Patient Education and Counseling 98 (2015) 783–787
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Patient perception, preference and participation
A patient-centered perspective of treating depressive symptoms in chronic heart failure: What do patients prefer? Nicole Lossnitzer a,*, Wolfgang Herzog a, Jobst Hendrik Schultz a, Tobias Taeger b, Lutz Frankenstein b, Beate Wild a a b
Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Heidelberg, Germany Department of Cardiology, University of Heidelberg, Heidelberg, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 August 2014 Received in revised form 19 December 2014 Accepted 7 February 2015
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. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Patient-centered care Chronic heart failure Depressive symptoms Psycho-social treatment Antidepressant Psychotherapy
1. Introduction Chronic heart failure (CHF) is a disabling disease with poor prognosis and a severely restricted quality of life [1,2]. Most patients suffer from agonizing symptoms such as dyspnoea, reduced functional capacity, and peripheral edema [3]. Daily activities are often impaired, and social life and relationships with significant others are restricted [4]. Furthermore, CHF is frequently accompanied by depressive symptoms: One in five persons with CHF suffers from clinical depression [5], and annual depressionincidence rates are very high [6]. Previous studies have shown that co-morbid depressive symptoms exacerbates the situation of heart failure patients: Depressive symptoms predict mortality, rehospitalisation, and an increased symptom-burden in CHF patients [7,8].
* Corresponding author at: Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Thibautstrasse 2, D-69115 Heidelberg, Germany. Tel.: +49 6221 5636695; fax: +49 6221 565330. E-mail address: [email protected] (N. Lossnitzer). http://dx.doi.org/10.1016/j.pec.2015.02.008 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Recent research is, therefore, increasingly focused on both pharmacological and non-pharmacological depression-treatment in CHF (e.g. [9–11]). Several studies have reported positive effects for various non-pharmacological depression-treatments in CHF patients (e.g. [5,9–14]). A few studies have also found an improvement of cardiac outcomes and clinical symptoms as a result of depression treatments [13,14], and Jiang et al. reported a potential relation between depression remission and cardiovascular outcome [15]. However, many studies either combined different treatment options (e.g. exercise and cognitive behavioural therapy) and/or relied on small patient-samples (e.g. [12]). Results of pharmacological treatment of depression are still contradictory: While two minor studies [16,17] found encouraging results concerning the efficacy of antidepressants in CHF, O’Connor and colleagues found no improvement of depression in their large placebo-controlled, double-blind trial comprising 469 patients [18]. In summary, larger randomized and controlled studies are needed before conclusions and generalizations regarding the effects of the various depression-treatment options may be drawn. However, another important question remains that to our
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knowledge has been only marginally investigated to date: What kind of treatment do depressed CHF patients prefer regarding their personal situation with conditions like tiredness, shortness of breath, or other co-morbid diagnoses? And further, what kind of treatment do they, in fact, accept, if they have a choice? Although de Boer et al. [19] reported that patient-centred care is especially important for CHF patients, until now, only few studies have investigated the patients’ perspective of treating depression in this patient group. The purpose of our study was, therefore, to analyse the preferences and objections of CHF patients suffering from depressive symptoms regarding various psychosocial treatment options. After a period of three months we analysed how many patients had actually participated in a treatment. 2. Methods 2.1. Patient sample The patients for our study were recruited from the CHF Outpatient Department of the Medical Hospital at the University of Heidelberg. All patients of this Outpatient Department had completed the German version of the 9-item depression module of the Patient Health Questionnaire (PHQ-9) as part of the clinical routine procedure [20,21]. The PHQ-9 asks for cognitive, affective, and somatic depression symptoms; each item corresponds to one of the nine DSM-IV diagnostic A-criteria of a major depressive disorder [22]. The stem question is, ‘‘Over the last two weeks, how often have you been bothered by any of the following problems?’’ Response options are as follows: ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’—scored 0, 1, 2, and 3, respectively. The operating characteristics of the PHQ-9 for diagnosing a depressive disorder have proven to be excellent [23]. Patients were asked to participate in our study if 2 items of the PHQ-9 were reported ‘on more than half the days’, and if at least one of these items was depressed mood or anhedonia—according to the PHQ-9 depression coding algorithm. Further inclusion criteria were stable, documented, systolic heart failure, and age 18. Suicidal ideation and ideas of self-harm were clarified immediately if patients reported them on the ninth item of the PHQ-9. To minimize sample bias, patients were recruited consecutively on predetermined days. Ethical approval for the study was obtained from the Ethics committee of the Medical Faculty of the University of Heidelberg. The study protocol conforms to the principles as outlined in the Declaration of Helsinki [24,25]. 2.2. Assessment of psychosocial and clinical variables Socio-demographic data concerning age, gender, level of education, employment status, and living situation were obtained from all patients. A comprehensive clinical status, including aetiology of CHF, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional classification, and current medication were recorded by the study physician. In addition, the patient’s health-related quality of life (HRQOL) was assessed using the German version of the 36-item Short-Form Health Survey (SF-36) [26,27]. The SF-36 is a multidimensional and well-validated instrument, comprised of eight subscales and two sum-scores: mental and physical. Scores are converted to a scale of 0–100, with higher scores indicating a better health-related quality of life. Because anxiety disorders belong to the most common mental disorders in medical populations [28], we assessed, in addition to depression and HRQOL, symptoms of generalized anxiety such as
