Effects of interventions on depression in heart failure: A systematic review

Psychosocial interventions and their effectiveness on quality of life among elderly persons living with HIV in Africa South of the Sahara: Systematic review and meta -analysis protocol

BACKGROUND

The number of elderly people living with HIV (EPLHIV) has increased significantly as a result of antiretroviral treatment (ART) and this has brought about a variety of psychosocial challenges that have an impact on their quality of life (QoL). Various psychosocial interventions have been tried or implemented in Sub-Saharan Africa (SSA) to improve QoL of EPLHIV. However, there is paucity of data on the types and effectiveness of these interventions. This systematic review, therefore, aims to explore available psychosocial interventions in SSA and their effectiveness in improving the QoL of EPLHIV.

METHODS

We will search PubMed, PsycINFO, LILACS, Cochrane Library, Google Scholar, HINARI, Africa Journals Online, Scopus and Web of Science to retrieve publications on psychosocial interventions implemented to improve QoL of EPLHIV from inception of the identified databases to 31st December 2023 without language restrictions. Also, supplementary sources such as conference proceedings, preprint repositories, databases of dissertations, as well as WHO and governmental databases can be explored for additional studies. For unpublished studies, trial registries and experts would be contacted, and reference lists of retrieved papers will be manually searched. Retrieved studies will be deduplicated using Mendeley and exported to Rayyan. At least two reviewers will independently select studies, extract data and assess the quality of the included studies using validated tools. Dichotomous outcomes data will be assessed and reported as odds ratio (OR) or risk ratio (RR) and for continuous outcomes, mean difference (MD) will be used; all reported with their 95% confidence interval (CI). Heterogeneity will be explored graphically by inspecting the overlapping of CIs and assessed quantitatively using the I2 statistic.

EXPECTED OUTCOMES

This systematic review will be the first to rigorously identify psychosocial intervention on QoL of EPLHIV in SSA and assess their effectiveness with the aim to provide regional and country- specific data that will inform the selection and implementation of appropriate and socially acceptable policies across countries in SSA. Key findings of the review are expected to contribute critical evidence on availability, types and effectiveness of psychosocial interventions for improving quality of life of vulnerable elderly persons in SSA living with HIV. Furthermore, the review will explore any variation and possible correlates of psychosocial interventions by age, sex, CD4 count (if available), setting and geographic location within SSA that will provide healthcare professionals with reliable evidence, with the ultimate goal of inspiring countries in SSA to adopt innovative interventions to improve HIV care.

TRIAL REGISTRATION

Systematic review registration: The systematic review protocol has been registered in the International Prospective Register for Systematic Reviews (PROSPERO), with registration ID CRD42021278218.

Clinical effects of cognitive behavioral therapy in heart failure patients: a meta-analysis of randomized controlled trials

BACKGROUND

About 20-40% of people with Heart failure (HF) suffer from some depression, which is 4-5% greater than the overall population. This depression can lead to undesirable outcomes, including elevated mortality rate and frequent hospitalization.

PURPOSE

The current study aims to evaluate the impact of cognitive behavioural therapy (CBT) on self-care and the symptoms of depression and anxiety in HF patients.

METHODS

We searched PubMed, Web of Science (WOS), Scopus, and Cochrane Library till 15 October 2022. All relevant randomized controlled trials (RCTs) were included. The data were extracted and pooled using Review Manager software (RevMan 5.4). Continuous data were pooled as mean difference and 95% confidence interval (CI).

RESULTS

Our search retrieved 1146 records, and 7 studies (611 patients) were finally included. We assessed the Beck Depression Inventory-II (BDI-II) as the primary outcome of the study. Hamilton Rating Scale for Depression (HRSD-17), Change in Beck Anxiety Inventory, Kansas City Cardiomyopathy Questionnaire (KCCQ), and Self-Care of Heart Failure Index (SCHFI) were also assessed as secondary outcomes. With CBT, BDI-II showed a significant reduction after 4 to 6 months follow-up (MD = -4.87, 95% CI: [-8.06; -1.69], P = 0.003) as well as 8 to 9 months follow-up (MD = -5.71, 95% CI: [-8.95; -2.46], P = 0.0006). But no significant difference was shown with 3 months follow-up (M.D=-4.34; 95%CI: [-10.70; 2.03], P = 0.18).

CONCLUSIONS

CBT has long-term (4-9 months) significant favorable outcomes decreasing anxiety and depression compared to non-CBT groups. No significant short-term (less than 3 months) impact on HF patients' self-care, depression, or anxiety were shown.

