Cognitive behavior therapy provides mixed results for heart failure patients with depression

Patients with heart failure and major depression who underwent cognitive behavior therapy had improvements in mental health and overall quality of life after six months, according to a randomized trial. However, the intervention did not improve heart failure self-care or physical functioning.

Lead researcher Kenneth E. Freedland, PhD, of Washington University in St. Louis, and colleagues published their findings online in JAMA Internal Medicine on Sept. 28.

Patrick G. O’Malley, MD, MPH, director of the division of general internal medicine at the Uniformed Services University in Bethesda, Md., noted in an accompanying editorial that the cognitive behavior therapy intervention led to more improvements in depressive symptoms compared with previous pharmacotherapy trials.

“This is supportive evidence for a shift in practice away from so much pharmacotherapy and more use of psychotherapy to achieve better mental health and overall quality-of-life outcomes in patients with heart failure,” O’Malley wrote. “In reframing how we think about the management of depression in patients with heart failure, we should be talking more and prescribing less.”

The researchers noted that heart failure patients commonly have major depression, which is difficult to treat and associated with a poor quality of life and increased risk for hospitalization and mortality. Patients also have inadequate self-care, which the researchers defined as behaviors that maintain physical functioning and prevent acute exacerbations such as a low-sodium diet, exercising, taking prescribed medications and monitoring edema.

Between Jan. 4, 2010, and June 28, 2013, the researchers randomized 158 patients at the Washington University Medical Center to receive usual care or cognitive behavior therapy. The patients had New York Heart Association Class I, II and III heart failure and comorbid major depression. At baseline, 26 patients in each group were taking an antidepressant.

During the trial, patients were allowed to continue their usual medical care. They also received educational materials on heart failure self-care, and a cardiac nurse reviewed the materials with them at baseline and on three, 30-minute phone calls within the first four weeks after randomization.

The cognitive behavior therapy intervention included up to six months of weekly one-hour sessions during which patients received an individualized treatment plan and goals. Two masters-level and two doctoral-level therapists were in charge of the sessions. Each had prior training and experience with cognitive behavior therapy for major depression.

The researchers measured depression using the Beck Depression Inventory. They also examined the 6-month Self-Care Maintenance and Confidence subscales.

After six months, 84 percent of patients had completed the post-treatment assessments. The cognitive behavior therapy group had lower depression scores and higher remission rates. The groups did not differ on the Self-Care Maintenance or Confidence subscales.

Further, the cognitive behavior therapy group had superior scores on the measures of depression, anxiety, heart failure-related quality of life, mental health-related quality of life, fatigue and social functioning. The groups had no differences in physical functioning or the composite endpoint of hospitalization or death.

“Comorbid major depression in heart failure may respond to [cognitive behavior therapy] even if antidepressant therapy is unsuccessful,” the researchers wrote. “Further research is needed on interventions to improve depression, self-care, physical functioning, and quality of life in patients with [heart failure] and comorbid major depression.”