‘not being able to stop or control worrying’, or ‘feeling nervous, anxious or on edge’. We therefore administered the 7-item anxiety scale (GAD-7) [29]. Response options are: ‘nearly every day’, ‘on more than half the days’, ‘several days’, and ‘not at all’—scored as 0, 1, 2, and 3, respectively. The GAD-7 has proven to be a valid and efficient tool for anxiety-screening [28–30]. 2.3. Assessment of treatment preferences Using a standardized interview, patients were asked about their preferences and retentions regarding psycho-social treatment options such as psychotherapy or self-help groups; the treatment options were briefly explained. Patients were then asked if they could envision adhering to such a treatment (e.g. ‘‘Could you envision adhering to weekly psychotherapy sessions?’’; answer options were: ‘‘Yes, I could envision adhering to such a treatment’’ or ‘‘No, I could not envision adhering to such a treatment’’). If patients answered with ‘‘no’’, they were asked for reasons by means of several options listed. After the interview was completed, patients could choose to utilize one of the treatments options, and were then referred. At the three-month follow-up, we determined how many patients hah actually participated in a treatment. 2.4. Statistical analyses Data are presented using frequency analyses for categorical data and descriptive analyses for continuous data. A logistic regression modelling process was applied to identify correlates of the most established depression treatment options (antidepressants and psychotherapy) and predictors of treatment utilization. We first conducted a series of univariate logistic regression analyses; all variables with p .05 were included in the final multivariate regression model. The variables ‘level of education’ and ‘aetiology of CHF’ were dummy-coded because of the nominal character of these variables. Due to its skewed distribution, a logarithmic transformation was performed for the variable ‘NTproBNP’. An approximation to a normal density was achieved by applying t = 2 lg10 (B + 10) 2, where B denotes the raw NT-proBNP value [31].
3. Results 3.1. Subjects A total of 85 patients fulfilling the criteria of a depressive disorder according to the PHQ-9 gave informed consent and completed all study questionnaires and interviews. The participation rate was 67.4%: 41 patients refused to take part; the most prevalent reasons for non-participation were exhaustion and fatigue due to chronic illness or conflicting appointments with other outpatient departments. Three patients were excluded due to missing data. At the three-month follow-up, 68 patients (80%) were reassessed; 2 patients (2.4%) had died, and 15 patients (17.6%) were lost to follow up. Dilatative cardiomyopathy was the main reason for CHF, followed by coronary heart disease and other disease entities. Socio-demographic data, as well as functional and psycho-social variables, are shown in Table 1. A total of 8 patients (9.4%) reported that they were currently in psychotherapeutic treatment. Sixteen patients (18.8%) reported that they regularly or occasionally took an antidepressant (SSRI/ SNRI) or sedative medication. Four patients reported to have suicidal ideations or ideas of self-harm on at least ‘more than half the days’.
N. Lossnitzer et al. / Patient Education and Counseling 98 (2015) 783–787 Table 1 Psychosocial and clinical data. n = 85
42.4% (n = 36) intended to utilize a treatment at the first assessment; 24.7% (n = 21) actually utilized a treatment after the three month follow-up. The most utilized treatments were ‘regular supportive talks’ (n = 14) and ‘heart-failure exercise group’ (n = 4).
n = 85
Mean age, years, M (SD) Gender, male, n (%) Living alone, n (%) Not employed, n (%) Level of education Primary school
58.6 (12.3) 63 (74.1) 15 (17.6) 64 (75.3)
Secondary school Etiology of CHF, n (%) Dilative cardiomyopathy Coronary artery disease Other NYHA class, n (%) NYHA I NYHA II
29 (34.1)
NYHA III
34 (40.0)
NYHA IV PHQ-9 sum-score, M (SD)
2 (2.4) 12.52 (4.66)
54 (63.5)
40 (47.1) 33 (38.8) 12 (14.1) 4 (4.7) 38 (44.7)
LVEF, n (%) LVEF 55 LVEF 45–54 LVEF 30–44 LVEF < 30 NT-proBNP, pg/l, Mdn Medication, n (%) B-Blockers ACE Diuretics ARB Cardiac glycosides Antidepressant GAD-7, sum-score, M (SD) Quality of life, SF-36 PCS, M (SD) MCS, M (SD)
9 (10.6) 23 (27.1) 19 (22.4) 33 (38.8) 693.00
3.3. Antidepressants
74 (87.1) 62 (72.9) 59 (69.4) 26 (30.6) 24 (28.2) 11 (12.9) 8.56 (5.18)
31.94 (10.57) 37.97 (11.59)
n = Number of patients; M = mean; SD = standard deviation; CHF = chronic heart failure; NYHA = New York Heart Association; LVEF = Left ventricular ejection fraction, NT-proBNP = amino-terminal pro-brain natriuretic peptide; Mdn = Median; ACE = angiotensin-converting enzyme inhibitors; ARB = angiotensin II receptor blocker; PHQ-9 = Patient Health Questionnaire 9-item depression module; GAD7 = 7-item anxiety scale; SF-36 = 36-item Short Form Health Survey; PCS = physical component score; MCS = mental component score.
