Download Prevalence of Depression in Hospitalized Patients With Congestive

Prevalence of Depression in Hospitalized Patients With Congestive Heart Failure
KENNETH E. FREEDLAND, PHD, MICHAEL W. RICH, MD, JUDITH A. SKALA, RN, MA, ROBERT M. CARNEY, PHD,
VICTOR G. DÁVILA-ROMÁN, MD, AND ALLAN S. JAFFE, MD
Objective: 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. Methods: 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. Results: 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 (ⱖ10). 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. Conclusions: 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. Key words: comorbidity, depression, depressive
disorder, heart failure, congestive, prevalence.
ADLs ⫽ activities of daily living; BDI ⫽ Beck Depression Inventory; CES-D ⫽ Center for Epidemiological
Studies Depression Scale; CHF ⫽ congestive heart failure; COPD ⫽ chronic obstructive pulmonary disease;
DIS ⫽ Diagnostic Interview Schedule; DSM-IV ⫽ Diagnostic and Statistical Manual of Mental Disorders,
fourth edition; HRDS ⫽ Hamilton Rating Scale for
Depression; LVEF ⫽ left ventricular ejection fraction;
MI ⫽ myocardial infarction; NYHA ⫽ New York Heart
Association.
INTRODUCTION
Numerous studies have documented high prevalence rates of major depression in patients with stable
coronary disease (1– 4) and in patients recovering from
an acute MI (5–7). The point prevalence has ranged
between 15% and 23% in most studies (8). Depression
has been associated with increased medical morbidity,
mortality, functional impairment, and occupational
From the Department of Psychiatry (K.E.F., J.A.S, R.M.C.), Cardiovascular Imaging and Clinical Research Core Laboratory (V.G.D.-R.),
and Cardiovascular Division, Department of Medicine (M.W.R,
V.G.D.-R.), Washington University School of Medicine, St. Louis,
Missouri; and the Cardiovascular Division, Department of Medicine
(A.S.J.), Mayo Clinic, Rochester, Minnesota.
Address reprint requests to: Kenneth E. Freedland, PhD, Department of Psychiatry, Washington University School of Medicine,
4625 Lindell Blvd., Suite 420, St. Louis, MO 63124. Email:
[email protected]
Received for publication August 10, 2001; revision received January 4, 2002.
DOI: 10.1097/01.PSY.0000038938.67401.85
Psychosomatic Medicine 65:119 –128 (2003)
0033-3174/03/6501-0119
Copyright © 2003 by the American Psychosomatic Society
disability; decreased adherence to medications and to
cardiovascular risk factor interventions; and worse
quality of life in these patients (4, 7, 9 –15). There has
been much less research on depression in patients
with CHF. This is unfortunate because CHF is the
leading cause of hospitalization in the elderly, a leading cause of disability and death, and the only major
cardiovascular disorder in which the incidence and
prevalence are increasing in the United States (16 –18).
Most of the existing studies of depression in patients with CHF have focused on outpatients and have
relied exclusively on cutoff scores on instruments
such as the CES-D (19 –21). The prevalence of depression defined in this manner may be as high as 42%
(21). The prevalence of depressive disorders defined
by the DSM-IV criteria has not been established in
outpatients with CHF.
There have been only two studies in which standardized interviews were used to establish the diagnosis of major depression in hospitalized patients with
CHF. The first, a small (N ⫽ 60) study of patients age
70 years or older, found a point prevalence of major
depression of 17% (22). More recently, Koenig (23)
reported a 37% rate of major depression and 22% rate
of minor depression in 107 patients age 60 or older
with CHF. The exclusion of younger patients and the
striking difference in prevalence estimates between
these two relatively small studies reveals the need for
a larger study to establish reliable estimates and to
identify demographic, medical, and psychosocial factors that may affect the prevalence of depression in
this patient population.
This study defines depression in several different
ways to facilitate comparison of prevalence rates with
119
K. E. FREEDLAND et al.
ones reported elsewhere. It examines whether the
prevalence of depression differs between strata defined by demographic, medical, and psychosocial
characteristics. It also identifies variables that are independently related to the likelihood of depression in
hospitalized patients with CHF. Unlike the Freedland
et al. (22) and Koenig (23) studies, our sample includes
both middle-aged and elderly patients, thus permitting
analysis of the effects of age on comorbid depression in
CHF.
