Psychosomatics 44:367-373, October 2003
© 2003 The Academy of Psychosomatic Medicine
Congestive Heart Failure and Depression in Older Adults: Clinical Course and Health Services Use 6 Months After Hospitalization
George Fulop, M.D., M.S.,
James J Strain, M.D., and
Glen Stettin, M.D.
Received July 5, 2002; revision received Nov. 8, 2002; accepted Dec. 2, 2002. From Medco Health Solutions, Inc.; and the Division of Behavioral Medicine and Consultation Psychiatry of Mount Sinai/NYU Medical Center/Health Service, New York. Address reprint requests to Dr. Fulop, Medical Policy and Programs, Medco Health Solutions, Inc., 100 Parsons Pond Dr., F2-2, Franklin Lakes, NJ 07417; george_fulop{at}medcohealth.com (e-mail).
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ABSTRACT
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The course of depression and the economic consequences in the 6-month period after hospitalization for congestive heart failure were examined in a prospective observational cohort study involving 203 older adults (mean age=76.8 years, SD=7.8). At discharge, 73 of 203 subjects (36%) were depressed according to the screening criteria of the Geriatric Depression Scale, and 44 (22%) were depressed according to the Structured Clinical Interview for DSM-III-R—Non-Patient Edition. The proportions were 33% and 20% of 166 subjects, respectively, at 4 weeks and 26% and 17% of 113 subjects, respectively, at 24 weeks. Depressed patients used more medical resources after discharge than nondepressed patients. Additional research is required to determine whether the optimal time to identify and treat depressed older adults with congestive heart failure is during a hospital stay or after discharge.
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INTRODUCTION
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Some preliminary studies have suggested that the association of cardiac disease in general, and congestive heart failure in particular, with concurrent depression may result in adverse clinical outcomes, including higher mortality rates.1,2 Congestive heart failure is one of the leading causes of hospitalization of older adults.3,4 Approximately 1 million hospitalizations and more than $10 billion in direct costs annually in the United States are related to congestive heart failure, making it a costly disease for both patients and society.3,4 Given the prevalence of congestive heart failure and the need to better characterize the rate and outcomes of concurrent depression among hospitalized older adults with congestive heart failure, we conducted a prospective observational cohort study to determine the course of depression and the economic consequences in the 6-month period after an inpatient stay for congestive heart failure.
Elderly medical inpatients are five times more likely to have major depression than elderly persons in the community, and depressed elderly persons stay 30%–50% longer in the general hospital and make two to four times as many outpatient medical visits as elderly persons who are not depressed.5–13 In a previous study we observed that less than 1% of older adults receive treatment for depression in a general hospital.5 Less than 10% of depressed older adults receive treatment for depression in the community.9 Depressive symptoms may evolve during hospitalization for an acute medical illness, with many apparent major affective disorders evolving to a diagnosis of adjustment disorder by discharge5 or by outpatient follow-up.7,14–17 Because there are few data on the course of depressive illness in medically ill patients, it remains unclear which patients should and should not be treated and at what point treatment should be provided: before discharge from the hospital, when the elderly patient has ready access to a mental health specialist and when the psychiatric intervention may be more acceptable because it is provided under the umbrella of the general medical care team, or after discharge.
There is also uncertainty about the course of untreated episodes of depressive illness after a medical hospitalization. The depression may constitute a transient dysphoric mood, an acute situational reaction (adjustment disorder), or a major depressive disorder.14–17 The depression may resolve or may worsen with continued improvement of the medical illness and/or discharge from the hospital.1,14–17
The aim of this study was to examine prospectively the course of depressive disorders identified at hospital discharge in elderly medical inpatients with a diagnosis of congestive heart failure and to compare the outcomes for this group with those of nondepressed elderly inpatients with congestive heart failure. Such data permit the characterization of the number and type of patients whose treatment for depression may be potentially initiated in the hospital or in the outpatient setting after discharge. In addition, observation of an episode of depressive illness in both inpatient and outpatient settings provides data for establishing guidelines for "bundling" hospital and postdischarge treatment plans for depression that is concurrent with congestive heart failure and other diseases. Furthermore, this design provides the opportunity to quantify the effects of concurrent depression on the use of health resources, and this information may be used to guide interventions to reduce both the clinical impact and the economic consequences of concurrent depression.