Cardiac sensory afferents modulate susceptibility to anxio-depressive behaviour in a mouse model of chronic heart failure

AIM

Impairments in cerebral structure and cognitive performance in chronic heart failure (CHF) are critical components of its comorbidity spectrum. Autonomic afferents that arise from cardiac sensory fibres show enhanced activity with CHF. Desensitization of these fibres by local application of resiniferatoxin (RTX) during myocardial infarction (MI) is known to prevent cardiac hypertrophy, sympathetic hyperactivity and CHF. Whether these afferents mediate cerebral allostasis is unknown.

METHODS

CHF was induced by myocardial infarction. To evaluate if cardiac afferents contribute to cerebral allostasis, RTX was acutely applied to the pericardial space in controls (RTX) and in MI treated animals (MI/RTX). Subjects were then evaluated in a series of behavioural tests recapitulating different symptoms of depressive disorders. Proteomics of the frontal cortices (FC) was performed to identify contributing proteins and pathways responsible for behavioural allostasis.

RESULTS

Desensitization of cardiac afferents relieves hallmarks of an anxio/depressive-like state in mice. Unique protein signatures and regulatory pathways in FCs isolated from each treatment reveal the degree of complexity inherent in the FC response to stresses originating in the heart. While cortices from the combined treatment (MI/RTX) did not retain protein signatures from the individual treatment groups, all three groups suffer dysregulation in circadian entrainment.

CONCLUSION

CHF is comorbid with an anxio/depressive-like state and ablation of cardiac afferents relieves the despair phenotype. The strikingly different proteomic profiles observed in FCs suggest that MI and RTX lead to unique brain-signalling patterns and that the combined treatment, potentially through destructive interference mechanisms, most closely resembles controls.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

The Efficacy of Psychological Interventions on Health-Related Quality of Life for Patients With Heart Failure and Depression: A Systematic Review

BACKGROUND

Depression is prevalent among adults with chronic heart failure (CHF) and is associated with higher rates of morbidity and mortality and higher healthcare costs.

OBJECTIVES

The aim of this study was to explore the efficacy of psychological interventions in reducing depression and improving quality of life and clinical outcomes (mortality, hospitalization) among adults with CHF.

METHODS

This study performed a systematic review involving searches of 6 databases (MEDLINE, CINAHL, EMBASE, PsycINFO, ASSIA, and SSCI), the Cochrane library, and gray literature, completed in January 2020. Experimental and nonexperimental quantitative studies of psychological interventions for adults with CHF were included. Each study was quality appraised, and key data were extracted and tabled. Overall findings are presented as a narrative synthesis.

RESULTS

Nine studies met eligibility. Study authors sampled 757 participants and evaluated 4 psychological interventions: cognitive behavioral therapy alone or combined with exercise, mindfulness-based psychoeducation, coping skills training, and innovative holistic meditation. Cognitive behavioral therapy was significantly associated with improved depression and quality of life, and reduced hospitalization risk. Mindfulness-based psychoeducation, holistic meditation, and coping skills training positively impacted depression and quality of life. Coping skills training also reduced hospitalization and mortality risks.

CONCLUSION

Although this review indicates that psychological interventions can be beneficial to adults with CHF who have depression, the overall weight of evidence contains a number of biases. Larger, higher-powered studies are needed to confirm or refute these findings and to better understand how specific intervention and sample characteristics relate to outcomes.

The Association Between Mutuality, Anxiety, and Depression in Heart Failure Patient-Caregiver Dyads: An Actor-Partner Interdependence Model Analysis

BACKGROUND

Heart failure (HF) patient-caregiver dyads experience severe psychological problems, such as anxiety and depression. A variable that has been found to be associated with anxiety and depression in patients and caregivers in severe chronic conditions is mutuality. However, this association has not been explored in HF patient-caregiver dyads to date.

OBJECTIVE

The aim of this study was to evaluate the associations among mutuality, anxiety, and depression in HF patient-caregiver dyads.

METHODS

This was a cross-sectional study. Mutuality, anxiety, and depression in HF patient-caregiver dyads were assessed using the Mutuality Scale (MS) total and 4 dimension scores and the Hospital Anxiety and Depression Scale, respectively. Data were analyzed using the actor-partner interdependence model to examine how mutuality of patients and caregivers was associated with both the patients' own (actor effect) and their partners' anxiety and depression (partner effect).

RESULTS

A sample of 366 dyads of patients with HF (mean age, 72 years; 56% male) and caregivers (mean age, 54 years; 73.3% female) was enrolled. Regarding patient anxiety, we observed only an actor effect between the MS dimension scores of "love and affection" and "reciprocity" and anxiety in patients (B = -1.108, P = .004 and B = -0.826, P = .029, respectively). No actor and partner effects were observed concerning caregiver anxiety. Regarding depression, we observed that only the MS dimension of "love and affection" in patients had both an actor (patient: B = -0.717, P = .032) and a partner (caregiver: B = 0.710, P = .040) effect on depression.