METHODS
Subjects
Patients age 40 years or older hospitalized at Barnes-Jewish Hospital, Washington University Medical Center, St. Louis, Missouri,
with an admitting diagnosis of CHF, dyspnea, or acute MI were
screened for eligibility. Inclusion in the study required the permission of the attending physician, a radiological report indicating CHF,
and documentation of at least two of the following: 1) dyspnea, 2)
third heart sound, 3) jugular venous distention, 4) hepatojugular
reflux, 5) pulmonary rales, 6) peripheral edema, or 7) symptomatic
or clinical improvement in response to diuretics. Similar inclusion
criteria are widely used in epidemiological research on CHF (16, 24,
25). Patients were excluded if they 1) were too medically unstable to
participate; 2) had documented, isolated right heart failure; 3) had
heart failure associated with valvular disease (severe mitral stenosis
and/or regurgitation, or severe aortic stenosis and/or regurgitation)
for which surgical correction was pending; 4) had a terminal illness
other than CHF; or 5) had a severe neuropsychiatric condition or
language deficit that would preclude informed consent or valid
assessment. If all eligibility criteria were met, the patient was briefed
about the study and asked to sign an informed consent document
approved by the Human Studies Committee at Washington University School of Medicine.
Assessment of Depression and Functional Status
Trained research interviewers administered a modified version
of the depression section of the National Institute of Mental Health
Diagnostic Interview Schedule (DIS) developed by Carney et al. to
diagnose depressive disorders in cardiac patients (1). This instrument was selected rather than the Structured Clinical Interview for
DSM-IV (SCID) or other alternatives because the majority of studies
on depressive disorders in patients with coronary heart disease (1, 4,
7, 26 –29) and both previous studies of major depression in hospitalized patients with heart failure (22, 23) have used modified or
standard versions of the DIS. Unlike the standard DIS, the Carney et
al. modified version starts the depression section of the interview
with somatic rather than cognitive or mood-related symptoms. It
also focuses on current rather than lifetime symptoms, and it probes
for the duration (chronicity) of current symptoms. Also, the DIS is
designed for trained lay interviewers; because of the sample size and
the setting of the interviews, it was not feasible to use an instrument
designed for administration by clinicians. However, to minimize the
possibility of overdiagnosis of depression in this seriously medically
ill patient population, the interviews were independently reviewed
by two clinicians (K.E.F., R.M.C.) following the DSM-IV criteria for
major and minor depression, with 98% interrater agreement. Disagreements were resolved by consensus.
In addition to current depression symptoms, the interview doc-
120
umented the patient’s psychiatric history, marital and employment
status, living arrangement, activities of daily living (ADLs), and need
for assistance with self-care or other activities. The patients were
also asked to complete the Beck Depression Inventory (BDI) to assess
the severity of 21 symptoms of depression (30). The BDI is frequently
used in research on depression in patients with heart disease, diabetes, and other chronic medical illnesses (31–35).
Medical Evaluation
Medical history. The patient’s hospital chart was reviewed and a
standardized medical data collection form was used to document 1)
whether this was the patient’s initial hospital admission for CHF or
if there had been at least one prior CHF admission, 2) medical
history and comorbid medical conditions, and 3) prescribed medications. The patient’s New York Heart Association (NYHA) functional classification during the 2-week period immediately preceding the hospitalization was determined by integrating data from the
interview and the medical chart. An experienced cardiac research
nurse (J.A.S.) supervised the collection of medical data in consultation with a study cardiologist with particular expertise in geriatric
cardiology and CHF (M.W.R.)
Left ventricular dysfunction. Transthoracic 2-dimensional, Doppler, and color flow echocardiography (Acuson Sequoia or HewlettPackard) was performed in the four standard views (parasternal
long- and short-axis views, and apical 4- and 2-chamber views)
within 48 hours of hospital admission if logistically feasible. The
images were stored on 1⁄2-inch videotape (S-VHS), and digitized in a
cine-loop format (Acuson KinetDx) for off-line analysis. All studies
were performed by experienced cardiac sonographers to ensure optimal visualization of the left ventricular endocardial borders and
cardiac chambers. The left ventricular volumes and ejection fraction
(LVEF) were calculated by the method of summation of disks (modified Simpson’s rule) from the apical 4-chamber view at end-diastole
and end-systole at end-expiration. All measurements were obtained
and averaged from five consecutive cardiac cycles by an expert
echocardiographer (V.G.D.-R.) who was blinded to other medical
and psychodiagnostic findings.
