hjärtsvikt som vårdas i öppenvård (Murberg & Bru, 1998;Mårtensson, Dracup, Canary, & Fridlund, 2003), men inte bland kvinnorna i Murberg och Brus studie (1998). I en grupp äldre, sjukhusvårdade patienter med måttlig till svår hjärtsvikt var depressiva symtom däremot vanligare hos kvinnor, och bland patienter som även hade kroniskt obstruktiv lungsjukdom, sömnsvårigheter och aptitlöshet (Lesman-Leegte, Jaarsma, Sanderman, Linssen, & van Veldhuisen, 2006). Friedman och Griffin (2001) fann bland patienter med hjärtsvikt att depression var starkare associerat till fysiska symtom än till fysisk funktionsnedsättning. Upplevelsen att ha kontroll över sitt liv och sin hälsa medförde lägre grad av depression och ångest bland medelålders patienter med svår hjärtsvikt (Dracup m.fl., 2003). ...
... In a study analysing depressive symptoms in heart failure, we found that 40% report depressive symptoms with a significant gender difference of 47% in women and 36% in men. 3 Patients with heart failure are vulnerable for hospitalization and mortality, which may even be worse in those with depressive symptoms. Exercise programmes might be beneficial for these patients; however, first, heart failure patients are often not referred to rehabilitation programmes and secondly female heart failure patients are often older and depend more on others for transportation and therefore do not enrol in these programmes. ...
... Depression and impaired quality of life (QoL) are major problems in patients with heart failure, and exposure to these factors is much higher compared with a community dwelling or age-matched population [1][2][3]. Depression due to a general medical condition is defined as a patient's clinical presentation, which is dominated by a persisting mood disorder, characterized by either or both depressed mood or considerably decreased interest or pleasure in nearly all activities, or a mood that is elevated, expansive or irritable [4]. Also, other cardiac conditions, such as atrial fibrillation, are known to show elevated levels of depression and anxiety [5]. ...
Telemonitoring positively influences some aspects of quality of life. Furthermore it reduces patients' depression and anxiety scores on the short run. The current article presents the results of a one year follow-up study regarding the impact of a first generation telemonitoring system on depression and Quality of Life scores in patients with heart failure.
... COACH was a multi-centre, randomised trial designed to compare basic and intensive support to standard treatment in patients with HF. The methodology , main results and baseline depression data of the trial have been published previously171819. In summary, patients were recruited during a period of 28 months from October 2002 to February 2005. ...
... The OR to suffer from depressive symptoms for patients complaining of difficulties initiating sleep, difficulties maintaining sleep and early morning awakenings increased by more than two fold. These rates corresponds almost the figures found by Leesman- Leegte et al. [24] who reported the OR between sleep disturbance and depressive symptoms to be three folded. However, in the study of Redeker et al. [1] the OR between difficulties initiating sleep and/or difficulties maintaining sleep and depressive symptoms was five folded [16]. ...
Introduction: Insomnia and depressive symptoms are common among patients with chronic heart failure (HF). Aim: The aim was to describe the prevalence of insomnia and depressive symptoms, as well as to examine the association between insomnia and depres-sive symptoms in patients with HF. Method: A cross-sectional descriptive study including 212 patients with HF. All patients responded to questionnaires regarding sleeping difficulties (Uppsala Sleep Inventory-Chronic Heart Failure), daytime sleepiness (Epworth Sleepiness Scale) and depressive symptoms (The Mental Health Scale). Results: Patients with depres-sive symptoms (34%) had, compared to those without, significantly more major complaints of insomnia as indicated by the sub-types; non-restorative sleep (66% vs. 32%, p < 0.0001), difficulty in maintaining sleep (35% vs. 16%, p = 0.003), difficulty in initiating sleep (29% vs. 14%, p = 0.009) and early morning awakenings (25% vs. 10%, p = 0.004). The odds ratio (OR) to suffer from depressive symptoms; were for; non-restorative sleep 5.2 (CI 95%, 2.2-12.3), difficulties maintaining sleep 2.5 (CI 95%, 1.2-4.9), difficulties in initiating sleep 2.2 (CI 95%, 1.1-4.4) and early morning awakenings 2.4 (CI 95%, 1.1-5.4). When categorising insomnia into three severity groups, 1) non insomnia, 2) mild insomnia, and 3) severe insomnia , the OR for depressive symptoms for the mild insomnia and severe insomnia group were 2.2 (CI 95%, 1.1-4.2) and 7.4 (CI 95%, 2.4-22.8) respectively , compared to the non insomnia group. Conclusion: Insomnia is independently associated to depres-sive symptoms. Assessment of depressive symptoms and insomnia in patients with HF is important since treatment could be targeted to depressive symptoms only and/or to the sleep disturbance.
... e utilized in measuring the variables of the study. The authors reported BMI results in relation to overall MLWHF, physical subscale, and emotional subscale scores were significant (p<0.001). The study concluded that obese HF patients have significantly poorer HRQOL, physical health, and emotional well-being; they also have more depressed symptoms. Lesman-Leegte et al. (2006) evaluated depressive symptoms among elderly hospitalized HF patients (n = 572). Depression was measured using the ...
Previous research on quality of life (QOL) and its relation to BNP levels in heart failure (HF) has been widely studied. However, the impact of physicians' knowledge of BNP levels at time of clinic visit on QOL and hospital length of stay (LOS) has yet to be fully investigated. The purpose of this study were to determine if physicians' knowledge of BNP levels affected a change in QOL scores at 90 days and reduce hospital length of stay among heart failure patients. QOL data from HF clinic patients (N = 108, 67.5 ± 12.3, 56% male, ejection fraction 26.5 ± 8.2) were analyzed. QOL was measured at time of clinic visit (T1) and at 90 days (T2) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). An independent t-test was utilized to compare the two groups. Findings: Both groups were comparable regarding demographic and baseline characteristics.
There was no significant association observed between the experimental and control group at 90 days, although the data indicated a decrease in the mean QOL scores at 90 days (37.46 ± 28.67) as compared to the mean QOL scores at baseline (46.87 ± 29.63) for both groups. Because the QOL scale is reversed, this indicated that there was a positive change in QOL scores during the 90 day time interval. Hospital LOS was similar for both groups (mean=3 days). BNP levels were significantly correlated with both baseline QOL scores (r=.25, p=.01) and physical subscale scores (r=.24, p=.01). Mortality was higher in the control when compared to the experimental group (t=1.99, df=90, p=.04). Conclusion: While physicians' awareness of BNP levels had not shown a significant change in QOL at 90 days, patients' QOL might already have been quite positive. Chronic HF patients may have adapted to their disease and have adjusted their perception of their QOL.
Therefore, QOL may be a stable construct at this time. Findings may have been different on newly diagnosed HF patients since they may not have adapted to their health condition.
... The OR to suffer from depressive symptoms for patients complaining of difficulties initiating sleep, difficulties maintaining sleep and early morning awakenings increased by more than two fold. These rates corresponds almost the figures found by Leesman- Leegte et al. [24] who reported the OR between sleep disturbance and depressive symptoms to be three folded. However, in the study of Redeker et al. [1] the OR between difficulties initiating sleep and/or difficulties maintaining sleep and depressive symptoms was five folded [16]. ...
Introduction: Insomnia and depressive symptoms are common among patients with chronic heart failure (HF). Aim: The aim was to describe the prevalence of insomnia and depressive symptoms, as well as to examine the association between insomnia and depres-sive symptoms in patients with HF. Method: A cross-sectional descriptive study including 212 patients with HF. All patients responded to questionnaires regarding sleeping difficulties (Uppsala Sleep Inventory-Chronic Heart Failure), daytime sleepiness (Epworth Sleepiness Scale) and depressive symptoms (The Mental Health Scale). Results: Patients with depres-sive symptoms (34%) had, compared to those without, significantly more major complaints of insomnia as indicated by the sub-types; non-restorative sleep (66% vs. 32%, p < 0.0001), difficulty in maintaining sleep (35% vs. 16%, p = 0.003), difficulty in initiating sleep (29% vs. 14%, p = 0.009) and early morning awakenings (25% vs. 10%, p = 0.004). The odds ratio (OR) to suffer from depressive symptoms; were for; non-restorative sleep 5.2 (CI 95%, 2.2-12.3), difficulties maintaining sleep 2.5 (CI 95%, 1.2-4.9), difficulties in initiating sleep 2.2 (CI 95%, 1.1-4.4) and early morning awakenings 2.4 (CI 95%, 1.1-5.4). When categorising insomnia into three severity groups, 1) non insomnia, 2) mild insomnia, and 3) severe insomnia , the OR for depressive symptoms for the mild insomnia and severe insomnia group were 2.2 (CI 95%, 1.1-4.2) and 7.4 (CI 95%, 2.4-22.8) respectively , compared to the non insomnia group. Conclusion: Insomnia is independently associated to depres-sive symptoms. Assessment of depressive symptoms and insomnia in patients with HF is important since treatment could be targeted to depressive symptoms only and/or to the sleep disturbance.
