Worsening depressive symptoms are associated with adverse clinical outcomes in patients with heart failure
Open accessAbstract
Objectives The purpose of this study was to assess the impact of changes in symptoms of depression over a 1-year period on subsequent clinical outcomes in heart failure (HF) patients.Background Emerging evidence shows that clinical depression, which is prevalent among patients with HF, is associated with a poor prognosis. However, it is uncertain how changes in depression symptoms over time may relate to clinical outcomes.Methods One-hundred forty-seven HF outpatients with ejection fraction of less than 40% were assessed for depressive symptoms using the Beck Depression Inventory (BDI) at baseline and again 1 year later. Cox proportional hazards regression analyses, controlling for established risk factors, were used to evaluate how changes in depressive symptoms were related to a combined primary end point of death or cardiovascular hospitalization over a median follow-up period of 5 years (with a range of 4 to 7 years and no losses to follow-up).Results The 1-year change in symptoms of depression, as indicated by higher BDI scores over a 1-year interval (1-point BDI change hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02 to 1.12, p = 0.007), was associated with death or cardiovascular hospitalization after controlling for baseline depression (baseline BDI HR: 1.1, 95% CI: 1.06 to 1.14, p < 0.001) and established risk factors, including HF cause, age, ejection fraction, plasma N-terminal pro-B-type natriuretic peptide level, and prior hospitalizations.Conclusions Worsening symptoms of depression are associated with a poorer prognosis in HF patients. Routine assessment of symptoms of depression in HF patients may help to guide appropriate medical management of these patients who are at increased risk for adverse clinical outcomes.
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Worsening depression over a year is a bad omen, hinting that regular monitoring could allow early intervention with the aim of improving outcomes.
“Worsening depression over a year is also a bad omen, hinting that regular monitoring could allow early intervention with the aim of improving outcomes. 100”
From Prioritizing symptom management in the treatment of chronic heart failure (2020) · cites this paper as [100]
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“Although changes in depressive symptoms have been assessed previously in HF patients (12,13), their relationship to HF clinical outcomes has not been evaluated.”
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“Worsening depression over a year is also a bad omen, hinting that regular monitoring could allow early intervention with the aim of improving outcomes.(100)A number of mood assessment tools are available including the Hospital Anxiety and Depression Scale, Geriatric Depression Scale–Short Form, and the Patient Health…”
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“In patients with HF, the evidence for the association be-tween depression and cardiovascular mortality is mixed (Pelle et al., 2010; Schiffer, et al., 2009; Sherwood et al., 2011; Testa et al., 2011).”
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“We and others have previously shown that elevated depressive symptoms, and depressive symptoms that worsen over time regardless of initial severity, are associated with adverse clinical outcomes in HF, independent of HF disease severity and comorbidity.(5)”
Disease management programs in chronic heart failure
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“Atrial fibrillation and depression have also been associated with more advanced symptoms of HF that require hospitalization.(16,17) These comorbid conditions may be the results of severe HF but could also contribute to worsening symptoms and decompensation.”
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“These findings are in line with the study of Sherwood and colleagues (36), showing that in addition to baseline values, a change in depressive symptoms was significantly associated with hospitalization and mortality in patients with HF.”
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“The present study was designed to further examine the relation of CV reactivity to mental stress to adverse clinical outcomes in patients with HF. AC C EP TE D M AN U SC R IP T Utilizing a simulated public speaking mental challenge, we also examined the association between BP and heart rate reactivity and a composite…”
MethodAssociation of depression with evolution of heart failure in patients with type 2 diabetes mellitus
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“Depression is an independent predictor of adverse clinical outcomes in HF, and increases the risk of mortality by 40–50% [15] In elderly patients with newly diagnosed HF, the presence of depression increased the risk of hospital admission by 20%, and depression screening has been suggested as a routine assessment at t…”
BackgroundAssociations Between Depressive Symptoms and HFpEF-Related Outcomes
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“18 for items (†) showing invariant item ord Discussion Depression in patients with HF is associated with increased hospitalisations, decreased medication adherence, poorer health outcomes, increased mortality, and significant economic costs [5-13].”
BackgroundDepression in Heart Failure: A Systematic Review.
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Time-course of depressive symptoms in patients with heart failure
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“In patients with HF (n=147) an increase in Beck Depression Inventory score (BDI) from baseline to 1-year follow-up was associated with an increased number of cardiovascular hospitalisations and deaths over a median of 5 years follow-up from baseline [12].”
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Changes in Depressive Symptoms and Mortality in Patients With Heart Failure
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“(10) reported that worsening depressive symptoms for 1 year were associated with increased risk of hospitalization or mortality in the subsequent 4 years, after controlling for baseline depression and risk factors.”
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“while worsening symptoms of depression are associated with a poorer prognosis [5, 6].”