Statistical Analysis
Patients were classified as having major depression, minor depression, or no current depressive disorder according to the DSM-IV
criteria, and as “probably depressed” or “not depressed” according
to whether their BDI score was 10 or higher. Chi-square tests were
used to determine whether the prevalence of depression differed
among subgroups defined by a selected set of demographic, medical,
and psychosocial variables. Age was dichotomized at 60 years to
compare depression rates in younger vs. older patients, and LVEF
was dichotomized at 35% to compare patients with relatively poor
vs. preserved left ventricular function. ␣ was set at 0.05 per
comparison.
Logistic regression analyses were conducted to determine which
of the variables identified in the univariate comparisons are independently associated with the presence of depression. In the first
analysis, patients were categorized with respect to the presence or
absence of major depression; those with minor depression or no
current depressive disorder were combined into a single comparison
group. All variables except LVEF that were significantly associated
with the DSM-IV diagnosis of depression in the univariate comparisons were entered simultaneously into this model. Nonsignificant
variables were then dropped, and a reduced model was fitted to the
remaining variables. All effects were adjusted for every other variable in the model. Similar analyses were conducted to model clin-
Psychosomatic Medicine 65:119 –128 (2003)
DEPRESSION AND CONGESTIVE HEART FAILURE
ically significant depression (ie, having either major or minor depression on the modified DIS) and depression as defined by a score
of 10 or higher on the BDI. Because 19% of the patients did not
undergo echocardiography, the sample sizes for these analyses
would have been reduced if LVEF were included. Consequently the
effects of LVEF were tested in secondary analyses determining
whether it was significantly related to depression after controlling
for the variables retained in the reduced models described above.
SAS 8.1 software was used for all statistical analyses.
RESULTS
Sample Characteristics
Of 3884 screening encounters, 1944 (50%) resulted
in the patient being excluded from the study for one or
more reasons, including dementia, delirium, or other
neurological or psychiatric complications that would
preclude valid assessment of depression (46%, 901 of
1944); patient refusal due to feeling too ill or tired to
participate (20%); patient refusal for other or unspecified reasons (6%); physician decision that the patient
was too seriously medically ill to participate (11%);
terminal noncardiac illness (8%); severe aphasia or
other insurmountable communication barrier (7%);
and/or acute medical instability or an excluded medical condition (6%). Of the excluded patients, 1039
(53%) were women, and 917 (47%) were African
Americans or other racial minorities. Their mean age
was 74 ⫾ 13 years. Eligibility determination was deferred in 1258 screening encounters because the patient was discharged before screening could be completed or consent obtained (64%, 811 of 1258),
medical instability (10%), patient request (6%), or
other reasons. These patients were rescreened if rehospitalized for CHF at Barnes-Jewish Hospital.
The 682 patients enrolled in the study thus represent 26% of the determinant screening encounters. Of
the enrolled patients, 355 (52%) were women and 278
(41%) were African Americans. Their mean age was 66
⫾ 12 years. The excluded and enrolled patient samples
did not differ significantly with respect to gender distribution, but the proportion enrolled was lower
among minority patients (23%) than whites (28%; p ⬍
.005), and the excluded patients were older than the
enrollees (p ⬍ .0001). The enrollees were more likely
than the excluded patients to have dyspnea on exertion (68% vs. 52%, p ⬍ .0001), paroxysmal nocturnal
dyspnea (45% vs. 32%, p ⬍ .0001), orthopnea (56% vs.
43%, p ⬍ .0001), third heart sound (37% vs. 31%, p ⫽
.001), jugular venous distention (59% vs. 53%, p ⫽
.003), hepatojugular reflux (12% vs. 9%, p ⫽ .02), and
a response to diuretics (69% vs. 58%, p ⬍ .0001). The
enrollees were less likely than the excluded patients to
have pulmonary rales (84% vs. 88%, p ⫽ .005). There
Psychosomatic Medicine 65:119 –128 (2003)
was no difference in the proportion of patients with
peripheral edema (74% vs. 72%, p ⫽ .15).
Prevalence of Depression
Among the 682 enrolled patients, 135 (20%) met
DSM-IV criteria for a current major depressive episode, 111 (16%) met DSM-IV criteria for a current
minor depressive episode, and 436 (64%) were classified as not currently depressed. Combining the groups
with major or minor depression, 245 (36%) of the
patients had clinically significant depression.