3.2. Patients’ treatment preferences and utilization of a treatment Fig. 1 presents the explained treatment options and patients’ treatment preferences. In summary, the most favoured treatment option (64.7%) was ‘regular supportive talks’ – concerning topics such as quality of life, financial stressors, overall health, and/or social relationships – ideally in conjunction with appointments in the CHF Outpatient Department. Furthermore, our interviewed patient sample was very interested in heart-failure education groups: 55.3% reported that they would accept such an offer.
%
30
3.4. Psychotherapy Forty patients (47.1%) reported that they could not envision adhering to regular weekly psychotherapy sessions; 9 patients did not respond. The most frequent reasons were the conviction that they would never need psychotherapy (n = 18) or scepticism about psychotherapy and its usefulness (n = 9), followed by the position that weekly appointments were too exhausting or time-consuming (n = 2), and other reasons (n = 11). In the univariate logistic regression analyses the variables ‘gender’, ‘NT-proBNP’, ‘severity of depressive symptoms’ (PHQ-9 sum-score), ‘quality of life’ (SF-36 mental health sum-score) and ‘generalized anxiety severity’ (GAD-7) were significantly related to the variable ‘I could envision adhering to weekly psychotherapy sessions’ (with the answer-options ‘yes’ or ‘no’; all p .05). The final multivariate regression model included only the variable ‘generalized anxiety severity’ (GAD-7; OR 1.13, 95% CI 1.07–1.41, p = .003).
n=48
60 40
Fortyeight patients (56.5%) reported that they would refuse an antidepressant; 8 patients did not respond. Half of this refusalsubgroup (n = 24) suspected adverse effects and/or negative interaction with their heart-failure medication. Further reasons for refusing antidepressant medication were the intent to never need antidepressants and/or the conviction that antidepressants were unhelpful (n = 24). In the univariate logistic regression analyses the variables ‘gender’, ‘LVEF category’, and ‘generalized anxiety severity’ (GAD-7 sum-score) were significantly related to the variable ‘I could envision taking an antidepressant’ (with the answer options ‘yes’ or ‘no’; all p .05). The final regression model included only the variables ‘LVEF category’ (odds ratio [OR] 0.50, 95% confidence interval [CI]: 0.29–0.85, p = .010) and ‘generalized anxiety severity’ (GAD-7 sum-score OR 1.14, 95% CI: 1.02–1.28, p = .027).
n=55
70 50
785
n=47 n=37
n=36 n=28
n=24
n=29
n=24
20
n=12
10 0
Fig. 1. Patients treatment preferences: ‘Yes, I could envision adhering. . ..’.
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3.5. Treatment utilization at three-month follow-up In total, nearly a quarter of our patients with depressive symptoms actually utilized one of the treatment offers after the three-month follow-up (n = 21 patients, 24.7%). We repeated the logistic regression modeling process to analyze which variables predicted the utilization of a treatment: Univariate analyses revealed that the variables ‘gender’ and ‘generalized anxiety severity’ (GAD-7 sum-score) were significantly related to treatment-utilization (all p .05). In the final regression analysis, only the variable ‘generalized anxiety severity’ remained in the regression model (OR 1.15, 95% CI: 1.04–1.28, p = .007). 4. Discussion and conclusion 4.1. Discussion In our study, we primarily pursued the objective of obtaining more information of CHF patients’ perspectives of treating depressive symptoms. In total, more than half of our interviewed sample reported that they could envision adhering to regular supportive talks over an extended time-interval, ideally corresponding to their appointments in the CHF Outpatient Department. This treatment option was also the most utilized option after the three-month follow-up period. In the course of these supportive sessions the patients wanted to address topics such as quality of life, financial stressors, and/or social relationships. In contrast, only 14.1% reported that they would like more time with their treating cardiologist to address questions concerning their heart disease. Both findings underscore the patients’ need to talk about the disease and its consequences within the context of their life—not only about subjects directly affecting their heart disease and its treatment. For future research it would be of interest to investigate if such supportive talks over an extended period could help reduce depressive symptoms (at least in minor depression), and perhaps ease the overall symptom-burden by treating CHF and depression simultaneously. If this were to be successful, it would be – in comparison to weekly psychotherapy for example – a comparatively low-priced and easily to be established opportunity for treating depression in CHF patients. Furthermore, it could also have some advantages in comparison to psychopharmacological medication in this patient group, since recent studies have suggested cardiovascular side effects of antidepressants in CHF patients [32]. In addition, our study revealed that many CHF patients have objections to antidepressants because they worry about adverse effects or negative medication interaction. The latter finding may also partially explain why – despite the close association between depression and mortality in CHF patients [7,8] – only very few studies, up to today, have investigated the efficacy of antidepressants in CHF patients [16–18]: The recruitment of patients for such studies may be difficult if most of the patients do not wish to take an antidepressant. When investigating the variables that correlated with treatment preferences, we found interesting results: the higher the generalized anxiety severity, the more likely was the patients’ expression of a readiness to start an antidepressant or weekly psychotherapy sessions. Furthermore, the amount of perceived anxiety also predicted the utilization of a treatment after three months: The higher the generalized anxiety severity, the more likely was a utilization of a treatment after three month. This may be an interesting finding for future research regarding the treatment decisions of CHF patients. Generalized anxiety is defined by symptoms such as not being able to stop worrying or worrying too much about different things. Addressing anxiety and worries
