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Blending mental healthcare and traditional models

Investigators try to mitigate the impact of depression on outcomes in HF patients

For reasons that are not entirely clear, HF patients with depression have significantly worse outcomes than HF patients who are not depressed.1 The issue is becoming increasingly important because, unlike with many other cardiovascular diseases in this country, the incidence of HF is increasing. An estimated five million Americans have the disease, with 550,000 new cases being diagnosed each year. Although studies suggest that as many as 20%–50% of HF patients are depressed, the condition goes undiagnosed and untreated in many of these patients.

Investigators acknowledge that detecting depression in a patient with HF can be challenging because some of the symptoms of depression—such as fatigue and low energy levels—mimic the symptoms of HF. Nonetheless, the benefits of early diagnosis and treatment of depression in these patients could be immense when you consider both the improvements in quality of life as well as the reductions in utilization that could potentially be achieved.

Although experts in this field urge PCPs and cardiologists to implement effective screening procedures for depression in HF patients, researchers are in the process of developing an intervention strategy designed to treat both HF and depression at the same time without a major realignment of healthcare resources.

Pilot to examine thresholds for treatment

The negative effect of depression on many different types of chronic disease, including coronary heart disease, is widely recognized, but studies have only recently looked at the specific relationship between depression and outcomes in HF patients. And what investigators have discovered is that depression may be as important a risk factor in these patients as high cholesterol or hypertension. In fact, in a study published earlier this year by Sherwood, et al., investigators found that HF patients with depression were more than 50% more likely to die or be hospitalized for their condition than patients who were not depressed.1

Although it is intuitive to conclude that treating the comorbid depression in HF patients would improve outcomes, researchers at the University of Pittsburgh are seeking to amass more specific information about how and when you should treat an HF patient. “One of the goals of our pilot study is to identify the appropriate cutoff points for treating depression [in HF patients],” says Bruce Rollman, MD, MPH, an associate professor of medicine and psychiatry at the University of Pittsburgh School of Medicine and the principal investigator of the study. “We are focusing on the more severe HF patients, the class IIs, IIIs, and IVs. And what we don’t know is whether or not the threshold for treating depression in a class IV patient might be different than for a class II patient because some of the symptoms of depression overlap with the HF.” Rollman adds that there may also be different optimal cut-points for men and women, as there is some evidence that the thresholds for treatment may be influenced by gender differences.

In addition to establishing thresholds for treatment, investigators are also testing the efficacy of a collaborative care approach that is modeled after an intervention now under study in a National Institutes of Health–funded clinical trial dubbed “Bypassing the Blues.” In that NIH-funded project, Rollman and colleagues are investigating whether treating depression makes a difference in patients who have undergone coronary artery bypass graft (CABG) surgery. However, Rollman suggests that the intervention utilized in that trial is similar to the approach that will be used in the HF study.

“We have nurses who telephone patients [to discuss] their depression following the bypass surgery, and it involves a lot of patient preference,” says Rollman. For example, he points out that patients who are already on seven or eight medications might be reluctant to add an antidepressant to their complicated medication regimen. Consequently, the nurse care managers will discuss therapeutic options with the patients, do lesson plans with them, and then make recommendations to their physicians. “If we can’t get people better, or if they have a lot of complex issues such as a marital separation or a job loss, then we refer them to a mental health specialist in the community,” says Rollman. “[Further], the nurse care managers call patients to make sure they keep their appointments—so they monitor adherence.”

Although the nurse care managers have no special training in mental health, Rollman explains that they are involved with weekly case review sessions in which they discuss new patients, patients who are not doing well, and other concerns with three specialists: Rollman, the project coordinator, who is a psychologist, and a study psychiatrist. “In an hour we might review 20 patients or more, and we have a registry, so it is all in accordance with the chronic care model,” he says.

In cases in which the patient is interested in medication for his or her depression, the doctor has to prescribe it, and the patient has to pay for it, says Rollman, emphasizing that there is no pharmaceutical funding involved with the study. “We are not examining whether one drug works better than any other. We are really examining the broader issue of whether effective depression care can reduce cardiovascular morbidity and healthcare costs. And we eventually hope to do the same with the HF study.”