BackgroundMood and Health-Related Quality of Life Among Pediatric Patients With Heart Failure
Menteer, J., Beas, V. N., Chang, J. C., Reed, K. P., & Gold, J. I. (2012) · Pediatric Cardiology · doi:10.1007/s00246-012-0477-3 · Cited by 21 · see citing works
“Depression, a common comorbidity of heart failure (HF) well described and studied in adult patients [6, 7], is associated with morbid and mortal outcomes [16].”
BackgroundPsychological Disorders in Heart Failure
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Depression and Quality of Life Among Heart Failure Patients in Georgia, Eastern Europe
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“[2] Studies report between 20% and 48% of heart failure (HF) patients who experience depression[3] which adversely affects their quality of life,[4] produces uncertain treatment outcomes,[5] and leads to increased service utilization/hospital re-admissions and premature mortality.”
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Cognitive and Psycholologic Considerations in Pediatric Heart Failure
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Comparative Effectiveness of Psychotherapy vs Antidepressants for Depression in Heart Failure
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Prognostic Significance of Depression in Blacks With Heart Failure
Mentz, R. J., Babyak, M. A., Bittner, V., Fleg, J. L., Keteyian, S. J., Swank, A. M., Piña, I. L., Kraus, W. E., Whellan, D. J., O’Connor, C. M., et al. (2015) · Circulation Heart Failure · doi:10.1161/circheartfailure.114.001995 · Cited by 14 · see citing works
“Other antidepressant 2% (9) 6% (64) 6% (13) 13% (51) <0.”
Effect of Depression and Sertraline Treatment on Cardiac Function in Female Nonhuman Primates
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A Patient’s Guide to Living Confidently With Chronic Heart Failure
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“This may also be an important opportunity to begin new activities that will help you regain good QoL.”
BackgroundInfluentialIncreased blood pressures in veterans with post traumatic stress disorder
Zadeh, E. M., Khoshdel, A., Avakh, F., & Rahmani, A. (2016) · The International Journal of Psychiatry in Medicine · doi:10.1177/0091217417696734 · Cited by 13 · see citing works
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“It has been used in numerous observational, epidemiological, and treatment studies (e.g., Blumenthal et al., 2012; Carney, Freedland, Steinmeyer, Rubin, & Rich, 2016; Sherwood et al., 2011; Wei et al., 2014).”
Ely, A. V., Alio, C., Bygrave, D. C., Burke, M., & Walker, E. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.00162 · Cited by 14 · see citing works
“While anxiety has been shown to interfere with cognitive function in healthy individuals (Snyder et al., 2015; Shields et al., 2016), it is also true that cognitive dysfunction is significantly anxiety-provoking, with elevated rates of anxiety reported in treatment-seeking patients with mild…”
BackgroundCall for a Disease-Specific Patient-Reported Outcome Tool in Adult Congenital Heart Disease
Cedars, A. M., & Spertus, J. A. (2014) · Circulation Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.114.001406 · Cited by 12 · see citing works
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“It is important to note that scientific research shows that depressive symptoms are common in patients with heart failure and have been associated with increased morbidity and mortality [70,71], as well as impaired health status [72].”
Emotional and behavioral problems in children with dilated cardiomyopathy
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Psychological Disorders in Heart Failure
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Depression and Severe Heart Failure: Benefits of Cardiac Resynchronization Therapy
Ploux, S., Verdoux, H., Whinnett, Z. I., Ritter, P., Santos, P. D. D., PICARD, F., Clémenty, J., Haı̈ssaguerre, M., & Bordachar, P. (2012) · Journal of Cardiovascular Electrophysiology · doi:10.1111/j.1540-8167.2011.02258.x · Cited by 9 · see citing works
“Age (years) (n = 68) 69 (12) 69 (13) 68 (11) 68 (13) 69 (11) Male gender (n = 68) 50 (74) 18 (69) 32 (76) 27 (69) 23 (79) Marital status (n = 62)”
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Antidepressant use in patients with heart failure
Freedland, K. E., Steinmeyer, B. C., Carney, R. M., Skala, J. A., & Rich, M. W. (2020) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2020.04.006 · Cited by 9 · see citing works
“Antidepressant use also had no effect on event-free survival in an observational study of 209 outpatients with HF [6], hospitalization-free survival in 147 outpatients with HF [7], or mortality in 1,017 outpatients with HF [8], although fluoxetine use predicted mortality in the latter study.”
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Cardiovascular Nursing in Rehabilitative Cardiology: A Review
Izzo, C., Visco, V., Loria, F., Squillante, A., Iannarella, C., Guerriero, A., Cirillo, A., Barbato, M. G., Ferrigno, O., Augusto, A., et al. (2025) · Journal of Cardiovascular Development and Disease · doi:10.3390/jcdd12060219 · Cited by 10 · see citing works
“It is a holistic approach which means that people feel supported in mind and body alike [51,52].”
Wang, B., Lei, L., Zhang, H., Miao, F., Zhang, L., Tian, A., & Li, J. (2022) · Journal of the American Heart Association · doi:10.1161/jaha.122.027438 · Cited by 7 · see citing works
“38,39 Our study highlighted that clinicians could easily perform PHQ-2 screening before discharge as well as at 1 month after discharge to identify the patients with high risks of depressive symptoms.”
