Cognitive behavioral therapy effective for depression but not self-care in heart failure

1. In this randomized controlled trial, heart failure patients randomized to cognitive behavioral therapy (CBT) had decreased depression as compared to usual care, but there was no significant impact on self-care.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Mental illnesses, such as major depressive disorder, may impact the ability of a patient with chronic disease to provide self-care. In particular, depression in heart failure patients is associated with poorer quality of life and increased risk of hospitalization and mortality. Given that self-care (i.e., following low sodium diet, exercising, taking medications as prescribed) is important in heart failure, it is vital to understand how we can improve self-care by controlling concomitant depression. This randomized controlled trial aimed to determine the efficacy of a CBT intervention for depression and self-care.

Integrative CBT was not significantly associated with improved self-care or physical functioning measures. However, CBT was associated with a significant decrease in depression. There were fewer hospitalizations and increased heart failure-related quality of life and social functioning scores in the CBT arm. However, hospitalization was an exploratory outcome, and groups did not differ on composite endpoint of death or hospitalization. The strengths of this study include studying cognitive behavioural therapies as opposed to medications, which were historically studied. Limitations of this study include having low enrollment. Although this did not underpower the primary outcomes, secondary and exploratory outcomes including hospitalizations should be interpreted with caution.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure

In-Depth [randomized controlled trial]: This randomized, single-blinded trial was conducted in Missouri, between January 2010 and June 2013. It included 158 patients with New York Heart Association (NYHA) class I-III heart failure and comorbid major depression. These patients were randomized to either cognitive behaviour therapy delivered by an experienced therapist plus usual care, or usual care alone. Usual care consisted of a structured heart failure education program provided by a cardiac nurse. The outcomes of interest included severity of depression at 6 months assessed by the Beck Depression Inventory; self-care as defined by the Self-Care of Heart Failure index, and as exploratory outcomes, hospitalizations and death.

A total of 158 patients were randomized with 79 to usual care and 79 to CBT with usual care. Antidepressant use at baseline was equal between groups. Depression scores at 6 months were lower in the CBT group as compared to the usual care arm (difference -4.43; 95%CI -7.68 to -1.18; p = 0.008). The groups did not differ on the self-care maintenance or confidence subscales. There was no significant difference between absolute numbers of hospitalizations between the usual care and CBT groups (35 vs. 32, p = 0.63). However, after controlling for antidepressant use, use of Poisson model and counting multiple readmissions, patients in the CBT arm had a lower rate of hospitalizations compared to usual care (incidence rate ratio 0.47; 95%CI 0.30-0.76; p = 0.002).

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