CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Thomas Rutledge, PhD*,
Veronica A. Reis, PhD and
Sarah E. Linke, BA
* Veterans Affairs San Diego Healthcare System, Psychology Service (116B), 3350 La Jolla Village Drive, San Diego, California 92161 (Email: Thomas.Rutledge{at}va.gov).
Dr. Persaud offers several valuable comments concerning our recent review (1). The relationship between depression and heart failure (HF) is complex, and we fully agree that furthering our understanding of how these conditions interrelate will require the study of important psychosocial factors such as social support and social isolation in addition to biological mechanisms.
Although our review primarily focused on rates and prospective significance of depression in HF patients, we would like to use Dr. Persaud’s comments as a platform to make several specific suggestions concerning applications to treatment.
First, treating and understanding depression’s effects on HF patients begins at the stage of symptom recognition, a surprisingly difficult task. Depression is notoriously underrecognized in medical patients. The clinical presentations of HF and depression are often similar, complicating diagnosis and assessment of treatment benefits. Social stigmas against mental health diagnoses can make patients reluctant to acknowledge depressive symptoms. Depression may delay treatment-seeking behaviors in some, while increasing health care utilization in others. Depression symptoms can also vary widely across patients, and the meaning of these differences for HF is not known. Collectively, these factors undermine and may even argue against the application of standardized depression treatments in HF populations.
Second, efficacious treatments for depression are still lacking, despite the development of state-of-the-art pharmacotherapies. A substantial patient population does not respond and/or maintains clinically significant symptoms despite treatment attempts (2), and responsiveness may itself have prognostic importance (3).
Third, the presence of depression is not random; rather, it is disproportionately diagnosed among patients who are female, those suffering more advanced disease, those who are socially isolated, and those of lower socioeconomic status. These factors can affect patients’ presenting symptoms, their ability or willingness to participate in treatment, their responsiveness to treatment, and their susceptibility to relapse.
Our review found the treatment literature for depression in HF to be poorly developed and methodologically inconsistent. At this early stage of research—and lacking any conclusive treatment evidence for survival or event outcomes from the much larger coronary artery disease literature—we believe it would be imprudent to call for clinical trials in HF at this time. Instead, we hope that our findings and insights from colleagues such as Dr. Persaud can be used to advance the treatment research in this area for potential future applications.
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References
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- Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes J Am Coll Cardiol 2006;48:1527-1537.[Abstract/Free Full Text]
- Keitner GI, Ryan CE, Solomon DA. Realistic expectations and a disease management model for depressed patients with persistent symptoms J Clin Psychiatry 2006;67:1412-1421.[ISI][Medline]
- Carney RM, Blumenthal JA, Freedland KE, et al. ENRICHD Investigators Depression and late mortality after myocardial infarction in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study Psychosom Med 2004;66:466-474.[Abstract/Free Full Text]
Related articles in JACC:
- Depression and Heart Failure: Why the Link Continues to Elude Us
- Raj Persaud
JACC 2007 49: 1503-1504.
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