Recently, the rates of depression among non-Veteran patients with heart failure (HF) are as high as 48%. In HF, the significance of depression as a comorbidity has been recognized due to its impact on patients' noncompliance with therapeutic recommendations, hospital readmissions, death and/or health care cost. Cross-sectional investigations reported that functional class severity or vitality score are the strongest predictor of depression in HF patients. However, a patient's functional class severity varies overtime, which may be related to treatment optimization, disease progression despite optimal treatment and/or other psychosocial factors.
Thus, the primary objectives of the study is to determine over a period of 1 year: 1) the prevalence of clinical depression during and after index hospitalization among Veterans with HF, 2) whether depression remains stable or covaries with functional class severity, and 3) the temporal relationship of clinical depression, changing functional class severity and levels of clinical biochemical markers (that are predictive of HF severity or disease progression), and 4) the association of sociodemographic, clinical and social support factors to clinical depression among Veterans with HF.
This is a single center prospective, longitudinal descriptive study. This will be a series of cross-sectional investigation (panel design) on the same subjects of Veterans with HF at various time points for 1 year: within 3 days of hospital admission, hospital discharge day, and post-discharge from index hospitalization at 2 weeks, 3, 6 and 12 months. Upon hospital admission, patients diagnosed with HF (determined by Ho's HF epidemiologic criteria) will be recruited. Other inclusion criteria: New York Heart Association [NYHA] Class I-IV, age > 18 years, and literate in English. Exclusion Criteria: documented cognitive impairment (i.e. dementia or Alzheimer's), acute infection, and/or any autoimmune disease. The measures for each of the variables are: 1) depression- the DSM-IV Depression Interview and Structured Hamilton by Freedland et al and the Beck Depression Inventory; 2) functional class severity- NYHA and Specific Activity Scale; and 3) biochemical markers (those associated with HF disease progression and/or severity)- brain-type natriuretic peptide and cytokines- i.e. tumor necrosis factor-alpha [TNF-a], interleukin-6 [IL-6] and interleukin-10 [IL-10], and ratio of TNF-a/IL-10 and IL-6/ IL-10). The prevalence of depression will be calculated using descriptive statistics (i.e. proportions). The correlations between functional class severity and depression status at each time point will be performed using Kendall's Tau. The correlations between biochemical markers and depression status for each time points will be performed using Pearson R.
The project team is completing remaining follow-up data collection, continuing data entry and initiating data analysis. We performed a secondary analysis on the hospital admission data of the first 57 HF subjects evaluating the relationship of social support and depressive symptoms. The preliminary findings are:
In 57 hospitalized HF patients (age 68.61 11.7 years, LVEF .39 .17, 23 [40%] NYHA I/II, 34 [60%] NYHA III/IV, 99% male), we evaluated the relationships of social connectedness variables to depressive symptoms in hospitalized HF patients. Initially, we performed bivariate correlations of Beck Depression Inventory (BDI) with physiological variables (age, diabetes mellitus [DM], and brain natriuretic peptide [BNP]) and social connectedness variables (measured by Medical Outcomes Social Support Survey [MOSSS] four individual subscale scores, voluntary group participation, and religious activity participation). After controlling for physiological variables, higher BDI scores were significantly accounted (r= .25, p= .04) by: presence of DM = 7% (r = .26, p= .03), participation in voluntary groups = 12% (r = -.35, p = .004), and MOSSS positive social interaction support subscale = 6% (r= -.25, p= .04). In summary, in hospitalized HF patients, those who were less connected socially had higher depressive symptoms. Thus, social integration maybe considered as an important factor in predicting presence of depressive symptoms among hospitalized HF patients.
The outcome of this study will potentially elucidate the relationship of clinical depression, functional class severity and levels of biochemical markers in patients with HF. Study outcome will provide clinicians with evidence to develop a protocol for timely, standardized assessment of depression and/or effectively coordinate the treatment of HF and comorbid depression to optimize outcomes in Veterans with HF. Thus, this study is consistent with the mission of the VA to improve quality of life for Veterans and to use resources efficiently.
- Corvera-Tindel TE, Doering LV. Social Connections and Depressive Symptoms in Heart Failure. Paper presented at: Heart Failure Society of America Annual Scientific Meeting; 2013 Sep 24; Orlando, FL.