The goal is integration

In designing the HF/depression program, Rollman says, the underlying economics, or how you pay for depression care, is a high-priority issue. Consequently, the ultimate idea is to develop a model for depression care that can be integrated into already existing HF programs. “These programs are already up and running, so we don’t want to create a parallel program . . . where you have an HF care manager, and then you also have a mental health or a depression care manager,” he says. “If we could develop a blended model, then if proven effective, our model of care is more likely to get picked up by other healthcare organizations.”

Through this approach, the cardiovascular care manager or the person in charge of monitoring a patient’s HF can also take charge of the depression care, explains Rollman. “The basic principles are generally the same: regular follow-ups, monitoring adherence, and adjusting care when necessary,” he says.

Rollman acknowledges that it will take more than this initial pilot study to determine whether the blended model that he and his colleagues envision for treating HF and depression will deliver cost savings. However, results from the “Bypassing the Blues” clinical trial, which is already under way, will shed some light on the financial effect of providing depression care to patients with heart disease. Certainly, HF patients tend to be older and sicker than patients who have undergone CABG surgery, but both sets of patients are similarly affected by comorbid depression.

For example, studies have shown that cardiac patients with depression are less likely to adhere to their cardiac regimen, whether that involves watching their diet, taking prescribed medications, or weighing themselves. By improving adherence, Rollman theorizes that patients may be less susceptible to adverse events that could land them back in the ER or the hospital.

Aside from the psychological effect of depression, there may be bio-physiological effects as well, according to Wei Jiang, MD, a medical psychiatrist at Duke University Medical Center in Durham, NC, who has done extensive research about the effect of depression on patients with heart disease. For example, she points out that depressed patients have altered blood aggregation properties and elevated immune-inflammatory responses, and there is a decrease in the heart’s ability to respond to stress, although it is unclear how these mechanisms correlate with depression.

Whatever is at work in HF patients who are depressed, Jiang’s research suggests that these patients are at much higher risk of mortality in the long term than HF patients who are not depressed. This is true even of patients who are mildly depressed, according a study Jiang presented to the annual scientific session of the American College of Cardiology meeting in Orlando in March 2005.

In that study, Jiang followed 1,005 HF patients for seven years to determine the ability to predict mortality based on the scores on the Beck Depression Inventory (BDI), a standard depression screen.

On the BDI, a score of 10 is considered mildly depressed—with higher scores indicating more severe depression. In Jiang’s study, patients who had a score of 10 or higher had a 44% greater risk of dying than patients who were not depressed. When the threshold was lowered to a score of 7 or higher, the risk of mortality jumped to 51%.

Consider depression in HF patients

Although these results are striking, the high incidence of depression in cardiac patients is generally well-known. The million dollar question, according to Jiang, is why cardiologists and PCPs are not more attuned to the issue. She speculates that part of the problem is that patients rarely report that they are depressed. “The chance that patients will come in to talk to their nonpsychiatric doctor about how depressed they are is [practically] nonexistent,” says Jiang. “They go to the doctor and talk about other things. Maybe they are stressed out, maybe they have a lot of physical conditions, or maybe they just feel miserable. Rarely will they say they are depressed.”

In addition, Jiang points out that nonpsychiatric physicians may feel they simply don’t have the time to deal with mental health issues, and they often lack training in this area. “They may not feel comfortable managing these types of problems,” adds Jiang.

To get around this issue, Jiang suggests that there are many validated depression screens, such as the BDI, that can be self-administered, and therefore do not take up too much time.

“Cardiologists need to keep in mind that depression is very common among HF patients,” says Jiang. “If they [see signs] that there are any abnormalities in this area, they can refer the patient to psychiatric care or start a patient on an antidepressant and initially watch them to see if there is a response.”

In fact, Jiang is currently investigating whether treating depressed HF patients with an antidepressant has any effect on their outcomes. Those results should be available in about one year.


1. Sherwood A, Blumenthal J, Trivedi R, et al. “Relationship of Depression to Death or Hospitalization in Patients with Heart Failure.” Archives of Internal Medicine 2007; 167: 367–373.