... It has acceptable validity and reliability, 66 and sensitivity and specificity. 67 The original 20 item version has been used widely with clinical populations, including chronic obstructive pulmonary disease 68 and heart failure, 69 although both versions of the scale include items that confound symptoms of physical illness with symptoms of depression (for example, "I felt that everything I did was an effort"; "My sleep was restless"). 70 Scores range from 0 to 30, with higher scores indicating more depressive symptoms. ...
Objective:- To assess the effect of second generation, home based telehealth on health related quality of life, anxiety, and depressive symptoms over 12 months in patients with long term conditions.
Design:- A study of patient reported outcomes (the Whole Systems Demonstrator telehealth questionnaire study; baseline n=1573) was nested in a pragmatic, cluster randomised trial of telehealth (the Whole Systems Demonstrator telehealth trial, n=3230). General practice was the unit of randomisation, and telehealth was compared with usual care. Data were collected at baseline, four months (short term), and 12 months (long term). Primary intention to treat analyses tested treatment effectiveness; multilevel models controlled for clustering by general practice and a range of covariates. Analyses were conducted for 759 participants who completed questionnaire measures at all three time points (complete case cohort) and 1201 who completed the baseline assessment plus at least one other assessment (available case cohort). Secondary per protocol analyses tested treatment efficacy and included 633 and 1108 participants in the complete case and available case cohorts, respectively.
Setting:- Provision of primary and secondary care via general practices, specialist nurses, and hospital clinics in three diverse regions of England (Cornwall, Kent, and Newham), with established integrated health and social care systems.
Participants:- Patients with chronic obstructive pulmonary disease (COPD), diabetes, or heart failure recruited between May 2008 and December 2009.
Main outcome measures:- Generic, health related quality of life (assessed by physical and mental health component scores of the SF-12, and the EQ-5D), anxiety (assessed by the six item Brief State-Trait Anxiety Inventory), and depressive symptoms (assessed by the 10 item Centre for Epidemiological Studies Depression Scale).
Results:- In the intention to treat analyses, differences between treatment groups were small and non-significant for all outcomes in the complete case (0.480≤P≤0.904) or available case (0.181≤P≤0.905) cohorts. The magnitude of differences between trial arms did not reach the trial defined, minimal clinically important difference (0.3 standardised mean difference) for any outcome in either cohort at four or 12 months. Per protocol analyses replicated the primary analyses; the main effect of trial arm (telehealth v usual care) was non-significant for any outcome (complete case cohort 0.273≤P≤0.761; available case cohort 0.145≤P≤0.696).
Conclusions:- Second generation, home based telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only. Telehealth did not improve quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months. The findings suggest that concerns about potentially deleterious effect of telehealth are unfounded for most patients.
Trial Registration: ISRCTN43002091.
... COACH was a multi-centre, randomised trial designed to compare basic and intensive support to standard treatment in patients with HF. The methodology, main results and baseline depression data of the trial have been published previously [17][18][19]. In summary, patients were recruited during a period of 28 months from October 2002 to February 2005. ...
... Investigators have found inflammation to be associated with depression or fatigue in patients with cancer (Bower et al., 2002; Bower et al., 2011; Orre et al., 2009). Heart failure is another condition that researchers have found to be associated with an activated inflammatory network (Torre-Amione et al., 1996), depression (Lesman-Leegte, Jaarsma, Sanderman, Linssen, & van Veldhuisen, 2006), sleepiness (Brostrom et al., 2004), and fatigue (Falk, Patel, Swedberg, & Ekman, 2009). In recent studies, investigators have found inflammation to be associated with depression in patients with heart failure (Johansson et al., 2011; Wirtz et al., 2009). ...
Sickness behavior is a cluster of symptoms that occur as a response to an infection and alterations in the inflammatory response. Under normal circumstances, sickness behavior is fully reversible once the pathogen has been cleared. Aging and chronic illness such as heart failure are associated with enhanced inflammatory activity that lasts for a long duration and no longer represents an adaptive response. The aim of this study was to explore whether inflammation mediates the relationship between impaired cardiac function and a symptom cluster including anhedonia, fatigue, and sleepiness, which might represent sickness behavior in community-dwelling elders. Structural equation modeling (SEM) showed that the factor impaired cardiac function (i.e., N-terminal fragment of pro-brain natriuretic peptide, left ventricular ejection fraction, and the heart failure medications angiotensin converting enzyme inhibitor, angiotensin receptor blockade, β-blocker, and diuretics) was associated with both inflammation (i.e., C-reactive protein; β = .26) and the symptom cluster (β = .31). Inflammation had a significant direct, but smaller, association with the symptom cluster (β = .21). By this pathway, inflammation also mediated an indirect association between impaired cardiac function and the symptom cluster (β = .05). Including creatinine, blood glucose, ischemic heart disease, previous and current tumor, respiratory disease, age, and body mass index in the SEM model did not change these associations. Our results imply that some aspects of the symptom panorama in elderly individuals with impaired cardiac function or heart failure could represent sickness behavior.
Background
Depressive symptoms are common among patients with heart failure and are often associated with adverse outcomes, including re-hospitalization and mortality. However, little is known about the association between depressive symptoms and subclinical markers of heart failure and cardiac function in community-based samples and little research has focused on South American Hispanics. The current study examined the cross-sectional association between depressive symptoms and cardiac function in South American Hispanic community-based adults.Methods
Participants included 527 adults enrolled in the Peruvian Study of Cardiovascular Disease (PREVENCION). Depressive symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS). Markers of cardiac function were assessed by impedance cardiography and included cardiac output, cardiac index, stroke volume, and stroke volume index. Several multiple regression analyses were used to examine the association between depressive symptoms and markers of cardiac function.ResultsIn adjusted analyses, depressive symptoms were associated with reduced cardiac output, cardiac index, stroke volume, and stroke volume index. These associations remained significant between depressive symptoms and cardiac output (β = − 0.106, p = 0.014), cardiac index (β = − 0.099, p = 0.029), and stroke volume (β = − 0.095, p = 0.022), and a trend was still observed between depressive symptoms and stroke index (β = − 0.083, p = 0.061), even after having controlled for demographic factors (age, gender, education), cardiovascular risk factors (smoking status, body mass index, low- and high-density lipoprotein cholesterol, triglycerides, fasting glucose, serum creatinine), and comorbidities (diabetes mellitus, hypertension, hypercholesterolemia).Conclusions
In the PREVENCION sample tested, depressive symptoms were independently associated with cardiac function among Hispanic adults, even above and beyond pertinent factors such as demographic factors, cardiovascular risk factors, and comorbidities. Future studies should determine whether depressive symptoms are prospectively associated with systolic dysfunction, and examine the bio-behavioral pathways of this association.
Dental implants are a mainstream treatment protocol to replace missing teeth. Patient and clinician demands have led to shorter length and narrower diameter implants, immediately placed implants into infected sites, and the use of implants in children. This article reviews some of the controversial topics in implant dentistry, and presents the evidence that supports and challenges these newer techniques. Because long-term studies are often not available, especially for implants in infected sites, mini implants, and implants in the growing patient, the field continues to evolve.
BACKGROUND
Depression in the elderly is a serious and often underdiagnosed psychiatric disorder that has been linked to adverse outcomes in the hospital setting.
OBJECTIVES
To determine the prevalence of depression and possible associated factors among hospitalized elderly.
DESIGN
An analytical cross-sectional study.
SETTINGS
Medical and surgical wards of King Abdulaziz University Hospital, Jeddah, Saudi Arabia.
PATIENTS AND METHODS
The study included 200 consecutively hospitalized patients aged 60 years and older. Participants were evaluated within 48 hours of admission using an interviewer-administered questionnaire to provide basic demographic and clinical information.
