Depression and other psychosocial risk factors can foster the onset of heart failure and exacerbate its course. The significance of this connection is often underestimated, however. A position paper by the European Association of Preventive Cardiology therefore recommends that psychosocial risk factors be more integrated into the treatment of patients with chronic heart failure.
“Patients with heart failure not only have physical problems, but most also have significant psychological problems, too,” said lead author Karl-Heinz Ladwig, MD, PhD, professor of psychosomatic medicine at the Rechts der Isar Hospital of the Technical University of Munich , Germany. “Psychosocial risk factors such as depression, social isolation, loneliness, and traumatic effects due to the disease are insufficiently considered in the treatment of these patients.”
Depression Implies Nonadherence
“Patterns of behavior linked to depression can cause coronary heart disease, with the possible consequences of heart failure, to develop more quickly and for the progression also to affect the heart failure negatively,” Christian Albus, MD, director of the Clinic and Polyclinic for Psychosomatics and Psychotherapy at the University Hospital of Cologne, Germany, told Medscape Medical News.
Depression is commonly associated with nonadherence. “And nonadherence is not just the ‘not-as-prescribed’ intake of medications, it also refers to the whole spectrum of health-promoting behaviors such as moderate physical activity, not smoking, and sufficient self-care,” said Albus.
A Two-Way Connection
In their position paper, the authors point out that depression and other psychosocial stress factors can contribute to a further exacerbation of heart failure via the distribution of hormones and neuroendocrine inflammatory mediators.
Patients commonly find themselves in a catch-22 because there is a two-way connection between depression and heart failure. “Should the heart weakness develop into a serious disease, this in turn fosters episodes of despair and hopelessness in the patients, which are a significant burden,” said Ladwig. It is therefore important to be aware of the emotional complications involved with heart failure and to treat the patient psychologically, he added.
Medicinal relief of the depressive symptoms is out of the question for patients with heart failure. Antidepressants have not demonstrated any good effect in this population. “In studies to date, neither a mortality advantage nor a clear positive effect on mental sensitivity has been shown,” said Albus.
The reason for these findings is unclear. “In other respects, antidepressants have a good effect in particular on recurrent, at least moderate depressive symptoms,” Albus continued. “But this still cannot be replicated in heart failure patients.”
Cognitive and Physical Therapy
Interventions that combine physical movement programs with cognitive behavioral therapy promise the best efficacy, according to the authors of the position paper. “In this way, negative thought patterns and perception deficits can be broken down in conversations with the behavioral therapists. Physical training improves the circulation in the brain and muscles and strengthens the patient’s physical and mental performance,” said Ladwig. Combined, these factors have favorable effects on depression and its symptoms.
However, in addition to cognitive behavioral therapy, the other psychotherapeutic procedures approved in Germany may also have an effect, said Albus. But for people with coronary heart disease and heart failure, we still have no studies in which deep-psychological procedures are tested. The statement that cognitive behavioral therapy is effective in the relief of depressive symptoms does not mean that other procedures are ineffective, there is just no evidence,” he added.
Consult a Psychiatrist
“A psychiatrist or a specialist in psychosomatic disorders should be consulted when attempting to treat serious, lasting depression,” said Ladwig. This recommendation applies especially to many patients with heart failure who require an implantable defibrillator (ICD) to prevent sudden cardiac death through malignant cardiac arrhythmias or who also requires a left ventricular assist device (LVAD) in an advanced stage.
“The psychological support of these patients and their relatives must be an integral component of the long-term treatment plan,” say the authors.
Depression Commonly Overlooked
“The problem lies in the current structure of services, that depression is still commonly overlooked in patients with myocardial infarct, but also those with heart failure,” said Albus. “It is likely that at most half of the true mental disorders are correctly diagnosed. And still fewer are treated optimally.”
The evidence shows that general practitioners and cardiologists without specific training are commonly too overstretched, in terms of time and the required expertise, to adequately diagnose mental comorbidities and to administer adequate therapy. “Under the current remuneration structures, general practitioners just can’t afford it either,” said Albus.
Examiner Care Managers
Researchers are examining whether introducing another person (ie, a care manager), who specifically tends to the psychosocial needs of patients with heart failure, would provide an advantage. “In Germany and Europe, the ESCAPE study is just starting,” said Albus. “It is testing whether the triangular support of the general practitioner and cardiologist with the ill patient via a care manager helps heart failure patients who are mentally stressed to develop better than patients who receive routine treatment.”
Albus also favors informing patients more effectively. “Heart failure patients are often just not aware that their poor mental state is relevant,” he said. “Many see feelings as a weakness, and lethargy primarily as a physical symptom.”
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