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Depression and Anxiety in Heart Failure: A Review

Celano, Christopher M., MD; Villegas, Ana C., MD; Albanese, Ariana M., BA; Gaggin, Hanna K., MD, MPH; Huffman, Jeff C., MD

doi: 10.1097/HRP.0000000000000162

Learning objectives After participating in this activity, learners should be better able to:

• Identify the relationships between depression, anxiety, and heart failure (HF).

• Assess methods for accurately diagnosing depression and anxiety disorders in patients with HF.

• Evaluate current evidence for treatment of anxiety and depression in patients with HF.

Background In patients with heart failure (HF), depression and anxiety disorders are common and associated with adverse outcomes such as reduced adherence to treatment, poor function, increased hospitalizations, and elevated mortality. Despite the adverse impact of these disorders, anxiety and depression remain underdiagnosed and undertreated in HF patients.

Methods We performed a targeted literature review to (1) identify associations between depression, anxiety, and HF, (2) examine mechanisms mediating relationships between these conditions and medical outcomes, (3) identify methods for accurately diagnosing depression and anxiety disorders in HF, and (4) review current evidence for treatments of these conditions in this population.

Results Both depression and anxiety disorders are associated with the development and progression of HF, including increased rates of mortality, likely mediated through both physiologic and behavioral mechanisms. Given the overlap between cardiac and psychiatric symptoms, accurately diagnosing depression or anxiety disorders in HF patients can be challenging. Adherence to formal diagnostic criteria and utilization of a clinical interview are the best courses of action in the evaluation process. There is limited evidence for the efficacy of pharmacologic and psychotherapy in patients with HF. However, cognitive-behavioral therapy has been shown to improve mental health outcomes in patients with HF, and selective serotonin reuptake inhibitors appear safe in this cohort.

Conclusions Depression and anxiety disorders in HF patients are common, underrecognized, and linked to adverse outcomes. Further research to improve detection and develop effective treatments for these disorders in HF patients is badly needed.

From Harvard Medical School (Drs. Celano, Gaggin, and Huffman); Departments of Psychiatry (Drs. Celano, Villegas, and Huffman, and Ms. Albanese) and Medicine, Division of Cardiology (Dr. Gaggin), Massachusetts General Hospital, Boston, MA.

Supported, in part, by National Heart Lung and Blood Institute grant no. K23HL123607 (Dr. Celano) and National Institutes of Health grant no. R01HL113272 (Dr. Huffman).

Original manuscript received 2 November 2016, accepted for publication subject to revision 13 January 2017; revised manuscript received 11 February 2017.

Correspondence: Christopher M. Celano, MD, Massachusetts General Hospital, Blake 11, 55 Fruit St., Boston, MA 02114. Email:

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