thoroughly may, therefore, help CHF patients to cope with their uncertainties regarding psycho-social treatment options and in making a coherent treatment decision. Apart from anxiety, the severity of the disease (measured by LVEF) also seems to influence the treatment preferences of CHF patients: The lower the LVEF, the more likely was a refusal of an antidepressant. This finding, however, is not very surprising since impaired well-being understandably hampers the motivation for regular treatment. 4.2. Limitations Certain limitations of our study should be noted: First, our patient-sample was recruited from a CHF outpatient department and may therefore not be representative of CHF patients recruited from the general population or of those in primary care [33]. Second, our participation rate was only 67%. Several patients explained their refusal to participate because of exhaustion due to the chronic illness; they did not feel that they had enough energy to manage the study participation. This comparatively low participation rate may thus affect the representativeness of our results. Third, we included only those variables with p .05 in the final multivariate regression analyses. Some variables may have been omitted on the basis of this criterion which could have been important in combination with another predictor. Nevertheless, the variable ‘generalized anxiety severity’ was consistently very closely associated with treatment preferences and treatment utilization. Another important limitation concerns our methods used to measure treatment preferences: Although we used standardized questions, it is important to keep in mind that we have no data on the validity and reliability of the answers. 4.3. Conclusion and practice implications In summary, our study sheds light on the often-neglected perspective of patients regarding the treatment of depressive symptoms and allows an estimate of how many patients actually participate in a treatment. Our results may therefore be helpful for the conceptualization of further studies in this research area. Our results also suggest that generalized anxiety seems to be a very important variable for the treatment motivation of CHF patients with depressive symptoms. Further studies investigating patientcentered care in CHF patients should consider the assessment of generalized anxiety. Acknowledgements This work was supported by a grant of the postdoctoral fellowship from the Medical Faculty, University of Heidelberg. We also thank Lena Warrington for her perceptive editing service.
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N. Lossnitzer et al. / Patient Education and Counseling 98 (2015) 783–787 [6] Lossnitzer N, Herzog W, Sto¨rk S, Wild B, Mu¨ller-Tasch T, Lehmkuhl E, et al. Incidence rates and predictors of major and minor depression in patients with heart failure. Int J Cardiol 2013;167:502–7. [7] Ju¨nger J, Schellberg D, Mu¨ller-Tasch T, Raupp G, Zugck C, Haunstetter A, et al. Depression increasingly predicts mortality in the course of congestive heart failure. Eur J Heart Fail 2005;7:261–7. [8] Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med 2001;161:1849–56. [9] Thombs BD, deJonge P, Coyne JC, Whooley MA, Frasure-Smith N, Mitchell AJ, et al. Depression screening and patient outcomes in cardiovascular care. A systematic review. J Amer Med Assoc 2008;300:2161–71. [10] Woltz PC, Chapa DW, Friedmann E, Son H, Akintade B, Thomas SA. Effects of interventions on depression in heart failure: a systematic review. Heart Lung 2012;41:469–83. [11] Dekker RL. Cognitive therapy for depression in patients with heart failure: a critical review. Heart Fail Clin 2011;7:127–41. [12] Gary RA, Dunbar SB, Higgins MK, Musselman DL, Smith AL. Combined exercise and cognitive behavioral therapy improves outcomes in patients with heart failure. J Psychosom Res 2010;69:119–31. [13] Sullivan MJ, Wood L, Terry J, Brantley J, Charles A, McGee V, et al. The support, education, and research in chronic heart failure study (SEARCH): a mindfulness-based psycheducational intervention improves depression and clinical symptoms in patients with chronic heart failure. Am Heart J 2009;157: 84–90. [14] Dekker RL, Moser DK, Peden AR, Lennie TA. Cognitive therapy improves threemonth outcomes in hospiltalized patients with heart failure. J Card Fail 2012;18:10–20. [15] Jiang W, Krishnan R, Kuchibhatla M, Cuffe MS, Martsberger C, Arias RM, et al. Characteristics of depression remission and its relation with cardiovascular outcome among patients with chronic heart failure (from the SADHART-CHF study). Am J Cardiol 2011;107:545–51. [16] Gottlieb SS, Kop WJ, Thomas SA, Katzen S, Vesely MR, Greenberg N, et al. A double-blind placebo-controlled pilot study of controlled-release paroxetine on depression and quality of life in chronic heart failure. Am Heart J 2007;153:868–73. [17] Lesperance F, Frasure-Smith N, Laliberte MA, et al. An open-label study of nefazodone treatment of major depression in patients with congestive heart failure. Can J Psychiatry 2003;48:695–701.
