Mental Health Burden in Heart Failure

Patients that suffer from heart failure (HF) face a 2-3 times higher risk of developing depressive or anxious symptoms. Further, depression increases the risk of developing HF over 5-7 years by 18-21%, suggesting a bidirectional relationship. Psychiatric comorbidities in HF patients are associated with impaired cardiac outcomes and a higher burden on the health care system. This study aimed to characterize the mental health burden in HF patients.

Methods: Patients admitted to a psycho-cardiological ward at the University Hospital Heidelberg (2009-2020) were retrospectively analyzed. Patients with HF were subgrouped by their left ventricular ejection fraction (EF) into mild (50-40% EF), moderate (40-30% EF), and severe (<30% EF) HF. Psychiatric symptoms were quantified using the PHQ-9 (depression), and the GAD-7 (anxiety). Additionally, the patient’s quality of life was assessed by the SF-36 questionnaire and quantified by the Physical (PCS) and Mental Component Summary Scale (MCS). For evaluation of the health care burden the length of hospital stay between the subgroups was compared, by grouping patients into those with (PHQ-9≥10) and without depression and with more anxious symptoms (GAD>4, median split) and less anxious patients. For comparing means between groups, a 2-sided Student’s T-test was used.

Results: A total of 578 patients (57% male, 43% female) with a mean age of 64.4y±15.9 were included, with 279 having a diagnosed HF (mild: n=81, moderate: n=95, severe: n=103). Patients with severe HF had a significantly higher mean PHQ-9 (9.34±6.1) compared to all other patients (mild HF: 6.4±5.6, moderate HF: 6.99±6.5, no HF: 7.06±5.9). Patients with an implantable cardioverter defibrillator (ICD) had the highest depression (11.53±6.6) and anxiety score (7.66±6.1) and those with diabetes mellitus (DM) also had increased PHQ-9 scores (8.28±6.5). For the PCS, patients with DM (30.15±10.8) and/or with severe HF (30.33±11.7) scored significantly lower. For the MCS, no significant correlations could be found. Multivariate regressions showed that severe heart failure (p=0.019), an ICD (p<0.001) or DM (p=0.032) significantly correlated with higher PHQ-9 scores. An ICD also correlated with an elevated GAD-7 (p=0.008) and a diagnosed DM with lower PCS (p<0.001). As reported in other studies, younger age (a) and the female sex (s) correlated with higher depression (p(a)=0.018, p(s)=0.003) and anxiety scores (p(a)<0.001, p(s)<0.001). While younger age correlated with higher PCS levels (p<0.001) and the female sex with a lower MCS (p=0.044) and PCS (p=0.004). In HF patients, depression and anxiety correlated with longer hospital stays, with depressive patients having an average hospital stay of 10.88±8.9 days (vs. 7.34±6, p=0.008). Similar results were found for anxiety with anxious patients averagely being hospitalized 9.9±8.6 days (vs.7.17±6.2, p=0.021).

 Conclusion: The presented data suggests that particularly patients suffering from severe HF have a significantly higher risk for depressive comorbidities. Further, DM and an ICD are risk factors for depression and anxiety. Depressive and anxious HF patients also showed significantly longer hospital stays, which underlines the importance of targeted screening and treatment for psychiatric comorbidities. However, due to the retrospective design of the study, limitations need to be considered, and further research is crucial for understanding the interplay between HF and mental health.