CBT for comorbid heart failure and depression may only work for the latter
The authors described the reduced anxiety and fatigue, improved social functioning, and better health-related quality of life as especially encouraging results in light of the negative findings of other trials.
Cognitive behavioral therapy (CBT) that targets both depression and heart failure self-care is effective for depression but not for heart failure self-care or physical functioning, a study found.
To determine the efficacy of an integrative CBT intervention for depression and heart failure self-care, researchers conducted a randomized clinical trial with single-blind outcome assessments among 158 outpatients with New York Heart Association Class I, II, and III heart failure and comorbid major depression treated at Washington University Medical Center in St. Louis between Jan. 4, 2010, and June 28, 2013.
Patients were randomized to CBT delivered by experienced therapists plus usual care or to usual care alone. Both intervention and control groups received a structured heart failure education program delivered by a cardiac nurse.
The primary outcome was severity of depression at 6 months as measured by the Beck Depression Inventory, with measures of the Self-Care of Heart Failure Index Confidence and Maintenance subscales as other primary outcomes. Secondary outcomes included measures of anxiety, depression, physical functioning, fatigue, social roles and activities, and quality of life.
Results were published online Sept. 28 by JAMA Internal Medicine.
The patients were randomized 1:1. Within each arm, 26 (33%) of the patients were taking an antidepressant at baseline. One hundred thirty-two (84%) of the participants completed the 6-month post-treatment assessments. Sixty (76%) of the usual care and 58 (73%) of the CBT participants completed every follow-up assessment.
Six-month depression scores were lower in the CBT arm than the usual care arm on the Beck Depression Inventory (BDI-II) (12.8 [SD, 10.6] vs. 17.3 [SD, 10.7]; P=0.008). The CBT group also showed significantly lower remission rates, according to the BDI-II (46% vs. 19%; number needed to treat [NNT]=3.76; 95% CI, 3.62 to 3.90; P<0.001) and the Hamilton Depression Scale (51% vs. 20%; NNT=3.29; 95% CI, 3.15 to 3.43; P<0.001).
Six-month outcomes were also superior in the CBT group relative to the usual care group on secondary measures of depression (Hamilton Depression and PROMIS Depression), anxiety (Beck Anxiety Inventory and PROMIS Anxiety), heart failure-related quality of life (Kansas City Cardiomyopathy Questionnaire), mental health-related quality of life (SF-12 Mental), fatigue (PROMIS Fatigue), and social functioning (PROMIS Discretionary Social Activities and PROMIS Social Roles). The Self-Care of Heart Failure Index Confidence and Maintenance subscales and measures of physical function did not differ significantly between groups.
The authors described the reduced anxiety and fatigue, improved social functioning, and better health-related quality of life as “an especially encouraging result in light of the negative findings of the SADHART-CHF and MOOD-HF antidepressant trials.”
An editor's note stated, “The good news is that CBT did significantly improve emotional health and overall quality of life, and the improvement in depressive symptoms associated with CBT was larger than observed in pharmacotherapy trials for depression in patients with heart disease. This is supportive evidence for a shift in practice away from so much pharmacotherapy and more use of psychotherapy to achieve better mental health and overall quality-of-life outcomes in patients with heart failure. In reframing how we think about the management of depression in patients with heart failure, we should be talking more and prescribing less.”
The October issue of ACP Internist features an article on the mind-body role in heart disease.