Diagnosis and Management of

Depression in Chronic Heart Failure

Noor Asyiqah Sofia

Division of Psychosomatic and
Palliative, Department of Internal
Medicine, Gadjah Mada University
 OUTLINE
• Chronic Heart Failure
• Depression and Heart Failure
• Diagnosis of Depression
• Management of Depression
 Definition of HF

• Heart Failure can be defined as an

abnormality of cardiac structure or
function, leading to failure of the heart to
deliver oxygen at a rate commensurate
with the requirements of the metabolizing
tissues, despite normal filling pressures (or
only at the expense of increased filling
pressures)
 The Burden of Heart Failure
• Number of Patients (21 million adults wordwide
are living with HF, this number is still raising)
• Economy burden (In 2012, the overall worldwide
cost of HF was nearly $108 billion)
• Mortality (50% of HF pts die within 5 years from
diagnosis)
• Rehospitalisation (HF is the number 1 cause of
hospitalisation for pts aged >65 years)
• Comorbidities (The vast majority of HF pts has
≥3 comorbities)
 CHF and QOL
Patients with HF commonly report
psychological distress, including:
• Depression
• Hostility and anxiety
• Limitation in their activities of daily living
• Disruption of work roles and social
interaction with friends and family
• Reduced sexual activity and satisfaction
 Depression
• Characterized by a depressed mood and
combination of other symptoms such as weight
change, sleep disturbance, insomnia, fatigue,
feelings of guilt, worthlessness, and/or
hopelessness.
• Depression can stimulate the autonomic
nervous system and HPA axis. It is also
proinflammatory and is associated with
increases in CRP, fibrinogen, IL-6 and other
inflammatory measures, independent of BMI
and other risk factors.
 Depression: Evaluation
• Measurement can be done by:
– Beck Depression Invetory, Patient Health Care Questionnaire
– Center for Epidemiologic Studies Depression Scale (CES-D)
– Diagnostic and Statistical Manual of Mental Disorders, fourth
edition (DSM-IV)

Major depression according to DSM-IV criteria indicates the

presence of severely depressed mood and/or inability to take
pleasure in all or most things that were previously considered
enjoyable, lasting 2 weeks or longer and accompanied by
functional impairment and somatic complaints, such as fatigue or
loss of energy nearly every day, insomnia or hypersomnia,
change in appetite, diminished ability to concentrate, feelings or
worthlessness or inappropriate guilt, and recurrent thoughts of
death or suicidal ideation
 DIAGNOSIS OF DEPRESSION (DSM IV)

Mood of depression

Diminish of interesr

Poor concentration Insomnia / hipersomnia

Weight loss/weight DEPRESSION Fatigue

gain

Guilty feeling Agitation/psychomotor

retardation

Idea or action of suicide

 Depression and Heart Failure
• Depression is a hard diagnosis (some of the
features coincide with the symptoms of HF).
• The psychological sequelae of depression have
been associated with increased morbidity.
• Depression remains undiagnosed due to
commonality in symptoms present in both HF
and depression .
• Comorbid depression and HF are associated
with significantly reduced physical and emotional
QOL.
• Depression is a common comorbid
condition in patients with heart failure with
prevalence rates reported to range from
13 to 77.5%.
• Closed relation between depression and
HF is caused by common neuro-endocrine
background of the two diseases.
• It’s widely accepted that depression and
heart failure is inter-related.
Cause and effect relation between heart failure and depression
Interrelation between depression and HF
 HF worsening/cautions depression

• Beta blockers: depression, fatigue, sexual

dysfunction.
• Diuretics: hampers social life, social isolation.
• Aldosterone antagonist: gynaecomastia, body
image
• Amiodarone: thyroid dysfunction, secondary
depression.
• HF: Mild cognitive impairment →associated with
depression.
 Depression Worsening Heart Failure

• Worsened heart failure symptoms

• Decreased performance on 6-mnt walking
test
• Decreased social functioning and QOL.
• Worse complication with medication and
diet
• Are more likely to use tobacco and
alcohol.
IDENTITAS PASIEN
 Biological mechanisms possibly underlying the
association between depression and heart disease

• Autonomic nervous system dysregulation (low heart rate variability is a powerful

predictor of mortality in patients with coronary heart disease; depressed patients
have a decreased heart rate variability than non-depressed controls).
• Blood clotting and endothelial dysfunction (depression is associated with
enhanced platelet activation, increased plasma levels of pro-thrombogenic
factors and reduced endothelial dependent vasodilatation).
• Inflammation (depression is associated with increased levels of pro-
inflammatory cytokines and inflammatory acute phase proteins; activation of the
inflammatory system is linked to ischemic cardiovascular events in patients with
coronary heart disease).
• Neuroendocrine abnormalities (depression is associated with an increased
activity of the hypothalamic-pituitary-adrenal axis, with a consequent
overstimulation of the sympathetic nervous system).