Neuroimmune Mechanisms of Depression in Heart Failure
Jiménez, J. A., & Mills, P. J. (2012) · Methods in molecular biology · doi:10.1007/978-1-62703-071-7_9 · Cited by 7 · see citing works
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“Psychological problems, such as depression and anxiety, can negatively affect daily activities and are associated with poor prognosis, especially in patients with HF (Falk et al., 2009; Moser et al., 2016; Sherwood et al., 2011).”
BackgroundScreening, assessment and treatment for depression in patients with chronic heart failure
Baird, D. E., Jackson, A. C., Higgins, R. O., Murphy, B. M., & Tully, P. J. (2018) · British Journal of Cardiac Nursing · doi:10.12968/bjca.2018.13.8.386 · Cited by 6 · see citing works
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“Research findings showed that heart failure patients with higher levels of depression were more likely to die compared with those who had no depressive symptoms [6-12] , and heart failure patients with more depressive symptoms had higher rehospitalization rates [7,10,12,13].”
BackgroundAssessment of Depression in Heart Failure Patients
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Sherwood, A., Blumenthal, J. A., Mentz, R. J., Koch, G. G., Rogers, J. G., Chang, P. P., Chien, C., Adams, K. F., Rose‐Jones, L. J., Jensen, B. C., et al. (2024) · ESC Heart Failure · doi:10.1002/ehf2.14758 · Cited by 5 · see citing works
“6,8 This limitation is central to understanding the cause – effect nature of the observed association, since worsening depressive symptoms may result in worsening HFrEF disease, or worsening HFrEF disease may result in worsening depressive symptoms.”
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“5 (30-100) 75,5 (20-100) 0,855 Salud general 17 70 (5-95) 80 (5-100) 0,01 22 62,5 (25-95) 65 (0-100) 0,410”
InfluentialQuality of Life and Psychosocial Care in Pediatric Heart Failure
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Escitalopram and Outcomes Among Patients With Depression and Heart Failure—Reply
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Apoio Social e Coping em Pacientes com Insuficiência Cardíaca
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Epidemiology of Cardiovascular Disease and Depression
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The Consultation-Liaison Psychiatry, an effective process between heart and sexuality
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Factors Associated With Depression and Anxiety for Community-Dwelling Patients With Heart Failure
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What Treatments Are Effective for Depression in the Palliative Care Setting?
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Developments in Heart Failure 2011
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Depression and race affect hospitalization costs of heart failure patients
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Psychological Management of Patients with Heart Failure
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Exercise Training as Treatment of Depression in Heart Failure
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Spiritual Well-Being Of Health Failure Patients
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“Depression is very dangerous for health failure patients if it is not treated, it worsens the condition of patients, and becomes a risk factor for death (Sherwood et al., 2011).”
BackgroundDepressive symptoms and their associated factors in heart failure patients
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- Authors
- Sherwood, A., Blumenthal, J. A., Hinderliter, A. L., Koch, G. G., Adams, K. F., Dupree, C. S., Bensimhon, D. R., Johnson, K. S., Trivedi, R., Bowers, M., Christenson, R. H., & O'Connor, C. M.
- Affiliations
- Duke Medical Center (US)
- Duke University (US)
- University of North Carolina at Chapel Hill (US)
- Cardiovascular Research Foundation (US)
- University of Maryland, Baltimore (US)
- Corresponding author
- Sherwood, Andrew
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2011-01
- Volume
- 57
- Issue
- 4
- Pages
- 418-423
- ISSN
- 0735-1097 (ISSN-L)
- PMC
- PMC3622450
- OpenAlex
- W2029552522
- Cited by
- 122
- References
- 24
- Citations by year
- 2026: 3 · 2025: 6 · 2024: 9 · 2023: 3 · 2022: 4 · 2021: 5 · 2020: 8 · 2019: 6 · 2018: 7 · 2017: 11 · 2016: 10 · 2015: 9 · 2014: 10 · 2013: 4 · 2012: 20
- FWCI
- 8.99
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute
- National Center for Research Resources
- National Institutes of Health (M01-RR-30)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Keywords
- heart failure, depression, depressive symptoms, prognosis, mortality, cardiovascular hospitalization, Beck Depression Inventory, symptom change over time, ejection fraction, N-terminal pro-brain natriuretic peptide, depression screening
- MeSH terms
- Aged, Cardiac Output, Cause of Death, Depression, Female, Heart Failure, Hospitalization, Humans, Male, Middle Aged, Outpatients, Predictive Value of Tests, Prognosis, Prospective Studies, Psychiatric Status Rating Scales, Regression Analysis, Severity of Illness Index, Cohort Studies, Incidence, Confidence Intervals, Odds Ratio, Survival Analysis, Hospital Mortality, Age Distribution, Sex Distribution, Sickness Impact Profile, Disease Progression, Risk Assessment
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