How should we manage depression in congestive heart failure?

Depression is common in congestive heart failure and may independendy predict a poor prognosis. The symptoms include crying spells, sadness, pessimism, isolation, asthenia, insomnia or hypersomnia, suicidal ideas, and, in severe cases, marked psychomotor dysfunction.

Depression may be considered not only as a reaction to the disease but also, according to Williams et al, a risk factor for heart failure among the elderly, in particular women. Depressed individuals display elevated noradrenergic and hypothalamo-pituitary-adrenal axis activity, which favors heart failure progression. Similar neuroendocrine mechanisms may be involved in the clinical onset of decompensated heart failure in ischemic or hypertensive heart disease.

Psychologic stress is believed to impair left ventricular function through various mechanisms, including the induction of transient changes in the electrophysiologic properties of the myocardium, subsequent ventricular arrhythmia, abnormal wall motion, and a resulting decrease in the ejection fraction. Patients with dilated Further reading

Giannuzzi P, Shabetai R, I m para to A, et al. Effects of mental exercise in patients with dilated cardiomyopathy and congestive heart failure. An echocardio-graphic Doppler study. Circulation. 1991 ;83(Suppl 4):lll 55-165.

Havranek EP, Ware MG, Lowes BD. Prevalence of depression in congestive heart failure. Am J Cardiol. 1999;84:348-350.

Jiang W, Alexander J, Christopher E, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161:1849-1856.

Koenig HG. Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry. 1998;20:29-43.

Michalsen A, Konig G, Thimme W. Preventable causative factors leading to hospital admission with decompensated heart failure. Heart. 1998;80:437-441. cardiomyopathy and heart failure display impaired left ventricular function during psychologic stress. Michalsen et al identified treatment and dietary noncompliance as the leading cause of hospital admission for decompensated heart failure, followed by ischemic heart disease and inadequate medical treatment. Depression is among the most important determinants of rehospitalization frequency in that it maintains or initiates negative behavior, manifested primarily as noncompliance with drug therapy, diet, fluid balance, and lifestyle advice (eg, against smoking). Given its effect on rehospitalization and heart failure progression, depression should never be underestimated, even in its milder manifestations. Unfortunately, it can be expressed in many often confusing ways, such as impairment of cognition (expressed by certain thoughts, expectations, beliefs), emotion (flat affect, associated anxiety), and behavior (asthenia, isolation, and impoverished activity patterns). Psychologic evaluation is thus most important, with psychiatric referral in severe cases. The nursing staff have a crucial role in recognizing the onset of depression. They should be instructed to report early symptoms promptly to the medical staff for assessment and appropriate management.

Middlekauff HR, Mark AL The treatment of heart failure: the role of neurohu-moral activation. Intern Med. 1998;37:112-122.

Roy A, Pickar D, De Jong J, Karoum F, Linnoila M. Norepinephrine and its metabolites in cerebrospinal fluid, plasma, and urine. Relationship to hypothalamic-piluitary-adrenal axis function in depression. Arch Gen Psychiatry. 1988;45:849-857. Tavazzi L, Zotti AM, Mazzuero G. Acute pulmonary edema provoked by psychologic stress. Report of two cases. Cardiology. 1987;74:229-235.

Williams SA, Kasl SV, Heiat A, Abramson JL, Krumholz HM, Vaccari-no V. Depression and risk of heart failure among the elderly: a prospective community-based study. Psychosom Med. 2002;64:6-12.

Keywords

symptom; diagnosis; depression; psychological stress; risk factor; management

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