DEPRESSION IN HEART FAILURE

Heart failure (HF) is a chronic and debilitating disease expanding globally at an alarming rate due to population ageing and secondary prevention of cardiovascular diseases. Worldwide, HF is affecting at least 26 million people while 550,000 new cases are diagnosed annually.^1,2 More  in detail, in Europe, almost  6.5 million people are suffering from HF with prevalence of ≥10% in individuals above 70 years old. ³ HF management involves symptom alleviation, reduction of hospitalizations and improvements in patients’ quality of life.^2,4

                  Depression is common among HF patients and often co-exists with anxiety, thus complicating the therapeutic approach.^4,5,6 According to estimates, prevalence of depression in HF  ranges  from 9% to 60% ³ while major depression ranges from 20% to 40%, which is 4–5% higher compared to general population.⁷ Differences in depression prevalence are also noticed among hospitalized patients and outpatients.⁸

                  Depression is  acknowledged as the most widely explored determinant in daily life of HF patients which leads to poor clinical outcome, increased morbidity and mortality. ^4,5,6

                  Though the mechanism by  which depression is affecting negatively HF clinical outcome is poorly understood, however, it is mainly attributed to physiological and behavioural  responses which in turn lead to failure in treatment adherence and lifestyle modifications.³ Furthermore, HF patients are frequently unwilling to follow all restrictions in family, professional, social life, thus experiencing depression. The intense of depression increases sharply with disease severity (NYHA classification). HF patients in NYHA grade IV are shown to be more depressed than those in NYHA grades II or III.  Moreover, intense of depression is high at disease deterioration  because only then, it becomes apparent that medical treatment is not essential. In such cases, patients experience feelings of abandonment at a time when they have demanding emotional needs. Communication and frequent contact with health professionals is a matter of vital importance. ^9,10

                  A recent study in Greece which explored 190 hospitalized HF patients in four public hospitals using the Hospital Anxiety and Depression Scale (HADs) showed that 17.4% of patients experienced minor and 24.2% major depression. The same researchers also showed that the higher probability of being depressed was associated with  the longer disease duration as well as with being single/divorced or widowed.  More in detail, married patients were 59% less likely to have major depression compared to unmarried counterparts.⁶ Likewise, a prior study in Greek population which  explored both HF hospitalized patients and outpatients showed that 20.9% and 17.2% of the sample experienced moderate and severe depression, respectively.⁹

                  Evaluation of depression is usually underestimated in daily clinical practice  for various reasons. For example, symptoms of depression frequently overlap HF symptoms

or  health professionals pay more attention to disease treatment or even worse patients are unwilling to reveal their emotional burden  for fear to  be stigmatized under the label of mental illness. ¹¹