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- Sarah J. Goodlin, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Sarah J. Goodlin, Patient-Centered Education and Research, 681 East 17th Avenue, Salt Lake City, Utah 84103
Depression or depressive symptoms are common in the general population, and more common in heart failure (HF) patients, ranging from about 20% based on structured psychiatric interview to almost 40% based on screening tools (1). Clinicians caring for HF patients may not have any particular expertise in the management of depression; thus, patients' depressive symptoms are at best challenging. In contrast to many aspects of HF care, there is nearly no evidence base to clarify a course of care for the sad, listless, or unenergetic HF patient.
The SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial reported in this issue of the Journalis the first randomized, controlled study to attempt to provide guidance regarding medication management of depression in HF, yet it leaves many questions unanswered (2). The SADHART-CHF trial is an almost 5-year double-blind, randomized trial of sertraline versus placebo in patients with depression and HF due to left ventricular systolic dysfunction. The study was limited by investigator titration of medication, achieving generally low doses of sertraline (mean 65 mg/day). Sertraline efficacy originally was established based on a mean dose of 145 mg/day. In general, clinical care doses of 200 mg/day of sertraline are common.
As the authors note, the Hamilton Depression Rating Scale scores of subjects may also have been lower than those of patients who typically respond to antidepressants. The SADHART-CHF trial tells us that discontinuation or adverse event rates were a bit higher with low-dose sertraline than with placebo, that low to moderate doses of sertraline are not associated with increased HF decompensation or death, and that supportive nursing interventions seem as effective as low-dose sertraline for HF patients with moderate depressive symptoms. Further research is needed to tell us whether higher doses of sertraline or other antidepressants are both safe and effective.
We know from many studies that depressive symptoms are more common in patients with a worse HF status. Studies of “depression” in HF unfortunately commonly use tools created to screen for depression in the general population, such as the Beck Depression Inventory. These tools do not correlate well with newer Diagnostic and Statistical Manual-Fourth Edition definitions of depression and include somatic symptoms that likely overlap with HF symptoms. A higher threshold for a positive screen on such tools is indicated in patients with chronic illness, and these tools have not been critically studied in HF per se. A positive screen on tools for depression does not a “depression” diagnosis make. How to recognize depression in HF patients is a long discussion, but newer tools, such as the Patient Health Questionnaire, a 9-item depression screen, that are based on Diagnostic and Statistical Manual-Fourth Edition criteria (3) or tools developed specifically for medically ill patients, such as the Geriatric Depression Scale (4), might help. Importantly though, screening for depression alone is not likely to benefit patients. Coordinated care that includes regular follow-up and support or counseling and, when medications are needed, up-titration or changes in prescription are essential.
Because HF includes neurohormonal activation, and we speculate that elevated levels of norepinephrine might be associated with symptoms of depression and anxiety in HF patients, a first step in managing depressive symptoms should be to aggressively treat the HF. Close to normal volume status should be achieved. For patients with systolic dysfunction, angiotensin-converting enzyme inhibitor and beta-blocker therapy should be maximized. Sleep-disordered breathing, in itself associated with elevated norepinephrine and epinephrine and with depression and anxiety, should be identified and treated. Although its effect on depression was not specifically evaluated in HF patients, exercise has been demonstrated to improve depression in general populations; thus, an exercise program should be initiated in any HF patient with depressive symptoms. Thigh muscle strengthening may have the added benefit of decreasing fatigue and dyspnea (5).
What about medication management of depression? We know very little in HF patients. Tricyclic antidepressants fell out of vogue when selective serotonin reuptake inhibitors became available, but both classes of drugs have potential benefits and adverse effects in HF patients. Tricyclic antidepressants have a quinidine-like effect causing QTc prolongation and have variable anticholinergic effects, the most significant of which may be orthostatic hypotension and dry mouth. (The latter might increase oral intake of fluids.) The selective serotonin reuptake inhibitors also cause orthostatic hypotension and, importantly in patients with mild to moderate renal impairment, can cause hyponatremia and fluid retention via antidiuretic hormone actions. All patients with renal impairment taking selective serotonin reuptake inhibitors need regular and ongoing assessment of serum sodium and volume status. Clinicians should become familiar with several antidepressants with different side effect profiles (clinicians should know one “sedating” or calming medication and one “activating” or stimulating medication at least). Therapy for individual patients should be titrated to improved symptoms.
Clearly further study of depression in HF patients is needed. What should the clinician do now?
• Aggressively treat HF, with particular attention to modulating neurohormonal activation (use beta-blockers and angiotensin-converting enzyme inhibitors at maximally tolerated doses).
• Identify and treat sleep-disordered breathing.
• Initiate an exercise program with special attention to thigh muscle strengthening.
• Provide nurse or other clinician supportive interventions and counseling to facilitate HF management and coping.
• Consider pharmacologic treatment of depression, monitoring response and side effects. Either up-titrate to an effective dose or change medications if no response or if side effects limit dosing. Connect the patient with clinicians more expert in psychiatric medical care when initial therapy is unsuccessful.
Dr. Goodlin has received research grants from St. Jude Medical Foundationand Boston Scientific CARE
↵⁎ Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology.
- American College of Cardiology Foundation
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