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METHOD
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A single common medical disease, congestive heart failure, was prospectively examined in a group of older adults. After obtaining permission from the admitting physician and informed consent from the patients, we evaluated older adult patients (age >65 years) with congestive heart failure for the presence or absence of depression at the time of discharge from an inpatient stay at Mount Sinai Hospital in New York City. We used two screening measures, the Geriatric Depression Scale18 and the nonpsychiatric patient version of the Structured Clinical Interview for DSM-III-R (SCID),19 the SCID Non-Patient Edition (SCID-NP).20 Patients with congestive heart failure were identified by the presence of an ICD-9 code 428.0 assigned by the admitting cardiologist/internist, and the diagnosis was confirmed by the study cardiologist/internist in accordance with the Framingham and the New York Heart Association functional class criteria. Among 263 patients consecutively admitted for treatment of congestive heart failure during a 15-month period, 60 (23%) patients refused to participate, resulting in a study sample of 203 older adults.
Since both depressive symptoms and the categorical diagnosis of depressive disorders are associated with significant impairment among older adults,21 we assessed the study patients with both a depression screening instrument (Geriatric Depression Scale) and a depression diagnostic instrument (SCID-NP). The Geriatric Depression Scale is a 30-item questionnaire commonly used to screen for depression in geriatric populations; a score of 10 or higher is suggestive of depression.18 Like other screening instruments, the Geriatric Depression Scale casts a wide net to capture a range of depressive morbidity. The SCID-NP is a guided interview that is used to determine the presence of mental disorders on the basis of the DSM-III-R diagnostic criteria.22 The SCID-NP allows the determination of specific psychiatric diagnoses. In practice, physicians' decisions to treat are based on a diagnosis of depressive disorder according to diagnostic criteria, such as those supplied by the SCID-NP, and not just on a positive screening result from the Geriatric Depression Scale.
In this report, we present data on depression status according to the Geriatric Depression Scale and the SCID-NP at discharge and at 4 and 24 weeks after discharge. Changes in depression status are reported in terms of depression prevalence and persistence (the percentage of patients identified as depressed at discharge who remained depressed at 4 and 24 weeks after discharge). The number of incident cases of depression among the patients who were not depressed at discharge is also reported for the 4- and 24-week endpoints.
Of the 203 study subjects evaluated at discharge, 53.2% were female (N=108), 47.3% were white (N=96), 31.0% were African American (N=63), 20.7% were Hispanic (N=42), and 0.5% (N=2) were other. The mean age was 76.8 years (SD=7.8, range=65–98). The distribution of New York Heart Association functional classes was as follows: class I=16% (N=33); class II=68% (N=138); class III=13% (N=26); and class IV=3% (N=6) (higher class numbers indicate more severe functional impact of congestive heart failure). We prospectively observed depression status and use of medical resources at 4 and 24 weeks after discharge from a medical hospitalization for congestive heart failure. All subjects received usual care from their primary physician. The hypotheses were 1) 50% of older adults identified as depressed at hospital discharge and 10% of older adults identified as nondepressed at discharge will be found to be depressed at 4 or 24 weeks after discharge; 2) older adults who are depressed at discharge will have higher rates of health services utilization for the 4- or 24-week follow-up periods, compared to the nondepressed group; and 3) older adults found to be depressed at 4 or 24 weeks after discharge will use more health services than the nondepressed group.
Health resource use encompassed all medical encounters, including physician office visits, emergency department visits, rehospitalization days (new days in the hospital after an index hospitalization), laboratory and radiology testing, visiting nurse services, home care, and long-term care. Cumulative data on the use of medical resources were collected at the 4- and 24-week evaluation visits and every 4 weeks for study weeks 8 through 20 by means of patient diaries and follow-up telephone contacts by a research assistant. The health resources utilization at 4 and 24 weeks of patients who were persistently depressed since hospitalization was compared with the utilization of those who were not depressed. To better understand the effects of depression on medical resource use, we also examined the resource use of patients who were depressed at the follow-up endpoints, whether or not they were depressed at hospital discharge.
To address the important issue of differences in illness severity and comorbidities between the study groups, the patients were assessed with the Duke University Severity of Illness Checklist developed by Parkerson et al.23 Ratings were summed for non-disease-specific parameters, including symptom severity, presence of complications, prognosis without treatment, and expected response to treatment. An overall disease severity score and individual comorbidity scores were calculated to control the effects of severity of illness, which would itself affect medical resource use.23
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RESULTS
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Depression Assessment
At discharge, 73 (36%) of 203 subjects were depressed according to the screening criteria of the Geriatric Depression Scale, and 44 (22%) met the criteria for a diagnosis of depression according to the SCID-NP. The Geriatric Depression Scale and SCID-NP both identified 73% of the subjects as either depressed or not depressed, but the findings from the two instruments were discordant for 26% of the subjects. At the 4- and 24-week follow-ups, 166 (82%) and 113 (56%) of the subjects completed evaluations. At 4 weeks, 54 (33%) of the 166 subjects were depressed according to the Geriatric Depression Scale, and 34 (20%) met the criteria for a depression diagnosis according to the SCID-NP. At 24 weeks, 29 (26%) of the 113 subjects were depressed according to the Geriatric Depression Scale, and 19 (17%) met depression diagnostic criteria according to the SCID-NP (Table 1).
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TABLE 1. Depression Status of Elderly Patients as Assessed With Two Measures of Depression at Discharge From Hospitalization for Congestive Heart Failure and 4 and 24 Weeks After Discharge
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All patients were reevaluated to identify persistent and incident cases of depression at 4 weeks after hospital discharge. Thirty-nine (53%) of the 73 subjects who were depressed at hospital discharge according to the Geriatric Depression Scale and 20 (45%) of the 44 subjects with a depression diagnosis according to the SCID-NP at discharge remained depressed at 4 weeks after discharge. Although a greater proportion of the depressed than the nondepressed patients met the criteria for New York Heart Association functional class III or IV at discharge (23% versus 11%) ( 2=8.02, df=1, p<0.05), there was no difference between groups in total burden of illness as measured with the Duke University Severity of Illness Checklist (depressed patients: mean score=67; nondepressed patients: mean score=63) (t=1.45, df=154, n.s.).
Nondepressed patients were evaluated at 4 weeks after discharge for incident cases of depression. Fifteen (12%) of the 130 subjects who screened negative for depression at discharge according to the Geriatric Depression Scale had a positive screen for depression at 4 weeks. Fourteen (9%) of the 159 subjects who did not meet criteria for a diagnosis of depression at discharge according to the SCID-NP were subsequently identified as depressed according to the SCID-NP at the 4-week follow-up.
All subjects were evaluated for persistent and incident cases of depression at 24 weeks after hospital discharge. Twenty-one (29%) of the 73 subjects who were depressed at discharge according to the Geriatric Depression Scale and 11 (25%) of the 44 subjects who met the criteria for a depression diagnosis at discharge according to the SCID-NP remained depressed 24 weeks after discharge.
In contrast, among the 130 subjects who screened negative for depression at discharge according to the Geriatric Depression Scale, eight (6%) had a positive screen at 24 weeks. Among the 159 subjects who did not meet the criteria for a diagnosis of depression at discharge according to the SCID-NP, eight (5%) met the depression criteria at the 24-week follow-up.
Health Services Utilization
At 4 weeks after discharge, there were no significant differences between the patients who had been identified as depressed at discharge according to the Geriatric Depression Scale and the nondepressed patients in the number of medical encounters (e.g., physician visits, emergency department visits, hospital admissions, laboratory tests) (3.0 versus 2.4 encounters) (t=1.33, df=162, p<0.19) or rehospitalization days (3.0 days versus 2.6 days) (t=0.37, df=162, p<0.71). In contrast, patients with a diagnosis of depression at discharge according to the SCID-NP had significantly more medical encounters (2.9 versus 2.6 encounters) (t=2.00, df=162, p<0.05) and rehospitalization days (4.5 versus 2.3 days) (t=1.96, df=162, p<0.05) at 4 weeks than the nondepressed patients (Table 2).
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TABLE 2. Medical Resource Use at 4 and 28 Weeks After Discharge From Hospitalization for Congestive Heart Failure, by Patients' Depression Status as Assessed by Two Measures of Depression at Discharge
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At 24 weeks posthospitalization, patients who had been identified as depressed at discharge according to the Geriatric Depression Scale had a higher number of medical encounters than the nondepressed patients (15.5 versus 13.1 encounters) (t=1.04, df=111, p<0.30) and more rehospitalization days than the nondepressed patients (14.4 days versus 9.4 days) (t=1.20, df=111, p<0.23).
Similarly, there were no significant differences between the patients who had a diagnosis of depression at discharge according to the SCID-NP and the nondepressed patients in the number of medical encounters (15.4 versus 13.5 visits) (t=0.73, df=111, p<0.47) and the number of rehospitalization days (14.0 versus 10.3 days) (t=0.78, df=111, p<0.44).
Patients who were depressed at 4 weeks after discharge (as screened by the Geriatric Depression Scale)—regardless of whether they had been depressed at discharge—had more medical encounters (2.9 versus 2.5) and more rehospitalization days (3.0 versus 2.7 days) in the 4 weeks since the index hospitalization than the patients who were not depressed at 4 weeks, but the differences were not significant (t=0.74, df=162, p<0.46 and t=0.38, df=162, p<0.70, respectively).
Patients with depression according to the SCID-NP at 4 weeks after discharge—regardless of whether they had met the criteria for a diagnosis of depression at discharge—had fewer medical encounters than the patients without depression according to the SCID-NP at 4 weeks (2.5 versus 2.7 visits) (t=0.24, df=162, p<0.81) but did not differ significantly from the nondepressed patients in the number of rehospitalization days (4.2 versus 2.4 days) (t=1.31, df=162, p<0.20).
In contrast, patients who were depressed at 24 weeks after discharge according to the Geriatric Depression Scale—regardless of whether they had been identified as depressed at discharge—had a significantly higher number of medical encounters in the 24 weeks since hospitalization (18.0 versus 12.6) (t=1.68, df=111, p<0.03) but no significant difference in the number of rehospitalization days (15.2 versus 9.8 days) (t=1.18, df=111, p<0.24), compared with patients who were not depressed at 24 weeks according to the Geriatric Depression Scale.
Patients with a diagnosis of depression according to the SCID-NP at the 24-week evaluation were not significantly different from the patients who did not meet criteria for depression according to the SCID-NP at 24 weeks in the number of medical encounters (16.5 versus 13.4 visits) (t=1.06, df=111, p<0.30) or days in the hospital (16.6 versus 10.0 days) (t=1.14, df=111, p<0.28).
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DISCUSSION
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In this 6-month follow-up study of older adults hospitalized for congestive heart failure, high rates of concurrent depression were observed at discharge and persistently high rates of depression were observed 1 and 6 months after discharge, confirming our initial hypotheses. Between 45% and 53% of the older adults with congestive heart failure in this study who were depressed at discharge remained so 4 weeks later, and between 25% and 29% remained depressed after 6 months. Furthermore, a significant percentage of those who were not depressed at discharge were subsequently observed to be depressed—more than 9% at 4 weeks and more than 5% at 24 weeks after hospital discharge. Similarly, Koenig reported that 36.5% of a group of older patients hospitalized for congestive heart failure were depressed, that more than 40% of the depressed patients remained so at 1-year follow-up, and that these patients used more outpatient and inpatient medical services than nondepressed patients.24 In a study of general medical patients, Fenton et al.7 noted similar overall findings: only 44% of major depressive episodes in older medical inpatients resolved at 1-year follow-up, few patients (30%) with major depression with superimposed dysthymic disorder improved, and new episodes of depression occurred in 21% of patients. Clearly, a significant burden of depression persists or arises in older patients between hospital discharge and 6 months to 1 year after discharge.
These high rates and fluctuations of depression represent significant challenges to physicians. Screening for depression among older adults hospitalized for congestive heart failure may yield high rates of undiagnosed depression at discharge or 4 weeks later. However, whether one should initiate treatment at discharge or wait until 1 month later remains an open question. Treating depression concurrently with intensive medical treatment for acute exacerbation of heart failure may involve introducing another medication—a psychotropic—with its potential for adverse events at a time of great change in the patient's medical management plan. It may be more appropriate to wait a month until the patient's congestive heart failure has stabilized and the patient has returned to a familiar environment before reevaluating the patient for depression and initiating antidepressant therapy. By 1 month postdischarge, patients with congestive heart failure who experienced dysphoria or an adjustment disorder with depressed mood at the time of hospitalization may have had enough time to return to euthymia and better adapt to their medical situation. Persistent depression at 1 month, after transient mood disturbances have had time to resolve, would be a more compelling finding that would indicate the need to begin treatment.
The elderly patients who were identified as depressed by the SCID-NP and who were untreated at discharge used more outpatient health resources 1 month after discharge than nondepressed patients, and those who were identified as depressed by the Geriatric Depression Scale at discharge or postdischarge used more outpatient resources at 6 months after discharge, compared with nondepressed patients. These findings are similar to those of Koenig, although he noted that the higher rate of medical service use was primarily related to greater severity of illness—medical acuity—in the depressed patients.24 Treating depressed medical outpatients has been shown to reduce inappropriate medical resource use and to promote appropriate psychiatric treatment and outcomes, with a potential for overall cost savings.25 It remains to be demonstrated whether treatment of depressed older patients with heart failure in the ambulatory setting would result in a cost-offset effect similar to the effect observed in a mixed-age group of patients with concurrent medical and depressive disorders.25
It is important to note the differences in rates of depression and health services utilization observed when depression is identified with a screening instrument (the Geriatric Depression Scale) versus a diagnostic tool (the SCID-NP). If one instrument had been used alone, important findings would not have been observed. Although the findings for the two instruments agreed in more than 73% of cases, the instruments were discordant in identifying depressed patients in a considerable percentage of cases, with the Geriatric Depression Scale identifying more cases of depression (N=73) than the SCID-NP (N=44). In addition, the depressed patients identified by the two instruments also had different rates of health service resource utilization. This difference raises the issues of which instrument should be used in future studies—a screening instrument or a diagnostic instrument—and of how the findings might differ if the patients were assessed with a traditional psychiatric clinical interview. As mentioned earlier, physicians' treatment plans are based on a diagnosis; however, more older adults were identified as depressed by the screening instrument than by the diagnostic tool. Identifying patients with depression by using only a diagnostic tool may result in a considerable percentage of depressed older adults not receiving treatment—pharmacotherapy or psychotherapy—despite notable persistence of depressive symptoms, disability, and high rates of medical resource use, such as were found among the depressed patients identified by the screening instrument in this study.
Medical and psychiatric disorders such as congestive heart failure and depression commonly coexist, raising the question of the validity of depression screening and diagnostic instruments, which were not developed in medically ill populations. Did the Geriatric Depression Scale or the SCID-NP adequately take into account vegetative signs and symptoms of depression, e.g., eating, sleeping, libido, and energy symptoms, all of which may be affected by the medical illness per se, as well as by the pharmacological agents prescribed in treatment protocols? Vegetative symptoms that can be attributable to the medical illness (axis III diagnoses) may not be used in the algorithm for the assessment of the diagnosis of depression. Yet, how does the evaluator know the source of dysfunctions in eating, sleeping, libido, or energy, especially in the face of serious medical illness? Psychiatric assessment instruments developed in non-medically-ill populations may be difficult to interpret when used with older and medically ill patients, and these difficulties constitute a limitation in this study and in this area of research in general. The ultimate choice of whether to use one type of instrument or another should be determined by the goal of the users—a wide screen or a narrower diagnostic assessment.
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CONCLUSIONS
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In older patients hospitalized for congestive heart failure, depression, whether identified by a screening instrument (Geriatric Depression Scale) or a diagnostic instrument (SCID-NP), fluctuated significantly from the time of hospital discharge throughout the following 6 months. More than 25% of the patients in this study who were depressed at discharge remained depressed at a 6-month follow-up. In addition, more than 5% of the patients who were not depressed at discharge were subsequently identified as depressed over the next 6 months. It is noteworthy that the depressed patients used more medical resources after discharge than nondepressed patients. Depression in elderly patients with congestive heart failure remains largely unrecognized and untreated both in inpatient and outpatient settings. More research is required to determine whether the optimal time to assess older patients with congestive heart failure for depression and to begin treatment of depression is during the hospital stay or after discharge in an outpatient setting.
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ACKNOWLEDGMENTS
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Supported by NIMH grant MH-50091 (Drs. Fulop and Strain). The authors thank Agnes Rupp, Ph.D., Kathy Magruder, Ph.D., Marianne Fahs, Ph.D., Charlotte Muller, Ph.D., Marrick L. Kukin, M.D., George Parkerson, M.D., and James Schmeidler, Ph.D., for assistance in the design, development, and support of the study as well as Jennifer Fetner, Mindy Gomes, Laura Golub, and Tom Pontos for assistance in conducting the study.
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ABSTRACT
INTRODUCTION