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[18] O’Connor CM, Jiang W, Kuchibhatla M, Silva SG, Cuffe MS, Callwood DD, et al. Safety and efficacy of sertraline for depression in patients with heart failure. J Am Coll Cardiol 2010;56:692–9. [19] DeBoer D, Delnoij D, Rademakers J. The importance of patient-centered care for various patients groups. Patient Educ Couns 2013;90:405–10. [20] Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiat Ann 2002;9:1–7. [21] Lo¨we B, Spitzer RL, Zipfel S, Herzog W. PRIME MD patient health questionnaire (PHQ)—German version. Manual and materials. 2nd ed. Karlsruhe: Pfizer; 2002. [22] American Psychiatric Association. Diagnostic and statistical manual of mental disorders DSM-IV-TR. 4th ed. (Text revision edition) Washington, DC: American Psychiatric Association; 2000. [23] Lo¨we B, Spitzer RL, Gra¨fe K, Kroenke K, Quenter A, Zipfel S, et al. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect Disord 2004;78:131–40. [24] Rickham PP. Human experimentation, code of ethics of the world medical association. Declaration of Helsinki. Br Med J 1964;2:177. [25] A fifth amendment for the Declaration of Helsinki. Lancet 2000;356:1123. [26] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SG-36) I. Conceptual framework and item selection. Med Care 1992;30:473–83. [27] Bullinger M, Kirchberger I. SF-36 Fragebogen zum Gesundheitszustand. Go¨ttingen: Hogrefe; 1999. [28] Kroenke K, Spitzer RL, Williams JBW, Lo¨we B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry 2010;32:345–59. [29] Spitzer RL, Kroenke K, Williams JBW, Lo¨we B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med 2006;166:1092–7. [30] Wild B, Herzog W, Schellberg D, Lechner S, Niehoff D, Brenner H, et al. Association between the prevalence of depression and age in a large representative German sample of people aged 53 to 80 years. Int J Geriatr Psychiatry 2012;27:375–81. [31] Hess G, Moecks J, Zdunek D. N-terminal pro BNP (NT-proBNP) as an indicator of cardiac dysfunction. A study in patients presenting with suspected cardiac disorders. Z Kardiol 2005;94:247–54. [32] Tousoulis D, Antonopoulus AS, Antoniades C, Saldari C, Stefanadi E, Siasos G, et al. Role of depression in heart failure—choosing the right antidepressive treatment. Int J Cardiol 2010;140:12–8. [33] Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D’Agostino RB, Kannel WB, et al. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation 2002;106:3068–72.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Patient perception, preference and participation
A patient-centered perspective of treating depressive symptoms in chronic heart failure: What do patients prefer? Nicole Lossnitzer a,*, Wolfgang Herzog a, Jobst Hendrik Schultz a, Tobias Taeger b, Lutz Frankenstein b, Beate Wild a a b
Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Heidelberg, Germany Department of Cardiology, University of Heidelberg, Heidelberg, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 August 2014 Received in revised form 19 December 2014 Accepted 7 February 2015
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. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Patient-centered care Chronic heart failure Depressive symptoms Psycho-social treatment Antidepressant Psychotherapy
1. Introduction Chronic heart failure (CHF) is a disabling disease with poor prognosis and a severely restricted quality of life [1,2]. Most patients suffer from agonizing symptoms such as dyspnoea, reduced functional capacity, and peripheral edema [3]. Daily activities are often impaired, and social life and relationships with significant others are restricted [4]. Furthermore, CHF is frequently accompanied by depressive symptoms: One in five persons with CHF suffers from clinical depression [5], and annual depressionincidence rates are very high [6]. Previous studies have shown that co-morbid depressive symptoms exacerbates the situation of heart failure patients: Depressive symptoms predict mortality, rehospitalisation, and an increased symptom-burden in CHF patients [7,8].
