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Depression in patients with heart failure
Journal of Cardiac Failure Vol. 11 No. 1 2005
Depression in Patients With Heart Failure CHERYL WESTLAKE, RN, PhD,1 KATHLEEN DRACUP, RN, DNSC,2 GREGG FONAROW, MD,3 AND MICHELE HAMILTON, MD3 Fullerton, California; Los Angeles, California
ABSTRACT Background: Psychologic comorbidities, particularly depression, often accompany heart failure and add to the complexity of clinical management. We conducted a study to describe the prevalence of depression, the differences between patients with minimal versus mild to severe depression, and the correlates of depression in patients with heart failure. Methods and Results: Data were collected from 200 patients with symptoms of heart failure resulting from systolic dysfunction. Psychologic assessment included depression, perceived control, neuroticism, educational needs, and social support/network. Patients were, on average, 57.0 (⫾12.1) years old, male (168, 84.0%), and in New York Heart Association (NYHA) class II or III (n ⫽ 140, 70.0%) with a mean ejection fraction of 25.5 ⫾ 6.4%. They had an average maximal oxygen uptake of 15.8 (⫾4.6) mL·kg·min and 6-minute walk distance of 1345.0 (⫾302.1) feet. Minimal depression was described by 105 (52.5%) patients, mild by 62 (31%), moderate by 30 (15%), and severe by 3 (1.5%). The significant differences between patients with minimal depression compared to mild to severe depression were NYHA class (χ2 ⫽ 14.05, P ⫽ .003), maximal oxygen uptake (t ⫽ 2.62, P ⫽ .010), 6-minute walk distance (t ⫽ 4.22, P ⬍ .001), β-blocker therapy (χ2 ⫽ 15.21, P ⬍ .001), perceived control (t ⫽ 7.93, P ⬍ .001), and neuroticism (t ⫽ ⫺8.85, P ⬍ .001). Conclusions: More than half the patients studied did not report experiencing significant depression. In those who did, both physical and psychosocial variables accounted for 48.6% of the variance. These findings warrant further research and indicate a need to test interventions aimed at enhancing perceived control, reducing neuroticism, and meeting educational needs to reduce depression in patients with heart failure. Key Words: Psychosocial outcomes, heart failure, 6-minute walk, depression.
between HF and depression is not clearly understood. In some studies, investigators have documented a univariate association, whereas, in others, the relationship has been multivariate, a distinction that may be related to statistical power.7,9 Depression is defined as a specific alteration in mood associated with self-reproach and self-blame, regressive and self-punitive wishes, vegetative changes, and changes in activity level.13 Although relatively little is known about depression in HF,14 in other clinical populations, depression appears to delay recovery from physical illness,15 increase length of hospital stay,16,17 be associated with poorer medical prognosis,18 and increase mortality.11,19–21 The purpose of this study was to describe the prevalence of depression in patients with HF, explore the differences between patients with minimal depression and those with mild to severe depression, and explore the correlates of depression in patients with HF.
Heart failure (HF) is a syndrome characterized by left ventricular dysfunction, exercise intolerance, reduced quality of life (QOL), and markedly shortened life expectancy. Depression is an important outcome used by clinicians and researchers to evaluate HF therapy.1–6 The diagnosis of depression is important because of its association with mortality,7–9 quality of life,5–6,10 and functional status11–12 in patients with HF independent of somatic parameters. The relationship From the 1California State University, Fullerton, California; 2University of California, San Francisco, School of Nursing, San Francisco, California; 3 University of California, Los Angeles, Ahmanson Cardiomyopathy Center, Los Angeles, California. All decisions regarding this manuscript were made by a guest editor. Manuscript received August 7, 2003; revised manuscript received March 29, 2004; revised manuscript accepted March 29, 2004. Reprint requests: Cheryl Westlake, RN, PhD, 327 Calle Pescador, San Clemente, CA 92672. Partially supported by a grant from the American Heart Association Western Division and a National Institutes of Health Training Grant (T32 NR07072). 1071-9164/$ - see front matter 쑕 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.cardfail.2004.03.007
Methods After approval for the study by the appropriate Institutional Review Board, permission to contact interested patients was obtained from cardiologists treating patients at a university-affiliated
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Depression in Patients With HF outpatient clinic. Sample selection criteria included adult HF patients older than age 18 with an ejection fraction ⬍40%. All HF patients who met the sample selection criteria were considered for inclusion in the study. Potential participants were identified through their care provider or through signs posted in the clinic. Because of this method of recruitment, there is no information about those patients who chose not to volunteer. Sample Patients were eligible for study if they were 18 years of age or older; able to speak, read, and write English; had symptoms of HF for 6 months or longer; and did not have another serious comorbidity. The patients were enrolled during a consultation visit at a university-affiliated, outpatient HF clinic over an 18-month period. Patients signed informed consent forms and were given the study questionnaires to complete in the clinic or at home. If patients elected to take the study materials home, they were also given a stamped envelope in which to return them. All eligible patients who were recruited to the study agreed to participate in the study. Of the 257 patients who met the eligibility criteria and verbalized interest in participating, only 200 (78%) completed all questionnaires. These 200 comprise the study sample; the remaining 56 patients are termed “nonparticipants.” Participants and nonparticipants were not significantly different on a variety of demographic and clinical variables (Table 1). However, a significant difference was noted in New York Heart Association (NYHA) classification (P ⫽ .001). Patients who did not return the study materials were more likely to have a higher (ie, worse) NYHA class than patients who completed the study. Instruments Depression was measured using the Beck Depression Inventory (BDI).13,22 The BDI is a widely used, self-reported, 21-item instrument comprising statements of symptoms and attitudes of depression. Response statements are rated on a 4-point scale ranging from 0 to 3 in terms of severity. The total score range is 0 to 63. A score of 0 to 9 is categorized as no or minimal depression, 10