MAIN OUTCOME MEASURE(S)
Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) screening method and the Structured Clinical Interview for the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) mood disorder module.
RESULTS
According to PHQ-9, 17% and 10.5% of the hospitalized patients were diagnosed with a major depressive disorder and other depressive disorders, respectively. The DSM-5 criteria identified 12% of elderly with major depression. Overall, the number of comorbidities associated with depression was significantly higher in the major depressive disorder group than in the no depression group (post hoc P=.022). Depression was also associated with female gender, unmarried status, lower income, and polypharmacy. In addition, cardiovascular disease and cancer were the most prevalent medical illnesses associated with depression among hospitalized elderly.
CONCLUSION
Major depressive disorder was prevalent among hospitalized elderly, especially among those with comorbid conditions. Hospital physicians must, therefore, maintain a high index of suspicion to identify early and manage depressive symptoms in these patients.
LIMITATION
The small size of certain subgroups limits the statistical power to examine for associations of depression with particular conditions.
Background:
Testosterone (TT) and dehydroepiandrosterone sulphate (DHEAS) are neurosteroids and their deficiencies constitute the hormone risk factors promoting the development of depression in elderly otherwise healthy men. We investigated the link between hypogonadism and depression in accordance with age and concomitant diseases in men with systolic HF using the novel scale previously dedicated for elderly population.
Methods:
We analysed the prevalence of depression and severity of depressive symptoms in population of 226 men with systolic HF (40-80 years) compared to 379 healthy peers. The severity of depression was assessed using the Polish long version of Geriatric Depression Scale (GDS).
Results:
In men aged 40-59 years the severity of depressive symptoms was greater in NYHA classes III-IV compared to NYHA classes I-II and reference group. In men aged 60-80 years depressive symptoms were more severe in NYHA class III-IV compared to controls (all p ≤ 0.001). In multivariate logistic regression model in men aged 40-59 years advanced NYHA class was associated with higher prevalence of mild depression (OR = 2.14, 95%CI: 1.07-4.29) and chronic obstructive pulmonary disease (COPD) with higher prevalence of severe depression (OR = 69.1, 95%CI: 2.11-2264.3). In men aged 60-80 years advanced NYHA class and TT deficiency were related to higher prevalence of mild depression (respectively: OR = 2.9, 95%CI: 1.3-6.4; OR = 3.6, 95%CI: 1.2-10.63).
Conclusion:
TT deficiency, COPD and advanced NYHA class were associated with higher prevalence of depression in men with systolic HF.
Objective:
Describe the etiology of pain among HF patients and examine the relationship between pain and QoL.
Background:
Little is known about the etiology of pain in patients with heart failure (HF) and the impact it has on quality of life (QoL).
Methods:
A prospective cohort study of outpatients with NYHA Class II or III HF were surveyed at baseline and at three-month follow-up. The study was conducted in Heart Failure clinics affiliated with a large, urban, academic medical center.
Results:
Of 104 patients that completed a baseline survey, 73 (70%) completed a follow-up survey. At baseline, 48% of patients reported having pain the previous week. Patients on prescription pain medication (n = 16) had more severe pain (Mean = 4.5 vs. 2.6; p = 0.001). Physician documented pain etiologies included: musculoskeletal (50%, n = 16), cardiac (22%, n = 7), and headache/neurological (22%, n = 7). Linear regression revealed that significant contributions to QoL included HF Class (p = 0.0001), dyspnea (p = 0.0001), and depression (p = 0.01). Pain was not independently associated with QoL (p = 0.17), but moderately correlated with depression (r = 0.49). Although 15% (n = 11) of patients reported a clinically meaningful improvement in pain scores, it was not associated with improvements in QoL (χ(2) = 1.6, p = 0.2).
Discussion:
Pain is prevalent and persistent, due largely to non-cardiac causes. Although pain did not predict QOL, it was associated with depression, which did adversely affect QoL. Clinicians should screen for and treat both symptoms.
Background:
The aim of this study is to evaluate the prevalence of depressive symptoms (DS) and its relation on hospitalization for cardiovascular (CV) causes and all-cause mortality risk among outpatients with HF.
Methods:
A prospective study was conducted on 130 adult outpatients with HF. The Beck Depression Inventory Scale-second edition (BDI-II) was used to screen for DS. All-cause mortality and hospitalization for CV causes were registered over 6 years. Logistic regression and multinomial logistic regression analysis were used to evaluate the independent prognostic value of DS on mortality and hospitalization for CV causes after adjustment for clinical risk factors.
Results:
During a mean follow-up of 6 years, 44% of patients were classified as having DS. Sixty-two participants died for all causes, representing 61% of those with DS and 37% of those without (p=0.006); Forty-nine participants (38%) were hospitalized for CV causes, representing 49% of those with DS and 29% of those without (p=0.027). Logistic regression analysis indicated that DS predicted all-cause mortality (OR: 2.905; 95% CI:1.228-6.870; p=0.006) and multinomial logistic regression indicated that DS were predictive of hospitalization for CV causes (OR: 3.169; 95% CI: 1.230-8.164; p=0.027). These associations were independent of conventional risk factors.
Limitations:
Only outpatient sample; measure of DS only at baseline; cause of death was not known.
Conclusion:
This study, first held in a portuguese population, showed that DS are independent predictors of death and hospitalization for CV causes among HF patients and its impact persists over 6 years.
Aims and objectives:
To explore the prevalence of decreased appetite and factors associated with appetite among patients with stable heart failure.
Background:
Decreased appetite is an important factor for the development of undernutrition among patients with heart failure, but there are knowledge gaps about prevalence and the factors related to appetite in this patient group.
Design:
Observational, cross-sectional study.
Methods:
A total of 186 patients with mild to severe heart failure were consecutively recruited from three heart failure outpatient clinics. Data were obtained from medical records (heart failure diagnosis, comorbidity and medical treatment) and self-rated questionnaires (demographics, appetite, self-perceived health, symptoms of depression and sleep). Blood samples were taken to determine myocardial stress and nutrition status. Heart failure symptoms and cognitive function were assessed by clinical examinations. The Council on Nutrition Appetite Questionnaire was used to assess self-reported appetite. Bivariate correlations and multivariate linear regression analyses were conducted to explore factors associated with appetite.
Results:
Seventy-one patients (38%) experienced a loss of appetite with a significant risk of developing weight loss. The final multiple regression model showed that age, symptoms of depression, insomnia, cognitive function and pharmacological treatment were associated with appetite, explaining 27% of the total variance.
Conclusion:
In this cross-sectional study, a large share of patients with heart failure was affected by decreased appetite, associated with demographic, psychosocial and medical factors.
Relevance to clinical practice:
Loss of appetite is a prevalent problem among patients with heart failure that may lead to undernutrition. Health care professionals should routinely assess appetite and discuss patients' experiences of appetite, nutrition intake and body weight and give appropriate nutritional advice with respect to individual needs.
Background:
Vitamin D (Vit D) is suggested to play a role in the regulation of physical function as well as in depression. Since, Vit D deficiency is common in patients with heart failure (HF), this study aims to explore if Vit D levels are associated with depressive symptoms and if this association is mediated by the patients' physical function.
Method:
506 HF patients (mean age 71, 38% women) were investigated. Depressive symptoms and physical function were measured with the Centre for Epidemiological Studies Depression Scale and the physical function scale from the RAND-36. Vit D was measured in blood samples RESULTS: At baseline there was no relationship between depressive symptoms and Vit D levels. However, at 18months follow-up 29% of patients with Vit D <50nmol/l at baseline had depressive symptoms compared 19% of those with Vit D levels >50nmol/l (p<0.05). Only in patients with Vit D <50nmol/l, Vit D correlated significantly to physical function and depressive symptoms (r=.29, p<0.001 and r=.20, p<0.01). In structural equation modelling an indirect association between Vit D and depressive symptoms was found, mediated by physical function (B=0.20). This association was only found in patients with Vit D levels <50nmol/l.
Conclusion:
In HF patients with Vit D <50nmol/l, Vit D is associated to depressive symptoms during follow-up and this association is mediated by physical function. This relationship is not found in patients with Vitamin D level >50nmol/l.
