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DURHAM, N.C. -- Duke University Medical Center researchers
have found that congestive heart failure patients with major
depression appear twice as likely than those who are not
depressed to die or be re-admitted to the hospital within 12
months.

Since up to half of patients with clinically significant
heart failure die within five years of diagnosis -- a rate that
has not improved significantly over the years despite
improvements in treatments -- the Duke researchers recommend
that all congestive heart failure (CHF) patients be tested for
the presence of major depression.

"Heart failure is a deadly disease, and now we know that
those patients who are suffering from major depression are at a
much greater risk of death," said Duke researcher Dr. Wei
Jiang, who published the results of her study Monday (Aug. 13)
in the journal Archives
of Internal Medicine. The study was supported by grants
from the National Institutes of
Health and the Claude D. Pepper Older Americans
Independence Centers.

Dr. Christopher O'Connor, Duke cardiologist, and Dr. Ranga
Krishnan, chairman of Duke's Department of Psychiatry, were
senior mentors for the research team.

"If more cardiologists considered the impact of depression
on their heart failure patients and treated the depression, the
outcomes for these patients may improve," she continued. "Given
what we know about depression and heart disease in general,
psychiatric screening should be a part of all cardiac
workups."

When compared to CHF patients without depression, the
patients with major depression in the Duke study died at a
2.5-times higher rate three months after admission, and
2.23-times higher rate one year later. As for hospital
re-admissions, the patients with major depression returned at a
1.9-times higher rate at three months, and a 3.07-times higher
rate at one year.

The researchers controlled for such factors as age and
severity of heart disease, and found that major depression was
an independent risk factor for increased death and
re-admission.

While the link between depression and worse outcomes for
patients with coronary artery disease has been firmly
established, Jiang said that very few studies have looked for
an association with CHF, which isn't so much a single disease,
but a constellation of conditions with many underlying causes.
The end result is that the quantity of blood pumped by the
heart each minute is insufficient to meet the body's normal
requirements for oxygen and nutrients.

The Duke researchers screened consecutive CHF patients
admitted to Duke University Hospital during a 15-month period
and found that of the 357 patients screened, 35.3 percent had
some symptoms of depression, with 13.9 percent of those
diagnosed with major depression.

Specifically, CHF patients who weren't depressed had
mortality rates of 5.7 percent at three months and 13.7 percent
at one year. However, for those with major depression, the
death rates jumped to 13 percent at three months and 26.1
percent at one year.

As for hospital re-admissions, 36.5 percent of the
non-depressed patients were re-admitted within three months,
and 52.3 percent at one year. For those with major depression,
the rates increased to 52.2 percent at three months, and 80.4
percent at one year.

"Obviously, the next step is to see whether treating these
patients' depression will have a beneficial outcome on their
heart failure," Jiang said. "No studies have yet been conducted
to see if strategies for treating depression can help these
patients."

That task will be a challenge, Jiang said, because most CHF
patients take as many as eight different medications for their
disease and current anti-depressive medications can interact
with them. Other non-pharmacologic approaches such as
cognitive-behavioral therapy or other forms of psychotherapies
also need to be considered, she added.

"This article makes an important contribution by showing
that patients with congestive heart failure and depression are
twice as likely to die within one year after hospitalization as
those with congestive heart failure alone," said Dr. Stanley L.
Slater, Deputy Associate Director for Geriatrics, National
Institute on Aging. "Future research must focus on whether
adding treatment for depression to treatment for congestive
heart failure will increase survival in patients sufferingfrom
both diseases."

Jiang emphasized that major depression is a clinically
distinct condition, and not just the expected feelings of
sadness a patient may experience as a result of having a
serious and potentially life-threatening medical or physical
condition.

While it is not known by what mechanism major depression
influences heart function, several theories are being
considered.

"People with major depression tend to have poor social
support networks or perceive their social support insufficient
and may not be as compliant with their medications," Jiang
said. "Also, some studies have shown an association with
depression and higher activity of platelets, which can cause
clots in arteries."

More than 2 million Americans have CHF, with 400,000 new
cases being diagnosed each year, according to the National
Heart, Lung and Blood Institute. Also, treating CHF is the
largest single expense for the Medicare system, with more that
$7 billion spent annually on more than 1 million
admissions.

Duke colleagues involved in the study included Dr. Jude
Alexander, Dr. Eric Christopher, Maragatha Kuchibhatia, Laura
Gaulden, Dr. Michael Cuffe, Dr. Michael Blazing, Charles
Davenport and Dr. Robert Califf.