- Exercise training and cognitive behavioral therapy (CBT) were associated with significant reductions in depressive symptoms in patients with heart failure, compared with usual care
- Antidepressants did not provide any significant therapeutic benefit compared with placebo or usual care
- Because exercise training has other benefits in heart failure, the researchers recommend it, alone or in combination with CBT, for patients who are also experiencing depression
Depression is an independent prognostic factor for patients with heart failure (HF), known to be associated with greater mortality, morbidity and reduced quality of life. The interventions most commonly studied for treating depression in HF are antidepressants, exercise training and cognitive behavioral therapy (CBT). However, no single study has compared the effectiveness of these interventions.
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To fill the knowledge gap, researchers at Massachusetts General Hospital performed a network meta-analysis and found that antidepressants do not provide any significant therapeutic benefit compared with placebo or usual care. Avash Das, MBBS, Bhaskar Roy, MBBS, and Saumya Das, MD, PhD, co-director of Resynchronization and Advanced Cardiac Therapeutics Program, and colleagues report their findings in the Journal of Psychiatric Research.
The researchers identified 21 relevant randomized, controlled trials before November 2016. These included three trials that compared antidepressants with placebo, four trials that compared CBT with usual care and 15 trials that compared exercise training with usual care. Overall, 1,989 patients received an active intervention and 1,826 patients were assigned to a control group (placebo or usual care). The average age of the study population was 63, and 61% of subjects were men.
The primary outcome was the change in depressive symptoms as rated on validated measures of depression. Because the studies used different scales to rate symptoms, the researchers calculated the standardized mean difference (SMD) as the effect size.
The results showed that both exercise training and CBT were associated with decreases in depressive symptoms, compared with control. The SMD for exercise was −0.38 (95% CI, −0.54 to −0.22) and the SMD for CBT was −0.29 (95% CI, −0.58 to −0.01).
Antidepressant therapy was no different from control in reducing depressive symptoms in patients with HF (SMD, −0.16; 95% CI, −0.44 to 0.11).
The studies were heterogeneous, so the researchers performed several subgroup analyses. They found that exercise training appeared to have a better effect in treating depression in patients ≤65 years of age than in older patients.
Two previous studies also found that antidepressants have no significant benefit in treating depression in HF, the researchers comment. Moreover, antidepressants can have cardiotoxic effects, such as QTc prolongation, arrhythmia and orthostatic hypotension.
In contrast to these downsides of antidepressants, the researchers say, increasing evidence suggests exercise training has additional benefits in patients with heart failure: better functional capacity, reduction in cardiovascular risk factors and improved clinical outcomes.
They recommend exercise training, alone or in combination with CBT, as a reasonable treatment for depression in HF.
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