Among the 613 (90%) patients who completed the
BDI, 310 (51%) scored 10 or higher and were classified
as probably depressed. Of patients scoring in the depressed range on the BDI, 105 (34%) met DSM-IV
criteria for major depression, 65 (21%) met the criteria
for minor depression, and 140 (45%) were not currently depressed according to the DIS interview.
Among those scoring in the nondepressed (⬍10) range
on the BDI, 15 (5%) met DSM-IV criteria for major
depression, 33 (11%) met the criteria for minor depression, and 255 (84%) were classified as nondepressed
on the DIS. Thus, only 55% of the patients scoring in
the depressed range on the BDI had clinically significant depression according to the DIS, and 16% of
patients classified as nondepressed on the BDI were
depressed according to the DIS. Nevertheless, there
was a strong association between the BDI and DSM-IV
classifications (␹2 ⫽ 111.4, p ⬍ .0001).
Univariate Associations with Depression
In Table 1, the sample is stratified by demographic,
psychosocial, and medical variables, and the proportion of patients within each stratum meeting DSM-IV
criteria for major or minor depression or the BDI ⱖ 10
criterion for depression is displayed. As expected, the
prevalence of current major depression was somewhat
elevated in patients with a family history of major
depressive disorder and markedly elevated among patients with past history of one or more major depressive episodes. Major depression was also significantly
more prevalent among patients who were female, less
than 60 years old, unable to work due to disability,
unable to perform self-care or other ADLs without
assistance, in a higher NYHA class, or admitted with a
history of COPD or sleep apnea.
In contrast, the prevalence of major depression was
not significantly affected by the presence of other major medical comorbidities such as diabetes or renal
disease or by whether at least one comorbid condition
was present. Furthermore, the number of comorbid
medical conditions did not differ among groups de-
121
K. E. FREEDLAND et al.
TABLE 1.
Proportions of Patients Classified as Depressed According to DSM-IV or BDI Criteria, by Demographic, Social, and
Medical Characteristics
DIS Interview-Based DSM-IV Diagnosis
Characteristic
Gender
Female
Male
Race
African American
White
Age
⬍60 y
ⱖ60 y
Education
⬍12 y
12 y (completed high school)
ⱖ13 y
Marital status
Single
Divorced or widowed
Married
Children
None
One or more
Principal lifetime occupation
Homemaker
Professional
Skilled labor
Unskilled labor
Employment status
Working or retired
Disabled
Living alone
No
Yes
Requires help with self-care or other ADLs
No
Yes
Family history of major depressive disorder
No
Yes
Previous major depressive episodes
None
One or more
NYHA class
I
II
III
IV
LVEF
ⱖ35%
⬍35%
Previously hospitalized for CHF
No
Yes
History of MI
No
Yes
History of anemia
No
Yes
History of arthritis
No
Yes
122
N
Major
Depression
Minor
Depression
355
327
0.25
0.14
278
404
BDI
p
N
Depressed
p
0.17
0.15
.001
310
303
0.54
0.47
.07
0.20
0.20
0.15
0.17
.89
235
378
0.59
0.52
.42
209
473
0.29
0.16
0.18
0.16
⬍.0001
186
427
0.60
0.47
.003
242
211
229
0.22
0.21
0.16
0.17
0.16
0.16
.51
217
189
207
0.53
0.51
0.47
.45
76
260
346
0.13
0.22
0.20
0.21
0.15
0.16
.46
223
320
70
0.49
0.52
0.50
.87
85
594
0.15
0.20
0.15
0.16
.50
73
539
0.56
0.50
.30
51
126
296
208
0.27
0.15
0.17
0.25
0.10
0.13
0.17
0.19
.06
47
113
259
193
0.60
0.46
0.49
0.53
.33
392
289
0.15
0.27
0.15
0.18
.0002
353
259
0.44
0.60
⬍.0001
502
180
0.20
0.18
0.18
0.12
.14
454
159
0.51
0.49
.66
330
352
0.13
0.26
0.14
0.18
⬍.0001
294
319
0.42
0.59
⬍.0001
497
152
0.18
0.27
0.16
0.16
.03
450
135
0.48
0.56
.11
487
195
0.16
0.30
0.14
0.22
⬍.0001
440
173
0.46
0.62
.0005
60
331
244
47
0.08
0.12
0.29
0.40
0.00
0.17
0.18
0.23
⬍.0001
53
295
222
43
0.11
0.41
0.67
0.79
⬍.0001
261
290
0.18
0.22
0.19
0.16
.40
234
265
0.45
0.55
.03
220
462
0.17
0.21
0.18
0.16
.47
195
418
0.48
0.52
.42
427
246
0.21
0.18
0.19
0.12
.03
380
224
0.53
0.47
.17
564
104
0.21
0.15
0.16
0.17
.45
505
94
0.50
0.57
.16
568
110
0.20
0.19
0.17
0.12
.37
511
98
0.52
0.45
.22
Psychosomatic Medicine 65:119 –128 (2003)
DEPRESSION AND CONGESTIVE HEART FAILURE
TABLE 1.