CONCLUSIONS

The assessment of MS in HF patient-caregiver dyads is important to formulate interventions aimed at improving anxiety and depression in patients and caregivers.

Mindfulness meditation for workplace wellness: An evidence map

BACKGROUND

Mindfulness interventions aim to foster greater attention and awareness of present moment experiences. Uptake of mindfulness programs in the workplace has grown as organizations look to support employee health, wellbeing, and performance.

OBJECTIVE

In support of evidence-based decision making in workplace contexts, we created an evidence map summarizing physical and mental health, cognitive, affective, and interpersonal outcomes from systematic reviews of randomized controlled trials (RCTs) of mindfulness interventions.

METHODS

We searched nine electronic databases to July 2017, dually-screened all reviews, and consulted topic experts to identify systematic reviews on mindfulness interventions. The distribution of evidence is presented as an evidence map in a bubble plot.

RESULTS

In total, 175 systematic reviews met inclusion criteria. Reviews included a variety of mindfulness-based interventions. The largest review included 109 randomized controlled trials. The majority of these addressed general health, psychological conditions, chronic illness, pain, and substance use. Twenty-six systematic reviews assessed studies conducted in workplace settings and with healthcare professionals, educators, and caregivers. The evidence map shows the prevalence of research by the primary area of focus. An outline of promising applications of mindfulness interventions is included.

CONCLUSIONS

The evidence map provides an overview of existing mindfulness research. It shows the body of available evidence to inform policy and organizational decision-making supporting employee wellbeing in work contexts.

Is Mental Illness a Risk Factor for Hospital Readmission?

People with mental illnesses (MI) receive suboptimal care for medical comorbidities and their high risk for readmission may be addressed by adequate medication management and follow-up care. We examined the association between MI, medication changes, and post-discharge outpatient visits with 30-day readmission in 40,048 Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure or pneumonia. Beneficiaries with MI were more likely to be readmitted than those without MI (14 vs. 11%). Probability of readmission was 13 and 12% when medications were dropped or added, respectively, versus 11% when no change was made. Probability of readmission also increased with outpatient visits.

Correlates of Exercise Self-efficacy in a Randomized Trial of Mind-Body Exercise in Patients With Chronic Heart Failure

PURPOSE

Exercise self-efficacy is one of the strongest predictors of physical activity behavior. Prior literature suggests that tai chi, a mind-body exercise, may increase self-efficacy; however, this is not extensively studied. Little is known about the factors associated with development of exercise self-efficacy in a population with heart failure.

METHODS

We utilized data from a randomized controlled trial of 12 weeks of group tai chi classes versus education in patients with chronic heart failure (n = 100). Multivariable linear regression was used to explore possible correlates of change in exercise self-efficacy in the entire sample and in the subgroup who received tai chi (n = 50). Covariates included baseline quality of life, social support, functional parameters, physical activity, serum biomarkers, sociodemographics, and clinical heart failure parameters.

RESULTS

Baseline 6-minute walk (β=-0.0003, SE = 0.0001, P = .02) and fatigue score (β= 0.03, SE = 0.01, P = .004) were significantly associated with change in self-efficacy, with those in the lowest tertile for 6-minute walk and higher tertiles for fatigue score experiencing the greatest change. Intervention group assignment was highly significant, with self-efficacy significantly improved in the tai chi group compared to the education control over 12 weeks (β= 0.39, SE = 0.11, P < .001). In the tai chi group alone, lower baseline oxygen uptake (β=-0.05, SE = 0.01, P = .001), decreased mood (β=-0.01, SE = 0.003, P = .004), and higher catecholamine level (epinephrine β= 0.003, SE = 0.001, P = .005) were significantly associated with improvements in self-efficacy.

CONCLUSIONS

In this exploratory analysis, our initial findings support the concept that interventions like tai chi may be beneficial in improving exercise self-efficacy, especially in patients with heart failure who are deconditioned, with lower functional status and mood.

