Elsevier

Journal of Affective Disorders

Volume 201, 1 September 2016, Pages 162-170
Journal of Affective Disorders

Research paper
Depression predicts mortality and hospitalization in heart failure: A six-years follow-up study

https://doi.org/10.1016/j.jad.2016.05.024Get rights and content

Abstract

Background

The aim of this study is to evaluate the prevalence of depressive symptoms (DS) and its relation on hospitalization for cardiovascular (CV) causes and all-cause mortality risk among outpatients with HF.

Methods

A prospective study was conducted on 130 adult outpatients with HF. The Beck Depression Inventory Scale–second edition (BDI–II) was used to screen for DS. All-cause mortality and hospitalization for CV causes were registered over 6 years. Logistic regression and multinomial logistic regression analysis were used to evaluate the independent prognostic value of DS on mortality and hospitalization for CV causes after adjustment for clinical risk factors.

Results

During a mean follow-up of 6 years, 44% of patients were classified as having DS. Sixty-two participants died for all causes, representing 61% of those with DS and 37% of those without (p=0.006); Forty-nine participants (38%) were hospitalized for CV causes, representing 49% of those with DS and 29% of those without (p=0.027).

Logistic regression analysis indicated that DS predicted all-cause mortality (OR: 2.905; 95% CI:1.228–6.870; p=0.006) and multinomial logistic regression indicated that DS were predictive of hospitalization for CV causes (OR: 3.169; 95% CI: 1.230–8.164; p=0.027). These associations were independent of conventional risk factors.

Limitations

Only outpatient sample; measure of DS only at baseline; cause of death was not known.

Conclusion

This study, first held in a portuguese population, showed that DS are independent predictors of death and hospitalization for CV causes among HF patients and its impact persists over 6 years.

Introduction

Heart failure (HF) is a serious and progressive medical condition associated with high mortality, morbidity and reduced quality of life (Johansson et al., 2006, Rosamond et al., 2008; The CONSENSUS trial study group, 1987; The SOLVD investigators, 1990). Depression is a common co-morbidity in these patients (Abramson et al., 2001, Joynt et al., 2004, Pelle et al., 2008, Rutledge et al., 2006) and in some studies has been associated with adverse outcomes, as increased risk of hospitalizations (Faris et al., 2002, Jiang et al., 2001, Rozzini et al., 2002); increased health costs (Koenig et al., 1998); functional decline (Rumsfeld et al., 2003, Vaccarino et al., 2001) and death (Sokoreli et al., 2016). The additional effect of depression on mortality in HF has been demonstrated in many studies over periods from 3 months to 3 years (short term effect) however, the long-term effect of depression on clinical outcome among these patients is not well known due to the high mortality verified within 5 years (Adams et al., 2012). Besides that, compared with the end point of mortality, there have been fewer studies evaluating the impact of depression on the end point of hospitalization for CV causes after adjusting for HF severity (in particular using the plasma B-type natriuretic peptide- BNP) and other prognostic factors (Faris et al., 2002; Januzzi, 2013; Jiang et al., 2001; Murberg and Furze, 2004).

Depression may contribute to poor outcome via adverse effects on health behaviour, including smoking, physical inactivity and nonadherence to prescribed treatment plans (Joynt et al., 2003); it has been related to reduced heart rate variability (Carney et al., 2001); blunted baroreflex sensitivity (Watkins and Grossman, 1999); heightened sympathetic nervous system activity (Hughes et al., 2004); blood hypercoagulability (Von Kanel et al., 2001); increased inflammation (Kop et al., 2002) and endothelial dysfunction (Sherwood et al., 2005). Each of these disease pathways may act independently or synergistically to increase risk in patients with HF (Sherwood et al., 2007).

The purpose of this study was to evaluate, in a portuguese population, whether DS independently predict long-term mortality due to all-causes or hospitalization for CV causes after adjustment for HF severity and other conventional risk factors of prognosis.

Section snippets

Participants

A letter describing the study design and inviting participation was sent to 197 patients, diagnosed with HF, identified from medical records held at an urban outpatient`s heart failure clinic at S. João Hospital, Porto Medical School over a period of six months. Eligible subjects were all adults aged ≥18 years. Exclusion criteria comprised neuropsychiatric disorders (assessed by a clinical psychiatric interview), cognitive impairments (assessed by the Mini-Mental State Examination – MMSE) and

Baseline characteristics of study patients

Descriptive analyses of the overall study population and by depression status are given in Table 1. The mean age of participants was 69 years. The majority of the subjects were male, married, retired and only a minority had ≥10 years of schooling. Patients were treated with ACE inhibitors, B-blockers, digitalis, diuretics, anticoagulant, calcium channel blockers, nitrates and statins. Only 8% of the patients were taking antidepressants. Comorbidities were prevalent in the subject sample at

Discussion

To our knowledge, the present study is the first to evaluate the effect of DS on mortality and CV hospitalization in a Portuguese population. In our sample we found a high prevalence rate of DS, assessed by the BDI-II (44%) and also of major depression assessed at the baseline by the principal investigator, a psychiatrist, according to the DSM-IV-TR (18%). Although in the literature there is evidence of increased prevalence of depression in HF, there has been a wide heterogeneity across the

Limitations

Some potential limitations of our study should be addressed. First, the generalizability of this study was limited as all patients were recruited from a cardiovascular outpatient clinic at a single university hospital in Oporto. Second, like many previous studies we had only baseline measure of DS. Therefore, we were not able to investigate whether changes in DS may have any effect on mortality. Depression status might have changed substantially over the study duration, and the relation of

Conclusion

The results of this study will contribute to draw the attention, in a Portuguese population, to the high prevalence of DS in HF patients and to its important impact on the outcome for a long period of follow-up. Our findings allow us also to underline the contribution of a group of four independent risk factors for mortality in HF: male gender; older age; high BNP levels and DS. Let us also add that the DS can, just like the BNP, increase the risk of worsening the cardiac condition requiring

Conflict of interest

There was no conflict of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institution and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in this study.

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