Depression and anxiety in heart failure patients linked to adverse outcomes

Symptoms of depression and anxiety are present in about one-third of patients with heart failure - and these patients are at higher risk of progressive heart disease and other adverse outcomes, according to a review and update in the July/August issue of Harvard Review of Psychiatry. The journal is published in the Lippincott portfolio by Wolters Kluwer.

Yet depression and anxiety remain underrecognized and undertreated in patients with heart failure, report Christopher Celano, MD, of Massachusetts General Hospital and colleagues. "Diagnosing a psychiatric illness can be challenging in view of the significant overlap" between psychiatric symptoms and those related to heart failure, Dr. Celano comments. Nevertheless, "making the effort can help to identify those who are at higher risk for poor cardiac outcomes and to implement the treatment of these disorders."

Depression and Anxiety in Heart Failure - Call to Improve Diagnosis and Treatment

Heart failure is a chronic, progressive condition in which the heart can't pump enough blood, causing symptoms such as fatigue and shortness of breath. Affecting more than five million Americans, heart failure causes death within five years in about 50 percent of patients.

Previous studies have linked psychiatric disorders to worse outcomes in patients with heart failure. To clarify these relationships, Dr. Celano and colleagues performed a targeted review of research on associations between heart failure, depression, and anxiety.

They found evidence confirming "markedly higher" rates of depression and anxiety disorders among patients with heart failure, compared to the general population. Studies have reported that one-third of heart failure patients report elevated symptoms of depression on standard questionnaires, while 19 percent meet diagnostic criteria for major depression or other depressive disorders.

"Depression has been linked to the development and progression of heart failure and other cardiovascular diseases," Dr. Celano and coauthors write. Studies suggest not only that heart failure patients with depression are at increased risk of death or cardiac events, but also that otherwise healthy adults with depression are more likely to develop heart failure.

Anxiety is also highly frequent among patients with heart failure: nearly 30 percent of patients have clinically significant anxiety symptoms, while 13 percent meet diagnostic criteria for anxiety disorders (such as generalized anxiety disorder, posttraumatic stress disorder, or panic disorder). Some studies have linked anxiety to adverse heart failure outcomes, although the evidence is less consistent than for depression.

Both physiological and behavioral factors may contribute to adverse outcomes. Depression and anxiety may make it more difficult for patients with heart failure to follow recommendations for diet, exercise, and medication use. Studies have also linked depression to metabolic changes, including increased levels of inflammatory markers.

Dr. Celano and colleagues believe that formal diagnostic interviews (i.e., based on DSM-5 criteria) can help in assessing the cause of overlapping symptoms between heart failure and depression or anxiety - for example, problems with sleep, concentration, or energy.

To date, there's relatively little research to guide treatment for depression and anxiety in heart failure. Psychotherapy may offer advantages over medications; cognitive-behavioral therapy is the only type of psychotherapy specifically shown to be effective in heart failure patients. Despite a lack of specific evidence for their effectiveness in patients with heart failure, antidepressants such as selective serotonin reuptake inhibitors are recommended, with close monitoring, given their known beneficial effects when treating depression and anxiety in other populations.

The researchers emphasize the need for further research on effective treatments for the large group of patients with heart failure complicated by depression and anxiety. Dr. Celano and coauthors conclude, "It is likely that an aggressive, multimodal treatment approach - such as collaborative care models or stepped care from a mental health professional - will be needed to improve psychiatric and cardiac health in this high-risk population."​