Effects of cognitive behavioural therapy for depression in heart failure patients: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the effects of cognitive behavioural therapy (CBT) on depression, quality of life, hospitalisations and mortality in heart failure patients. The search strategy was developed for Ovid MEDLINE and modified accordingly to search the following bibliographic databases: PubMed, EMBASE, PsycINFO, CENTRAL and CINAHL. Databases were searched from inception to 6 March 2016 for randomised controlled trials (RCTs) or observational studies that used CBT in heart failure patients with depression or depressive symptoms. Six studies were identified: 5 RCTs and 1 observational study, comprising 320 participants with predominantly NYHA classes II-III, who were mostly male, with mean age ranging from 55 to 66 years. Compared to usual care, CBT was associated with a greater improvement in depression scores both initially after CBT sessions (standardised mean difference -0.34, 95% CI -0.60 to -0.08, p = 0.01) and at 3 months follow-up (standardised mean difference -0.32, 95% CI -0.59 to -0.04, p = 0.03). Greater improvement in quality of life scores was evident for the CBT group initially after CBT sessions, but with no difference at 3 months. Hospital admissions and mortality were similar, regardless of treatment group. CBT may be more effective than usual care at improving depression scores and quality of life for heart failure patients initially following CBT and for depression at 3 months. Larger and more robust RCTs are needed to evaluate the long-term clinical effects of CBT in heart failure patients.

Men With a Terminal Illness Relax Their Criteria for Facial Attractiveness

According to the life history paradigm, in life-threatening conditions, sexual selection criteria are relaxed in order to increase the probability of a last resort reproduction, ultimately contributing to reproductive success. This should be reflected in loosened mating preferences — a process observed in nonhuman animals. Studies investigating this aspect in humans, however, are scarce. This study explored the aesthetic preferences towards facial and nonfacial stimuli in terminally ill patients with heart failure (HF) and their healthy, same-sex peers. The aim was to examine if these two groups of men demonstrate different patterns of aesthetic judgments. Using a 7-point scale, 65 male patients with HF and 143 healthy men evaluated the perceived attractiveness of 15 photographs (five adult male faces, five adult female faces, and five nonfacial pictures). A mixed-design analysis of variance was run to assess group differences in aesthetic preferences. Compared to healthy controls, stimuli. HF patients rated the pictures using significantly higher scores, but this applied only to male and female, but not nonfacial, stimuli. We propose that lower criteria for facial attractiveness in HF patients are linked to relaxation of mate preferences as a result of a life-threatening conditions, and that this process can be an adaptive mating strategy from an ultimate, evolutionary perspective. However, other mechanisms (e.g., seeking social support) may be also responsible for the observed patterns.

Depression in heart failure: Intricate relationship, pathophysiology and most updated evidence of interventions from recent clinical studies

Heart failure (HF) is a burgeoning chronic health condition affecting more than 20million people worldwide. Patients with HF have a significant (17.1%) 30-day readmission rate, which invites substantial penalty in payment to hospitals from Centers for Medicare and Medicaid Services, as per the newly introduced Hospital Readmissions Reduction Program. Depression is one of the important risk factors for readmission in HF patients. It has a significant prevalence in patients with HF and contributes to the overall poor quality of life in them. Several behavioral (smoking, obesity, lack of exercise and medication noncompliance) and pathophysiological factors (hypercortisolism, elevated inflammatory biomarkers, fibrinogen, and atherosclerosis) have been found responsible for the adverse outcome in patients with HF and concomitant depression. Hippocampal volume loss noted in patients with acute HF exacerbations may contribute to the development of depressive symptoms in them. Screening for depression in HF patients continues to be challenging due to a considerable overlap in symptoms. Published trials on the use of antidepressants and cognitive behavioral therapy (CBT) have shown variable outcomes. Newer modalities like internet-based CBT have been tried in small studies, with promising results. A recent meta-analysis observed the beneficial role of aerobic exercise training in patients with HFrEF. Future long-term prospective studies may contribute to the formulation of a detailed screening and management guideline for patients with HF and depression. Our review is aimed to summarize the intricate relationship between depression and heart failure, with respect to their epidemiology, pathophysiological aspects, and optimal management approach.

A Systematic Review of Relaxation, Meditation, and Guided Imagery Strategies for Symptom Management in Heart Failure

BACKGROUND

Pain, dyspnea, fatigue, and sleep disturbance are prevalent and distressing symptoms in persons with advanced heart failure. Although many lifestyle and self-care interventions have been developed to control heart failure progression, very few studies have explored treatments exclusively for symptom palliation. Cognitive-behavioral strategies may be effective treatment for these symptoms in advanced heart failure.

OBJECTIVE

A systemic review was conducted to describe the effect of cognitive-behavioral strategies on pain, dyspnea, fatigue, and sleep disturbance in patients with heart failure.

METHODS

CINAHL, Medline, and PsychINFO were searched from inception through December 2014. Articles were selected for inclusion if they tested a cognitive-behavioral strategy using a quasi-experimental or experimental design, involved a sample of adults with heart failure, and measured pain, dyspnea, fatigue, sleep disturbance, or symptom-related quality of life. The 2 authors evaluated study quality, abstracted data elements from each study, and synthesized findings.