From Monteleone P. The association between depression and heart disease: the role of
biological mechanisms. In: Depression and Heart Disease. Glassman AH, Maj M,
Sartorius N (eds). Chichester: Wiley, 2010.
 HOW TO SCREEN DEPRESSION IN HEART
FAILURE

• Fewer than 25% of cardiac patients with

major depression are diagnosed as
depressed, and only about one-half of
cardiac patients diagnosed as depressed
receive treatment for depression.
• Therefore,the process of identification
starts with recognizing the risk factors and
employing psychometric tools to assess
for depression in heart failure patients.
 Among hospitalized HF patients, a positive
PHQ-2 depression screen is associated with an
elevated 12-month mortality risk.
 TABEL PHQ-2
Dalam 2 minggu Tidak sama Beberapa Lebih Hampir
ini sekali hari dari setiap
semingg hari
u
Keinginan untuk 0 1 2 3
melakukan sesuatu
yang pernah
disenangi turun
Perasaan sedih, 0 1 2 3
tertekan, atau
semangat berkurang

If PHQ-2 > 2 then continue to PHQ-9

 TABEL PHQ-9
Dalam 2 minggu ini Tidak Beberapa Lebih dari Hampir
sama hari seminggu setiap
sekali hari
Keinginan untuk melakukan sesuatu 0 1 2 3
yang pernah disenangi turun
Perasaan sedih, tertekan atau 0 1 2 3
semangat berkurang
Sulit jatuh tidur atau mudah 0 1 2 3
terbangun atau terlalu banyak tidur
Merasa lelah atau kehilangan energi 0 1 2 3

Tidak nafsu makan atau makan 0 1 2 3

berlebih
Merasa sedih atau gagal 0 1 2 3
Sulit konsentrasi terhadap sesuatu 0 1 2 3
Bergerak atau berbicara lebih 0 1 2 3
lambat atau pelan atau sebaliknya
Berpikir lebih baik mati atau melukai 0 1 2 3
diri sendiri
INTERPRETATION OF PHQ-9

Score Severity of
Depression
0-4 Normal
5-9 Mild
10-19 Moderate
≥20 Severe
Management of Depression in CHF
• Psychosomatic approach: Hollistic and
Eclictic.
• Multi-aspects: BIO-PSYCHO-SOCIO-
SPIRITUAL.
 BIOLOGICAL ASPECT

Physical examination
Treat physical problems
Pharmacotherapy and psychotherapy
Suggestion of healthy life style
 PSYCHOEDUCATION

PSYCHOTHERAPY(Superfisial)
Good relationship (doctor – patient)
Ventilation
Re – education
Spiritual approach
Cognitive and Behavior Therapy (CBT)
 ANTI DEPRESSANT
Class of drug Drug
Trisiklik Amitriptillin, Clomipramin, Imipramin,
Dotiepin, Amineptin, Opipramol, Doxepin
Tetrasiklik Maprotilin, Mianserin, Amoksapin
MAOI (irreversible) Isocarboksazid, Phenelzin
MAOI (reversible) = RIMA Moklobemid
Atipik Trazodon, Nefazodon
SSRI Escitalopram, Sitalopram, Fluoksetin,
Sertralin, Fluvoksamin Paroksetin
SSRE Tianeptine

SNRI Venlafaksin

NaSSA Mirtazapine

Phytofarmaka Hypericum Perforatum

 Selected Studies on Depression in HF

STUDY STUDY TYPE Subjects Duration Conclusions of Study

Angermann et al Double clind 372 24 In pts with CHF and

2016 placebo months depression, 18 months
controlled RCT treatment of
ESCITALOPRAM did not
significantly reduced all
cause mortality or
hospitalization, and there was
no significant improvement In
depression
O Connor et al Double clind 469 3 months Sertraline did not improved
2010 placebo depression in HF.
controlled RCT
Yeh et al 2011 Single blind 100 12 weeks Tai chi exercise may improve
parallel group QOL, mood, and exercise self
RCT efficacy in pts with HF
 POTENSIAL PHARMACOKINETIC
INTERACTION BETWEEN ANTIDEPRESSANT
PHARMACODYNAMIC EFFECT OF
ANTI-DEPRESSANT
Recommendations for clinicians providing care for patients
with comorbid depression and heart disease - I

• Sleep. Ask your patients about their sleep habits. Ask about why
patients are awakening, and see if changes in treatment or the timing of
medications might decrease the need to awaken during the night to
pass urine or because of breathlessness.
• Physical activity. Strongly encourage your patients to exercise at home
and to become involved (and stay involved) in structured exercise
programs. Greater involvement in exercise may improve symptoms of
depression.
• Cigarette smoking. Ask every patient whether he/she smokes, and
counsel about smoking cessation if appropriate. Every clinician should
become familiar with medications that help patients quit, and should
offer specific advice on how to quit and/or set a quit date.

From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression and heart disease.
In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Recommendations for clinicians providing care for patients
with comorbid depression and heart disease - II

• Medication adherence. Specifically address the issue of medication

adherence with every patient and try to decrease barriers to
adherence. Simplifying medication regimens, eliminating
medications that are not absolutely necessary, and prescribing low-
cost alternatives may be helpful in specific circumstances.
• Attitudes and beliefs about cardiac treatment regimens. Anticipate
the possibility that patients with depression may have greater levels
of concern and more negative attitudes and beliefs about medical
treatment regimens. Discuss the importance of each medication,
what the goals of treatment are, and how the patient’s particular
health goals are more likely to be achieved by adhering to a
particular medical treatment.

From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression and heart disease.
In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Recommendations for clinicians providing care for patients
with comorbid depression and heart disease - III

• Social isolation. Encourage patients to socialize with family

and friends; offer to engage family and friends on behalf of
the patient, encourage the patient to participate in group
activities that may be appropriate and desirable (sport clubs,
hobbies, religious groups).
• Self-efficacy. Inquire about your patient’s confidence that
he/she can accomplish a given task or behaviour (e.g.,
participation in a cardiac rehabilitation program, stopping
smoking, following a proper diet). If the patient’s confidence
is low, consider specific counseling that might enhance self-
efficacy.

From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression and heart disease.
In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
 Conclusions

• Depression is prevalent in CHF patients and

remains a major source of morbidity and
mortality.
• Identifying these patients and intervening early
will be the first step in decreasing the frequency
and subsequently improving the quality of life.
• Psychosomatic approach is suitable methods for
treating depression in CHF patients.
ALHAMDULILLAH….