Depression – the hidden enemy in heart-failure cases

Studies show the risk of death and associated health issues in heart-failure patients suffering from depression is more than double that of heart-failure patients who are not depressed.

By Susy Santos

Depression often plagues heart failure survivors, threatening recovery.

Heart failure is a condition that results from damage to the heart muscle and valves, and is associated with severe illness and high mortality. The incidence of heart failure increases with age and is a significant problem in Canada, as our aging population is the fastest growing demographic group.

Heart failure is a complicated disease to treat, but multidisciplinary treatment can bring a fuller recovery and improve the overall quality of life.

Statistics Canada figures show that over half a million Canadians suffer from some form of heart disease, with over 50,000 being treated for highly developed heart failure annually. One of the most common health concerns in heart failure patients is depression.

According to a current study, one in five people with heart failure has clinical depression and up to 48 per cent have significant depressive symptoms. Studies show the risk of death and associated health issues in depressive heart-failure patients is more than double that of heart-failure patients who are not depressed. These health issues include physical functioning, social functioning, mental health, re-hospitalization and a worsening prognosis.

Depression among heart-failure patients requires careful assessment and detection, since the visible manifestations may be unique. Some signs of hidden depression are emotional instability, hypersensitivity, anxiety, chronic worrying and hypochondriac issues. Since there is overlap between the signs and symptoms of heart failure and those of depression, the depressive condition may be under-assessed. Heart failure patients may not mention symptoms of depression because they assume it is part of their disease.

In order to assess depression in heart-failure patients, it’s crucial to identify predisposing risk factors such as being under age 65, being female, having a history of major depression, alcohol abuse, poor health perception, poor social support, existential suffering, living alone and having a high stage of heart failure.

Studies looking at issues associated with depression amonheart-failure patients show most factors related to their high re-admission rate, worsening of disease and increased mortality rate are behavioural and psycho-social. These factors include under-use of medications, inadequate patient education regarding the nature of heart failure and the importance of self-management, non-compliance in following a medication and dietary regimen, inadequate social support networks, inadequate and even non-existent psychological support and interventions, in addition to insufficient follow-up.

Clinical depression in heart failure patients needs to be detected by validated screening and a systemized self-report inventory. Although pharmacological interventions have positive effects on morbidity and mortality rates in heart-failure patients, they do not produce impressive improvement in the health issues associated with heart failure.

Non-pharmacological approaches for reducing depression in such patients include cognitive behavioural therapy, spiritual care, social work and quality-of-life education that focuses on diet, exercise, sleep and metabolic syndrome.

Early diagnosis and suitable management of this depression may result in better clinical outcomes. Although depression often co-exists with heart failure, it is not clear which one is the cause or the effect.

Accurate assessment, diagnosis, treatment and follow-up of depression in depressed heart-failure patients are critical in preventing functional decline. The integration of a multidisciplinary, non-pharmacological care plan for depression should therefore be considered a standard part of the treatment for these patients.

Susy Santos is director of the Victoria Institute of Clinical Research & Evaluation at Victoria General Hospital. To support Vic R&E and patient care at the Vic, please contact Victoria General Hospital Foundation at 204- 477-3513 or online at www.thevicfoundation.ca.

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