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to 16 as mild, 17 to 29 as moderate, and 30 to 63 as severe depression. 22 Demographic and clinical variables were measured by chart review. NYHA classification was assessed by the HF clinic cardiologist after a complete history and physical. This measure of functional status is based on the degree of activity required to evoke symptoms. NYHA class I requires prolonged or extreme exertion to evoke symptoms; a NYHA class IV requires no exertion to evoke symptoms (ie, symptoms occur at rest). Therefore, a lower NYHA classification reflects a higher functional status. Functional status was also measured by both maximal oxygen consumption and distance walked over six minutes. Maximal oxygen uptake was measured during a bicycle cardiopulmonary exercise test and is reported as mL·kg·min. Previously, it has been shown that patients who exercise at 14 mL·kg·min or less have a significantly worse prognosis than patients who with higher exercise capacity.23 The 6-minute walk test was performed in an area of the clinic where distances were premeasured. A research assistant used a script to instruct the patients and then walked behind them for the entire time to avoid influencing the pace of walking. The 6-minute walk distance has been used in numerous clinical trials with patients similar to those in the present study and has adequate reliability and validity.24–27 Perceived control was measured using the Control Attitudes Scale (CAS).28 The CAS is a 4-item questionnaire comprising questions such as: “Regarding your heart problems, how much control do you feel?” and “Regarding your heart problems, how helpless do you feel?” Response statements are scored from 1 (none) to 5 (very much) on a Likert scale according to the degree to which patients agree or disagree with a given statement. Scoring is reversed on half of the items. The instrument has items related to both the patient’s perception of his or her own control and the family members’ perception of control. The total score range is 4 to 20, with higher scores reflecting higher feelings of control. Neuroticism was assessed using the Eysenck Personality Inventory (EPI).29 The EPI is a 6-item questionnaire comprising questions such as, “Do you sometimes feel happy, sometimes depressed, without any apparent reason?” and “Are you frequently ‘lost in thought’ even when supposed to be taking part in a conversation?”
Table 1. Comparison of Participants and Nonparticipants in Study
Variable Age (years) Ejection fraction (%) Maximal oxygen uptake Six-minute walk distance (feet)
Variable Gender Male Female New York Heart Association class I II III IV
Participant (n ⫽ 200) mean ⫾ SD 57.0 25.53 15.80 1345.0
⫾ ⫾ ⫾ ⫾
12.4 6.44 4.57 302.14
Nonparticipant (n ⫽ 56) mean ⫾ SD
df
t test
P value
⫾ ⫾ ⫾ ⫾
208 211 141 213
0.01 –0.29 –0.43 0.72
.99 .77 .67 .47
df
χ2
P value
1
0.21
.65
3
16.78
.001
57.24 26.58 18.02 1318.44
13.25 7.04 7.57 390.54
Participant (n ⫽ 200) n, %
Nonparticipant (n ⫽ 56) n, %
168, 84 32, 16
49, 87.5 7, 12.5
29, 60, 80, 31,
14.5 30 40 15.5
4, 11, 40, 1,
7.1 19.6 71.4 1.9
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Responses are scored ⫹1 for yes and ⫺1 for no. The range is ⫺6 to 6, with a higher score denoting greater neuroticism.30 The Medical Outcomes Study-Social Support Survey (MOSSSS) was used to assess the social network and social support.31 The MOS-SSS is a 20-item survey of functional social support and represents multiple dimensions of support: emotional, informational, tangible, affectionate, and positive social interaction. An item measuring the number of close friends and relatives available for support provides an index of the social network. The remainder of items focuses on the perceived availability, if needed, of various components of functional support (eg, “Someone to take you to the doctor if you needed it” and “Someone who hugs you”). Response statements are scored from 1 (none of the time) to 5 (all of the time). The range is 19 to 95, with a higher score denoting greater social support. The MOS-SSS has good construct and discriminant validity.31 All of the assessment instruments are widely used well-standardized self-report inventories with established reliability and validity. Procedures A member of the research team presented the study and outlined the subject’s participation requirements to interested patients. Patients were informed that their responses would be kept confidential and that under no circumstances would their participation or lack of participation influence treatment decisions or jeopardize their care. If willing to participate, they signed a written consent form. Before receiving the questionnaires to complete, patients underwent a 6-minute walking test along an enclosed corridor of the clinic. Questionnaires were compiled in random order, bound into a booklet, and numerically coded to ensure subject anonymity. Completion of the battery of instruments required approximately 45 minutes. Patients were asked to complete the packet of instruments during the time of the initial consultation visit whenever possible. Patients who chose not to complete the packet during the time of the clinic visit were given a self-addressed, stamped envelope in which to return the completed instruments. Statistical Analysis Statistical analyses were performed using SPSS for Windows 10.0 release (SPSS Inc., Chicago, Ill). Frequencies and percents were calculated for discrete categorical variables and means and standard deviations were calculated for the continuous variables. The characteristics of patients with minimal depression versus mild to severe depression were compared using independent t tests. A stepwise linear multiple regression was performed to determine the relative contributions of demographic, clinical, and psychosocial characteristics to the variability in depression. Before the regression analysis, zero-order correlations among predictors were examined to avoid multicollinearity. Correlations less than .80 were judged as demonstrating a lack of redundancy. A level of significance of P ⬍ .05 was set a priori for statistical significance.