Background:
Decreased appetite in heart failure (HF) may lead to undernutrition which could negatively influence prognosis. Appetite is a complex clinical issue that is often best measured using self-report instruments. However, there is a lack of self-rated appetite instruments. The Council on Nutrition Appetite Questionnaire (CNAQ) and the Simplified Nutritional Appetite Questionnaire (SNAQ) are validated instruments developed primarily for elderly people. Yet, the psychometric properties have not been evaluated in HF populations. The aim of the present study was to evaluate the psychometric properties of CNAQ and SNAQ in patients with HF.
Methods and results:
A total of 186 outpatients with reduced ejection fraction and with New York Heart Association (NYHA) classifications II-IV were included (70% men; median age 72 years). Data were collected using a questionnaire that included the CNAQ and SNAQ. The psychometric evaluation included data quality, factor structure, construct validity, known-group validity and internal consistency. Unidimensionality was supported by parallel analysis and confirmatory factor (CFA) analyses. The CFA results indicated sufficient model fit. Both construct validity and known-group validity were supported. Internal consistency reliability was acceptable, with ordinal coefficient alpha estimates of 0.82 for CNAQ and 0.77 for SNAQ.
Conclusion:
CNAQ and SNAQ demonstrated sound psychometric properties and can be used to measure appetite in patients with HF.
To assess the sleep pattern and depression in patients hospitalised with congestive heart failure, and to study the correlation of poor-quality sleep and depression.
The cross-sectional, descriptive, co-relational study was conducted from October 2011 to March 2012 and comprised New York Heart Association Class III or IV congestive heart failure patients aged >18 years, admitted at teaching hospitals of Rawalpindi, Pakistan. A standardised questionnaire designed in collaboration with cardiologists and psychiatrists of Rawalpindi Medical College and allied teaching hospitals was administered to the patients while they were hospitalised. Pittsburgh Sleep Quality Index and Beck Depression Inventory questionnaire were also used. Statistical analysis was done using SPSS 20.
Of the 40 patients recruited, 26(65%) were males and 14(35%) were females. The overall mean age was 60±13 years. The mean Pittsburgh Sleep Quality Index score was 15.6±3, with 37(92.5%) patients having poor sleep quality. The mean depression score was 27.65±7.5, with all 40(100%) patients affected. Among them, 14(35.7%) patients had severe clinical depression. Class IV congestive heart failure patients suffered from greater daytime dysfunction (p<0.008) and poor sleep efficiency (p<0.009) compared to Class III. No association of poor sleep quality and depression was found with previous history of smoking, diabetes and hypertension. The study revealed a significant relationship between sleep quality and depression (p<0.005).
Hospitalised congestive heart failure patients suffered from poor sleep and depressive symptoms with overall female predominance. The two symptoms were highly co-related and were more severe in Class IV patients than in Class III. A regular screening of such patients is thus essential for prognosis.
The concept of self-care is now well established in government policy and guides the clinical management of patients with long-term conditions, including those with heart failure. Self-care is defined here as adherence to medication and recommended lifestyle advice (self-care maintenance), and recognising, monitoring and responding to symptoms (self-care management). In this literature review, the influence of biological, psychological and social factors on self-care in heart failure are considered. Levels of social support, the patient provider relationship, functional and cognitive ability, depression, personal beliefs, knowledge and psychological factors such as motivation and self-efficacy have all been shown to influence self-care in this patient group. The implications for practice in the light of this review are considered.
Background: Heart Failure (HF) disproportionately affects Native Hawaiians and Other Pacific Islanders (NHOPIs). This study examines risk factors associated with left ventricular ejection fraction (LVEF) among 151 hospitalized NHOPI HF patients enrolled at a single tertiary care hospital between June 2006 and April 2010.
Methods: Enrollment criteria: (1) NHOPI by self-identification. (2) Age � 21 yrs. (3) Diagnosis of HF defined: (a) left ventricular ejection fraction (LVEF)
: 40% or LVEF : 60% with abnormal diastolic function and (b) classic HF signs/symptoms. LVEF was measured by echocardiography within 6 weeks of hospitalization. Clinical measures, medical history, and questionnaires were assessed using standardized protocols. Linear regression modeling was used to examine the association of significant correlates of LVEF, which were then included en bloc into the final model. A P-value < .05 was considered statistically significant.
Results: Of 151 participants, 69% were men, mean age 54.3 ± 13.5 years, blood pressure 112 ± 20/69 ± 15 mmHg, and body mass index (BMI) 36.9 ± 9 kg/m2. Twenty-five percent of participants were smokers, 45% used alcohol and 23% reported a history of methamphetamine use. Clinically, 72% had hypertension, 49% were diabetic and 37% had a prior myocardial infarction. Nearly 60% had moderate to severe LVEF (< 35%). Higher LVEF was independently associated with female sex and greater BMI (P < .04) while pacemaker/deibrillator and methamphetamine use was independently a sociated with lower LVEF (P < .05).
Conclusions: Methamphetamine use and BMI may be important modifiable risk factors associated with LVEF and may be important targets for improving HF morbidity and mortality.
Objectives
: To investigate whether depression after heart failure (HF) was a predictor for subsequent cardiovascular and all-cause mortality in prospective observational studies.
Methods
: Pubmed, Embase, and PsycInfo databases were searched for prospective studies reported depression after HF and subsequent risk of cardiovascular or all-cause mortality (prior to May 2013). Pooled adjust hazard ratio (HR) and corresponding 95% confidence intervals (CI) were calculated separately for categorical risk estimates.
Results
: Nine studies with 4012 HF patients were identified and analyzed. Pooled HR of all-cause mortality was 1.51 (95% CI 1.19-1.91) for depression compared with non-depressive patients. Subgroup analyses showed that major depression significantly increased all-cause mortality (HR = 1.98, 95% CI 1.23- 3.19), but not mild depression (HR = 1.04, 95% CI 0.75-1.45). Pooled HR of cardiovascular mortality was 2.19 (95% CI 1.46-3.29) for depression compared with non-depressive patients.
Conclusion
: Major depression after HF was a predictor for subsequent all-cause mortality, but not mild depression. More well-designed studies are needed to explore the influence of depression and antidepressant medication use on cardiovascular and all-cause mortality in HF patients.
Heart failure is a prevalent chronic health condition in the United States. Individuals who have heart failure experience as many as 2 to 9 symptoms. The examination of relationships among heart failure symptoms may benefit patients and clinicians who are charged with managing heart failure symptoms.
The purpose of this systematic review was to summarize what is known about relationships among heart failure symptoms, a precursor to the identification of heart failure symptom clusters, as well as to examine studies specifically addressing symptom clusters described in this population.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed in the conduct of this systematic review. PubMed, PsychINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Database were searched using the search term heart failure in combination with a pair of symptoms.
Of a total of 1316 studies identified from database searches, 34 were included in this systematic review. More than 1 investigator found a moderate level of correlation between depression and fatigue, depression and anxiety, depression and sleep, depression and pain, anxiety and fatigue, and dyspnea and fatigue.
The findings of this systematic review provide support for the presence of heart failure symptom clusters. Depression was related to several of the symptoms, providing an indication to clinicians that individuals with heart failure who experience depression may have other concurrent symptoms. Some symptom relationships such as the relationships between fatigue and anxiety or sleep or pain were dependent on the symptom characteristics studied. Symptom prevalence in the sample and restricted sampling may influence the robustness of the symptom relationships. These findings suggest that studies defining the phenotype of individual heart failure symptoms may be a beneficial step in the study of heart failure symptom clusters.
As the field of medicine continues to advance, people are living longer with more comorbid medical and psychiatric conditions. This higher burden of illness and the numbers of medications used to treat these conditions plays an important role in the quality and quantity of sleep in older adults. In approaching sleep complaints in geriatric patients, it is essential that practitioners recognize the multidimensional mechanisms by which illness impacts sleep. Equally important, a balanced management approach that includes optimizing the underlying illness, adjusting medications, using cognitive-behavioral approaches, and using judicious hypnotic therapy seems justified based on the current evidence.
This study examined the reliability and validity of a two-factor structure of the Center for Epidemiologic Studies Depression
(CES-D) scale. The study was conducted in a large group of cancer patients (n = 475) and a matched reference group (n = 255).
Both groups filled in a questionnaire at two points in time; patients 3 and 15 months after diagnosis. Factor analysis confirmed
our hypothesis that the 16 negatively and four positively formulated items measure two relatively independent factors, i.e.
