Almost half of the heart failure outpatients given standard questionnaires scored as being depressed

"Depression is probably very important both in evaluating patients with heart failure and in affecting how they feel. We can't ignore depression in these patients. And unless we deal with their depression, we can't improve the symptoms of these patients as much as we would like," said Stephen S. Gottlieb, MD, FACC from the University of Maryland School of Medicine in Baltimore.

The study also involved researchers at the University of Maryland School of Nursing and the Baltimore Veterans Administration Medical Center, as well as Brooklyn College in Brooklyn, New York.

Most previous studies of heart failure and depression have involved hospitalized patients. For this study, the researchers recruited 155 outpatients with stable heart failure. Each participant completed three standard questionnaires to assess general quality of life, the specific influence of heart failure on quality of life, and depression.

A total of 48 percent 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 quality of life. However, they did not differ in ejection fraction (a measure of heart function) or treatment, except that depressed patients were significantly less likely to be receiving beta-blockers. Although beta-blockers are commonly thought to raise the risk of depression, this study and a recent meta-analysis of other studies did not see evidence of such a link.

The depressed patients reported lower quality of life and less ability to exercise. The researchers noted that in a previous study, depressed patients actually performed better on an exercise test than patients who weren't depressed. Dr. Gottlieb noted that other studies have linked depression to personal expectations, which may help explain why younger patients were more likely to score as depressed.

This study provided just a snapshot of depression in this group of heart failure patients and did not look at links between depression and eventual health outcomes. Dr. Gottlieb said the specific percentages of depressed patients are less important than the overall picture.

"The prevalence of depression in this heart failure population was very large. Many people with congestive heart failure score as being depressed on commonly accepted questionnaires," Dr. Gottlieb said.

Dr. Gottlieb said physicians should look for signs of depression in their heart failure patients. The researchers also called for more studies that specifically evaluate the effectiveness of depression treatments in patients with heart failure.

In an editorial in the journal, Christopher M. O'Connor, MD, FACC and medical student Karen E. Joynt from Duke University Medical Center in Durham, N.C., also called for screening heart failure patients for depression and treating it when it is found.

"This study is particularly important because it extends our knowledge about the high prevalence of depression in heart failure into the outpatient population. Gottlieb et al. found that nearly half of their sample was depressed- and given the negative impact that we understand depression to have on prognosis in patients with and without heart disease; this represents a major, and largely overlooked, contributor to the poor prognosis of heart failure patients in the community. This study highlights the importance of continued research investigating the mechanistic link between depression and heart failure as well as the impact of the treatment of depression on symptoms and prognosis in patients with heart failure," they commented.

Sharon A. Hunt, MD, FACC at the Stanford University Medical Center in Palo Alto, Calif., who was not connected to this study, called the work significant.

"It nicely documents the very high incidence of depression in an unselected outpatient group of patients with heart failure and draws attention to a facet of the illness that may be under-recognized in everyday practice and the treatment of which may greatly improve quality of life for the patients who have it. It sets the stage for trials to investigate the best ways to alleviate depression in this setting and to document whether such therapies do indeed improve perceived quality of life, and possibly even prolong life," Dr. Hunt said.

The American College of Cardiology, a 29,000-member nonprofit professional medical society and teaching institution, is dedicated to fostering optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and guidelines, and the formulation of health care policy.