(continued)
DIS Interview-Based DSM-IV Diagnosis
Characteristic
History of coronary artery disease
No
Yes
History of cerebrovascular accident
No
Yes
History of diabetes mellitus
No
Yes
History of gastrointestinal disorder
No
Yes
History of hypertension
No
Yes
History of COPD
No
Yes
History of sleep apnea
No
Yes
History of renal disease
No
Yes
History of 1 or more comorbid medical conditions
No
Yes
History of coronary artery bypass surgery
No
Yes
␤-Blocker
No
Yes
Calcium channel blocker
No
Yes
Digitalis
No
Yes
Angiotensin-converting enzyme inhibitor
No
Yes
N
Major
Depression
Minor
Depression
p
N
Depressed
p
350
322
0.21
0.19
0.19
0.13
.08
316
288
0.53
0.48
.20
615
63
0.19
0.30
0.16
0.17
.07
552
57
0.50
0.58
.25
393
289
0.18
0.22
0.15
0.18
.22
344
269
0.50
0.51
.75
612
67
0.19
0.27
0.16
0.15
.30
554
56
0.49
0.64
.03
214
461
0.22
0.18
0.15
0.16
.48
197
409
0.56
0.48
.06
511
163
0.17
0.28
0.16
0.16
.01
463
143
0.47
0.62
.003
636
43
0.19
0.30
0.16
0.23
.05
571
39
0.50
0.64
.08
522
160
0.21
0.18
0.16
0.18
.61
470
143
0.49
0.57
.10
46
636
0.28
0.19
0.15
0.16
.33
42
571
0.60
0.50
.23
507
172
0.20
0.19
0.17
0.14
.53
454
156
0.52
0.47
.26
561
121
0.21
0.13
0.16
0.17
.13
502
111
0.53
0.41
.02
454
228
0.20
0.18
0.15
0.20
.21
409
113
0.48
0.55
.09
357
325
0.18
0.22
0.18
0.14
.27
319
294
0.48
0.53
.24
186
496
0.20
0.20
0.16
0.17
.94
167
446
0.57
0.49
.12
fined by depression diagnosis (2.7 ⫾ 1.6 vs. 2.6 ⫾ 1.5
vs. 2.6 ⫾ 1.4 for the major depression, minor depression, and nondepressed groups, respectively; F ⫽ 0.57,
p ⫽ .57.)
Contrary to expectation, the prevalence of depression was lower among patients with than without a
history of MI. This may be explained by the fact that
patients with a history of MI were more likely to be
more than 60 years old (␹2 ⫽ 14.6, p ⬍ .0001) and male
(␹2 ⫽ 11.1, p ⬍ .001). Patients with these characteristics were less likely to be depressed than were younger
patients and females.
Several classes of drugs commonly used to treat
Psychosomatic Medicine 65:119 –128 (2003)
BDI
patients with heart disease (␤-blockers, calcium
channel blockers, digitalis, angiotensin-converting
enzyme inhibitors) have been suspected of causing
dysphoric mood in some patients (36 – 42), but none
of these agents were associated with significantly
higher prevalence rates of major depression. Among
the 551 (81%) patients for whom echocardiographic
findings were available, the prevalence of depression was also unaffected by whether there had been
previous hospitalizations for CHF or whether the
patient had poor left ventricular function (LVEF ⬍
35%).
The rates of minor depression were affected by
123
K. E. FREEDLAND et al.
most of the same variables associated with major
depression, but the differences between strata were
generally smaller. When depression was defined by
a score of 10 or higher on the BDI, the prevalence
rates again differed by past history of major depression, age, disability status, dependence in ADLs,
NYHA class, and history of chronic obstructive pulmonary disease (COPD). Depression on the BDI
tended to be more common among women than men,
but the gender difference was not significant, and it
also did not differ significantly according to whether
there was a family history of major depressive disorder. In contrast to major depression, the prevalence of depression on the BDI was significantly
higher among patients who had relatively poor left
ventricular function or a history of gastrointestinal
disease and significantly lower among patients on
␤-blockers.
Independent Predictors of Depression
Variables that were related to the DSM-IV diagnosis
of major depression in the univariate analyses were
then entered into a multiple logistic regression analysis. Family history of depression and patient history of
COPD, MI, or sleep apnea were not independently
TABLE 2.
associated with major depression in this analysis. A
reduced model was then fitted, including the variables
remaining after the initial logistic regression. Gender,
age, past history of major depression, NYHA class,
dependence in ADLs, and inability to work due to
disability were retained. The reduced model is presented in Table 2. Figure 1 displays the prevalence of
major depression by its two strongest independent correlates (NYHA class and age.)
The same variables were entered into a logistic regression analysis of predictors of clinically significant
depression (ie, the presence of either major or minor
depression). In addition to the variables that dropped
out of the major depression model, gender and inability to work due to disability dropped out of this analysis. Table 2 displays the reduced model of clinically
significant depression.
Finally, the variables that were related to depression as defined by the BDI cutoff (ⱖ10) were entered
into a separate logistic regression analysis. Age, disability status, LVEF, COPD, and ␤-blockade dropped
out of this analysis, and past history of major depression, NYHA class, gastrointestinal disease, and dependence in ADLs were retained. The reduced
model of depression as defined by the BDI is displayed in Table 2.
Reduced Logistic Regression Models of Major Depression, Clinically Significant Depression, and Depression Defined as a
BDI Score > 10
Odds Ratio
Effect
Major depression
Gender
Age
Past history of major depression
NYHA class
Categories
f vs. m
⬍60 vs. ⱖ60 y
Y vs. N
IV vs. I
III vs. I
II vs. I
Dependence in ADLs
Y vs. N
Unable to work because of disability
Y vs. N
Clinically significant (major or minor) depression
Age
⬍60 vs. ⱖ60 y
Past history of major depression
Y vs. N
NYHA class
IV vs. I
III vs. I
II vs. I
Dependence in ADLs
Y vs. N
BDI score ⱖ10
Past history of major depression
Y vs. N
NYHA class
IV vs. I
III vs. I
II vs. I
Gastrointestinal disease
Y vs. N
Dependence in ADLs
Y vs. N
124
Point
Estimate
95% CI
1.54
1.96
2.15
4.98
2.75
1.25
1.86
1.58
1.00–2.36
1.27–3.01
1.41–3.29
1.61–15.41
1.02–7.43
0.46–3.40
1.20–2.88
1.03–2.41
1.95
2.34
16.22
7.64
4.16
1.83
1.36–2.81
1.63–3.37
5.31–49.61
2.91–20.08
1.59–10.89
1.29–2.60
1.79
24.76
14.54
5.17
2.10
1.64
1.21–2.63
7.89–77.14
5.89–35.93
2.12–12.56
1.27–3.93
1.15–2.34
Wald ␹2
p
3.87
9.39
12.67
⬍.05
.002
.004
21.30
⬍.0001
7.82
4.47
.005
.03
13.03
20.95
.0003
⬍.0001
34.76
⬍.0001
11.52
.0007
8.51
.004
59.74
⬍.0001
5.44
7.57
.02
.006
Psychosomatic Medicine 65:119 –128 (2003)
DEPRESSION AND CONGESTIVE HEART FAILURE
Fig. 1.
Prevalence of major depression by age and New York Heart
Association (NYHA) class.
DISCUSSION
Prevalence Estimates
This is the largest study to date of the prevalence
of depression in hospitalized patients with CHF and
the first that is not limited to elderly patients. Overall, 20% of the patients met DSM-IV criteria for a
current major depressive episode during the index
admission. This is slightly higher than the 17% reported by Freedland et al.(22), comparable to the
prevalence of major depression reported in studies
of post-MI patients (7, 43), and substantially lower
than the 37% prevalence in CHF patients reported
by Koenig (23). An additional 16% of the patients in
the present sample met DSM-IV criteria for minor
depression, a figure that is also lower than the 32%
prevalence reported by Koenig.
These differences may be due to methodological
factors. In our reports, depressive disorders were
defined only by DSM-IV criteria. Koenig’s report
used both DSM-IV criteria and scores on the CES-D
and the HRSD. Nondepressed control subjects had to
score ⱕ10 on the CES-D and the HRSD and to have
fewer than two DSM-IV symptoms. Thirty-seven percent of screened patients did not meet the criteria to
be either a depressed case or a nondepressed control.
