Are depression and heart failure related, and is there a treatment target?

Several studies have shown that patients with chronic heart failure suffer mod-erate-to-severe depression or anxiety, similarly to those with other chronic diseases. However, the relationship between the two sets of variables cardiology and psychology (mental health and health-related quality of life) has rarely been explored in depth. In particular, only a few cardiology variables have been assessed, while the comparison has often focused on physical functioning as a measure of health-related quality of life.

Majani et al conducted parallel cardiology and psychology studies in men with chronic heart failure. The psychological assessment used two instruments: the (objective) Cognitive Behavioural Assessment 2.0 Battery and the (subjective) Satisfaction Profile. The objective instrument showed higher depression and psychosomatic scores in heart failure patients than in healthy volunteers. However, anxiety scores were not higher, while fear and phobia scores were actually lower, as were social anxiety scores. Even medical-related anxiety tended to be lower, for reasons that were unclear.

This study illuminates the relationships between disease severity, objective psychological well-being, and subjective health (health-related quality of life). It revealed that the only correlation between objective cardiologic data (New York Heart Association functional class and, to a lesser extent, pulmonary resistance) and subjective satisfaction involved satisfaction with physical functioning. No relationship was found w’ith satisfaction in other aspects of life (psychological functioning and social relationships). The authors believe this gives scope for helping patients come to terms with their disease and accept its limitations, by focusing on the positive aspects of their lives, and drawing upon their well-being resources. In other words, the study data not only confirm the importance of subjectivity in health-related quality of life, but show that psychological intervention can reinforce the positive aspects of patients’ lives rather than alleviate the negative aspects.

However, mental health intervention as a target for therapy is a difficult issue. Before time and resources are invested in any new intervention in medicine, the treatment concerned must have proved effective, in terms of both cure and cost. Neither condition applies in the case of mental health intervention in heart failure. There is no hard evidence of patient benefit, even from care by an expert psychologist/psychiatrist, nor is there proof that drug therapy is effective or safe. Given that many health-care systems lack even adequate echocardiographic services for the diagnosis of heart failure, the case for investing resources into routine mental health care for patients with heart failure remains premature. For the time being, specific specialist or drug intervention to improve psychological well-being in heart failure remains firmly dependent on further research and/or educated guesswork.

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