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Depression, not Antidepressants, Increases Mortality Risks in Heart Failure

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Duke Health News 919-660-1306

DURHAM, N.C. -- People who are depressed have an increased
risk of dying from heart failure, and a new study by Duke
University Medical Center researchers may help explain why.

Analyzing more than 1,000 depressed patients with heart
failure, the researchers found that it was the depression
itself, not the patients' use of antidepressant medications
that increased mortality risk.

The finding may provide additional evidence for the current
national debate over whether the increased mortality seen in
heart failure patients with depression is due to the depression
itself or the medications prescribed to treat it, the
researchers said.

The researchers, led by internist and psychiatrist Wei
Jiang, M.D., said the finding also should help convince
physicians who care for heart failure patients to pay closer
attention to their patients' mental status, since these
patients may be helped by aggressive therapies that target
heart problems and depression. Jiang said many physicians who
treat heart disease patients continue to pay too little
attention to managing their depression.

"In our analysis, we found that heart failure patients who
were depressed had 15 percent higher rate of death than those
who were not depressed," said Jiang, who presented the results
of the study on Monday, Nov. 13, at the annual scientific
sessions of the American Heart Association, in Chicago.
"Although patients who were taking antidepressants during the
first admission to the hospital were more likely to die than
the patients who were not taking antidepressants, the
association was confounded by existence of depression."

She said that it is the depression, not the use of
antidepressants, especially the newest class of antidepressants
known as selective serotonin reuptake inhibitors, that
negatively affected the prognosis of patients with heart
failure.

"The results provide further evidence that physicians who
take care of heart failure patients must not only prescribe
antidepressants to them as the treatment of their depression,
but also continue to follow those patients closely," Jiang
said. "Depression must be considered a serious risk factor in
heart failure."

The study was supported by the National Institute of Mental
Health and by an American Psychiatric Institute Research in
Education/Merck Early Academic Career Research Award.

Heart failure, also known as congestive heart failure, is
marked by the inability of the heart muscle to pump enough
oxygen and nutrients in the blood to the body's tissues.
Despite its name, not everyone dies immediately and many live
for years.

A variety of factors can cause heart failure, including
infections of the heart, coronary artery disease, high blood
pressure, previous heart attacks and malfunctioning heart
valve. An estimated 4.7 million Americans have heart failure,
with 400,000 new cases reported each year, and it is the only
cardiovascular disease that is rising in incidence, according
to the researchers.

For their analysis, Jiang and colleagues examined the
medical records of 1,006 heart failure patients who were
hospitalized at Duke from March 1997 to June 2003 and asked
them to rate their depressive symptoms by a questionnaire.
During the first admission, 30 percent of the patients were
depressed and 16.1 percent were taking antidepressants, Jiang
said.

The patients in the study were followed for an average of
two years and seven months, and Jiang's team found that 42.7
percent of the patients died during the follow-up period. This
mortality rate is in line with national averages, Jiang said,
adding that approximately 50 percent of all heart failure
patients die within five years of being diagnosed.

Jiang said many cardiologists and primary care physicians
who treat heart failure patients may be unfamiliar with the
typical psychological assessments that can be used to evaluate
patients for depression, or they may consider themselves too
busy to include such assessments in their regular practice.
Physicians who are uncomfortable with treating depression
should refer those patients to a psychiatrist, she said.

"Probably only half of the physicians who treat heart
failure patients feel comfortable about treating patients for
their depression," Jiang said. "Also, those physicians that do
prescribe antidepressants shouldn't just write the prescription
and see the patients three or six months later."

Not only should more physicians treat their depressed
patients for their disease, or at least refer them to a
specialist for treatment, but physicians also should ensure
that the patients receive adequate follow-up attention, Jiang
said.

"Physicians need to know if their patients are experiencing
side effects of their medication, or if the initial dose is
correct," she said. "In some patients, it can take some time
finding the right antidepressant and the proper dose. Also,
treating physicians need to know that their patients are
continuing to take their medications, and that requires regular
follow-up."

Although this and other studies have demonstrated links
between depression and worse outcomes for patients with
cardiovascular disease, the mechanisms behind the correlation
are not well understood, Jiang said. Among possible factors,
depressed patients are known to have overly active immune
systems, a decrease in the ability of their blood platelets to
clot properly and a decrease in their heart's ability to react
appropriately to the stresses of everyday life, she said.

"We also know that depressed patients tend not to comply
with their treatments, are not as motivated to stick with
exercise or rehabilitation programs, and often miss doctor's
appointments" Jiang said. "Also, depressed patients tend to
make unhealthy lifestyle choices in such areas as diet and
smoking."

Jiang said she is investigating ways to improve how health
care providers without psychiatric backgrounds can manage
depression in heart patients, including finding ways to boost
providers' confidence that they can appropriately manage such
patients. She and her Duke colleagues have also been conducting
a clinical trial investigating whether selective serotonin
reuptake inhibitors will improve the cardiac prognosis of heart
failure patients with depression. They are currently recruiting
patients to the study and hope to publish the results of the
study in mid-2008.

"Many times it can be impractical to make sure every patient
with heart failure sees a psychiatrist," Jiang said. "That is
why it is so important to improve the knowledge and confidence
of nonpsychiatric professionals for care of depression."

Other researchers involved in the study were Maragatha
Kuchibhatla, Greg Clary, Michael Cuffe, Eric Christopher, Jude
Alexander, Christopher O'Connor, Robert Califf, and Ranga
Krishnan.

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