The real world mental health needs of heart failure patients are not reflected by the depression randomized controlled trial evidence.
BACKGROUND
International depression screening guidelines in heart failure (HF) are partly based on depression treatment efficacy from randomized controlled trials (RCTs). Our aim was to test the external validity of depression RCT criteria in a sample of real-world HF patients.


METHODS
HF patients admitted to 3 hospitals in South Australia were referred to a HF psychologist if not already receiving current psychiatric management by psychologist or psychiatrist elsewhere. Screening and referral protocol consisted of the following; (a). Patient Health Questionnaire ≥ 10; (b). Generalized Anxiety Disorder Questionnaire ≥ 7); (c). positive response to 1 item panic attack screener; (d). evidence of suicidality. Patients were evaluated against the most common RCT exclusion criteria personality disorder, high suicide risk, cognitive impairment, psychosis, alcohol or substance abuse or dependency, bi-polar depression.


RESULTS
Total 81 HF patients were referred from 404 HF admissions, and 73 were assessed (age 60.6 ± 13.4, 47.9% female). Nearly half (47%) met at least 1 RCT exclusion criterion, most commonly personality disorder (28.5%), alcohol/substance abuse (17.8%) and high suicide risk (11.0%). RCT ineligibility criteria was more frequent among patients with major depression (76.5% vs. 46.2%, p<.01) and dysthymia (26.5% vs. 7.7%, p = .03) but not significantly associated with anxiety disorders. RCT ineligible patients reported greater severity of depression (M = 16.6 ± 5.0 vs. M = 12.9 ± 7.2, p = .02) and were higher consumers of HF psychotherapy services (M = 11.5 ± 4.7 vs. M = 8.5 ± 4.8, p = .01).


CONCLUSIONS
In this real-world sample comparable in size to recent RCT intervention arms, patients with depression disorders presented with complex psychiatric needs including comorbid personality disorders, alcohol/substance use and suicide risk. These findings suggest external validity of depression screening and RCTs could serve as a basis for level A guideline recommendations in cardiovascular diseases.
Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany ; Medical Psychology and Medical Sociology, Medical Faculty, University of Freiburg, Freiburg, Germany ; Freemasons Foundation Centre for Men's Health, Discipline of Medicine, School of Medicine, The University of Adelaide, Adelaide, Australia ; Heart Failure Support Service, The Queen Elizabeth Hospital, Woodville, Australia.
Phillip J
PJ
Tully
Freemasons Foundation Centre for Men's Health, Discipline of Medicine, School of Medicine, The University of Adelaide, Adelaide, Australia.
Gary
G
Wittert
Heart Failure Support Service, The Queen Elizabeth Hospital, Woodville, Australia.
Terina
T
Selkow
Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany ; Medical Psychology and Medical Sociology, Medical Faculty, University of Freiburg, Freiburg, Germany.
Harald
H
Baumeister
D000368:Aged; D001008:Anxiety Disorders / Q000453:epidemiology / Q000209:etiology; D015897:Comorbidity; D003863:Depression / Q000453:epidemiology / Q000209:etiology*; D005260:Female; D006301:Health Services Needs and Demand; D006333:Heart Failure / Q000150:complications* / Q000523:psychology*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008603:Mental Health / Q000706:statistics & numerical data*; D008875:Middle Aged; D020380:Needs Assessment; D015995:Prevalence; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors