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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) REFERENCES 1. Carney RM, Rich MW, teVelde A, Saini J, Clark K, Jaffe AS. Major depressive disorder in coronary artery disease. Am J Cardiol 1987;60:1273–5. 2. Gonzalez MB, Snyderman TB, Colket JT, Arias RM, Jiang JW, O’Connor CM, Krishnan KR. Depression in patients with coronary artery disease. Depression 1996;4:57– 62. 3. Hance M, Carney RM, Freedland KE, Skala J. Depression in patients with coronary heart disease: a 12-month follow-up. Gen Hosp Psychiatry 1996;18:61–5. 4. Steffens DC, O’Connor CM, Jiang WJ, Pieper CF, Kuchibhatla MN, Arias RM, Look A, Davenport C, Gonzalez MB, Krishnan KR. The effect of major depression on functional status in patients with coronary artery disease. J Am Geriatr Soc 1999;47: 319 –22. 5. Carney RM, Freedland KE, Jaffe AS. Insomnia and depression prior to myocardial infarction. Psychosom Med 1990;52:603–9. 6. Forrester AW, Lipsey JR, Teitelbaum ML, DePaulo JR, Andrzejewski PL. Depression following myocardial infarction. Int J Psychiatry Med 1992;22:33– 46. 7. Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA 1993; 270:1819 –25. 8. Carney RM, Freedland KE, Sheline YI, Weiss ES. Depression and coronary heart disease: a review for cardiologists. Clin Cardiol 1997;20:196 –200. 9. Carney RM, Freedland KE, Eisen SA, Rich MW, Jaffe AS. Major depression and medication adherence in elderly patients with coronary artery disease. Health Psychol 1995;14:88 –90. 10. Carney RM, Freedland KE, Jaffe AS. Depression as a risk factor for coronary heart disease mortality. Arch Gen Psychiatry 2001; 58:229 –30. 11. Frasure-Smith N, Lesperance F, Gravel G, Masson A, Juneau M, Talajic M, Bourassa MG. Depression and health-care costs during the first year following myocardial infarction. J Psychosom Res 2000;48:471– 8. 12. Schleifer SJ, Macari-Hinson MM, Coyle DA, Slater WR, Kahn M, Gorlin R, Zucker HD. The nature and course of depression following myocardial infarction. Arch Intern Med 1989;149:1785–9. 13. Spertus JA, McDonell M, Woodman CL, Fihn SD. Association between depression and worse disease-specific functional status in outpatients with coronary artery disease. Am Heart J 2000;140: 105–10. 14. Sullivan MD, LaCroix AZ, Baum C, Grothus LC, Kaufmann MW. Functional status in coronary artery disease: a one-year prospective study of the role of anxiety and depression. Am J Med 1997;103:348 –56. 15. Ziegelstein RC, Fauerbach JA, Stevens SS, Romanelli J, Richter DP, Bush DE. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med 2000;160:1818 –23. 16. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 1993;22:6A-13A. 17. McMurray JJ, Svebak S. Epidemiology, aetiology, and prognosis of heart failure. Heart 2000;83:596 – 602. 18. Senni M, Tribouilloy CM, Rodeheffer RJ, Jacobsen SJ, Evans JM, Bailey KR, Redfield MM. Congestive heart failure in the community: trends in incidence and survival in a 10-year period. Arch Intern Med 1999;159:29 –34. 19. Havranek EP, Ware MG, Lowes BD. Prevalence of depression in congestive heart failure. Am J Cardiol 1999;84:348 –50. 20. Murberg TA, Bru E, Aarsland T, Svebak S. Functional status and 127 K. E. FREEDLAND et al. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 128 depression among men and women with congestive heart failure. Int J Psychiatry Med 1998;28:273–91. Skotzko CE, Krichten C, Zietowski G, Alves L, Freudenberger R, Robinson S, Fisher M, Greenblatt DJ. Depression is common and precludes accurate assessment of functional status in elderly patients with congestive heart failure. J Card Fail 2000;6:300 –5. Freedland KE, Carney RM, Rich MW, Caracciolo A, Krotenberg JA, Smith LJ, Sperry J. Depression in elderly patients with congestive heart failure. J Geriatr Psychiatry 1991;24:59 –71. Koenig HG. Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry 1998;20:29 – 43. Cleland JG, Habib F. Assessment and diagnosis of heart failure. J Intern Med 1996;239:317–25. Mosterd A, Deckers JW, Hoes AW, Nederpel A, Smeets A, Linker DT, Grobbee DE. Classification of heart failure in population based research: an assessment of six heart failure scores. Eur J Epidemiol 1997;13:491–502. Carney RM, Rich MW, Freedland KE, Saini J, teVelde A, Simeone C, Clark K. Major depressive disorder predicts cardiac events in patients with coronary artery disease. Psychosom Med 1988;50:627–33. Carney RM, Saunders RD, Freedland KE, Stein P, Rich MW, Jaffe AS. Association of depression with reduced heart rate variability in coronary artery disease. Am J Cardiol 1995;76:562– 4. Carney RM, Freedland KE, Veith RC, Cryer PE, Skala JA, Lynch T, Jaffe AS. Major depression, heart rate, and plasma norepinephrine in patients with coronary heart disease. Biol Psychiatry 1999;45:458 – 63. Wells KB, Rogers W, Burnam MA, Camp P. Course of depression in patients with hypertension, myocardial infarction, or insulindependent diabetes. Am J Psychiatry 1993;150:632– 8. Beck AT, Ward CH, Mendelsohn