and clinical variables. However, a significant difference was noted in NYHA classification (P ⫽ .001). A larger percentage of nonparticipants were in NYHA class III (71.4%) than were participants (40.0%). However, there were a larger percentage of participants in NYHA class IV (15.5%) than nonparticipants (1.9%). Patients who did not return the study materials were more likely to have a worse (ie, higher) NYHA class than patients who completed the study. Patients on average were 57.0 (⫾12.1) years of age with an ejection fraction of 25.5% (⫾6.4%). The majority was male (168, 84.0%) and NYHA class III (80, 40.0%). They had a mean 6-minute walk distance of 1345.0 (⫾302.1) feet and a maximal oxygen uptake of 15.8 (⫾4.6) mL/kg/min. On average, patients demonstrated a mild level of depression (10.5 ⫾ 7.3). They reported moderate levels of neuroticism (⫺1.3 ⫾ 3.8) and perceived control (11.2 ⫾ 3.3) and excellent social support (79.6 ⫾ 15.6)m with an average social network of 10.39 ⫾ 11.0 people. Prevalence of Depression
A score of 0 to 9 is categorized as minimal depression, 10 to 16 as mild, 17 to 29 as moderate, and 30 to 63 as severe depression. Moderate to severe depression is considered clinically significant and requires treatment.22 Minimal depression was described by 105 (52.5%) patients, mild depression by 62 (31%), moderate by 30 (15%), and severe by 3 (1.5%) patients (Table 2). Therefore, 16% of patients studied in this sample warranted clinical evaluation by a mental health professional and 47.5% reported symptoms of depression. Differences Between Patients With Minimal and Mild to Severe Depression
Patients with minimal depression (n ⫽ 105, 52.5%) are those patients who scored a 0 to 9 on the BDI. Patients with mild to severe depression (n ⫽ 95, 47.5%) scored ⬎9 on the BDI. The differences between patients with minimal and mild to severe depression are presented in Table 3. This bivariate approach to the diagnosis of depression allows for consideration of those with depression for whom quality and quantity of life may be a significant consideration. The significant differences between those patients with minimal depression and those with mild to severe depression were
Table 2. Classification of Depression by Beck Depression Inventory (BDI)19 and Distribution in Study Sample
Results To identify the existence of participation bias, we compared the demographic and clinical characteristics of patients who completed all the questionnaires (termed “participants,” n ⫽ 200) with those who did not (termed “nonparticipants,” n ⫽ 56) (Table 1). Participant and nonparticipants were not significantly different on a variety of demographic
BDI score Minimal depression Mild depression Moderate depression Severe depression
Depression classification 0–9 10–16 17–29 30–63
Severity of depression n
%
105 62 30 3
52.5 31 15 1.5
Depression in Patients With HF
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Table 3. Comparison of Heart Failure Patients With Minimal vs. Mild-Severe Depression Minimal depression (n ⫽ 105) mean ⫾ SD Age (years) Ejection fraction Maximal oxygen uptake (mL/kg) Six-minute walk distance (feet) Control Neuroticism Social network Social support
55.68 26.2 16.59 1427.22 12.75 ⫺3.22 11.53 80.30
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
11.75 6.86 5.046 295.03 2.96 2.98 13.66 14.20
Mild to severe depression (n ⫽ 95) mean ⫾ SD
t test
P value
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
–1.58 1.55 2.62 4.22 7.93 –8.85 1.56 0.68
.115 .123 .010 ⬍.001 ⬍.001 ⬍.001 .120 .500
χ2
P value
3.44
.064
14.05
.003
15.21
⬍.001
58.39 24.79 14.92 1254.05 9.55 0.76 9.12 78.81
n, % Gender Male Female New York Heart Association class I II III IV β-blocker Yes No
12.45 5.99 3.82 284.68 2.74 3.38 6.71 17.02
n, %
93, 88.5 12, 11.5
75, 79 20, 21
23, 33, 39, 10,
6, 27, 41, 21,
21.9 31.4 37.2 9.5
66, 62.9 39, 37.1
6.3 28.4 43.2 22.1
32, 33.7 63, 66.3
NYHA class (χ2 ⫽ 14.05, P ⫽ .003), maximal oxygen uptake (t ⫽ 2.62, P ⫽ .010), 6-minute walk distance (t ⫽ 4.22, P ⬍ .001), β-blocker therapy (χ2 ⫽ 15.21, P ⬍ .001), perceived control (t ⫽ 7.93, P ⬍ .001), and neuroticism (t ⫽ ⫺8.85, P ⬍ .001). Patients with minimal depression tended to have higher functional status and perceived control, were less neurotic and were receiving β-blocker therapy.
are reported in Table 5. The functional status variables of NYHA classification, maximal oxygen uptake and 6-minute walk distance explained 13.3% of the variability in depression. The addition of the pharmaceutical intervention of βblockers contributed only an additional 2.4%. However, the psychologic factors of perceived control and neuroticism explained an additional 22.9% of the variance in depression. The overall model explained 48.6% of the variability in depression (F ⫽ 32.4, P ⬍ .001).
Factors Influencing Depression
Discussion
Correlational analyses were performed to identify the variables to be used in the multiple regression, as well as to avoid multicollinearity. Correlations ⬍0.80 were judged as demonstrating a lack of redundancy. These results are provided in Table 4. To identify the relative contribution of the factors that influenced depression in patients with HF a stepwise linear regression analysis was conducted. Results
Table 5. Stepwise Linear Regression Analysis of the Influence of Functional Status, Medication, and Psychologic States on Depression
Table 4. Correlations of Variables With Depression Variables
The current study contributes to the growing body of knowledge about depression in patients with HF by identifying its prevalence in a group of chronic patients and defining and measuring variables previously untested. Specifically, perceived control and neuroticism were identified as related to depression.
r
P
.08 .10 –.09 .28 –.17 –.33 .23 –.54 .65 –.11 –.12
.28 .15 .21 ⬍.001 .02 ⬍.001 ⬍.001 ⬍.001 ⬍.001 .13 .08
Variables Age Gender Ejection fraction New York Heart Association Maximal oxygen uptake Six-minute walk distance β-blocker therapy Perceived control Neuroticism Social network Social support
Functional status NYHA classification, maximal oxygen uptake, 6-minute walk distance Medication β-blockers Psychologic variables Perceived control, neuroticism
r2
Adjusted r2
F
P
.146
.133
11.17
⬍.001
.174
.157
10.25
⬍.001
.502
.486
32.40
⬍.001
NYHA, New York Heart Association.