* Corresponding author at: Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Thibautstrasse 2, D-69115 Heidelberg, Germany. Tel.: +49 6221 5636695; fax: +49 6221 565330. E-mail address: [email protected] (N. Lossnitzer). http://dx.doi.org/10.1016/j.pec.2015.02.008 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Recent research is, therefore, increasingly focused on both pharmacological and non-pharmacological depression-treatment in CHF (e.g. [9–11]). Several studies have reported positive effects for various non-pharmacological depression-treatments in CHF patients (e.g. [5,9–14]). A few studies have also found an improvement of cardiac outcomes and clinical symptoms as a result of depression treatments [13,14], and Jiang et al. reported a potential relation between depression remission and cardiovascular outcome [15]. However, many studies either combined different treatment options (e.g. exercise and cognitive behavioural therapy) and/or relied on small patient-samples (e.g. [12]). Results of pharmacological treatment of depression are still contradictory: While two minor studies [16,17] found encouraging results concerning the efficacy of antidepressants in CHF, O’Connor and colleagues found no improvement of depression in their large placebo-controlled, double-blind trial comprising 469 patients [18]. In summary, larger randomized and controlled studies are needed before conclusions and generalizations regarding the effects of the various depression-treatment options may be drawn. However, another important question remains that to our
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knowledge has been only marginally investigated to date: What kind of treatment do depressed CHF patients prefer regarding their personal situation with conditions like tiredness, shortness of breath, or other co-morbid diagnoses? And further, what kind of treatment do they, in fact, accept, if they have a choice? Although de Boer et al. [19] reported that patient-centred care is especially important for CHF patients, until now, only few studies have investigated the patients’ perspective of treating depression in this patient group. The purpose of our study was, therefore, to analyse the preferences and objections of CHF patients suffering from depressive symptoms regarding various psychosocial treatment options. After a period of three months we analysed how many patients had actually participated in a treatment. 2. Methods 2.1. Patient sample The patients for our study were recruited from the CHF Outpatient Department of the Medical Hospital at the University of Heidelberg. All patients of this Outpatient Department had completed the German version of the 9-item depression module of the Patient Health Questionnaire (PHQ-9) as part of the clinical routine procedure [20,21]. The PHQ-9 asks for cognitive, affective, and somatic depression symptoms; each item corresponds to one of the nine DSM-IV diagnostic A-criteria of a major depressive disorder [22]. The stem question is, ‘‘Over the last two weeks, how often have you been bothered by any of the following problems?’’ Response options are as follows: ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’—scored 0, 1, 2, and 3, respectively. The operating characteristics of the PHQ-9 for diagnosing a depressive disorder have proven to be excellent [23]. Patients were asked to participate in our study if 2 items of the PHQ-9 were reported ‘on more than half the days’, and if at least one of these items was depressed mood or anhedonia—according to the PHQ-9 depression coding algorithm. Further inclusion criteria were stable, documented, systolic heart failure, and age 18. Suicidal ideation and ideas of self-harm were clarified immediately if patients reported them on the ninth item of the PHQ-9. To minimize sample bias, patients were recruited consecutively on predetermined days. Ethical approval for the study was obtained from the Ethics committee of the Medical Faculty of the University of Heidelberg. The study protocol conforms to the principles as outlined in the Declaration of Helsinki [24,25]. 2.2. Assessment of psychosocial and clinical variables Socio-demographic data concerning age, gender, level of education, employment status, and living situation were obtained from all patients. A comprehensive clinical status, including aetiology of CHF, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional classification, and current medication were recorded by the study physician. In addition, the patient’s health-related quality of life (HRQOL) was assessed using the German version of the 36-item Short-Form Health Survey (SF-36) [26,27]. The SF-36 is a multidimensional and well-validated instrument, comprised of eight subscales and two sum-scores: mental and physical. Scores are converted to a scale of 0–100, with higher scores indicating a better health-related quality of life. Because anxiety disorders belong to the most common mental disorders in medical populations [28], we assessed, in addition to depression and HRQOL, symptoms of generalized anxiety such as
‘not being able to stop or control worrying’, or ‘feeling nervous, anxious or on edge’. We therefore administered the 7-item anxiety scale (GAD-7) [29]. Response options are: ‘nearly every day’, ‘on more than half the days’, ‘several days’, and ‘not at all’—scored as 0, 1, 2, and 3, respectively. The GAD-7 has proven to be a valid and efficient tool for anxiety-screening [28–30]. 2.3. Assessment of treatment preferences Using a standardized interview, patients were asked about their preferences and retentions regarding psycho-social treatment options such as psychotherapy or self-help groups; the treatment options were briefly explained. Patients were then asked if they could envision adhering to such a treatment (e.g. ‘‘Could you envision adhering to weekly psychotherapy sessions?’’; answer options were: ‘‘Yes, I could envision adhering to such a treatment’’ or ‘‘No, I could not envision adhering to such a treatment’’). If patients answered with ‘‘no’’, they were asked for reasons by means of several options listed. After the interview was completed, patients could choose to utilize one of the treatments options, and were then referred. At the three-month follow-up, we determined how many patients hah actually participated in a treatment. 2.4. Statistical analyses Data are presented using frequency analyses for categorical data and descriptive analyses for continuous data. A logistic regression modelling process was applied to identify correlates of the most established depression treatment options (antidepressants and psychotherapy) and predictors of treatment utilization. We first conducted a series of univariate logistic regression analyses; all variables with p .05 were included in the final multivariate regression model. The variables ‘level of education’ and ‘aetiology of CHF’ were dummy-coded because of the nominal character of these variables. Due to its skewed distribution, a logarithmic transformation was performed for the variable ‘NTproBNP’. An approximation to a normal density was achieved by applying t = 2 lg10 (B + 10) 2, where B denotes the raw NT-proBNP value [31].
