Clinicians taking care of patients with heart failure would probably acknowledge that taking care of heart failure itself can be relatively straightforward. It is when patients have multiple comorbidities to address along with their heart failure that the challenge and complexity of caring for these patients increase.

One of the most challenging comorbidities we encounter is depression. It occurs frequently in this population and it has been associated with untoward outcomes such as difficulty adhering to self-care measures, decreased quality of life, and increased mortality. Despite this, we still have much to learn about the phenomenon of depression in patients with heart failure.

The article by Allman et al in March/April 2009 issue of Journal of Cardiovascular Nursing provides us with some information to help us better understand the occurrence of depression in our patients. These authors conducted a detailed review of 6 trials that studied depression and coping in patients with heart failure to determine if certain types of coping were more common in these patients. From this review, the authors concluded that, overall, those patients using adaptive coping methods (such as active coping, acceptance, and planning) had lower levels of depression than did those patients who used maladaptive coping methods (such as denial and disengagement).1

Thus, it would seem that patients with heart failure who accept their illness and plan their approach to treatment may have less depression than do those patients who deny their illness or disengage themselves from the treatment process. However, there are some limitations and unknowns about the study that may affect this interpretation.

First, it is important to note that although there may be an association between depression and types of coping in patients with heart failure, we have no evidence of causation, nor do we know the direction of any association (ie, depression causing maladaptive coping or maladaptive coping causing depression). Second, the summary information is based on only 579 patients, most of whom were white men in their early 60s with systolic heart failure, which is not the population typically seen in community-based heart failure clinics. Third, as clearly noted by the authors, multiple tools were used to measure depression and coping, which raises questions about the ability to reliably compare findings.

Fourth, there is some missing information that would help us better understand the relationship between depression and coping. One of the studies that were reviewed (Vollman et al2) noted how many patients in that study were depressed and how many were on antidepressants, but these findings were not discussed in relationship to depression and coping-that is, did treatment of the depression make a difference in the associations found between depression and coping? Furthermore, no information was provided about the other 5 studies in relation to how many patients were depressed and whether they were on antidepressants.

Another key piece of unknown information is what medications patients were taking. Of the 6 studies, 5 studies (except Murberg et al3) were composed of subjects with left ventricular systolic dysfunction, an entity with established treatments known to improve symptoms and mortality. One wonders if optimally treated patients may have different levels of coping and/or depression than do patients not on an adequate regimen. In addition, it is unknown what other comorbidities were present in these patient groups. The presence of multiple chronic illnesses, in addition to heart failure and depression, may have affected coping mechanisms.

Having said all of that, I think the reader comes away from this article knowing more about depression in patients with heart failure than before they read it. In addition to the take-home message about an association between coping and depression in select patients, one learns that this area is wide open for research, with still many unanswered questions.

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