Rethinking Depression Treatment for Heart Failure Patients

Summary and Comment |
July 18, 2016

Rethinking Depression Treatment for Heart Failure Patients

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

Chronic escitalopram did not improve outcomes in this population.

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

In patients with cardiovascular diseases, depression is substantially more prevalent than in the general population. Epidemiological evidence has shown a robust relationship between depression and adverse outcomes in patients with heart failure (HF), including death, hospitalization, and worse health status. The benefits of pharmacotherapy for depression in HF patients are unproven, however. In the randomized, 12-week SADHART-CH trial, the selective serotonin reuptake inhibitor (SSRI) sertraline did not improve depression symptoms or clinical status in HF patients (NEJM JW Cardiol Nov 2010 and J Am Coll Cardiol 2010; 56:692). Now, researchers in the German, partially industry-supported, multisite MOOD-HF trial assessed longer-term effects of the SSRI escitalopram.

Of 2872 patients with confirmed symptomatic systolic HF, left ventricular ejection fraction <45%, and depressive symptoms, 372 patients (mean age, 62; 25% women) met DSM-IV criteria for major depression and were randomized to escitalopram (starting at 5 mg/day, titrated to ≤20 mg/day over 6 weeks as tolerated) or placebo.

All patients received increasing doses of HF therapies, as tolerated, and counseling and empowerment exercises. The Data Safety Monitoring Board terminated the study early for futility (median participation time, approximately 18.5 months).

The primary outcome, death or hospitalization, did not differ between the escitalopram and placebo groups (63% and 64%). At 12 weeks, health status and depression symptoms improved similarly in the two groups. Safety events did not differ between groups except for worsening depression, which occurred more commonly with placebo. Discontinuation of therapy at 12 weeks was significantly more frequent with escitalopram than with placebo (15% vs. 7%).

Comment

As with SADHART-CH, MOOD-HF raises questions about the usefulness of SSRIs in depressed patients with HF, even for treating depressive symptoms. Although practitioners may continue to be tempted to use SSRIs, it is important to acknowledge that we're principally treating ourselves; the patient isn't likely to benefit.

Editor Disclosures at Time of Publication

  • Disclosures for Frederick A. Masoudi, MD, MSPH, FACC, FAHA at time of publication Grant / Research support National Heart, Lung, and Blood Institute; American College of Cardiology; Patient-Centered Outcomes Research Institute; John. A. Hartford Foundation Editorial boards Circulation: Cardiovascular Quality and Outcomes Leadership positions in professional societies American College of Cardiology (Chief Science Officer, National Cardiovascular Data Registries; Member, Board of Trustees); American Heart Association (Immediate Past Chair, Council on Quality of Care and Outcomes Research); American Board of Internal Medicine (Member, Cardiology Board)

Citation(s):

Reader Comments (2)

Kurt Elward Physician, Family Medicine/General Practice

Dr. Masoudi's comments are out of place. The article states that these patients WERE depressed - and yet citalopram did not help. That does not mean we just leave them be . It means better treatments should be developed. It also is instructive that both groups received counseling - which is unusual for many patients to receive. Perhaps the message here is that we are NOT treating ourselves - but that many people benefit from counseling and support, as many other studies show. And it may need more than just tossing more medicine at them.

HRobert Physician, Cardiology, Preventive Medicine Center

The problem psychologically in CHF is loss of psychological power (non-sexual potency)/independence/and lack of support: these will not be fixed with an antidepressant. One thing Hillary Clinton did correctly which is relevant & will be successful in CHF with depression is that "It Takes A Village": a multi-pronged team to effectively treat depression & the CHF. HRS, MD, FACC

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