Author + information
- Stephen S. Gottlieb, MD, FACC* (, )
- Sue Ann Thomas, RN, PhD, FAAN and
- Erika Friedmann, PhD
- ↵*University of Maryland, Cardiology, 22 S. Greene Street, Baltimore, MD 21201-1544
We agree with the comments of Dr. Fauchier regarding our recent study (1) suggesting that many factors influence the prevalence of depression in patients with congestive heart failure (HF). However, it should not be assumed that a patient with a longer duration of symptoms is more likely to be depressed. It is just as likely that patients may become more adjusted to their situation, resulting in less depressive symptoms. Although it is difficult to determine duration of symptoms reliably, we did not attempt to do so; thus, we encourage others to test these hypotheses.
As indicated by our previous study referenced by Dr. Fauchier, we believe that defibrillators (ICDs) may have important psychological consequences (2). Because more ICDs are likely to be implanted owing to the SCD–HeFT study (3), it is crucial to understand their psychological impact. For this reason, we obtained and are analyzing data from a substudy of SCD–HeFT addressing this issue.
We also agree with Dr. Ahmed that a collaborative model of treatment should be used in all patients with congestive HF. It is thus important that primary care physicians (including gerontologists) understand that patients who are still symptomatic despite treatment should be referred to a specialist in HF regardless of the patient's age.
One can debate Dr. Ahmed's assertion that depression is more common in the elderly; the data he references suggest that major depression is less common, whereas “minor” depressive symptoms may be more common (4,5). The current study involved many patients under age 65 years, dictating use of an instrument appropriate for a broad age range. However, we do not consider determination of the exact prevalence of depression in various groups as the important result of our study. Rather, our findings emphasize the difference in patterns of depression between patients with severe HF and the general population. Furthermore, we demonstrated (in the wide range of patients studied) that depression, as quantified by standard questionnaires, was extremely common in all groups. In our sample, 53% of those under age 65 years and 43% of those age 65 years and older reported symptoms of depression.
As Dr. Freudenberger and colleagues are well aware, the interaction of depression and symptoms of HF is complex; three of the co-authors of our manuscript (S.S.G., M.L.F., S.R.) co-authored a publication with two of them (R.F., C.S.), which demonstrated that patients with depression believe themselves to be more ill even when there are no objective criteria supporting this perception (6). Furthermore, as Dr. Ahmed's letter points out, diagnosis of depression is affected by many variables, including age, gender, and race. Indeed, any diagnosis of depression is, by definition, arbitrary. Thus, determination of the exact prevalence of depression can be debated ad nauseam, leading to obfuscation of the important points: depression is common and diagnosis may be impacted by various demographic factors. Although it is unreasonable to expect all patients with HF to be screened by psychiatrists, the Beck-Depression Inventory (BDI) is an excellent screening tool, and awareness of the prevalence of depression can lead to treatment and improved quality of life.
Dr. Freudenberger and colleagues are of course correct that physical components of the scales might be influenced by the physical limitations of HF. It is for this reason that we reported the various subscales of both the Minnesota Living With Heart Failure (MLWHF) and SF-36 questionnaires. Both the emotional and physical subscales of the MLWHF (a disease-specific quality-of-life questionnaire) exhibited extremely close correlations with the BDI. Similarly, various components of the SF-36, including those not influenced by physical limitations, strongly correlated with the BDI.
Depression may contribute to symptoms in any HF patient. Treatment efficacy will probably vary based upon age, gender, race or other factors, and these variables need to be assessed when intervention trials are performed. We now know, however, that consideration of the possible impact of depression upon symptoms is essential for all patients with HF.
- American College of Cardiology Foundation
- Gottlieb S.S.,
- Khatta M.,
- Friedmann E.,
- et al.
- ↵Bardy GH, Lee KL, Mark DB, et al. SCD–HeFT: Sudden Cardiac Death–Heart Failure Trial. Presented at the Annual Scientific Sessions of the American College of Cardiology, New Orleans, March 7–10, 2004.
- ↵Office of the Surgeon General: Depression in older adults. Mental health: a report of the Surgeon General. Available at: http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec3.html.
- The National Institute of Mental Health. Older Adults: Depression and Suicide Facts. A brief overview of the statistics on depression and suicide in older adults, with information on depression treatments and suicide prevention. Available at: http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm#4.