Skip the antidepressant when the patient has chronic disease?

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.

It makes sense to think that treating patients who have congestive heart failure (CHF) and depression with an antidepressant would be effective. But common sense is not always supported by empiric observation or evidence.

In this month’s PURL, the authors summarize the MOOD-HF study,¹ a randomized controlled trial (RCT) of escitalopram for the treatment of patients with CHF and depression. After 2 years, no outcomes—including depression scores—were better in the treatment vs the placebo group. One can only speculate as to why this antidepressant was not effective in this population. Clearly, this group differs somehow from subjects enrolled in traditional depression trials; notably, their depression was diagnosed after the onset of CHF, suggesting the depression was a reaction to their illness.

Not the first time. This is the second large trial to find no benefit to using a selective serotonin reuptake inhibitor (SSRI) to treat depression in patients with CHF; the previous trial to do so looked at sertraline.² In fact, when it comes to patients with chronic diseases, such as diabetes and coronary artery disease, there is scant evidence to support the common belief that screening them for depression and treating them with SSRIs improves patient outcomes.³ On the other hand, there are no definitive clinical trials investigating other antidepressants in the treatment of depressed patients with chronic illness, so it is possible that other drugs could be effective. There is evidence, however, from a recent RCT that cognitive behavioral therapy—compared with usual care—improves depression, anxiety, fatigue, and social functioning in patients with CHF.⁴

Where does that leave us? In our practice, we annually screen all adults, including those with chronic illness, for depression with the 2-question Patient Health Questionnaire. As a matter of course, we should acknowledge and explore all patients’ depressed mood, offer emotional support, and refer for psychotherapy when appropriate. And since collaborative care has been shown to improve outcomes in patients with depression and, for that matter, diabetes (see this month’s audiocast), consider this model of care if it is available.⁵

One can only speculate as to why this antidepressant was not effective in this population.

I believe it’s worthwhile to discuss the use of antidepressants with patients who have CHF. It’s reasonable to be optimistic with them and to expect that their depression will improve with time, as noted in the placebo groups of the randomized trials mentioned above.^1,2 And giving patients hope is always good medicine.