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Рецензент: д.мед.н., проф. В.О. Тєрьошин
УДК 616.8 – 085 : 616.12 - 008.46
ГУ «Национальный институт терапии им. Л.Т. Малой НАМНУ» (Харьков)
GI «L. T. Mala National Therapy Institute of the NAMS of Ukraine» (Kharkov)
One of the major health problem in the world is chronic heart failure (HF), which is growing together with the increasingly age of population. HF is also the leading cause for hospitalization among the patients, and its five-year mortality rate following first hospitalization exceeds that of all cancers except lung [1,2]. Several co-morbidities usually coexist in these patients such as hypertension, diabetes mellitus and depression. One potential contributor to increased morbidity and mortality in patient with HF is the presence of unrecognized and inadequately treated depression.
Depression is highly prevalent among HF patients [3, 4,5]. Meta-analysis of 27 studies reported the prevalence of depression in HF patients to range from 9% to 60% depending on the use of different definitions of depression. In a meta-analysis by Rutledge and colleagues5 of 27 studies investigating the prevalence of depression in heart failure participants, the overall prevalence rate was 21.5%, with an aggregated prevalence of 26.1% for men and 32.7% for women [6,7,8].
In general, it was found that the prevalence of depression was positively correlated with poorer prognosis of HF. According to the study of Bruce L. Rollman, the hospitalized HF patients who were suspected of being depressed and then screened positive for depressive symptoms prior to discharge experienced a significantly elevated 12-month risk of all-cause and cardiovascular mortality compared to HF patients who screened negative for depressive symptoms .
Several potential physiological mechanisms linking depression and adverse cardiac events have been proposed and they are eloquently presented in the literature [10,11]. Among these mechanisms there are increased platelet activity and aggregation, inflammation, heart rhythm disturbances, elevated levels of catecholamines, and endothelial dysfunction [12,13]. Also it was found that depressive symptoms were related to social aspects such as younger age, female gender, unemployment, divorce or separation, and a lower educational level. The impact of depression on HF can also be seen through environmental and behavioral factors. Individuals with depression show poor compliance to healthy behaviors and engage in additional risks, such as smoking, sedentary behavior, poor diet, and substance abuse, which may lead to increasing the risks of cardiovascular disease or worsening existing conditions .
The association between depression and HF is complicated, and the conditions can occur through many pathways. In the context of HF, hypoperfusion can cause structural changes in the brain which can lead to depression. Or elevated cytokines can decrease serotonin production resulting in depression and disrupt its regulation [14,15]. Also the effect of cortisol may also be important in HF. One study measured serum levels of cortisol and aldosterone in 294 patients with chronic HF .and found levels of cortisol to be elevated in HF. Elevated cortisol level was reported in current and remitted depression as well as nonsuppression by dexamethasone using dexamethasone suppression tests. Prolonged exposure to elevated cortisol levels has shown to reduce hippocampal volume in depression, which has adverse effects on verbal memory [16,17].
The presence of depression in HF is associated with poor health-related self-care, which could compromise a patient's ability to understand and follow treatment plans and may lead to frequent hospitalizations in patients with HF. The strong association between noncompliance and depression was evident in a meta-analysis where nondepressed patients were three times more likely to adhere to their medical treatment compared to depressed patients. In another study of elderly patients with HF, compliance rate was reported to be as low as 10% in such patients [19,20 ].
According to the clinical guidelines (number 90 and 91, October 2009) issued by the National Institute for Health and Clinical Excellence (NICE) regarding treatment and management of depression in adults generally and adults with chronic physical health problems, respectively, there are several therapeutic approaches, varying from individual, computerized, or group cognitive behavioral therapy (CBT), interpersonal therapy (IPT), medications, or combinations of the above [21,22]. Medications are monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin norepinephrine reuptake inhibitors (SNRIs).
MAOIs and TCAs are generally avoided in patients with cardiovascular diseases since trials in antidepressants’ use have shown adverse cardiac effects in patients without established heart disease In addition, they increase heart rate, cause orthostatic hypotension, impede cardiac conduction, and increase the risk of arrhythmias [22-25].
There are several areas where information about the relation between HF and depression are lacking such as data on the effectiveness of treatment for depression and how this modifies the pathways shared by HF and depression. Existing studies with specific drugs such as the Safety and Efficacy of Sertraline for Depression in Patients with Congestive Heart Failure (SADHART-CHF) trial and others have shown no difference in cardiovascular outcomes, whereas smaller studies have shown improvements in symptoms of depression, quality of life, and compliance when patients are treated [26-30].
The systematic review, which was done by Woltz PC and others (2012) and included twenty-three experimental and quasiexperimental studies that enrolled a total of 3564 persons with HF contributed evidence about 6 types of interventions: SSRIs, an erythropoiesis-stimulating agent, exercise, disease management programs, complementary and alternative medicine (CAM), and a multimodal intervention of CBT and exercise. Studies with SSRIs examined effects of sertraline, paroxetine, and citalopram. The CAM interventions included tai chi, progressive muscle relaxation therapy, and mindfulness-based stress reduction. It was shown that pharmacology and CAM may improve depression. Moderate evidence supports the use of exercise. A strong body of evidence indicates that disease management programs do not improve depression .
In the other study, which was designed to assess whether depression and the use of antidepressants were related to long-term mortality in heart failure, was shown that use of any antidepressant was not independently associated with mortality (HR, 0.89; 95% CI, 0.71-1.13), but benzodiazepines showed a protective role (HR, 0.70; 95% CI, 0.57-0.87). On the contrary, fluoxetine prescriptions, but not duration of fluoxetine treatment, were associated with increased mortality (HR, 1.66; 95% CI, 1.13-2.44) .
Multiple regression analyses in the study of Kato N (2012) showed that independent predictors of depressive symptoms were non-usage of beta-blockers and being widowed or divorced in HF reduced ejection function. On the other hand, usage of warfarin was the only independent risk factor for depressive symptoms in HF preserved ejection function (all, p<0.05) .
CBT and IPT are two forms of psychotherapy that are employed in managing depression, can also be used in the treatment of HF patients. CBT is based on the idea that individuals’ thoughts cause their feelings and behavior, not external things such as people, situations, or events. The benefit of this fact is that the way someone thinks can be changed in order to feel and act better even if the situation does not change. Emphasis is also placed on problem solving and on increasing the time and frequency of pleasurable activities .
IPT is a short-term supportive psychotherapy that focuses on the connection between interactions that people have and the development of psychiatric symptoms. The goals of IPT in the treatment of depression are to diagnose depression explicitly and educate the patient about depression, its causes, and the various treatments available for it; to identify the interpersonal context of depression as it relates to symptom development; to develop strategies for the patient to follow in coping with the depression. The targeted approach of IPT has demonstrated improvement for patients with problems ranging from mild situational depression to severe depression with a recent history of suicide attempts .
It is very important that in the clinical care of HF patients, medical professionals be aware of the high rate of cooccurrence between HF and depression. Future studies should also seek to investigate neuropsychiatric rehabilitation for depression in patients with HF in improving heart function as well as reducing rates of hospitalization and mortality from HF.
1. More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure / S. Stewart, K. MacIntyre, D.J. Hole [et. al.] // Eur. J. Heart Fail. – 2001. – Vol. 3 (3). - Р. 315-322.
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