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• W2019919567 abstract "The article by Farris et al. and the editorial by Miller in the recent issue of European Journal of Heart Failure elucidated the increasing evidence of depression among congestive heart failure (CHF) patients and its impact on morbidity and mortality 1,2. The study pointed out that clinical depression is significantly associated with reduced survival and increased readmission rates in non-ischemic CHF patients. However, last year, Jiang et al., in a prospective study among 374 CHF patients, reported that 35.3% had a Beck Depression Inventory Score of 10 or higher and 13.9% had major depression 3. In their study, when compared with those without depression, patients with major depression had increased mortality and readmission rates independent of New York Heart Association (NYHA) class and ischemic etiology. Moreover, Koenig, in 1998, reported a 36.5% prevalence of major depression in 542 consecutive in-hospital elderly patients with CHF 4. Thus it is reasonable to establish that there is an increased prevalence of depression among CHF patients irrespective of its etiology. As depression invariably affects such patients’ clinical outcome, its identification and management is becoming very crucial in the treatment of CHF. Given the high prevalence of depression in patients with CHF and the magnitude of its negative influence on the clinical outcome, it is plausible to predict that concomitant use of antidepressants should also be high. Hence we looked at the rate at which antidepressants were used in patients with CHF admitted to a local non-psychiatric community hospital. Retrospectively, 391 CHF patients (NYHA class III–IV, age 67±11, 160 males and 231 females) admitted over a period of 1 year were identified from the hospital database. Individual charts were reviewed for the frequency of admissions and the pattern of antidepressants, anxiolytics and other sedative-hypnotics prescribed during the course of the hospital stay. Of the 391 patients, 78% had one admission while 22% had two or more admissions; women being readmitted more than men (32 males and 54 females). Surprisingly, only 7.9% were prescribed antidepressants—either tricyclics or selective serotonin reuptake inhibitors (SSRIs). However, 20.5% patients received benzodiazepines and 8.2% received Benadryl. One of the limitations of the study was that we did not include patients admitted to other facilities for CHF exacerbation and hence the relationship between readmission rates and antidepressant usage was not studied. The above results clearly show that antidepressants are not being prescribed adequately given the rate of depression among CHF patients. Interestingly, depression may easily be overlooked in patients with CHF due to the overlapping signs and symptoms such as apathy, fatigue, anergia. Patients who have concomitant underlying depressive process will also have subjective symptoms such as hopelessness, worthlessness, self-blame and low self-esteem. We believe that the inadequate use of antidepressants in our study was most likely due to depression that may have been overlooked. Another interesting observation was the increased use of benzodiazepines and Benadryl. It is possible that these patients were being treated for probable anxiety, irritability or lack of sleep that often accompany depression. Benzodiazepine use may thus be justified, but the fact that depression is being overlooked is perhaps underestimated. It is known that depression can have a wide spectrum of symptomatology ranging from minor depressive symptoms to major depression. Minor depression defined by the presence of two to five depressive symptoms, can be more prevalent than major depression in any given population, and the notion that minor depression requires ‘minor treatment’ can be misleading 5. Cognitive-behavioral modes of therapy and SSRIs have demonstrated efficacy in primary care patients with minor depression 5. This should also hold strong in CHF though no controlled studies have proven it so far. Depression and anxiety alter autonomic balance thereby reducing heart rate variability (HRV) and myocardial contractility. Decreased HRV has been associated with a higher risk of cardiac events in advanced CHF 6. Since SSRIs have been shown to normalize HRV, its use in CHF patients with depression is justified. In comparison with tricyclics, newer SSRIs have very minimal or indeed no cardiac side effects and hence should not pose any greater risk in CHF 7–9. The prognostic importance of marital quality and gender influence has already been proven 10,11. A combined approach with SSRIs and psychosocial therapy may have better outcome than any one modality alone. This needs to be established by well-designed prospective clinical trials. To conclude, there is underutilization of antidepressants among CHF patients. This may partly be due to under-recognition of the symptomatology or under-treatment of depression. Unless the minor depressive symptoms and overlapping signs are specifically looked for, depression can easily be missed or even mistaken in CHF. Hence, it appears that mandating questions to rule out depressive symptoms and its incorporation into the routine evaluation protocol for CHF will help identify such patients at risk. An interdisciplinary approach should be encouraged to develop better strategies of work up for CHF evaluation. Primary care physicians and Cardiologists should be trained specifically to look for and identify subtle symptoms of depression in patients with CHF at an early stage. Timely management of depression in such patients will not only improve the overall clinical outcome, but also contribute to treatment compliance thereby refining the morbidity, mortality and cost of care in CHF. Multi-center studies are warranted to see whether SSRIs improve the outcome of CHF patients who have depressive symptoms. Moreover, will early recognition and treatment of subtle depressive symptoms, or even the prophylactic use of SSRIs have any role in the management of CHF in this subset of population?" @default.
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• W2019919567 title "Depression and congestive heart failure: are antidepressants underutilized?" @default.
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• W2019919567 doi "https://doi.org/10.1016/s1388-9842(02)00297-0" @default.
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