If the additional CES-D and HRSD criteria excluded
more nondepressed and marginally depressed patients than patients with major depression, the net
effect would have been to increase the prevalence of
major depression. This is supported by the fact that
in the whole CHF sample (which included depressed cases, nondepressed controls, and patients
Psychosomatic Medicine 65:119 –128 (2003)
in neither category), the prevalence of major depression decreased to 26% and that of minor depression
increased to 32%.
Many studies of medically ill patients use standard
cutoff scores on self-report questionnaires such as the
BDI or CES-D to define cases of depression. In general,
prevalence estimates based on this approach are
higher than ones based on structured psychodiagnostic interviews and DSM-IV criteria. This is clearly evident in the present study, because 51% of the patients
scored 10 or higher on the BDI. Forty-five percent of
the patients scoring in the depressed range on the BDI
were classified as nondepressed by DSM-IV criteria.
The low specificity of the BDI helps to explain why it
yields such a high prevalence of “depression” in this
patient population.
However, different cutoff scores can yield very different specificities, sensitivities, and predictive values
when the BDI is used to screen for depressive disorders in medically ill patients (34, 44). A score of ⱖ10
was chosen for this study because it is the most widely
used cutoff in research and clinical practice, but it
might not be optimal when screening hospitalized patients with CHF. Regardless of the cutoff score that is
used, the BDI cannot substitute for a careful clinical
interview. A detailed analysis of the screening performance of the BDI is outside the scope of this article,
but it is the subject of a report in progress.
Correlates of Depression
The prevalence of comorbid depression in hospitalized patients with CHF depends not only on the definition of depression but also on the characteristics of
the sample. In this study major depression was significantly more common in patients less than 60 years
than in older patients (29% vs. 16%). Koenig’s (23)
sample was limited to patients age 60 or older, which
further highlights the difference in prevalence rates
between these studies.
Several other characteristics also affect prevalence
rates. Major depression is more common in women
and in patients who are disabled, who have a history of
depression, or who have comorbid COPD or sleep apnea. In addition, there is a strong relationship between
major depression and NYHA class. Patients in class IV
are at very high risk for major depression. Alternatively, because depression predicts functional impairment in patients with coronary disease, it might exacerbate functional impairment in CHF (13, 14).
In contrast to its strong association with NYHA
class, major depression is unrelated to LVEF, prior
hospitalization for CHF, and medical comorbidity.
COPD and sleep apnea were associated with major
125
K. E. FREEDLAND et al.
depression in univariate analyses but were not retained
as independent correlates. The prevalence of major depression differed by race in our earlier, smaller study (22)
but not in this one. It did not differ by education, marital
status, living arrangement, or ␤-blockade. We reported a
similar finding concerning ␤-blockade in patients with
coronary disease (45). ␤-Blockers improve prognosis in
CHF (46 –50), but physicians may be reluctant to prescribe them for depressed patients. Whether this increases the risk of morbidity and mortality deserves
investigation.
Several univariate correlates of major depression
dropped out of the multivariable analysis. Independent predictors include NYHA class, age below 60
years, depression history, dependence in ADLs, disability status, and gender. Most correlates of major
depression also correlate with minor depression, but
not as strongly. For example, major depression affected
29% of younger vs. 16% of older patients; for minor
depression, the difference was only 18% vs. 16%. Most
predictors of major depression also predicted clinically
significant (major or minor) depression, but neither gender nor disability predicted the latter.
Although the BDI is not very specific vis-a-vis
DSM-IV diagnoses, it correlates with most of the
same variables. BDI scores are affected by age, depression history, CHF severity, medical comorbidity, disability, and dependence in ADLs. Unlike major depression, BDI-defined depression is not higher
among women, but is associated with worse left
ventricular dysfunction. However, the LVEF relationship is modest (55% for LVEF ⬍ 35 vs. 45% for
LVEF ⱖ 35.) Age, disability, LVEF, and COPD
dropped out of the multivariable analysis, leaving
NYHA class, gastrointestinal disease, depression
history, and dependence in ADLs as independent
predictors of depression on the BDI. It is not clear
why gastrointestinal disease was the only independent medical predictor of depression on the BDI. It
could be an artifact because the BDI includes items
assessing appetite and weight loss. It is also not clear
why age and disability are independently associated
with clinically significant depressive disorders but not
with depression as defined by the BDI. Perhaps having
CHF when relatively young and being too ill to maintain
employment increases vulnerability to depressive disorders. Other patients may be just as vulnerable to subclinical depressive symptoms, but they are less likely to
develop clinically significant depression.
