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Cognitive Function in Heart Failure Is Associated With Nonsomatic Symptoms of Depression But Not Somatic Symptoms

Hawkins, Misty A.W. PhD; Dolansky, Mary A. PhD, RN; Schaefer, Julie T. MS, RD; Fulcher, Michael J. BA; Gunstad, John PhD; Redle, Joseph D. MD; Josephson, Richard MS, MD; Hughes, Joel W. PhD

doi: 10.1097/JCN.0000000000000178

Background: Patients with heart failure (HF) have high rates of cognitive impairment and depressive symptoms. Depressive symptoms have been associated with greater cognitive impairments in HF; however, it is not known whether particular clusters of depressive symptoms are more detrimental to cognition than others.

Objective: The aim of this study was to identify whether somatic and/or nonsomatic depressive symptom clusters were associated with cognitive function in persons with HF.

Methods: Participants were 326 HF patients (40.5% women, 26.7% non-white race-ethnicity, aged 68.6 ± 9.7 years). Depressive symptoms were measured using a depression questionnaire commonly used in medical populations: the Patient Health Questionnaire-9. Somatic and nonsomatic subscale scores were created using previous factor analytic results. A neuropsychological battery tested attention, executive function, and memory. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and clinical factors were conducted.

Results: Regressions revealed that Patient Health Questionnaire-9 total was associated with attention (β = −.14, P = .008) and executive function (β = −.17, P = .001). When analyzed separately, the nonsomatic subscale, but not the somatic symptoms subscale (P values ≥ .092), was associated with attention scores (β = −.15, P = .004) and memory (β = −.11, P = .044). Both nonsomatic (β = −.18, P < .001) and somatic (β = −.11, P = .048) symptoms were related to executive function. When included together, only the nonsomatic symptom cluster was associated with attention (β = −.15, P = .020) and executive function (β = −.19, P = .003).

Conclusions: Greater overall depressive symptom severity was associated with poorer performance on multiple cognitive domains, an effect driven primarily by the nonsomatic symptoms of depression.

Clinical Implications: These findings suggest that screening explicitly for nonsomatic depressive symptoms may be warranted and that the mechanisms underlying the depression-cognitive function relationship in HF are not solely related to sleep or appetite disturbance. Thus, interventions that target patients’ somatic symptoms only (eg, poor appetite or fatigue) may not yield maximum cognitive benefit compared with a comprehensive treatment that targets depressed mood, anhedonia, and other nonsomatic symptoms.

Misty A.W. Hawkins, PhD Research Fellow, Department of Psychology, Kent State University, Ohio.

Mary A. Dolansky, PhD, RN Associate Professor, School of Nursing, Case Western Reserve University, Cleveland, Ohio.

Julie T. Schaefer, MS, RD PhD Candidate, College of Public Health, Kent State University, Ohio.

Michael J. Fulcher, BA Project Coordinator, Department of Psychiatry, Summa Health System, Akron City Hospital, Ohio.

John Gunstad, PhDAssociate Professor, Department of Psychology, Kent State University, Ohio.

Joseph D. Redle, MD Cardiologist, Cardiovascular Institute, Summa Health System, Akron City Hospital, Ohio.

Richard Josephson, MS, MD Professor, School of Medicine, Case Western Reserve University, and Harrington Heart & Vascular Institute, University Hospitals, Cleveland, Ohio.

Joel W. Hughes, PhD Associate Professor, Department of Psychology, Kent State University, and Department of Psychiatry, Summa Health System, Akron City Hospital, Ohio.

This work was supported by the National Heart, Lung, and Blood Institute at the National Institute of Health (R01 HL096710-01A1 to M.A.D. and J.W.H).

The authors have no conflicts of interest to disclose.

Correspondence Misty A.W. Hawkins, PhD, Department of Psychology, 327 Kent Hall Addition, PO Box 5190, Kent State University, Kent, OH 44240 (

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