Depression and Heart Failure: Research and Statistics

The study was conducted jointly with the Scientific and Clinical Center "Healthy Heart", First Moscow State Medical University named after Sechenov, co-author - Doctor of Medical Sciences M. Yu. Drobizhev.

In addition, many authors indicate that the combination of heart failure and depression aggravates the severity of pathophysiological disorders common to both diseases, such as activation of the sympathetic nervous system, increased production of proinflammatory cytokines and hypercoagulation.

A significant drawback of most studies of depression in patients with heart failure is the clearly unsatisfactory clinical characteristics of depression. Most often, no diagnoses presented in Class V (Mental and behavioral disorders) are used to describe them. Instead, they report the presence of depression or depressive symptoms in patients.

In particular, they report the presence of major depressive disorder in patients with CHF, which is any first severe depression, when further observation is required for a more accurate conclusion. Meanwhile, there are diagnostic headings that are much better suited to identifying depressive symptoms in patients with CHF.

Among them, the first to be mentioned is adaptive response disorder. This diagnosis is specifically intended to qualify depressions that are a pathological reaction to significant stress, which may be a serious somatic disease (or its complication). This disorder is fundamentally reversible.

Regardless of whether psychotropic drugs or psychotherapy were prescribed, depressive (and anxiety) symptoms should be eliminated within 6 months (short-term depressive reaction or mixed - depressive and anxious) to 2 years (prolonged reactions). This is facilitated by the de-actualization of stress (in our case, a decrease in the severity of CHF), as well as the patient's adaptation to the disease situation.

In a significant portion of patients with CHF, depressive symptoms are associated not with pathological (disorder of adaptive reactions), but with completely normal psychological reactions ("grief", depressive "coping").

The latter in many ways resemble a mental disorder:

• provoked by a somatic disease;
• reversible;
• depressive (and often anxious) symptoms are noted in their structure.

However, they occur only from time to time and are so weakly expressed that such a reaction cannot be called pathological. A significant part of depressive symptoms in patients with CHF refers to a relatively mild and reversible disorder of adaptive reactions or is not a mental disorder at all. That is, they are unlikely to have a significant impact on the course of cardiovascular pathology.

Therefore, existing recommendations for the detection and treatment of depressive symptoms in patients with CHF should be critically reviewed. The implementation of the stated goal required additional statistical analysis of the data obtained in the CHANCE study (School and Outpatient Monitoring of Patients with Heart Failure), carried out by the Heart Failure Society (HFS).

The results of the study show that the studied mental symptoms meet the criteria for depressive reactions to CHF. The structure of the condition is dominated by stable depressive symptoms, which are accompanied by less persistent manifestations of anxiety. These manifestations are reversible and disappear without the use of any psychotropic drugs or psychotherapy against the background of effective treatment of CHF.

• In 60% of cases, manifestations of depression and anxiety are subthreshold in nature and most likely reflect normal psychological reactions of patients to CHF.
• In 40% of cases, suprathreshold mild or moderate symptoms can be seen.

In this scenario, F43.2 - disorder of adaptive reactions - can be diagnosed.

The data obtained in this study are of both theoretical and practical importance. Currently, when studying depression in cardiac patients, the dominant goal is to establish the adverse effect of mental symptoms on cardiovascular pathology. However, such studies do not take into account the fact that depressions themselves can depend on a somatic disease and even be considered as its mental complication.

In this situation, it is advisable to establish the symptoms of cardiovascular disease that have the maximum psychotraumatic effect on the patient, and therefore are the most depressogenic. It is necessary to determine diagnostic approaches to identifying normal and pathological depressive reactions, as well as the validity of such measures as prescribing psychotropic drugs or psychotherapy.

Thus, the American Heart Association recommends using the Patient Health Questionnaire-9 (PHQ-9, Depression Screening Scales) for this purpose, designed to identify a depressive state. All patients are asked the first two questions of the PHQ-9, which are designed to identify loss of interest and ability to experience pleasure, as well as depressed mood (Little interest or pleasure in doing things and Feeling down, depressed, or hopeless).

Then the severity of these symptoms of depression is assessed. If the patient answers that such complaints are not typical for him, then the answers are assessed at 0 points.

• If the symptoms bother for several days out of the last two weeks, then the score is 1 point.
• If the complaints are present on more than half of the days out of the same time period, then the answers are assessed at 2 points.
• The maximum score - 3 points - is set when the symptoms appear almost every day.

If the patient scores less than 3 points, then further diagnostic procedures are suspended.

When the patient has mild symptoms of depression that occur from time to time, then psychological support, patient education and observation for one month are recommended. Naturally, the same consultation is indicated in all other cases. For example, when moderate symptoms are detected or when data on severe depression are obtained.

During a consultation with a mental health specialist, the issue of prescribing an antidepressant or other treatment (for example, psychotherapy) is decided. Subsequently, all participants in the treatment process monitor the intake of drugs, the effectiveness and safety of therapy. The results of the study show that more than half of the studied patients with CHF need a consultation with a psychiatrist or psychotherapist.

That is why it is extremely important to continue research on depressive reactions in patients with CHF. It is quite possible that the results of such studies will allow a more accurate description of situations that do not require intervention (normal depressive reactions), and pathological depressive reactions, in which consultations with a psychiatrist, psychotherapist and the prescription of antidepressants are absolutely necessary.