Depressed Affect and Positive Affect. Therefore, these items should not be combined into an overall sumscore. In both groups,
Depressed Affect proved to be a reliable and valid measure of depressive symptomatology, as indicated by its good internal
consistency, its strong correlations with other measures of psychological distress and neuroticism, and its effectiveness
in discriminating patients from the reference group on depressive symptomatology. In contrast, the validity of the Positive
Affect factor could not be confirmed, since it was only weakly related to other measures of psychological distress and extraversion.
Depressed and Positive Affect were about equally related to self-esteem, life satisfaction, and quality of life. These findings
support the use of a sumscore based on the 16 negatively formulated CES-D items as a more valid measure of depressive symptomatology,
in cancer patients and in healthy individuals from the general population.
The Center for Epidemiologic Studies Depression scale (CES-D) has been widely used in studies of late-life depression. Psychometric properties are generally favourable, but data on the criterion validity of the CES-D in elderly community-based samples are lacking. In a sample of older (55-85 years) inhabitants of the Netherlands, 487 subjects were selected to study criterion validity of the CES-D. Using the 1-month prevalence of major depression derived from the Diagnostic Interview Schedule (DIS) as criterion, the weighted sensitivity of the CES-D was 100%; specificity 88%; and positive predictive value 13.2%. False positives were not more likely among elderly with physical illness, cognitive decline or anxiety. We conclude that the criterion validity of the CES-D for major depression was very satisfactory in this sample of older adults.
Patients with congestive heart failure (CHF) may have a high prevalence of depression, which may increase the risk of adverse outcomes.
To determine the prevalence and relationship of depression to outcomes of patients hospitalized with CHF.
We screened patients aged 18 years or older having New York Heart Association class II or greater CHF, an ejection fraction of 35% or less, or both, admitted between March 1, 1997, and June 30, 1998, to the cardiology service of one hospital. Patients with a Beck Depression Inventory score of 10 or higher underwent a modified National Institute of Mental Health Diagnostic Interview Schedule to identify major depressive disorder. Primary care providers coordinated standard treatment for CHF and other medical and psychiatric disorders. We assessed all-cause mortality and readmission (rehospitalization) rates 3 months and 1 year after depression assessment. Logistic regression analyses were used to evaluate the independent prognostic value of depression after adjustment for clinical risk factors.
Of 374 patients screened, 35.3% had a Beck Depression Inventory score of 10 or higher and 13.9% had major depressive disorder. Overall mortality was 7.9% at 3 months and 16.2% at 1 year. Major depression was associated with increased mortality at 3 months (odds ratio, 2.5 vs no depression; P =.08) and at 1 year (odds ratio, 2.23; P =.04) and readmission at 3 months (odds ratio, 1.90; P =.04) and at 1 year (odds ratio, 3.07; P =.005). These increased risks were independent of age, New York Heart Association class, baseline ejection fraction, and ischemic etiology of CHF.
Major depression is common in patients hospitalized with CHF and is independently associated with a poor prognosis.
Objective: Using various measures (electronic monitoring, patient/provider report, pharmacy data), the authors assessed the association between depression and diabetes medication adherence among older patients with Type 2 diabetes. Methods: Patients completed a baseline survey on depression ( Patient Health Questionnaire) and were given electronic monitoring caps (EMCs) to use with their oral hypoglycemic medication. At the time of the patient baseline survey, providers completed a survey on their patients' overall medication adherence. Upon returning the caps after 30 days, patients completed a survey on their overall medication adherence. EMC adherence was defined as percent of days out of 30 with correct number of doses. Using pharmacy refill data from the patient baseline through 1 year later, they defined adherence as the percentage of days with adequate medication, based on days' supply across refill periods. Results: Of 203 patients ( mean age: 67 years), 10% ( N = 19) were depressed. Depressed patients were less likely to self-report good adherence and had a lower median percentage of days with adequate medication coverage ( on the basis of pharmacy refill data). After adjustment for alcohol use, cognitive impairment, age, and other medication use, depression was still negatively associated with adequate adherence, according to patient report and pharmacy data. Depression showed no associated with adherence on the basis of provider or EMC data. Conclusions: Depression was independently associated with inadequate medication adherence on the basis of patient self-report and pharmacy data.
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 Center for Epidemiologic Studies Depression scale (CES-D) has been widely used in studies of late-life depression. Psychometric properties are generally favourable, but data on the criterion validity of the CES-D in elderly community-based samples are lacking. In a sample of older (55-85 years) inhabitants of the Netherlands, 487 subjects were selected to study criterion validity of the CES-D. Using the 1-month prevalence of major depression derived from the Diagnostic Interview Schedule (DIS) as criterion, the weighted sensitivity of the CES-D was 100%; specificity 88%; and positive predictive value 13 . 2%. False positives were not more likely among elderly with physical illness, cognitive decline or anxiety. We conclude that the criterion validity of the CES-D for major depression was very satisfactory in this sample of older adults.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
Chronic heart failure (CHF) remains an important and increasing public health care problem. It is a complex syndrome affecting many body systems. Body wasting (i.e., cardiac cachexia) has long been recognised as a serious complication of CHF. Cardiac cachexia is associated with poor prognosis, independently of functional disease severity, age, and measures of exercise capacity and cardiac function. Patients with cardiac cachexia suffer from a general loss of fat tissue, lean tissue, and bone tissue. Cachectic CHF patients are weaker and fatigue earlier, which is due to both reduced skeletal muscle mass and impaired muscle quality. The pathophysiologic alterations leading to cardiac cachexia remain unclear, but there is increasing evidence that metabolic, neurohormonal and immune abnormalities may play an important role. Cachectic CHF patients show raised plasma levels of epinephrine, norepinephrine, and cortisol, and they show high plasma renin activity and increased plasma aldosterone level. Several studies have also shown that cardiac cachexia is linked to raised plasma levels of tumour necrosis factor alpha and other inflammatory cytokines. The degree of body wasting is strongly correlated with neurohormonal and immune abnormalities. The available evidence suggests that cardiac cachexia is a multifactorial neuroendocrine and metabolic disorder with a poor prognosis. A complex imbalance of different body systems may cause the development of body wasting.
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.
Although evaluation of the treatment of congestive heart failure is usually based on objective clinical outcomes, patient self-assessment is increasingly recognized as an important component of evaluation. A study was designed to measure the quality of life of 134 patients with symptoms of advanced heart failure who were being evaluated for possible heart transplantation. The patients' quality of life was assessed using a mix of subjective and objective measures, including functional status, physical symptoms, emotional state, and psychosocial adaptation. There was no significant relationship between patients' cardiac ejection fraction and any quality-of-life measures; however, the results of a 6-minute walking test, New York Heart Association classification, and self-reported functional status were all significantly correlated with psychosocial adjustment. Self-reported functional status, depression, and hostility accounted for 43% of the variance in total psychosocial adjustment to illness. These findings support the inclusion of quality of life as an outcome measure in any evaluation of treatment efficacy and suggest that interventions to improve the quality of life of patients with advanced heart failure need to be targeted at reducing depression and hostility and increasing daily activity levels.
Heart failure has been associated with poor quality of life, which can improve after heart transplantation. Long-term quality-of-life comparisons between patients with heart failure stabilized with medical therapy and heart transplant recipients have not been performed. We assessed quality of life at the time of heart transplantation evaluation and again after 41 months in 12 patients with advanced heart failure stabilized with medical therapy and in 19 patients who had gone on to undergo heart transplantation. Quality of life was measured by three questionnaires. Both groups had similar quality-of-life and clinical features during the transplantation evaluation. Over time, feelings of anxiety and depression, psychologic adaptation, and perceived functional capability improved in the transplant recipients. However, transplant recipients reported more weakness after surgery; this was the major symptom that limited activities. At follow-up 41 months later, we found no significant differences in quality-of-life changes over time between patients stabilized with medical therapy and heart transplant recipients. Overall quality of life for patients who remain stable while receiving medical therapy may not be significantly different from patients who have undergone transplantation.
The study was designed 1) to examine the prevalence of depression in patients with congestive heart failure (CHF); 2) to explore associations between the physician's rating of functional status (NYHA class) and patient's assessment of functional status (physical limitation, dyspnea) with symptoms of depression; and 3) to explore gender related differences in relation to physician's rating and patient's rating of function status, and symptoms of depression.