RESULTS

Thirteen articles describing 9 unique studies met criteria and were included in the review. Five studies tested relaxation strategies, 3 tested meditation strategies, and 1 tested a guided imagery strategy. Of the 9 studies, 7 demonstrated some improvement in symptom outcomes. Relaxation, meditation, guided imagery, or combinations of these strategies resulted in less dyspnea and better sleep compared with attention control or usual care conditions and reduced pain, dyspnea, fatigue, and sleep disturbance within treatment groups (pretreatment to posttreatment). Symptom-related quality of life was improved with meditation compared with attention control and usual care conditions and improved pre- to post-guided imagery.

CONCLUSIONS

Studies exploring cognitive-behavioral symptom management strategies in heart failure vary in quality and report mixed findings but indicate potential beneficial effects of relaxation, meditation, and guided imagery on heart failure-related symptoms. Future research should test cognitive-behavioral strategies in rigorously designed efficacy trials, using samples selected for their symptom experience, and measure pain, dyspnea, fatigue, and sleep disturbance outcomes with targeted symptom measures.

An evidence map of the effect of Tai Chi on health outcomes

BACKGROUND

This evidence map describes the volume and focus of Tai Chi research reporting health outcomes. Originally developed as a martial art, Tai Chi is typically taught as a series of slow, low-impact movements that integrate the breath, mind, and physical activity to achieve greater awareness and a sense of well-being.

METHODS

The evidence map is based on a systematic review of systematic reviews. We searched 11 electronic databases from inception to February 2014, screened reviews of reviews, and consulted with topic experts. We used a bubble plot to graphically display clinical topics, literature size, number of reviews, and a broad estimate of effectiveness.

RESULTS

The map is based on 107 systematic reviews. Two thirds of the reviews were published in the last five years. The topics with the largest number of published randomized controlled trials (RCTs) were general health benefits (51 RCTs), psychological well-being (37 RCTs), interventions for older adults (31 RCTs), balance (27 RCTs), hypertension (18 RCTs), fall prevention (15 RCTs), and cognitive performance (11 RCTs). The map identified a number of areas with evidence of a potentially positive treatment effect on patient outcomes, including Tai Chi for hypertension, fall prevention outside of institutions, cognitive performance, osteoarthritis, depression, chronic obstructive pulmonary disease, pain, balance confidence, and muscle strength. However, identified reviews cautioned that firm conclusions cannot be drawn due to methodological limitations in the original studies and/or an insufficient number of existing research studies.

CONCLUSIONS

Tai Chi has been applied in diverse clinical areas, and for a number of these, systematic reviews have indicated promising results. The evidence map provides a visual overview of Tai Chi research volume and content.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009907.

The prognostic impact and optimal timing of the Patient Health Questionnaire depression screen on 4-year mortality among hospitalized patients with systolic heart failure

OBJECTIVE

An American Heart Association (AHA) Science Advisory recommends patients with coronary heart disease undergo routine screening for depressive symptoms with the two-stage Patient Health Questionnaire (PHQ). However, little is known on the prognostic impact of a positive PHQ screen on heart failure (HF) mortality.

METHODS

We screened hospitalized patients with systolic HF (left ventricle ejection fraction≤40%) for depression with the two-item Patient Health Questionnaire (PHQ-2) and administered the follow-up nine-item Patient Health Questionnaire (PHQ-9) both immediately following the PHQ-2 and by telephone 1 month after discharge. Later, we ascertained vital status at 4-year follow-up on all patients who completed the inpatient PHQ-9 and calculated mortality incidence and risk by baseline PHQ.

RESULTS

Of the 520 HF patients we enrolled, 371 screened positive for depressive symptoms on the PHQ-2. Of these, 63% scored PHQ-9≥10 versus 24% of those who completed the PHQ-9 1 month later (P<.001). PHQ-2 positive status was an independent predictor of 4-year all-cause mortality (HR: 1.50; P=.04), and mortality incidence was similar by baseline PHQ-9 score.

CONCLUSIONS

Among hospitalized patients with systolic HF, a positive PHQ-2 screen for depressive symptoms is an independent risk factor for increased 4-year all-cause mortality. Our findings extend the AHA's Science Advisory for depression to hospitalized patients with systolic HF.

The Short-Term and Long-Term Effects of Biofeedback-Assisted Relaxation Therapy in Patients With Heart Failure

Background

Relaxation techniques can reduce sympathetic nervous system activation and stress, potentially improving heart failure patients’ physical and psychological outcomes.

