In the current study, HF severity, as indicated by NYHA classification, was not related to changes in depression or anxiety. This finding goes beyond most of the studies of patients with HF that found a relationship between depression1,2,12–18,45 or anxiety14,17 and HF severity. The current study addresses change in depression and anxiety, whereas the previous studies examined a cross-sectional relationship.
Successful management of HF requires the active involvement of the patient in his/her own care. In HF, self-management or self-care includes adherence with medication, regular exercise, and dietary restrictions on salt as instructed by the healthcare provider as well as monitoring and interpreting signs and symptoms to assess disease status and seeking care when indicated. Poor self-management is associated with psychosocial distress.49,50 On the basis of a randomized intervention study in HF patients, Jaarsma et al51 concluded that general disease management programs are not effective for HF patients who are depressed and recommended identification of depressive symptoms before initiation of a disease management program. Poor social support inhibits the development and use of HF self-management skills.26,49
No large clinical trials of education or self-management interventions demonstrate the effectiveness of these interventions to improve social support or reduce depression or anxiety in HF patients.52,53 In a small treatment group–only pilot study in HF patients (N = 26), depression and social support were significantly improved 1 year after baseline.54 A larger study with a comparison group found lower depression and a tendency for better social functioning in the self-management intervention than in the control group at 3 months but not at 1 year.55 Education and self-management interventions may increase perceptions of control and decrease depression and anxiety. Future studies are needed to assess the effectiveness of self-management interventions with depressed and anxious HF patients.
The amount of missing data is of potential concern. It is possible that more depressed or anxious participants refused to participate in the study, withdrew from the study, or died. Our analyses indicated that data were missing at random, which means that initial status (depression scores, anxiety scores, social support, NYHA class, age, gender) does not predict missing data at subsequent data collection points or patterns of missing data. The linear mixed-models statistical technique used in the current study uses all data points and allows different numbers of measurements for each case. Data that are missing at random are expected and do not compromise the analysis.39,42 Only a small proportion of variability in outcomes was explained by the variables assessed in the current study. Additional variables may help to explain changes in depression and anxiety in this population.
The authors gratefully acknowledge the support of the principal investigators of SCD-HeFT, Gust Bardy, MD, FACC, and Kerry Lee, PhD, and the Seattle Institute for Cardiovascular Research Clinical Research Coordinator, Jill Anderson, RN.
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