A sample of 119 clinically stable heart failure patients (85 males and 34 females) was recruited from an outpatient cardiology hospital practice. The patients underwent a physical examination and completed a set of questionnaires. Prevalence of depressive symptoms and the association of these symptoms with NYHA class and patient's perceived functional status was studied.
Findings indicate that depressive symptoms were not predominant among this sample of CHF patients. Path analyses showed non-significant direct associations between NYHA class as well as patient's perception of dyspnea with depression. In contract, the subjective indicator of physical limitations was strongly associated with symptoms of depression among the males, but this relation was not significant among the females.
Results suggest that men and women respond differently to the burden of heart failure. However, interpretation of the results from the present study should be considered as tentative and additional research is required to examine mechanisms that explain gender differences in response to heart failure.
Patients with congestive heart failure had higher scores than control subjects using a case-finding instrument for depression; such patients also were more likely to exceed the diagnostic threshold for depression with this instrument. Identification and treatment of depressed CHF patients may significantly improve level of functioning in these patients.
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).
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.
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 objective of the present study is to compare the QL of a wide range of chronic disease patients. Secondary analysis of eight existing data sets, including over 15,000 patients, was performed. The studies were conducted between 1993 and 1996 and included population-based samples, referred samples, consecutive samples, and/or consecutive samples. The SF-36 or SF-24 were employed as generic QL instruments. Patients who were older, female, had a low level of education, were not living with a partner, and had at least one comorbid condition, in general, reported the poorest level of QL. On the basis of rank ordering across the QL dimensions, three broad categories could be distinguished. Urogenital conditions, hearing impairments, psychiatric disorders, and dermatologic conditions were found to result in relatively favorable functioning. A group of disease clusters assuming an intermediate position encompassed cardiovascular conditions, cancer, endocrinologic conditions, visual impairments, and chronic respiratory diseases. Gastrointestinal conditions, cerebrovascular/neurologic conditions, renal diseases, and musculoskeletal conditions led to the most adverse sequelae. This categorization reflects the combined result of the diseases and comorbid conditions. If these results are replicated and validated in future studies, they can be considered in addition to information on the prevalence of the diseases, potential benefits of care, and current disease-specific expenditures. This combined information will help to better plan and allocate resources for research, training, and health care.
Congestive heart failure (CHF) and depression are independently known to result in physical decline and diminished functional capacity in the general population. The prevalence and relationship of depressive symptoms in CHF to physical limitations has not been objectively examined.
The Center for Epidemiological Studies Depression Scale (CES-D) was used to ascertain depressive symptoms in 33 elderly ambulatory individuals with CHF. Self-report assessment of functional status, cardiopulmonary exercise testing (CPX), and measurement of energy expenditure by doubly labeled water and Caltrac Accelerometer (Muscle Dynamics, Torrance, CA) were performed. Depressed and nondepressed groups were compared. Forty-two percent of the patients scored in the depressed range (CES-D score of 16 or greater). There were no differences in demographic variables or severity of illness between the depressed and nondepressed patients. Energy expenditure was comparable across groups. Although obtaining similar maximal heart rate and maximal oxygen consumption (VO2max) on CPX, the depressed group showed less exertion on exercise testing with a significantly lower respiratory quotient (P = .017).
Depressive symptoms were common and unrelated to the severity of CHF. Although depressed individuals tended to report worse physical functioning than nondepressed individuals, objective assessment of energy expenditure was comparable. Depressed patients appear to underestimate their functional ability. Subsequently, inaccurate assessment of functional status may occur.
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.
Although the association between depression and the incidence of coronary heart disease has been established in many studies, the impact of depression on the incidence of heart failure has not been previously investigated.
We examined the effect of depression (assessed by means of the Center for Epidemiological Studies Depression Scale (CES-D) with a cutoff point of > or =21) on the incidence of heart failure in a community sample of persons aged > or =65 years who were participants in the New Haven cohort of the Established Populations for Epidemiological Studies in the Elderly.
At baseline 2501 individuals were free of heart failure. Of these, 188 (132 women and 56 men) scored as depressed. Depressed participants were significantly more likely to have hypertension, diabetes, and mobility-related functional limitations and were less likely to be male or married. During the 14-year follow-up period, 313 participants (146 men and 167 women) developed heart failure, defined as hospital admission for heart failure or mortality with heart failure as the underlying cause of death. After adjusting for baseline differences in demographic and comorbidity factors and functional status using Cox regression, depression tended to be associated with a greater risk of heart failure (hazard ratio (HR) = 1.52, 95% confidence interval (CI) = 0.94-2.43, p =.09). This effect was significant in women (HR = 1.96, 95% CI = 1.11-3.46, p =.02) but not in men (HR = 0.62, 95% CI = 0.23-1.71, p =.05 for the interaction term between sex and depression).
Depression is an independent risk factor for heart failure among elderly women but not elderly men.
Over several decades, a large body of evidence has emerged to suggest that depressive disorder is a risk factor for heart diseases, both aetiologically and prognostically. Several large, prospective, longitudinal studies have examined the relationship between depression and the development of coronary artery disease (CAD); they reveal that the relationship is significant and independent of conventional risk factors. Prognostic studies have shown that depression is associated with two to three times higher mortality after myocardial infarction, unstable angina or coronary artery bypass grafting, and in patients with stable CAD compared with such patients without depression. Depression also has been found to increase mortality and morbidity in patients with heart failure, regardless of its aetiology. Such adverse associations persist after adjustment for conventional prognostic risk factors. Despite all of these findings, depressed patients with heart disease are less likely to be recognised clinically as being depressed than those patients who have depression but no heart disease. The very limited evidence available from pharmacological clinical trials raises concern about the safety of antidepressants in CAD and heart failure. In addition, no research has addressed whether the treatment of depression in patients with heart disease will improve their prognosis.
Objectives of this study were to: (1) describe perceived social support during a baseline hospitalization and 12 months later among heart failure patients; (2) examine differences in social support as a function of gender and age (less than 65 and 65 years or older); and (3) examine social support as a predictor of health-related quality of life.
Social support is a predictor of well-being and mortality, but little is known about support patterns among heart failure patients and how they influence quality of life.
The sample included 227 hospitalized patients with heart failure who completed the Social Support Survey and the Chronic Heart Failure Questionnaire at baseline; 147 patients completed these questionnaires again 12 months after baseline.
Mean baseline and 12-month total support scores were 56 and 53, respectively, with a score of 76 indicating the most positive perceptions of support. The ANOVA indicated significant interactions of gender by age for total (F = 5.04; p = 0.03) and emotional/informational support (F = 4.87; p = 0.03) and for positive social interactions (F = 4.43; p = 0.04), with men under age 65 perceiving less support than men aged 65 and older and women in either age group. Baseline support did not predict 12-month health-related quality of life, but changes in social support significantly predicted changes in health-related quality of life (R2 = 0.14).
Overall, perceptions of support were moderate to high, but there was wide variation in perceptions over time. Men under age 65 reported less support than other groups of patients. Importantly, changes in social support were significant predictors of changes in health-related quality of life.
Several studies have shown that depression is an important predictor of morbidity and mortality in patients with ischaemic heart failure. We have investigated whether clinically recognised depression is linked to mortality in patients with non-ischaemic heart failure due to dilated cardiomyopathy (DCM) in the Royal Brompton Hospital (RBH), a tertiary cardiac centre located in London, UK. We retrospectively examined a cohort of 396 consecutive adult patients with DCM who satisfied our inclusion and exclusion criteria identified from an echocardiographic database and the hospital medical records. Mean age was 53+/-15 years. In all, 83 patients (21%) were clinically depressed, the majority of which (60%) were taking antidepressant therapy. After a follow-up period of 48 months, 83 (21%) patients died, 15 (4%) underwent cardiac transplantation and 130 (33%) were readmitted; 29 (35%) of the deaths and 40 (31%) of the readmissions were among clinically depressed patients. After 5 years, clinically depressed patients had significantly higher mortality and readmission rates than non-depressed; 36 vs. 16% (hazards ratio for death, 3.0; 95% CI, 1.4-6.4; P=0.004), and 87 vs. 74% (hazards ratio for readmission, 0.25; 95% CI, 0.07-0.90; P=0.03), respectively. The risk of depression was greatly increased in the presence of other recognised adverse clinical variables at baseline. Depression increases the risk of death and readmission in patients with heart failure secondary to non-ischaemic DCM. The risk associated with depression appears to be greatest among patients with milder disease, those with a shorter duration of symptoms and those demonstrating a lower systolic or diastolic blood pressure, renal impairment, or a restrictive left ventricular physiology on echocardiography. Interventions targeted at reducing depression warrant further study as a possible way to improve quality of life and/or outcome in patients with heart failure.