M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–71. Carney RM, Freedland KE, Stein PK, Skala JA, Hoffman P, Jaffe AS. Change in heart rate and heart rate variability during treatment for depression in patients with coronary heart disease. Psychosom Med 2000;62:639 – 47. Frasure-Smith N, Lesperance F, Talajic M. Depression and 18month prognosis after myocardial infarction. Circulation 1995; 91:999 –1005. Freedland KE, Lustman PJ, Carney RM, Hong BA. Underdiagnosis of depression in patients with coronary artery disease: the role of nonspecific symptoms. Int J Psychiatry Med 1992;22:221–9. Lustman PJ, Clouse RE, Griffith LS, Carney RM, Freedland KE. Screening for depression in diabetes using the Beck Depression Inventory. Psychosom Med 1997;59:24 –31. Stein PK, Carney RM, Freedland KE, Skala JA, Jaffe AS, Kleiger RE, Rottman JN. Severe depression is associated with markedly reduced heart rate variability in patients with stable coronary heart disease. J Psychosom Res 2000;48:493–500. Dunn NR, Freemantle SN, Mann RD. Cohort study on calcium channel blockers, other cardiovascular agents, and the prevalence of depression. Br J Clin Pharmacol 1999;48:230 –3. Eccleston D, Cole AJ. Calcium-channel blockade and depressive illness. Br J Psychiatry 1990;156:889 –91. Gerstman BB, Jolson HM, Bauer M, Cho P, Livingston JM, Platt R. The incidence of depression in new users of beta-blockers and selected antihypertensives. J Clin Epidemiol 1996;49: 809 –15. Patten SB, Williams JV, Love EJ. Self-reported depressive symptoms in association with medication exposures among medical inpatients: a cross-sectional study. Can J Psychiatry 1995;40:264–9. Perez-Stable EJ, Halliday R, Gardiner PS, Baron RB, Hauck WW, Acree M, Coates TJ. The effects of propranolol on cognitive 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. function and quality of life: a randomized trial among patients with diastolic hypertension. Am J Med 2000;108:359 –35. Ried LD, McFarland BH, Johnson RE, Brody KK. Beta-blockers and depression: the more the murkier? Ann Pharmacother 1998; 32:699 –708. Schleifer SJ, Slater WR, Macari-Hinson MM, Coyle DA, Kahn M, Zucker HD, Gorlin R. Digitalis and beta-blocking agents: effects on depression following myocardial infarction. Am Heart J 1991;121:1397– 402. Lesperance F, Frasure-Smith N, Talajic M. Major depression before and after myocardial infarction: its nature and consequences. Psychosom Med 1996;58:99 –110. Beck AT, Steer RA, Geisser ME. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100. Carney RM, Rich MW, teVelde A, Saini J, Clark K, Freedland KE. Prevalence of major depressive disorder in patients receiving betablocker therapy versus other medications. Am J Med 1987;83:223–6. Funck-Brentano C, Lancar R, Le Heuzey JY, Lardoux H, Soubrie C, Lechat P. Predictors of medical events in patients enrolled in the cardiac insufficiency bisoprolol study (CIBIS): a study of the interactions between beta-blocker therapy and occurrence of critical events using analysis of competitive risks. Am Heart J 2000;139:262–71. Heidenreich PA, Lee TT, Massie BM. Effect of beta-blockade on mortality in patients with heart failure: a meta-analysis of randomized clinical trials. J Am Coll Cardiol 1997;30:27–34. McMurray JJ. Major beta blocker mortality trials in chronic heart failure: a critical review. Heart 1999;82(Suppl 4):IV14 –22. Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med 1996;334:1349–55. Packer M. Effects of beta-adrenergic blockade on survival of patients with chronic heart failure. Am J Cardiol 1997;80:46L–54L. Chen P, Ganguli M, Mulsant BH, DeKosky ST. The temporal relationship between depressive symptoms and dementia: a community-based prospective study. Arch Gen Psychiatry 1999; 56:261– 6. Karlsson I, Godderis J, Augusto De Mendonca LC, Nygaard H, Simanyi M, Taal M, Eglin M. A randomised, double-blind comparison of the efficacy and safety of citalopram compared to mianserin in elderly, depressed patients with or without mild to moderate dementia. Int J Geriatr Psychiatry 2000;15:295–305. Lyketsos CG, Sheppard JM, Steele CD, Kopunek S, Steinberg M, Baker AS, Brandt J, Rabins PV. Randomized, placebo-controlled, double-blind clinical trial of sertraline in the treatment of depression complicating Alzheimer’s disease: initial results from the Depression in Alzheimer’s Disease study. Am J Psychiatry 2000;157:1686 –9. Newman SC. The prevalence of depression in Alzheimer’s disease and vascular dementia in a population sample. J Affect Disord 1999;52:169 –76. Hickie I, Scott E. Late-onset depressive disorders: a preventable variant of cerebrovascular disease? Psychol Med 1998;28: 1007–13. Katz IR. Diagnosis and treatment of depression in patients with Alzheimer’s disease and other dementias. J Clin Psychiatry 1998;59(Suppl 9):38 – 44. Rosenstein LD. Differential diagnosis of the major progressive dementias and depression in middle and late adulthood: a summary of the literature of the early 1990s. Neuropsychol Rev 1998;8:109 – 67. Psychosomatic Medicine 65:119 –128 (2003)