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STATE-OF-THE-ART PAPER

Depression in Heart Failure

A Meta-Analytic Review of Prevalence, Intervention Effects, and Associations With Clinical Outcomes

Thomas Rutledge, PhD^_*,,_*, Veronica A. Reis, BSc^_*,, Sarah E. Linke, BA, Barry H. Greenberg, MD, FACC and Paul J. Mills, PhD

^_* VA San Diego Health Care System, San Diego, California
University of California, San Diego, San Diego, California
University of Southern California, Los Angeles, California
San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California. David S. Sheps, MD, MSPH, acted as the guest editor for this article

Manuscript received March 6, 2006; revised manuscript received May 10, 2006, accepted June 16, 2006.

^_* Reprint requests and correspondence: Dr. Thomas Rutledge, VA San Diego Healthcare System, Psychology Service (116B), 3350 La Jolla Village Drive, San Diego, California 92161. (Email: Thomas.Rutledge{at}va.gov).

This article describes a meta-analysis of published associations between depression and heart failure (HF) in regard to 3 questions: 1) What is the prevalence of depression among patients with HF? 2) What is the magnitude of the relationship between depression and clinical outcomes in the HF population? 3) What is the evidence for treatment effectiveness in reducing depression in HF patients? Key word searches of the Medline and PsycInfo databases, as well as reference searches in published HF and depression articles, identified 36 publications meeting our criteria. Clinically significant depression was present in 21.5% of HF patients, and varied by the use of questionnaires versus diagnostic interview (33.6% and 19.3%, respectively) and New York Heart Association–defined HF severity (11% in class I vs. 42% in class IV), among other factors. Combined results suggested higher rates of death and secondary events (risk ratio = 2.1, 95% confidence interval 1.7 to 2.6), trends toward increased health care use, and higher rates of hospitalization and emergency room visits among depressed patients. Treatment studies generally relied on small samples, but also suggested depression symptom reductions from a variety of interventions. In sum, clinically significant depression is present in at least 1 in 5 patients with HF; however, depression rates can be much higher among patients screened with questionnaires or with more advanced HF. The relationship between depression and poorer HF outcomes is consistent and strong across multiple end points. These findings reinforce the importance of psychosocial research in HF populations and identify a number of areas for future study.

Abbreviations and Acronyms   BDI = Beck Depression Inventory   CAD = coronary artery disease   HF = heart failure   IL = interleukin   NYHA = New York Heart Association

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