Prevalence estimates of depression in hospitalized patients with congestive heart failure (CHF) differ considerably across studies. This article reports the prevalence of depression in a larger sample of hospitalized patients with CHF and identifies demographic, medical, psychosocial, and methodological factors that may affect prevalence estimates.
A modified version of the Diagnostic Interview Schedule was administered to a series of 682 hospitalized patients with CHF to determine the prevalence of DSM-IV major and minor depression; 613 patients also completed the Beck Depression Inventory. Medical, demographic, and social data were obtained from hospital chart review, echocardiography, and patient interview.
In the sample as a whole, 20% of the patients met the DSM-IV criteria for a current major depressive episode, 16% for a minor depressive episode, and 51% scored above the cutoff for depression on the Beck Depression Inventory (>or=10). However, the prevalence of major depression differed significantly between strata defined by the functional severity of heart failure, age, gender, employment status, dependence in activities of daily living, and past history of major depression. For example, the prevalence ranged from as low as 8% among patients in New York Heart Association class I failure to as high as 40% among patients in class IV.
The prevalence of depression in hospitalized patients with CHF is similar to rates found in post-myocardial infarction patients. However, it is considerably higher in certain subgroups, such as patients with class III or IV heart failure. Further research is needed on the prognostic importance and treatment of comorbid depression in CHF.
Congestive chronic heart failure (CHF) is a progressive disorder in which a complex interaction of haemodynamic, neurohormonal and metabolic disturbances leads to subsequent immune activation. The greatest attention has been given to the concept that the progression of heart failure is due to neurohormonal abnormalities and this has led to substantial therapeutic benefits for CHF. The aim of this review is to describe a number of the interactions between neurohormonal pathways and metabolic problems relevant in CHF. Besides the renin-angiotensin-aldosterone-system, steroid and thyroid hormones, growth factors, insulin and inflammatory cytokines (e.g. tumour necrosis factor-alpha [TNF-alpha]) are considered. TNF-alpha is potentially a key molecule with enormous interactive opportunities within a regulatory network of energy metabolism, immune function and neuroendocrine and hormonal function. The most dramatic metabolic problem in heart failure patients is the development of cardiac cachexia. Currently, no specific therapy exists and the prognosis is poor. There are promising approaches (counteracting TNF-alpha or applying anabolic growth factors) but these are not without risk and are expensive, and their application may, therefore, be limited to certain subgroups of patients. In the future, it will not be enough to monitor cardiac function and symptomatic status in heart failure patients. Rather, the patients' metabolic status may need to be taken, as well as an assessment of peak oxygen consumption, body composition and hormonal status.
Psychological depression is shown to be associated with several aspects of coronary artery disease (CAD), including arrhythmias, myocardial infarction, heart failure and sudden death. The physiological mechanisms accounting for this association are unclear. Hypothalamic-pituitary-adrenal dysregulation, diminished heart rate variability, altered blood platelet function and noncompliance with medial treatments have been proposed as mechanisms underlying depression and cardiovascular disease. Recent evidence also suggests that reduced baroreflex sensitivity, impaired immune function, chronic fatigue and the co-morbidity of depression and anxiety may be involved in the relationship between depression and cardiovascular dysregulation. An experimental strategy using animal models for investigating underlying physiological abnormalities in depression is presented. A key to understanding the bidirectional association between depression and heart disease is to determine whether there are common changes in brain systems that are associated with these conditions. Such approaches may hold promise for advancing our understanding of the interaction between this mood disorder and CAD.
Although spouses are a key support for patients with heart failure, and help them remain in the community, no one has studied patient-spouse pairs to determine the nature of their experience. Therefore, we conducted a study of patients and spouses to compare their levels of depression and health-related quality of life (HRQOL), and to identify factors that contribute to depression and HRQOL in patient-spouse pairs.
Forty-eight couples, in which all patients were men with heart failure, were recruited from a university-affiliated, outpatient heart failure clinic. Data were collected using the Beck Depression Inventory, the 12-item Short Form (that measures physical and mental components of QOL), and the 6-minute walk test.
Patients with heart failure were significantly more depressed and had poorer physical quality of life compared with spouses. Patients' depression was correlated with their own functional status and mental quality of life, with the combination of 6-minute walk distance and mental QOL contributing 51% of the variance in patient depression. Spouse depression and HRQOL did not significantly influence patient depression. In contrast, spouses' depression was related to their husbands' functional status and employment, as well as their own mental QOL. The mental component of spouse QOL and the age of the patient accounted for 33% of the adjusted variance in spousal depression.
Patients with heart failure and their spouses experience significantly different levels of depression and physical QOL. In developing interventions, it may be important to take these differences into account and focus on their unique needs as well as those issues that affect the couple together. Interventions that improve patient functional status may result in decreased depression and improved HRQOL on the part of both patients and spouses.
The key focus of this longitudinal study in the Netherlands was to determine the role of social support (i.e. perceived availability of emotional support, lack of received problem-focused emotional support, and negative interactions) and positive and negative self-esteem in depressive symptoms in 475 recently diagnosed cancer patients and 255 individuals without cancer from the general population. Patients and the comparison group were interviewed and filled in a questionnaire at two points in time: 3 months (T1) and 15 months (T2) after diagnosis. The results indicated that social support and self-esteem were weakly to moderately related to each other. Negative self-esteem was more strongly related to all three types of social support, compared to positive self-esteem. Regression analyses showed that social support and self-esteem were independently related to depressive symptoms (concurrently), such that lower levels of social support and self-esteem were strongly associated with higher levels of depressive symptoms. This finding suggests that these two resources supplement each other additively. A longitudinal analysis showed that social support and self-esteem also predicted future levels of depressive symptoms, although the explained variance was much lower than in a cross-sectional analysis. Comparisons between cancer patients and the comparison group generally revealed no significant differences between the two groups in the associations of social support and self-esteem with depressive symptoms. The only exception was a lack of problem-focused emotional support. At three months after diagnosis, a lack of this type of support, characterised by reassuring, comforting, problem-solving, and advice, was more strongly related to depressive symptoms in patients than in the comparison group.
The purpose of this study was to assess whether depressive symptoms are independently associated with changes in heart failure (HF)-specific health status.
Depression is common in patients with HF, but the impact of depressive symptoms on the health status of these patients over time is unknown.
We conducted a multicenter prospective cohort study of outpatients with HF. Data from 460 patients who completed a baseline Medical Outcomes Study-Depression Questionnaire and both a baseline and follow-up (6 +/- 2 weeks) Kansas City Cardiomyopathy Questionnaire (KCCQ) were analyzed. The KCCQ measures HF-specific health status, including symptoms, physical and social function, and quality of life. Multivariable regression was used to evaluate depressive symptoms as a predictor of change in KCCQ scores, adjusting for baseline KCCQ scores and other patient variables. The primary outcome was change in KCCQ summary scores (range 0 to 100; higher scores indicate better health status; 5 points is a clinically meaningful change).
Approximately 30% (139/460) of the patients had significant depressive symptoms at baseline. Depressed patients had markedly lower baseline KCCQ summary scores (beta = -19.6; p < 0.001). After adjustment for potential confounders, depressed patients were at risk for significant worsening of their HF symptoms, physical and social function, and quality of life (average change in KCCQ summary score = -7.1 points; p < 0.001). Depressive symptoms were the strongest predictor of decline in health status in the multivariable models.
Depressive symptoms are a strong predictor of short-term worsening of HF-specific health status. The recognition and treatment of depression may be an important component of HF care.
Approximately 5 million Americans are currently living with heart failure (HF), and 550,000 new cases are diagnosed yearly [(1,2)][1]. Patients with HF demonstrate a poor quality of life compared with patients who have other chronic diseases, scoring poorly on measures of physical function,
The goal of this study was to determine the prevalence of depression in an out-patient heart failure (HF) population; its relationship to quality of life (QOL); and the impact of gender, race, and age.