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Journal of Cardiac Failure Vol. 11 No. 1 February 2005
Using the relatively low cutoff of nine on the BDI, 47.5% of this sample of patients with HF was categorized as experiencing some degree of depression. This is higher than the 36.5% level reported by Koenig,32 but consistent with the findings of others.12 This finding is clinically important because these patients may benefit from additional interventions for depression (ie, pharmacotherapy or psychotherapy). Koenig32 found that the majority of depressed HF patients did not receive treatment for their depression and did not see mental health specialists any more frequently than nondepressed patients, suggesting that clinicians need to be alert to the possibility of depression in their population. A psychologic intervention such as the ones described by Balestroni33 or Luskin4 may be indicated and efficacious. The relationship between functional status and depression found in this sample supports previous research.7,12,32,34–39 Because of the cross-sectional design of the study, it is not possible to know whether patients are depressed because they have poor functional status or if they have poor functional status because they are depressed. Future study in this area is warranted. However, our findings may suggest a need for clinicians to work to improve patients’ functional status not only for the physical benefits accrued but for the psychologic benefits. In light of recent clinical trials indicating the value of β-blockers to reduce morbidity and mortality in patients with HF,1,39,40 the identification of a significant relationship between β-blocker therapy and depression is timely. The data demonstrate that patients on β-blocker therapy experience less severe depression; this finding is in contradiction to previous research41 and may indicate that more severely depressed patients are not prescribed β-blockers because of their potentially deleterious effect on psychologic health. Additional research is indicated to sufficiently understand this relationship. More importantly, the amount of variance in depression is quite small, suggesting a minimal effect. Identifying patients with characteristics associated with depression may allow clinicians to use diminishing health care resources by better targeting those patients at high risk for depression. Perceived low control may predict those patients at higher risk for depression. The relationship between perceived control and depression has been previously described in myocardial infarction and coronary artery bypass graft surgery patients,42 and supports our previous finding in HF patients.43 The findings suggest that future research should be aimed at testing this relationship and potential interventions designed to promote patients’ perception of control related to their disease as one approach to reducing depression. Interventions that have been described as enhancing patients’ perceived control include providing patients with treatment choices, helping them to see the options related to their cardiac disease, encouraging active participation, providing information, and increasing predictability of the circumstances surrounding cardiac disease.43 These strategies must be presented in a way that specifically heightens perceived control.5 Further research is indicated
regarding the efficacy of these interventions in enhancing perceived control in patients with HF. The finding of neurotic individuals experiencing more severe depression supports the findings of Murberg and colleagues,44 but refutes the prognostic findings of Carinici45 related to neuroticism. The data suggest that neuroticism may predict those patients at higher risk for depression. The amenability of neuroticism to change is an area for future research. Further, the findings suggest that future research be aimed at testing interventions designed to diminish patients’ neuroticism as one approach to improving depression. The importance of social support related to depression has been demonstrated previously.44,46 However, in this sample neither the size of the social network nor the nature of the social support influenced depression significantly. This finding refutes previous studies and warrants additional study before conclusions may be drawn. The ability to generalize this study’s findings to all patients with HF is limited by the fact that patients were recruited from a university-affiliated HF program and therefore may not be characteristic of all HF patients. Second, because the sample self-selected for participation in the study, the results may be biased. Because we were unable to track individuals who refused to participate, we don’t know if depression is under- or overrepresented in our sample. This is especially likely because the outcome variable, depression, characteristically causes individuals to refuse to participate; however, we do not know the level of depression in these individuals. Finally, depression was measured by a paper-and-pencil test focusing on symptoms of depression. Some of these symptoms (eg, fatigue, loss of appetite) appear in both depression and HF. Therefore, patients may not be able to distinguish between the two states. Conclusions This study supports the inclusion of variables beyond traditional physiologic measures to explain variability in depression. Specifically, functional status, β-blocker therapy, perceived control, and neuroticism were identified as correlates of depression. The assessment of these variables requires about 20 minutes and minimal instrumentation, making such assessment clinically feasible. After depression is identified, a mental health specialist can appropriately treat patients experiencing moderate to severe depression with antidepressants or psychotherapy. Health care providers should continue to focus on enhancing functional status as well as attending to the psychologic variables of perceived control and neuroticism in patients with HF.