3. Results 3.1. Subjects A total of 85 patients fulfilling the criteria of a depressive disorder according to the PHQ-9 gave informed consent and completed all study questionnaires and interviews. The participation rate was 67.4%: 41 patients refused to take part; the most prevalent reasons for non-participation were exhaustion and fatigue due to chronic illness or conflicting appointments with other outpatient departments. Three patients were excluded due to missing data. At the three-month follow-up, 68 patients (80%) were reassessed; 2 patients (2.4%) had died, and 15 patients (17.6%) were lost to follow up. Dilatative cardiomyopathy was the main reason for CHF, followed by coronary heart disease and other disease entities. Socio-demographic data, as well as functional and psycho-social variables, are shown in Table 1. A total of 8 patients (9.4%) reported that they were currently in psychotherapeutic treatment. Sixteen patients (18.8%) reported that they regularly or occasionally took an antidepressant (SSRI/ SNRI) or sedative medication. Four patients reported to have suicidal ideations or ideas of self-harm on at least ‘more than half the days’.
N. Lossnitzer et al. / Patient Education and Counseling 98 (2015) 783–787 Table 1 Psychosocial and clinical data. n = 85
42.4% (n = 36) intended to utilize a treatment at the first assessment; 24.7% (n = 21) actually utilized a treatment after the three month follow-up. The most utilized treatments were ‘regular supportive talks’ (n = 14) and ‘heart-failure exercise group’ (n = 4).
n = 85
Mean age, years, M (SD) Gender, male, n (%) Living alone, n (%) Not employed, n (%) Level of education Primary school
58.6 (12.3) 63 (74.1) 15 (17.6) 64 (75.3)
Secondary school Etiology of CHF, n (%) Dilative cardiomyopathy Coronary artery disease Other NYHA class, n (%) NYHA I NYHA II
29 (34.1)
NYHA III
34 (40.0)
NYHA IV PHQ-9 sum-score, M (SD)
2 (2.4) 12.52 (4.66)
54 (63.5)
40 (47.1) 33 (38.8) 12 (14.1) 4 (4.7) 38 (44.7)
LVEF, n (%) LVEF 55 LVEF 45–54 LVEF 30–44 LVEF < 30 NT-proBNP, pg/l, Mdn Medication, n (%) B-Blockers ACE Diuretics ARB Cardiac glycosides Antidepressant GAD-7, sum-score, M (SD) Quality of life, SF-36 PCS, M (SD) MCS, M (SD)
9 (10.6) 23 (27.1) 19 (22.4) 33 (38.8) 693.00
3.3. Antidepressants
74 (87.1) 62 (72.9) 59 (69.4) 26 (30.6) 24 (28.2) 11 (12.9) 8.56 (5.18)
31.94 (10.57) 37.97 (11.59)
n = Number of patients; M = mean; SD = standard deviation; CHF = chronic heart failure; NYHA = New York Heart Association; LVEF = Left ventricular ejection fraction, NT-proBNP = amino-terminal pro-brain natriuretic peptide; Mdn = Median; ACE = angiotensin-converting enzyme inhibitors; ARB = angiotensin II receptor blocker; PHQ-9 = Patient Health Questionnaire 9-item depression module; GAD7 = 7-item anxiety scale; SF-36 = 36-item Short Form Health Survey; PCS = physical component score; MCS = mental component score.
3.2. Patients’ treatment preferences and utilization of a treatment Fig. 1 presents the explained treatment options and patients’ treatment preferences. In summary, the most favoured treatment option (64.7%) was ‘regular supportive talks’ – concerning topics such as quality of life, financial stressors, overall health, and/or social relationships – ideally in conjunction with appointments in the CHF Outpatient Department. Furthermore, our interviewed patient sample was very interested in heart-failure education groups: 55.3% reported that they would accept such an offer.
%
30
3.4. Psychotherapy Forty patients (47.1%) reported that they could not envision adhering to regular weekly psychotherapy sessions; 9 patients did not respond. The most frequent reasons were the conviction that they would never need psychotherapy (n = 18) or scepticism about psychotherapy and its usefulness (n = 9), followed by the position that weekly appointments were too exhausting or time-consuming (n = 2), and other reasons (n = 11). In the univariate logistic regression analyses the variables ‘gender’, ‘NT-proBNP’, ‘severity of depressive symptoms’ (PHQ-9 sum-score), ‘quality of life’ (SF-36 mental health sum-score) and ‘generalized anxiety severity’ (GAD-7) were significantly related to the variable ‘I could envision adhering to weekly psychotherapy sessions’ (with the answer-options ‘yes’ or ‘no’; all p .05). The final multivariate regression model included only the variable ‘generalized anxiety severity’ (GAD-7; OR 1.13, 95% CI 1.07–1.41, p = .003).
n=48
60 40
Fortyeight patients (56.5%) reported that they would refuse an antidepressant; 8 patients did not respond. Half of this refusalsubgroup (n = 24) suspected adverse effects and/or negative interaction with their heart-failure medication. Further reasons for refusing antidepressant medication were the intent to never need antidepressants and/or the conviction that antidepressants were unhelpful (n = 24). In the univariate logistic regression analyses the variables ‘gender’, ‘LVEF category’, and ‘generalized anxiety severity’ (GAD-7 sum-score) were significantly related to the variable ‘I could envision taking an antidepressant’ (with the answer options ‘yes’ or ‘no’; all p .05). The final regression model included only the variables ‘LVEF category’ (odds ratio [OR] 0.50, 95% confidence interval [CI]: 0.29–0.85, p = .010) and ‘generalized anxiety severity’ (GAD-7 sum-score OR 1.14, 95% CI: 1.02–1.28, p = .027).
n=55
70 50
785
n=47 n=37
n=36 n=28
n=24
n=29
n=24
20
n=12
10 0
Fig. 1. Patients treatment preferences: ‘Yes, I could envision adhering. . ..’.
