In Bangladeshi cardiac patients, heart failure is one of the major causes of mortality and morbidity [1]. Combination of heart failure and depression may worsen the symptoms. There may be a vicious cycle of bad prognosis (Figure 1) [2]. However, there are limited data on the psychological correlation with heart failure in Bangladeshi patients. This study was performed to see the prevalence of depression in heart failure patients among Bangladeshi population.

This was an observational and cross-sectional study. The study enrolled 90 patients with heart failure admitted in university cardiac center of Bangabandhu Sheikh Mujib Medical University; Shahbag, Dhaka, Bangladesh from March, 2019 to February, 2020. History taking and complete medical records were reviewed carefully. The structured questionnaire used in this study gathered information on respondent demographic and disease characteristics and information obtained from the Depression Questionnaire.

Working definition of depression:

A deep understanding of the relation between these diseases across all the stages of heart failure is essential as depression and heart failure share a common genetic and pathophysiologic basis [3]. Depression is a common psychiatric disorder, in which there are loss of interests in anything and several other features that are present almost daily for at least two weeks. A person with depression reflects a pathological change in the mental sphere in relation to a previously healthy mental state.

According to the Diagnostic and Statistical Manual of Mental Disorders, the diagnosis of a depressive syndrome involves the following: a) insomnia or hypersomnia b) diminished concentration c) diminished interest or pleasure from activities d) loss of energy or fatigue e) excessive or inappropriate guilt f) decrease or increase in appetite and resulting weight loss or gain g) psychomotor retardation/agitation h) recurrent thoughts of death, suicidal ideation or suicide attempt [3].

Figure 1: Depression in Heart Failure [2]

The prevalence of depression was 41.11%. Those who had sleep disturbances, followed no regular exercise regimen, had family disharmony were higher risk of depression (Tables 1-3).

Table 1: Socio-demographic parameters of the study patients (n=90)

Although there are recent improvements in heart failure treatment, about 50% having an average life expectancy of less than five years and those with advanced forms of heart failure, nearly 90% die within one year [4].

Table 2: Depression in the study patients’ (n=90):

In a progressive & debilitating disease like chronic heart failure, the quality of life of the patients gradually declines and socio-economic burdens increase day by day [5].

Depression and anxiety are often observed in patients with Chronic Heart Failure (CHF) [6]. These psychiatric diseases complicate the therapeutic option and increase hospitalizations and mortality rate [7,8]. Approximately one-fifth of patients with CHF affected by depression and as a result, worsening the functional class. Depression affects two- to three-times more in HF patients than the general population [7]. 

In our study we also found that, patients in heart failure with depression were more (64.8%) in NYHA functional class III-IV in comparison to heart failure without depression (37.7%). 

Polikandrioti et al. [9] demonstrated that HF patients who are elderly (over 60 years old) feel more depressed due to the fact that they experience functional and cognitive impairment and this condition is making their daily life more difficult.

Table 3: Medical advice adherence parameters of the study population (n=90)

In a study, 70 years older heart failure patients with depression readmit more (67%) than the heart failure patients without depression (44%) [10].

Our heart failure patients who were in depression readmitted (78.3%) more in hospital than patients without depression (58.4%).

Usually, heart failure patients do not easily accept the disease condition; they show non-compliance to drug therapy for low socio-economic and educational status. These factors influence depression. As a result, these patients are unwilling to report their depressive symptoms and financial problems. Our heart failure patients with depression also had fewer adherences to diet, lifestyle, medicines and worsening functional class.

They seek for medical advice only when the disease process has reached in advanced level. HF severity is related to depression. Because physical or cognitive impairment imposes limitations on every dimension of personal, family and occupational lives; thus, depression is affecting the mental sphere of these vulnerable heart failure patients [9,11,12].

Care should be taken for heart failure patients in a holistic model to be emphasized in biological, psychological and social aspects of the individual. With conventional cardiac treatment, assessment of coronary disease patients, systematic screening of depression, counseling of the patients and psychological interventions including support groups at hospitals should be included in the holistic model [13].

Heart failure (HF) and depression are debilitating diseases with significantly reduce functional status and deteriorate quality of life. Despite many advanced therapies for HF; mortality remains still high. Heart failure and depression often coexist. Patients with depression develop more symptoms of HF, have worse compliance with medications, are slower to return to work and social activities and thus they lead a poorer quality of life [14].

Prevalence of depression in HF patients should be kept in mind of healthcare providers. Early identification of HF patients with depression, healthcare providers may prevent worse prognosis and ensure the provision of appropriate rehabilitation to this population.

1. Ministry of Health and Family Welfare (MoHFW). Strategic Plan for Surveillance and Prevention of Non-Communicable Disease in Bangladesh 2007-2010. Government of People’s Republic of Bangladesh, 2007.

2. Ghosh, R.K. et al. “Depression in heart failure: intricate relationship, pathophysiology and most updated evidence of interventions from recent clinical studies.” International Journal of Cardiology, vol. 224, 2016, pp. 170-177.

3. Dimos, A.K. et al. “Depression and heart failure.” Hellenic Journal of Cardiology, vol. 50, no. 5, 2009, pp. 410-417.

4. Warner, J. “Heart failure patients too optimistic.” WebMD Health News, June 2008.

5. Ramani, G.V. et al. “Chronic heart failure: contemporary diagnosis and management.” Mayo Clinic Proceedings, vol. 85, no. 2, February 2010, pp. 180-195.

6. Janssen, D.J. et al. “Symptoms, comorbidities and health care in advanced chronic obstructive pulmonary disease or chronic heart failure.” Journal of Palliative Medicine, vol. 14, no. 6, 2011, pp. 735-743.

7. DeJongh, B. et al. “Managing comorbidities in patients with chronic heart failure: first, do no harm.” American Journal of Cardiovascular Drugs, vol. 15, no. 3, 2015, pp. 171-184.

8. Vongmany, J. et al. “Anxiety in chronic heart failure and the risk of increased hospitalisations and mortality: a systematic review.” European Journal of Cardiovascular Nursing, vol. 15, no. 7, 2016, pp. 478-485.

9. Polikandrioti, M. et al. “Evaluation of depression in patients with congestive failure.” Health Science Journal, vol. 4, no. 1, 2010, pp. 37-47.

10. Rozzini, R. et al. “Depression and major outcomes in older patients with heart failure.” Archives of Internal Medicine, vol. 162, no. 3, 2002, pp. 362-363.

11. DiMatteo, M.R. et al. “Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence.” Archives of Internal Medicine, vol. 160, no. 14, 2000, pp. 2101-2107.

12. Cline, C.M.J. et al. “Non-compliance and knowledge of prescribed medication in elderly patients with heart failure.” European Journal of Heart Failure, vol. 1, no. 2, 1999, pp. 145-149.

13. Polikandrioti, M. et al. “The effects of anxiety and depression on the needs of patients hospitalized with coronary disease.” Archives of Hellenic Medicine, vol. 29, no. 1, 2012, pp. 33-43.

14. Nair, N. et al. “Commonality between depression and heart failure.” The American Journal of Cardiology, vol. 109, no. 5, 2012, pp. 768-772.