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24. Butland RJA, Pang J, Gross ER. Two-, six-, and twelve-minute walking tests in respiratory disease. BMJ 1982;284:241–3. 25. Guyatt GH. Use of the six-minute walk test as an outcome measure in clinical trials in chronic heart failure. Heart Fail 1987;3:211–7. 26. Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor DW, et al. The six-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J 1985;132:919–23. 27. Lipkin DP, Perrins J, Poole-Wilson PA. Respiratory gas exchange in the assessment of patients with impaired ventricular function. Br Heart J 1985;54:321–8. 28. Moser DK, Dracup K. Psychosocial recovery from a cardiac event: the influence of perceived control. Heart Lung 1995;24:273–80. 29. Eysenck HJ. A short questionnaire for the measurement of two dimensions of personality. J Appl Psycho 1958;42:14–7. 30. Eysenck HJ, Eysenck SBG. Eysenck Personality Questionnaire Manual (Adult). San Diego (CA): Educational and Industrial Testing Service, 1975. 31. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32:705–14. 32. Koenig HG. Depression in hospitalized older patients with congestive heart failure. Gene Hosp Psych 1998;20:29–43. 33. Balestroni GL. Psychological intervention and heart failure: from theory to clinical practice. Monaldi Arch Chest Dis 2002;58:166–73. 34. Tsay SL, Chao YF. Effects of perceived self-efficacy and functional status on depression patients with chronic heart failure. J Nurs Res 2002;10:271–8. 35. Zipfel S, Lowe B, Paschke T, Immel B, Lange R, Zimmermann R, et al. Psychological distress in patients awaiting heart transplant. J Psychosom Res 1998;45:465–70. 36. Zipfel S, Lowe B, Schneider A, Herzog W, Bergmann G. Quality of life, depression and coping behavior in patients awaiting heart transplant. Psychother Psychosom Med Psychol 1999;49:187–94. 37. Zipfel S, Lowe B, Paschke T, Zimmermann R, Herzog W, Bergmann G. Emotional status of patients on the waiting list for heart transplantation. Z Kardiol 1998;87:436–42. 38. Stewart AL, Hays RD, Wells KB, Rogers WH, Spritzer KL, Greenfield S. Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the Medical Outcomes Study. J Clin Epdemiol 1994;47:719–30. 39. Metra M, Nardi M, Giubbini R, Dei Cas L. Effects of short- and long-term carvedilol administration on rest and exercise hemodynamic variables, exercise capacity and clinical conditions in patients with idiopathic dilated cardiomyopathy. J Am Coll Cardiol 1994;24:1678– 87. 40. Waagstein F, Bristow MR, Swedberg K, Camerini F, Fowler MB, Silver MA, et al. Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Metoprolol in Dilated Cardiomyopathy (MDC) Trial Study Group. Lancet 1993;342:1441–6. 41. Wassertheil-Smoller S, Blaufox MD, Oberman A, Davis BR, Swencionis C, Knerr MO, et al. Effect of antihypertensives on sexual function and quality of life: the TAIM study. Ann Intern Med 1991; 114:613–20. 42. Krantz DS. Cognitive processes and recovery from heart attack: a review and theoretical analysis. J Human Stress 1980;6:27–37. 43. Dracup K, Westlake C, Erickson VS, Moser DK, Caldwell ML, Hamilton MA. Perceived control reduces emotional stress in patients with heart failure. J Heart Lung Transplant 2003;22:90–3. 44. Murberg TA, Bru E, Aarsland T, Svebak S. Social support, social disability and their role as predictors of depression among patients with congestive heart failure. Scand J Soc Med 1998;26:87–95. 45. Carinici C, Christensen H, Henderson S, Korten AE, MacKinnon AJ, Scott R. Neuroticism and self-reported health in an elderly community sample. Person Individ Diff 1997;15:515–21. 46. Muirhead J, Meyerowitz BE, Leedham B, Eastburn TE, Merrill WH, Frist WH. Quality of life and coping in patients awaiting heart transplantation. J Heart Lung Transplant 1992;11:265–72.
Depression in Patients With Heart Failure CHERYL WESTLAKE, RN, PhD,1 KATHLEEN DRACUP, RN, DNSC,2 GREGG FONAROW, MD,3 AND MICHELE HAMILTON, MD3 Fullerton, California; Los Angeles, California
ABSTRACT Background: Psychologic comorbidities, particularly depression, often accompany heart failure and add to the complexity of clinical management. We conducted a study to describe the prevalence of depression, the differences between patients with minimal versus mild to severe depression, and the correlates of depression in patients with heart failure. Methods and Results: Data were collected from 200 patients with symptoms of heart failure resulting from systolic dysfunction. Psychologic assessment included depression, perceived control, neuroticism, educational needs, and social support/network. Patients were, on average, 57.0 (⫾12.1) years old, male (168, 84.0%), and in New York Heart Association (NYHA) class II or III (n ⫽ 140, 70.0%) with a mean ejection fraction of 25.5 ⫾ 6.4%. They had an average maximal oxygen uptake of 15.8 (⫾4.6) mL·kg·min and 6-minute walk distance of 1345.0 (⫾302.1) feet. Minimal depression was described by 105 (52.5%) patients, mild by 62 (31%), moderate by 30 (15%), and severe by 3 (1.5%). The significant differences between patients with minimal depression compared to mild to severe depression were NYHA class (χ2 ⫽ 14.05, P ⫽ .003), maximal oxygen uptake (t ⫽ 2.62, P ⫽ .010), 6-minute walk distance (t ⫽ 4.22, P ⬍ .001), β-blocker therapy (χ2 ⫽ 15.21, P ⬍ .001), perceived control (t ⫽ 7.93, P ⬍ .001), and neuroticism (t ⫽ ⫺8.85, P ⬍ .001). Conclusions: More than half the patients studied did not report experiencing significant depression. In those who did, both physical and psychosocial variables accounted for 48.6% of the variance. These findings warrant further research and indicate a need to test interventions aimed at enhancing perceived control, reducing neuroticism, and meeting educational needs to reduce depression in patients with heart failure. Key Words: Psychosocial outcomes, heart failure, 6-minute walk, depression.
between HF and depression is not clearly understood. In some studies, investigators have documented a univariate association, whereas, in others, the relationship has been multivariate, a distinction that may be related to statistical power.7,9 Depression is defined as a specific alteration in mood associated with self-reproach and self-blame, regressive and self-punitive wishes, vegetative changes, and changes in activity level.13 Although relatively little is known about depression in HF,14 in other clinical populations, depression appears to delay recovery from physical illness,15 increase length of hospital stay,16,17 be associated with poorer medical prognosis,18 and increase mortality.11,19–21 The purpose of this study was to describe the prevalence of depression in patients with HF, explore the differences between patients with minimal depression and those with mild to severe depression, and explore the correlates of depression in patients with HF.