Purpose

To examine the effects of biofeedback-assisted relaxation (BFAR) therapy in patients with heart failure.

Methods

A prospective randomized control study was conducted. Participants in the treatment group received BFAR therapy, while participants in the control group received standard of care. Short-term outcomes were physical symptoms and psychosocial variables measured at baseline and 3 months; long-term outcomes were cardiac events and mortality assessed at 12 months.

Results

Fifty-two heart failure patients participated in the study: 23 (mean age 60.0 ± 13.7 years; 60.9% male; 39.1% New York Heart Association III/IV) in the treatment group and 29 (mean age 59.2 ± 12.2 years; 72.4% male; 48.3% New York Heart Association III/IV) in the control group. Short-term effects of BFAR on outcome variables were not significantly different between treatment and control groups. However, longer event-free survival was found in the treatment group compared with the control group ( p = .019).

Conclusions/Implications for Practices

BFAR therapy is effective to improve cardiac event-free survival of heart failure patients and can be applied to clinical setting.

Long Term Follow-Up after a Randomized Integrated Educational and Psychosocial Intervention in Patient-Partner Dyads Affected by Heart Failure

BACKGROUND

To date, contemporary heart failure care remains patient-focused, but awareness of the partners' and families' situation is increasing. Randomized studies have mainly evaluated the short-term effects of dyadic interventions. Therefore, the aim of this study was to determine the 24-month effects of an intervention with psych-educational support in dyads of heart failure patients and their partners.

METHODS

This study used a randomized study design and 155 patient-partner dyads were enrolled. The intervention included a nurse-led program of three sessions addressing psychoeducational support.

RESULTS

The intervention did not have any effect on health, depressive symptoms or perceived control among the patient-partner dyads after 24 months. Furthermore, time to first event did not differ significantly between the intervention group and the control patients.

CONCLUSION

This study may be regarded as a first step in trying to understand dyads' need for supportive care. Individualized and more targeted interventions seem necessary to achieve a higher impact on dyad outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02398799.

Internet-based cognitive behavior therapy for patients with heart failure and depressive symptoms: A proof of concept study

OBJECTIVE

The aim was (1) to describe the development of a guided internet-based CBT (ICBT) program adapted to patients with heart failure (HF) and (2) to evaluate the feasibility of the ICBT program in regard to depressive symptoms, the time used by health care providers to give feedback, and participants' perceptions of the ICBT program.

METHOD

A multi-professional team developed the program and seven HF patients with depressive symptoms were recruited to the study. The Patient Health Questionnaire-9 (PHQ-9) and the Montgomery Åsberg Depression Rating-Self-rating scale (MADRS-S) were used to measure depression, and patients were interviewed about their perceptions of the program.

RESULTS

Based on research in HF and CBT, a nine-week program was developed. The median depression score decreased from baseline to the end of the study (PHQ-9: 11-8.5; MADRS-S: 25.5-16.5) and none of the depression scores worsened. Feedback from health care providers required approximately 3h per patient. Facilitating perceptions (e.g. freedom of time) and demanding perceptions (e.g. part of the program demanded a lot of work) were described by the patients.

CONCLUSION

The program appears feasible and time-efficient. However, the program needs to be evaluated in a larger randomized study.

A patient-centered perspective of treating depressive symptoms in chronic heart failure: What do patients prefer?

OBJECTIVE

To date, very little is known about the specific needs of patients with chronic heart failure (CHF) who must cope with depression. We therefore questioned CHF patients reporting depressive symptoms about their concerns and preferences regarding various psychosocial treatment options. After three-month, we determined how many patients had actually participated in a treatment.

METHODS

85 patients with CHF fulfilling the criteria of a depressive disorder according to the PHQ-9 were investigated. Data were analyzed using descriptive and frequency, as well as logistic regression analyses.

RESULTS

64.7% of the sample reported that they could envision adhering to supportive talks at longer intervals, whereas only 34.1% would accept an antidepressant. After three months, 24.7% of the patients had actually participated in a treatment. Generalized anxiety severity (GAD-7) was very closely associated with treatment preferences and treatment utilization: The higher the generalized anxiety severity, the more likely was the patients' disposition to begin an antidepressant and/or psychotherapy.

CONCLUSIONS

The most favoured treatment option was a low-threshold service with supportive talks.

PRACTICE IMPLICATIONS

Future studies investigating the improvement of patient-centred care in CHF patients should include measurements of generalized anxiety.