Causal Relationships
This study shows that there is a strong association
between depression and the functional severity of
126
heart failure, but it does not define the direction of this
relationship. However, it provides some interesting
clues. Functional severity, as measured by NYHA
class, is the strongest correlate of depression in this
sample. This raises the possibility that CHF is “depressogenic,” particularly when the heart failure has advanced to the stage at which the patient is severely
functionally impaired and is experiencing severe dyspnea and other exertional symptoms. It is also possible, however, that depression might exacerbate the
symptoms of heart failure and increase the severity of
functional impairment. This latter possibility is consistent with the finding that depression correlates with
NYHA class but not with LVEF. This finding suggests
that in a group of patients with equally severe left
ventricular dysfunction, those who are depressed are
likely to report worse symptoms of heart failure and
worse functional impairment in everyday activities
than are those who are not depressed. Because the
present findings are consistent with both causal models, further research is needed to resolve this question.
It will be necessary to conduct longitudinal studies in
which multiple markers of the physiological and functional severity of CHF are obtained. Clinical trials are
also needed to determine the effects of depression
treatment on the course and outcome of CHF as well as
the effects of treating CHF on the course and outcome
of depression.
Limitations
Unlike the previous studies of depressive disorders
in hospitalized patients with CHF, both of which were
restricted to elderly patients, this one includes patients as young as 40 years of age. Because of its larger
and more inclusive sample, the present findings provide better estimates of the prevalence of depression in
the population of patients hospitalized with congestive heart failure when compared with the earlier studies. Furthermore, this report identifies a number of
patient characteristics that help to explain why the
observed prevalence of major depression has varied so
widely across studies.
Nevertheless, the enrolled sample includes only
about one fourth of the patients who were screened for
participation. Twenty percent of patients who were
screened refused to participate because they felt too
fatigued or too ill, and 6% refused for other reasons.
Depressed patients may be more likely than nondepressed patients to feel extremely fatigued, ill, or socially withdrawn, which may make them more likely
refuse to participate in clinical research. If so, the prevalence of depression might have been underestimated.
Most of the excluded patients were objectively too seri-
Psychosomatic Medicine 65:119 –128 (2003)
DEPRESSION AND CONGESTIVE HEART FAILURE
ously ill or too cognitively impaired to participate. Dementia, delirium, and other neuropsychiatric complications were the most common reason for exclusion,
particularly among older patients. This is unfortunate
because depression is a common and treatable problem
in the early stages of Alzheimer’s and vascular dementia (51–54). The depression measures used in
the present study were designed for cognitively intact subjects, so it was necessary to exclude patients
with cognitive impairment. In future studies, however, it might be possible to assess depression in
CHF patients with mild cognitive impairment by
using specialized techniques developed for use with
patients in early dementia (55–57).
Although there are limits to the generalizability of the
present findings, there was no viable alternative to excluding patients who were too ill or cognitively impaired
to participate. This limitation is inherent in virtually
every study in psychiatric epidemiology, but it is more
obvious in studies of psychiatric comorbidity in severely
medically ill patients. Despite this limitation, we were
able to recruit 47 patients who, although in class IV heart
failure, had physician approval to participate. Most of
these patients were too ill even to sit up. Thus, our
findings extend not only to hospitalized patients in mild
heart failure but, with due caution, to those in severe
heart failure as well.
CONCLUSIONS
Depression is very common in hospitalized patients
with CHF. Its prevalence varies according to how depression is defined and according to the demographic,
medical, and social characteristics of the patients.
These factors should be taken into account in planning
future studies as well as screening and intervention
programs for comorbid depressive disorders in hospitalized patients with CHF. Further research is also
needed to test competing causal models of the relationship between depression and heart failure.
This study was supported in part by National Institutes of Health Grants MH51419, R01HL58878, and
S10RR14778, and a grant from the Barnes-Jewish Hospital Foundation to the Cardiovascular Imaging and
Clinical Research Core Laboratory. We are grateful to
Justine Cowen, Norma Fiedotin, Christianne Meier,
and Neva Parker for their assistance with recruitment,
interviews, and other data collection, and to Alan D.
Waggoner, RDCS, MHS, for his assistance with the
performance of echocardiography.
Psychosomatic Medicine 65:119 –128 (2003)
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