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3.5. Treatment utilization at three-month follow-up In total, nearly a quarter of our patients with depressive symptoms actually utilized one of the treatment offers after the three-month follow-up (n = 21 patients, 24.7%). We repeated the logistic regression modeling process to analyze which variables predicted the utilization of a treatment: Univariate analyses revealed that the variables ‘gender’ and ‘generalized anxiety severity’ (GAD-7 sum-score) were significantly related to treatment-utilization (all p .05). In the final regression analysis, only the variable ‘generalized anxiety severity’ remained in the regression model (OR 1.15, 95% CI: 1.04–1.28, p = .007). 4. Discussion and conclusion 4.1. Discussion In our study, we primarily pursued the objective of obtaining more information of CHF patients’ perspectives of treating depressive symptoms. In total, more than half of our interviewed sample reported that they could envision adhering to regular supportive talks over an extended time-interval, ideally corresponding to their appointments in the CHF Outpatient Department. This treatment option was also the most utilized option after the three-month follow-up period. In the course of these supportive sessions the patients wanted to address topics such as quality of life, financial stressors, and/or social relationships. In contrast, only 14.1% reported that they would like more time with their treating cardiologist to address questions concerning their heart disease. Both findings underscore the patients’ need to talk about the disease and its consequences within the context of their life—not only about subjects directly affecting their heart disease and its treatment. For future research it would be of interest to investigate if such supportive talks over an extended period could help reduce depressive symptoms (at least in minor depression), and perhaps ease the overall symptom-burden by treating CHF and depression simultaneously. If this were to be successful, it would be – in comparison to weekly psychotherapy for example – a comparatively low-priced and easily to be established opportunity for treating depression in CHF patients. Furthermore, it could also have some advantages in comparison to psychopharmacological medication in this patient group, since recent studies have suggested cardiovascular side effects of antidepressants in CHF patients [32]. In addition, our study revealed that many CHF patients have objections to antidepressants because they worry about adverse effects or negative medication interaction. The latter finding may also partially explain why – despite the close association between depression and mortality in CHF patients [7,8] – only very few studies, up to today, have investigated the efficacy of antidepressants in CHF patients [16–18]: The recruitment of patients for such studies may be difficult if most of the patients do not wish to take an antidepressant. When investigating the variables that correlated with treatment preferences, we found interesting results: the higher the generalized anxiety severity, the more likely was the patients’ expression of a readiness to start an antidepressant or weekly psychotherapy sessions. Furthermore, the amount of perceived anxiety also predicted the utilization of a treatment after three months: The higher the generalized anxiety severity, the more likely was a utilization of a treatment after three month. This may be an interesting finding for future research regarding the treatment decisions of CHF patients. Generalized anxiety is defined by symptoms such as not being able to stop worrying or worrying too much about different things. Addressing anxiety and worries
thoroughly may, therefore, help CHF patients to cope with their uncertainties regarding psycho-social treatment options and in making a coherent treatment decision. Apart from anxiety, the severity of the disease (measured by LVEF) also seems to influence the treatment preferences of CHF patients: The lower the LVEF, the more likely was a refusal of an antidepressant. This finding, however, is not very surprising since impaired well-being understandably hampers the motivation for regular treatment. 4.2. Limitations Certain limitations of our study should be noted: First, our patient-sample was recruited from a CHF outpatient department and may therefore not be representative of CHF patients recruited from the general population or of those in primary care [33]. Second, our participation rate was only 67%. Several patients explained their refusal to participate because of exhaustion due to the chronic illness; they did not feel that they had enough energy to manage the study participation. This comparatively low participation rate may thus affect the representativeness of our results. Third, we included only those variables with p .05 in the final multivariate regression analyses. Some variables may have been omitted on the basis of this criterion which could have been important in combination with another predictor. Nevertheless, the variable ‘generalized anxiety severity’ was consistently very closely associated with treatment preferences and treatment utilization. Another important limitation concerns our methods used to measure treatment preferences: Although we used standardized questions, it is important to keep in mind that we have no data on the validity and reliability of the answers. 4.3. Conclusion and practice implications In summary, our study sheds light on the often-neglected perspective of patients regarding the treatment of depressive symptoms and allows an estimate of how many patients actually participate in a treatment. Our results may therefore be helpful for the conceptualization of further studies in this research area. Our results also suggest that generalized anxiety seems to be a very important variable for the treatment motivation of CHF patients with depressive symptoms. Further studies investigating patientcentered care in CHF patients should consider the assessment of generalized anxiety. Acknowledgements This work was supported by a grant of the postdoctoral fellowship from the Medical Faculty, University of Heidelberg. We also thank Lena Warrington for her perceptive editing service.
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