Nitric oxide dysregulation in patients with heart failure: the association of depressive symptoms with L-arginine, asymmetric dimethylarginine, symmetric dimethylarginine, and isoprostane

OBJECTIVE

Nitric oxide (NO) regulation plays a critical role in cardiovascular diseases including heart failure (HF). Markers of NO dysregulation have been found in individuals with depression without cardiovascular disease. Because depression is associated with poor HF outcomes, the present study tested the hypothesis that depression is associated with a dysregulated NO pathway in patients with HF.

METHODS

Serum levels of NO regulation (L-arginine, asymmetric dimethylarginine [ADMA], and symmetric dimethylarginine [SDMA]) and oxidative stress (isoprostane 8-epi prostaglandin F2α) were measured in 104 patients with HF (mean [standard deviation] age = 65.7 [8.4] years, 28% women) at baseline and 12 months. Depressive symptoms were measured using the Beck Depression Inventory. The associations between depressive symptoms with markers of NO regulation were examined with mixed-model analysis, adjusted for age, sex, time of assessment, left ventricular ejection fraction, creatinine, and hypertension.

RESULTS

Depressive symptoms were correlated with a lower L-arginine/ADMA ratio (r = -0.22, p = .003) and higher SDMA levels (r = 0.28, p < .001). Associations were similar for somatic depressive symptoms and cognitive-affective symptoms (L-arginine/ADMA ratio: r = -0.20 [p = .009] versus r = -0.19 [p = .013]; ADMA: r = 0.16 [p = .043] versus r = 0.10 [p = .20]; SDMA: r = 0.27 [p < .001] versus r = 0.22 [p = .005], respectively). No associations were found between depressive symptoms and isoprostane. The association between depression and the L-arginine/ADMA ratio remained significant in multivariate adjusted models.

CONCLUSIONS

Depressive symptoms were associated with markers of NO dysregulation, particularly the L-arginine/ADMA ratio and SDMA, in patients with HF. The lower L-arginine/ADMA ratio indicates less available NO, suggesting that NO-related endothelial dysfunction may play a role in the adverse risk of HF progression associated with depression.

Personality disorders in heart failure patients requiring psychiatric management: comorbidity detections from a routine depression and anxiety screening protocol

Several international guidelines recommend routine depression screening in cardiac disease populations. No previous study has determined the prevalence and comorbidities of personality disorders in patients presenting for psychiatric treatment after these screening initiatives. In the first stage 404 heart failure (HF) patients were routinely screened and 73 underwent structured interview when either of the following criteria were met: (a) Patient Health Questionnaire ≥10; (b) Generalized Anxiety Disorder Questionnaire ≥7); (c) Response to one item panic-screener. Or (d) Suicidality. Patients with personality disorders were compared to the positive-screen patients on psychiatric comorbidities. The most common personality disorders were avoidant (8.2%), borderline (6.8%) and obsessive compulsive (4.1%), other personality disorders were prevalent in less than <3% of patients. Personality disorder patients had significantly greater risk of major depression (risk ratio (RR) 1.2; 95% confidence interval (CI) 1.2-13.3), generalized anxiety disorder (RR 3.2; 95% CI 1.0-10.0), social phobia (RR 3.8; 95% CI 1.3-11.5) and alcohol abuse/dependence (RR 3.2; 95% 1.0-9.5). The findings that HF patients with personality disorders presented with complex psychiatric comorbidity suggest that pathways facilitating the integration of psychiatric services into cardiology settings are warranted when routine depression screening is in place.

A dynamic view of comorbid depression and generalized anxiety disorder symptom change in chronic heart failure: the discrete effects of cognitive behavioral therapy, exercise, and psychotropic medication

PURPOSE

No previous study has reported upon comorbid depression and anxiety disorders and their treatment in heart failure (HF), which the current study has sought to document.

MATERIALS AND METHODS

Total 29 HF patients under psychiatric management underwent primary depression cognitive behavioral therapy (CBT; n = 15) or primary generalized anxiety disorder (GAD) CBT (n = 14), and participated in a community exercise program and standard physician care. Repeated measures analysis of variance assessed Patient Health Questionnaire (PHQ-9) and GAD-7 symptom change pre- and post-CBT treatment, and assessed the interaction effects of treatment type, exercise, anti-depressant and anxiolytic.

RESULTS

There was a significant time and treatment interaction effect that favored the primary GAD CBT group for reduction in PHQ symptoms (F(1, 24) = 4.52, p = 0.04). Analysis of PHQ-somatic symptoms also showed a significant main effect for participation in the exercise program (F(1, 24) = 4.21, p = 0.05) and a significant time and anxiolytic interaction (F(1, 24) = 3.98, p = 0.05). The average number of cardiac hospital readmissions favored the primary GAD CBT group (p = 0.05).