Heart failure (HF) is a syndrome characterized by left ventricular dysfunction, exercise intolerance, reduced quality of life (QOL), and markedly shortened life expectancy. Depression is an important outcome used by clinicians and researchers to evaluate HF therapy.1–6 The diagnosis of depression is important because of its association with mortality,7–9 quality of life,5–6,10 and functional status11–12 in patients with HF independent of somatic parameters. The relationship From the 1California State University, Fullerton, California; 2University of California, San Francisco, School of Nursing, San Francisco, California; 3 University of California, Los Angeles, Ahmanson Cardiomyopathy Center, Los Angeles, California. All decisions regarding this manuscript were made by a guest editor. Manuscript received August 7, 2003; revised manuscript received March 29, 2004; revised manuscript accepted March 29, 2004. Reprint requests: Cheryl Westlake, RN, PhD, 327 Calle Pescador, San Clemente, CA 92672. Partially supported by a grant from the American Heart Association Western Division and a National Institutes of Health Training Grant (T32 NR07072). 1071-9164/$ - see front matter 쑕 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.cardfail.2004.03.007
Methods After approval for the study by the appropriate Institutional Review Board, permission to contact interested patients was obtained from cardiologists treating patients at a university-affiliated
30
Depression in Patients With HF outpatient clinic. Sample selection criteria included adult HF patients older than age 18 with an ejection fraction ⬍40%. All HF patients who met the sample selection criteria were considered for inclusion in the study. Potential participants were identified through their care provider or through signs posted in the clinic. Because of this method of recruitment, there is no information about those patients who chose not to volunteer. Sample Patients were eligible for study if they were 18 years of age or older; able to speak, read, and write English; had symptoms of HF for 6 months or longer; and did not have another serious comorbidity. The patients were enrolled during a consultation visit at a university-affiliated, outpatient HF clinic over an 18-month period. Patients signed informed consent forms and were given the study questionnaires to complete in the clinic or at home. If patients elected to take the study materials home, they were also given a stamped envelope in which to return them. All eligible patients who were recruited to the study agreed to participate in the study. Of the 257 patients who met the eligibility criteria and verbalized interest in participating, only 200 (78%) completed all questionnaires. These 200 comprise the study sample; the remaining 56 patients are termed “nonparticipants.” Participants and nonparticipants were not significantly different on a variety of demographic and clinical variables (Table 1). However, a significant difference was noted in New York Heart Association (NYHA) classification (P ⫽ .001). Patients who did not return the study materials were more likely to have a higher (ie, worse) NYHA class than patients who completed the study. Instruments Depression was measured using the Beck Depression Inventory (BDI).13,22 The BDI is a widely used, self-reported, 21-item instrument comprising statements of symptoms and attitudes of depression. Response statements are rated on a 4-point scale ranging from 0 to 3 in terms of severity. The total score range is 0 to 63. A score of 0 to 9 is categorized as no or minimal depression, 10
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to 16 as mild, 17 to 29 as moderate, and 30 to 63 as severe depression. 22 Demographic and clinical variables were measured by chart review. NYHA classification was assessed by the HF clinic cardiologist after a complete history and physical. This measure of functional status is based on the degree of activity required to evoke symptoms. NYHA class I requires prolonged or extreme exertion to evoke symptoms; a NYHA class IV requires no exertion to evoke symptoms (ie, symptoms occur at rest). Therefore, a lower NYHA classification reflects a higher functional status. Functional status was also measured by both maximal oxygen consumption and distance walked over six minutes. Maximal oxygen uptake was measured during a bicycle cardiopulmonary exercise test and is reported as mL·kg·min. Previously, it has been shown that patients who exercise at 14 mL·kg·min or less have a significantly worse prognosis than patients who with higher exercise capacity.23 The 6-minute walk test was performed in an area of the clinic where distances were premeasured. A research assistant used a script to instruct the patients and then walked behind them for the entire time to avoid influencing the pace of walking. The 6-minute walk distance has been used in numerous clinical trials with patients similar to those in the present study and has adequate reliability and validity.24–27 Perceived control was measured using the Control Attitudes Scale (CAS).28 The CAS is a 4-item questionnaire comprising questions such as: “Regarding your heart problems, how much control do you feel?” and “Regarding your heart problems, how helpless do you feel?” Response statements are scored from 1 (none) to 5 (very much) on a Likert scale according to the degree to which patients agree or disagree with a given statement. Scoring is reversed on half of the items. The instrument has items related to both the patient’s perception of his or her own control and the family members’ perception of control. The total score range is 4 to 20, with higher scores reflecting higher feelings of control. Neuroticism was assessed using the Eysenck Personality Inventory (EPI).29 The EPI is a 6-item questionnaire comprising questions such as, “Do you sometimes feel happy, sometimes depressed, without any apparent reason?” and “Are you frequently ‘lost in thought’ even when supposed to be taking part in a conversation?”
Table 1. Comparison of Participants and Nonparticipants in Study
Variable Age (years) Ejection fraction (%) Maximal oxygen uptake Six-minute walk distance (feet)
Variable Gender Male Female New York Heart Association class I II III IV
Participant (n ⫽ 200) mean ⫾ SD 57.0 25.53 15.80 1345.0
⫾ ⫾ ⫾ ⫾
12.4 6.44 4.57 302.14
Nonparticipant (n ⫽ 56) mean ⫾ SD
df
t test
P value
⫾ ⫾ ⫾ ⫾
208 211 141 213
0.01 –0.29 –0.43 0.72
.99 .77 .67 .47
df
χ2
P value
1
0.21
.65
3
16.78
.001
57.24 26.58 18.02 1318.44
13.25 7.04 7.57 390.54
Participant (n ⫽ 200) n, %
Nonparticipant (n ⫽ 56) n, %
168, 84 32, 16
49, 87.5 7, 12.5
29, 60, 80, 31,
14.5 30 40 15.5
4, 11, 40, 1,
7.1 19.6 71.4 1.9
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Responses are scored ⫹1 for yes and ⫺1 for no. The range is ⫺6 to 6, with a higher score denoting greater neuroticism.30 The Medical Outcomes Study-Social Support Survey (MOSSSS) was used to assess the social network and social support.31 The MOS-SSS is a 20-item survey of functional social support and represents multiple dimensions of support: emotional, informational, tangible, affectionate, and positive social interaction. An item measuring the number of close friends and relatives available for support provides an index of the social network. The remainder of items focuses on the perceived availability, if needed, of various components of functional support (eg, “Someone to take you to the doctor if you needed it” and “Someone who hugs you”). Response statements are scored from 1 (none of the time) to 5 (all of the time). The range is 19 to 95, with a higher score denoting greater social support. The MOS-SSS has good construct and discriminant validity.31 All of the assessment instruments are widely used well-standardized self-report inventories with established reliability and validity. Procedures A member of the research team presented the study and outlined the subject’s participation requirements to interested patients. Patients were informed that their responses would be kept confidential and that under no circumstances would their participation or lack of participation influence treatment decisions or jeopardize their care. If willing to participate, they signed a written consent form. Before receiving the questionnaires to complete, patients underwent a 6-minute walking test along an enclosed corridor of the clinic. Questionnaires were compiled in random order, bound into a booklet, and numerically coded to ensure subject anonymity. Completion of the battery of instruments required approximately 45 minutes. Patients were asked to complete the packet of instruments during the time of the initial consultation visit whenever possible. Patients who chose not to complete the packet during the time of the clinic visit were given a self-addressed, stamped envelope in which to return the completed instruments. Statistical Analysis Statistical analyses were performed using SPSS for Windows 10.0 release (SPSS Inc., Chicago, Ill). Frequencies and percents were calculated for discrete categorical variables and means and standard deviations were calculated for the continuous variables. The characteristics of patients with minimal depression versus mild to severe depression were compared using independent t tests. A stepwise linear multiple regression was performed to determine the relative contributions of demographic, clinical, and psychosocial characteristics to the variability in depression. Before the regression analysis, zero-order correlations among predictors were examined to avoid multicollinearity. Correlations less than .80 were judged as demonstrating a lack of redundancy. A level of significance of P ⬍ .05 was set a priori for statistical significance.
