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Mental health-related risk factors and interventions in heart failure – EAPC position paper

A position paper by the European Association of Preventive Cardiology recommends psychosocial risk factors be more integrated into the treatment of patients with chronic heart failure to counter depression and other factors hastening heart failure and exacerbating its course.

“Patients with heart failure not only have physical problems, but most also have significant psychological problems, too,” said lead author Karl-Heinz Ladwig, professor of psychosomatic medicine at the Rechts der Isar Hospital of the Technical University of Munich, Germany. “Psychosocial risk factors such as depression, social isolation, loneliness, and traumatic effects due to the disease are insufficiently considered in the treatment of these patients.”

Depression implies non-adherence

“Patterns of behaviour linked to depression can cause coronary heart disease, with the possible consequences of heart failure, to develop more quickly and for the progression also to affect the heart failure negatively,” Dr Christian Albus, director of the Clinic and Polyclinic for Psychosomatics and Psychotherapy at the University Hospital of Cologne, Germany, told Medscape Medical News.

Depression is commonly associated with non-adherence. “And non-adherence is not just the ‘not-as-prescribed’ intake of medications, it also refers to the whole spectrum of health-promoting behaviours such as moderate physical activity, not smoking, and sufficient self-care,” he said.

A two-way connection

In their position paper, the authors point out that depression and other psychosocial stress factors can contribute to a further exacerbation of heart failure via the distribution of hormones and neuroendocrine inflammatory mediators.

Patients commonly find themselves in a Catch-22 situation because there is a two- way connection between depression and heart failure. “Should the heart weakness develop into a serious disease, this in turn fosters episodes of despair and hopelessness in the patients, which are a significant burden,” said Ladwig. So it is important to be aware of the emotional complications involved with heart failure and to treat the patient psychologically.

Antidepressants ineffective

Medicinal relief of the depressive symptoms is out of the question for patients with heart failure. Antidepressants have not demonstrated any good effect in this population. “In studies to date, neither a mortality advantage nor a clear positive effect on mental sensitivity has been shown,” said Albus.

The reason for these findings is unclear. “In other respects, antidepressants have a good effect in particular on recurrent, at least moderate depressive symptoms,” he said. “But this still cannot be replicated in heart failure patients.”

Cognitive and physical therapy

Interventions that combine physical movement programmes with cognitive behavioural therapy promise the best efficacy, according to the authors of the paper. “In this way, negative thought patterns and perception deficits can be broken down in conversations with the behavioural therapists. Physical training improves the circulation in the brain and muscles and strengthens the patient’s physical and mental performance,” said Ladwig. Combined, these factors have favourable effects on depression and its symptoms.

However, in addition to cognitive behavioural therapy, the other psychotherapeutic procedures approved in Germany may also have an effect, said Albus.

“But for people with coronary heart disease and heart failure, we still have no studies in which deep-psychological procedures are tested. The statement that cognitive behavioural therapy is effective in the relief of depressive symptoms does not mean that other procedures are ineffective, there is just no evidence,” he added.

Consult a psychiatrist

“A psychiatrist or a specialist in psychosomatic disorders should be consulted when attempting to treat serious, lasting depression,” said Ladwig. This recommendation applies especially to many patients with heart failure who require an implantable defibrillator (ICD) to prevent sudden cardiac death through malignant cardiac arrhythmias or who also require a left ventricular assist device (LVAD) in an advanced stage.

“The psychological support of these patients and their relatives must be an integral component of the long-term treatment plan,” say the authors.

Depression commonly overlooked

“The problem lies in the current structure of services, that depression is still commonly overlooked in patients with myocardial infarct, but also those with heart failure,” said Albus. “It is likely that at most half of the true mental disorders are correctly diagnosed. And fewer still are treated optimally.”

The evidence shows that general practitioners and cardiologists without specific training are commonly too overstretched, in terms of time and the required expertise, to adequately diagnose mental comorbidities and to administer adequate therapy. “Under the current remuneration structures, general practitioners just can’t afford it either,” added Albus.

Examining care managers

Researchers are examining whether introducing another person (ie, a care manager), who specifically tends to the psychosocial needs of patients with heart failure, would provide an advantage. “In Germany and Europe, the ESCAPE study is just starting,” said Albus. “It is testing whether the triangular support of the general practitioner and cardiologist with the ill patient via a care manager helps heart failure patients who are mentally stressed to develop better than patients who receive routine treatment.”

He also favours informing patients more effectively. “Heart failure patients are often just not aware that their poor mental state is relevant,” he said. “Many see feelings as a weakness, and lethargy primarily as a physical symptom.”

Study details

Mental health-related risk factors and interventions in patients with heart failure: a position paper endorsed by the European Association of Preventive Cardiology (EAPC)

Karl-Heinz Ladwig, Thomas C Baghai, Frank Doyle, Mark Hamer, Christoph Herrmann-Lingen, Evelyn Kunschitz, Cédric Lemogne, Margarita Beresnevaite, Angelo Compare, Roland von Känel et al.

Published in the European Journal of Preventive Cardiology on 1 February 2022

The prevalence and public health burden of chronic heart failure (CHF) in Europe is steadily increasing mainly caused by the ageing population and prolonged survival of patients with CHF. Frequent hospitalisations, high morbidity and mortality rates, and enormous healthcare costs contribute to the health-related burden. However, multidisciplinary frameworks that emphasise effective long-term management and the psychological needs of the patients are sparse. The present position paper endorsed by the European Association of Preventive Cardiology (EAPC) provides a comprehensive overview on the scientific evidence of psychosocial aspects of heart failure (HF). In order to synthesise newly available information and reinforce best medical practice, information was gathered via literature reviews and consultations of experts. It covers the evidence for aetiological and prospective psychosocial risk factors and major underlying psycho-biological mechanisms. The paper elucidates the need to include psychosocial aspects in self-care concepts and critically reviews the current shortcomings of psychotherapeutic and psycho-pharmacological interventions. It also highlights the need for involvement of psychological support in device therapy for patients with HF and finally calls for better palliative care in the final stage of HF progression.


Medscape article – Patients With Heart Failure May Need Psychological Treatment (Open access)


European Journal of Preventive Cardiology position paper – Mental health-related risk factors and interventions in patients with heart failure (Open access)


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Inflammation — the possible link between heart disease and depression


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The high mortality cost of depression in coronary artery disease


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