CONCLUSION

The findings support the use of multifaceted interventions in the rehabilitation of HF patients with comorbid psychiatric needs. Implications for Rehabilitation Comorbid depression and anxiety disorders are a clinical and research focus that deserves more attention in the treatment of heart failure patients. Cognitive behavioral therapy, exercise, and anxiolytic use was associated with significant changes in depression and anxiety though discrete effects were evident. Multifaceted interventions are most likely to be successful in the rehabilitation of HF patients with psychiatric needs.

Pathophysiological Relationships Between Heart Failure and Depression and Anxiety

Depression and anxiety are common comorbid conditions in patients with heart failure. Patients with heart failure and depression have increased mortality. The association of anxiety with increased mortality in patients with heart failure is not established. The purpose of this article is to illustrate the similarities of the underlying pathophysiology of heart failure, depression, and anxiety by using the Biopsychosocial Holistic Model of Cardiovascular Health. Depression and anxiety affect biological processes of cardiovascular function in patients with heart failure by altering neurohormonal function via activation of the hypothalamic-pituitary-adrenal axis, autonomic dysregulation, and activation of cytokine cascades and platelets. Patients with heart failure and depression or anxiety may exhibit a continued cycle of heart failure progression, increased depression, and increased anxiety. Understanding the underlying pathophysiological relationships in patients with heart failure who experience comorbid depression and/or anxiety is critical in order to implement appropriate treatments, educate patients and caregivers, and educate other health professionals.

So much research, so little application: Barriers to dissemination and practical implementation of Tai Ji Quan

Despite the large number of articles published in the medical literature advocating the use of Tai Ji Quan for a wide variety of health-related outcomes, there has been little systematic broad-scale implementation of these programs. It may be argued that the lack of funding from organizations capable of implementing and overseeing large-scale programs, such as governmental health agencies or national non-governmental organizations concerned with healthcare for older adults, is to blame. However, the evidence these organizations need to justify underwriting such programs is in short supply because of conflicting priorities and standards related to determining the efficacy and effectiveness of Tai Ji Quan. Establishing efficacy through acceptable designs such as randomized controlled trials involves strict protocols to ensure meaningful internal validity but different approaches are needed to demonstrate meaningful effectiveness (external validity) outside the study setting. By examining the quality, quantity, and relative proportions of the randomized controlled trials, systematic reviews, and dissemination studies reported in the medical literature, this paper highlights the disparity in emphasis between efficacy and effectiveness research that has impeded the development of a cohesive literature on Tai Ji Quan and concludes that until more researchers develop a systematic, long-range commitment to investigating its health-related benefits, the research related will remain fractured and sporadic, limiting the incentive of large funding agencies to support its wide-spread use.

The real world mental health needs of heart failure patients are not reflected by the depression randomized controlled trial evidence

INTRODUCTION

International depression screening guidelines in heart failure (HF) are partly based on depression treatment efficacy from randomized controlled trials (RCTs). Our aim was to test the external validity of depression RCT criteria in a sample of real-world HF patients.

METHODS

HF patients admitted to 3 hospitals in South Australia were referred to a HF psychologist if not already receiving current psychiatric management by psychologist or psychiatrist elsewhere. Screening and referral protocol consisted of the following; (a). Patient Health Questionnaire ≥ 10; (b). Generalized Anxiety Disorder Questionnaire ≥ 7); (c). positive response to 1 item panic attack screener; (d). evidence of suicidality. Patients were evaluated against the most common RCT exclusion criteria personality disorder, high suicide risk, cognitive impairment, psychosis, alcohol or substance abuse or dependency, bi-polar depression.

RESULTS

Total 81 HF patients were referred from 404 HF admissions, and 73 were assessed (age 60.6 ± 13.4, 47.9% female). Nearly half (47%) met at least 1 RCT exclusion criterion, most commonly personality disorder (28.5%), alcohol/substance abuse (17.8%) and high suicide risk (11.0%). RCT ineligibility criteria was more frequent among patients with major depression (76.5% vs. 46.2%, p<.01) and dysthymia (26.5% vs. 7.7%, p = .03) but not significantly associated with anxiety disorders. RCT ineligible patients reported greater severity of depression (M = 16.6 ± 5.0 vs. M = 12.9 ± 7.2, p = .02) and were higher consumers of HF psychotherapy services (M = 11.5 ± 4.7 vs. M = 8.5 ± 4.8, p = .01).

CONCLUSION

In this real-world sample comparable in size to recent RCT intervention arms, patients with depression disorders presented with complex psychiatric needs including comorbid personality disorders, alcohol/substance use and suicide risk. These findings suggest external validity of depression screening and RCTs could serve as a basis for level A guideline recommendations in cardiovascular diseases.