and clinical variables. However, a significant difference was noted in NYHA classification (P ⫽ .001). A larger percentage of nonparticipants were in NYHA class III (71.4%) than were participants (40.0%). However, there were a larger percentage of participants in NYHA class IV (15.5%) than nonparticipants (1.9%). Patients who did not return the study materials were more likely to have a worse (ie, higher) NYHA class than patients who completed the study. Patients on average were 57.0 (⫾12.1) years of age with an ejection fraction of 25.5% (⫾6.4%). The majority was male (168, 84.0%) and NYHA class III (80, 40.0%). They had a mean 6-minute walk distance of 1345.0 (⫾302.1) feet and a maximal oxygen uptake of 15.8 (⫾4.6) mL/kg/min. On average, patients demonstrated a mild level of depression (10.5 ⫾ 7.3). They reported moderate levels of neuroticism (⫺1.3 ⫾ 3.8) and perceived control (11.2 ⫾ 3.3) and excellent social support (79.6 ⫾ 15.6)m with an average social network of 10.39 ⫾ 11.0 people. Prevalence of Depression
A score of 0 to 9 is categorized as minimal depression, 10 to 16 as mild, 17 to 29 as moderate, and 30 to 63 as severe depression. Moderate to severe depression is considered clinically significant and requires treatment.22 Minimal depression was described by 105 (52.5%) patients, mild depression by 62 (31%), moderate by 30 (15%), and severe by 3 (1.5%) patients (Table 2). Therefore, 16% of patients studied in this sample warranted clinical evaluation by a mental health professional and 47.5% reported symptoms of depression. Differences Between Patients With Minimal and Mild to Severe Depression
Patients with minimal depression (n ⫽ 105, 52.5%) are those patients who scored a 0 to 9 on the BDI. Patients with mild to severe depression (n ⫽ 95, 47.5%) scored ⬎9 on the BDI. The differences between patients with minimal and mild to severe depression are presented in Table 3. This bivariate approach to the diagnosis of depression allows for consideration of those with depression for whom quality and quantity of life may be a significant consideration. The significant differences between those patients with minimal depression and those with mild to severe depression were
Table 2. Classification of Depression by Beck Depression Inventory (BDI)19 and Distribution in Study Sample
Results To identify the existence of participation bias, we compared the demographic and clinical characteristics of patients who completed all the questionnaires (termed “participants,” n ⫽ 200) with those who did not (termed “nonparticipants,” n ⫽ 56) (Table 1). Participant and nonparticipants were not significantly different on a variety of demographic
BDI score Minimal depression Mild depression Moderate depression Severe depression
Depression classification 0–9 10–16 17–29 30–63
Severity of depression n
%
105 62 30 3
52.5 31 15 1.5
Depression in Patients With HF
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Table 3. Comparison of Heart Failure Patients With Minimal vs. Mild-Severe Depression Minimal depression (n ⫽ 105) mean ⫾ SD Age (years) Ejection fraction Maximal oxygen uptake (mL/kg) Six-minute walk distance (feet) Control Neuroticism Social network Social support
55.68 26.2 16.59 1427.22 12.75 ⫺3.22 11.53 80.30
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
11.75 6.86 5.046 295.03 2.96 2.98 13.66 14.20
Mild to severe depression (n ⫽ 95) mean ⫾ SD
t test
P value
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
–1.58 1.55 2.62 4.22 7.93 –8.85 1.56 0.68
.115 .123 .010 ⬍.001 ⬍.001 ⬍.001 .120 .500
χ2
P value
3.44
.064
14.05
.003
15.21
⬍.001
58.39 24.79 14.92 1254.05 9.55 0.76 9.12 78.81
n, % Gender Male Female New York Heart Association class I II III IV β-blocker Yes No
12.45 5.99 3.82 284.68 2.74 3.38 6.71 17.02
n, %
93, 88.5 12, 11.5
75, 79 20, 21
23, 33, 39, 10,
6, 27, 41, 21,
21.9 31.4 37.2 9.5
66, 62.9 39, 37.1
6.3 28.4 43.2 22.1
32, 33.7 63, 66.3
NYHA class (χ2 ⫽ 14.05, P ⫽ .003), maximal oxygen uptake (t ⫽ 2.62, P ⫽ .010), 6-minute walk distance (t ⫽ 4.22, P ⬍ .001), β-blocker therapy (χ2 ⫽ 15.21, P ⬍ .001), perceived control (t ⫽ 7.93, P ⬍ .001), and neuroticism (t ⫽ ⫺8.85, P ⬍ .001). Patients with minimal depression tended to have higher functional status and perceived control, were less neurotic and were receiving β-blocker therapy.
are reported in Table 5. The functional status variables of NYHA classification, maximal oxygen uptake and 6-minute walk distance explained 13.3% of the variability in depression. The addition of the pharmaceutical intervention of βblockers contributed only an additional 2.4%. However, the psychologic factors of perceived control and neuroticism explained an additional 22.9% of the variance in depression. The overall model explained 48.6% of the variability in depression (F ⫽ 32.4, P ⬍ .001).
Factors Influencing Depression
Discussion
Correlational analyses were performed to identify the variables to be used in the multiple regression, as well as to avoid multicollinearity. Correlations ⬍0.80 were judged as demonstrating a lack of redundancy. These results are provided in Table 4. To identify the relative contribution of the factors that influenced depression in patients with HF a stepwise linear regression analysis was conducted. Results
Table 5. Stepwise Linear Regression Analysis of the Influence of Functional Status, Medication, and Psychologic States on Depression
Table 4. Correlations of Variables With Depression Variables
The current study contributes to the growing body of knowledge about depression in patients with HF by identifying its prevalence in a group of chronic patients and defining and measuring variables previously untested. Specifically, perceived control and neuroticism were identified as related to depression.
r
P
.08 .10 –.09 .28 –.17 –.33 .23 –.54 .65 –.11 –.12
.28 .15 .21 ⬍.001 .02 ⬍.001 ⬍.001 ⬍.001 ⬍.001 .13 .08
Variables Age Gender Ejection fraction New York Heart Association Maximal oxygen uptake Six-minute walk distance β-blocker therapy Perceived control Neuroticism Social network Social support
Functional status NYHA classification, maximal oxygen uptake, 6-minute walk distance Medication β-blockers Psychologic variables Perceived control, neuroticism
r2
Adjusted r2
F
P
.146
.133
11.17
⬍.001
.174
.157
10.25
⬍.001
.502
.486
32.40
⬍.001
NYHA, New York Heart Association.
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Using the relatively low cutoff of nine on the BDI, 47.5% of this sample of patients with HF was categorized as experiencing some degree of depression. This is higher than the 36.5% level reported by Koenig,32 but consistent with the findings of others.12 This finding is clinically important because these patients may benefit from additional interventions for depression (ie, pharmacotherapy or psychotherapy). Koenig32 found that the majority of depressed HF patients did not receive treatment for their depression and did not see mental health specialists any more frequently than nondepressed patients, suggesting that clinicians need to be alert to the possibility of depression in their population. A psychologic intervention such as the ones described by Balestroni33 or Luskin4 may be indicated and efficacious. The relationship between functional status and depression found in this sample supports previous research.7,12,32,34–39 Because of the cross-sectional design of the study, it is not possible to know whether patients are depressed because they have poor functional status or if they have poor functional status because they are depressed. Future study in this area is warranted. However, our findings may suggest a need for clinicians to work to improve patients’ functional status not only for the physical benefits accrued but for the psychologic benefits. In light of recent clinical trials indicating the value of β-blockers to reduce morbidity and mortality in patients with HF,1,39,40 the identification of a significant relationship between β-blocker therapy and depression is timely. The data demonstrate that patients on β-blocker therapy experience less severe depression; this finding is in contradiction to previous research41 and may indicate that more severely depressed patients are not prescribed β-blockers because of their potentially deleterious effect on psychologic health. Additional research is indicated to sufficiently understand this relationship. More importantly, the amount of variance in depression is quite small, suggesting a minimal effect. Identifying patients with characteristics associated with depression may allow clinicians to use diminishing health care resources by better targeting those patients at high risk for depression. Perceived low control may predict those patients at higher risk for depression. The relationship between perceived control and depression has been previously described in myocardial infarction and coronary artery bypass graft surgery patients,42 and supports our previous finding in HF patients.43 The findings suggest that future research should be aimed at testing this relationship and potential interventions designed to promote patients’ perception of control related to their disease as one approach to reducing depression. Interventions that have been described as enhancing patients’ perceived control include providing patients with treatment choices, helping them to see the options related to their cardiac disease, encouraging active participation, providing information, and increasing predictability of the circumstances surrounding cardiac disease.43 These strategies must be presented in a way that specifically heightens perceived control.5 Further research is indicated
regarding the efficacy of these interventions in enhancing perceived control in patients with HF. The finding of neurotic individuals experiencing more severe depression supports the findings of Murberg and colleagues,44 but refutes the prognostic findings of Carinici45 related to neuroticism. The data suggest that neuroticism may predict those patients at higher risk for depression. The amenability of neuroticism to change is an area for future research. Further, the findings suggest that future research be aimed at testing interventions designed to diminish patients’ neuroticism as one approach to improving depression. The importance of social support related to depression has been demonstrated previously.44,46 However, in this sample neither the size of the social network nor the nature of the social support influenced depression significantly. This finding refutes previous studies and warrants additional study before conclusions may be drawn. The ability to generalize this study’s findings to all patients with HF is limited by the fact that patients were recruited from a university-affiliated HF program and therefore may not be characteristic of all HF patients. Second, because the sample self-selected for participation in the study, the results may be biased. Because we were unable to track individuals who refused to participate, we don’t know if depression is under- or overrepresented in our sample. This is especially likely because the outcome variable, depression, characteristically causes individuals to refuse to participate; however, we do not know the level of depression in these individuals. Finally, depression was measured by a paper-and-pencil test focusing on symptoms of depression. Some of these symptoms (eg, fatigue, loss of appetite) appear in both depression and HF. Therefore, patients may not be able to distinguish between the two states. Conclusions This study supports the inclusion of variables beyond traditional physiologic measures to explain variability in depression. Specifically, functional status, β-blocker therapy, perceived control, and neuroticism were identified as correlates of depression. The assessment of these variables requires about 20 minutes and minimal instrumentation, making such assessment clinically feasible. After depression is identified, a mental health specialist can appropriately treat patients experiencing moderate to severe depression with antidepressants or psychotherapy. Health care providers should continue to focus on enhancing functional status as well as attending to the psychologic variables of perceived control and neuroticism in patients with HF.
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