Between 4 and 5% of patients seen at Veterans Affairs Medical Centers suffer heart failure. HF is the number one discharge diagnosis within the VHA. One of the most significant comorbidities in heart failure is depression. Depression predicts increased hospitalization and mortality even after controlling for key prognostic indicators. This HSR&D study aimed to test the effectiveness of a psychotherapy intervention for depression combined with illness management to illness management alone in veterans with heart failure.
To demonstrate better depression, health-related quality-of-life, and adherence outcomes for an illness management combined with psychotherapy intervention (COMBO) as compared to an illness management alone program (IMO).
This was a two-site, two-arm, randomized controlled trial comparing COMBO to IMO. The total number of patients recruited for the study was 148. Retention was comparable between groups, though depression severity predicted drop out in the IMO condition but not the COMBO condition. Patients completed study assessments at baseline, week 4, week 8 (post-intervention) and at 26- and 52-week follow-up.
Total score on the Beck Depression Inventory-II for patients in the COMBO condition dropped only slightly from 9.24 to 8.58 and is comparable to scores for the IMO condition which dropped from 9.33 to 9.01 over the course of the 8-week intervention (group*time interaction term -F 2, 116 = 0.09; p=0.90). Scores on the SF-36 10-item physical function measure improved from 37.2 to 43.1 while those of the IMO group lowered slightly going from 36.8 to 36.5 (F2, 110=2.08; p=0.13). Similarly, there were no significant treatment effects on the SF-36 Role Physical subscale (F2, 110=0.04; p=0.96),SF-36 role emotional (F2, 118=2.08; p=0.54), social function (F2, 113=0.18; p=0.84), and vitality (F2, 110=0.82; p=0.44) subscales. The IMO condition did show significantly greater improvements in patient adherence at 10-week (F 2, 117=5.13; p=0.007) and 52-week assessments (F 4, 101=3.11; p=0.02) when compared with the COMBO condition. The study developed and tested the use of Interactive Voice Recording (IVR) Home Monitoring to monitor depressive symptom severity for patients in the COMBO condition. At Week 5, patients received the Patient Health Questionnaire 9-item version through IVR while also completing a paper-and-pencil measure. The intraclass correlation coefficient between the two modes of assessment was 0.66 reflecting moderate agreement. The Kappa statistic derived from comparing the IVR PHQ score to the pencil and paper gold standard, using 10 or higher as the threshold, was 0.18 which is unacceptably low.
These findings demonstrate the difficulty engaging depressed patients in illness management successfully. More severely depressed patients in standard illness management were more likely to drop out than those in the COMBO condition. Interactive Voice Recording for monitoring depression is feasible. However, the IVR assessments did not accurately detect moderate to severe levels of depression severity. This lack of sensitivity is important as the VA is expanding its use of IVR in home monitoring and severe depression is a strong risk factor for suicide.
- Turvey C, Sheeran T, Dindo L, Wakefield B, Klein D. Validity of the Patient Health Questionnaire, PHQ-9, administered through interactive-voice-response technology. Journal of telemedicine and telecare. 2012 Sep 1; 18(6):348-51.
- Roberts L, Wakefield BJ, Scherubel MN, Sheeran T, Nelson S, Turvey CL, Klobucar TF, Rabinowitz T, Kaboli PJ. Depression Tele-care for Elderly Patients at Home: Successes and Challenges. Presented at: American Telemedicine Association Annual Meeting; 2011 May 3; Tampa, FL.
Aging, Older Veterans' Health and Care, Health Systems
Treatment - Observational, Prevention
Cardiovasc’r disease, Care Management, Telemedicine