Most studies of depression in HF have evaluated hospitalized patients (a small percentage of the population) and have ignored the influence of various patient characteristics. Although reported depression rates among hospitalized patients range from 13% to 77.5%, out-patient studies have been small, have reported rates of 13% to 42%, and have not adequately accounted for the impact of age, race, or gender.
A total of 155 patients with stable New York Heart Association functional class II, III, and IV HF and an ejection fraction <40% were given questionnaires to assess QOL and depression. These included the Medical Outcomes Study Short Form, the Minnesota Living with Heart Failure questionnaire, and the Beck Depression Inventory (BDI). Depression was defined as a score on the BDI of > or =10.
A total of 48% of the patients scored as depressed. Depressed patients tended to be younger than non-depressed patients. Women were more likely (64%) to be depressed than men (44%). Among men, blacks (34%) tended to have less depression than whites (54%). Depressed patients scored significantly worse than non-depressed patients on all components of both the questionnaires measuring QOL. However, they did not differ in ejection fraction or treatment, except that depressed patients were significantly less likely to be receiving beta-blockers.
Depression is common in patients with HF, with age, gender, and race influencing its prevalence in ways similar to those observed in the general population. These data suggest that pharmacologic or non-pharmacologic treatment of depression might improve the QOL of HF patients.
Depression is 4 to 5 times as common in heart failure (HF) patients as in the general population, might confer a higher risk of developing HF, and negatively affects prognosis in established HF.
A review was undertaken via Medline (1966-2003) and PsycINFO (1872-2003) searches using the subject headings "depressive disorder" and "heart failure, congestive." Our findings suggest that the link between depression and HF may be due to shared pathophysiology. Depression may augment catecholamine release, arrhythmias, elaboration of proinflammatory cytokines, and platelet activation--processes that may influence prognosis in HF. Depression is also associated with a higher risk of noncompliance and lower levels of social support, which have been shown to worsen prognosis in HF. The impact of pharmacologic or behavioral treatment for depression on physiologic parameters or clinical outcomes in HF remains unclear. Inherent difficulties in recognition of depression in the setting of HF may decrease the likelihood that depressed patients receive the treatment they need.
Depression is common in HF, may contribute to the development of HF in susceptible populations, and is independently predictive of poor clinical outcomes. Pathophysiologic pathways and psychosocial issues that are shared between the 2 conditions might explain these observations and represent potential therapeutic targets. Vigilant attention to the recognition and treatment of depression in HF patients is warranted.
Depression impairs health status among patients with coronary disease. The effect of depression on patients with heart failure has been studied to date only in hospitalized patients.
Prospective cohort study of 113 outpatients with advanced heart failure. At baseline, 19% (n = 21) had major depression or dysthymia, 9% (n = 10) had minor depression, and 72% (n = 82) had no current depression diagnosis. Repeated measures analyses of covariance adjusting for demographic and clinical differences demonstrated that the depression groups differed on observed function (6-minute walk distance [F = 4.8, P = .01]), and self-reported generic (SF-36) and disease-specific (Kansas City Cardiomyopathy Questionnaire) health status. Depression groups also differed in severity of self-reported breathlessness, chest pain, and fatigue. Subject- and spouse-reported role function also differed between the groups. Partial correlation (controlling for the same covariates) between baseline Hamilton Depression Scale scores and these outcomes was highly significant at baseline and follow-up.
Depression is prospectively associated with poorer health status in patients with advanced heart failure. Physical and role function, symptom severity, and quality of life are all significantly affected.
High levels of psychological distress have been reported in patients with congestive heart failure (CHF), resulting in increased morbidity and mortality. Yet, little is known about its associated factors. The purpose of this study is to identify the significant demographic, clinical and psychosocial correlates of psychological distress in CHF patients.
Cross-sectional data were obtained from a sample of a consecutive series of hospitalized CHF patients (n = 227) with measures of psychological distress, functional status, symptom status, social support and health perception. Objective clinical variables were obtained from the hospital records.
High levels of psychological distress, in particular, depression, were found in patients with CHF. In hierarchical regression analysis, poorer perceived emotional-informational support, higher levels of fatigue, poorer health perception and not living with family were identified as the significant correlates of psychological distress. These correlates, in total, explained 49% of the variance for the scores of psychological distress. None of the objective clinical variables demonstrated a significant contribution that accounted for psychological distress in CHF patients.
The findings highlight the importance of addressing social support for CHF patients. Assisting this vulnerable patient group to cope with fatigue and to cultivate a positive health perception are also highly prioritized treatment goals.
Congestive heart failure (CHF) is frequently associated with depression. However, the impact of depression on prognosis has not yet been sufficiently established.
To prospectively investigate the influence of depression on mortality in patients with CHF.
In 209 CHF patients depression was assessed by the Hospital Anxiety and Depression Scale (HADS-D).
Compared to survivors (n=164), non-survivors (n=45) were characterized by a higher New York Heart Association (NYHA) functional class (2.8+/-0.7 vs. 2.5+/-0.6), and a lower left ventricular ejection fraction (LVEF) (18+/-8 vs. 23+/-10%) and peakVO(2) (13.1+/-4.5 vs. 15.4+/-5.2 ml/kg/min) at baseline. Furthermore, non-survivors had a higher depression score (7.5+/-4.0 vs. 6.1+/-4.3) (all P<0.05). After a mean follow-up of 24.8 months the depression score was identified as a significant indicator of mortality (P<0.01). In multivariate analysis the depression score predicted mortality independent from NYHA functional class, LVEF and peakVO(2). Combination of depression score, LVEF and peakVO(2) allowed for a better risk stratification than combination of LVEF and peakVO(2) alone. The risk ratio for mortality in patients with an elevated depression score (i.e. above the median) rose over time to 8.2 after 30 months (CI 2.62-25.84).
The depression score predicts mortality independent of somatic parameters in CHF patients not treated for depression. Its prognostic power increases over time and should, thus, be accounted for in risk stratification and therapy.
Using various measures (electronic monitoring, patient/provider report, pharmacy data), the authors assessed the association between depression and diabetes medication adherence among older patients with Type 2 diabetes.
Patients completed a baseline survey on depression (Patient Health Questionnaire) and were given electronic monitoring caps (EMCs) to use with their oral hypoglycemic medication. At the time of the patient baseline survey, providers completed a survey on their patients' overall medication adherence. Upon returning the caps after 30 days, patients completed a survey on their overall medication adherence. EMC adherence was defined as percent of days out of 30 with correct number of doses. Using pharmacy refill data from the patient baseline through 1 year later, they defined adherence as the percentage of days with adequate medication, based on days' supply across refill periods.
Of 203 patients (mean age: 67 years), 10% (N=19) were depressed. Depressed patients were less likely to self-report good adherence and had a lower median percentage of days with adequate medication coverage (on the basis of pharmacy refill data). After adjustment for alcohol use, cognitive impairment, age, and other medication use, depression was still negatively associated with adequate adherence, according to patient report and pharmacy data. Depression showed no associated with adherence on the basis of provider or EMC data.
Depression was independently associated with inadequate medication adherence on the basis of patient self-report and pharmacy data.
While there are data to support the use of comprehensive non-pharmacological intervention programs in patients with heart failure (HF), other studies have not confirmed these positive findings. Substantial differences in the type and intensity of disease management programs make it impossible to draw definitive conclusions about the effectiveness, optimal timing and frequency of interventions.
1. To determine the effectiveness of two interventions (basic support vs. intensive support) compared to 'care as usual' in HF patients, on time to first major event (HF readmission or death), quality of life and costs. 2. To investigate the role of underlying mechanisms (knowledge, beliefs, self-care behaviour, compliance) on the effectiveness of the two interventions.
This is a randomised controlled trial in which 1050 patients with heart failure will be randomised into three treatment arms: care as usual, basic education and support or intensive education and support. Outcomes of this study are; time to first major event (HF hospitalisation or death), quality of life (Minnesota Living with HF Questionnaire, RAND36 and Ladder of Life) and costs. Data will be collected during initial admission and then 1, 6, 12, and 18 months after discharge. In addition, data on knowledge, beliefs, self-care behaviour and compliance will be collected.
The study started in January 2002 and results are expected at the end of 2005.
This study will help health care providers in future to make rational and informed choices about which components of a HF management program should be expanded and which components can possibly be deleted.
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