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Cognitive behavior therapy intervention effective for depression but not self-care for heart failure

September 28, 2015

A cognitive behavior therapy intervention that targeted both depression and heart failure self-care was effective for depression but not for heart failure self-care or physical functioning compared to enhanced usual care, according to an article published online by JAMA Internal Medicine.

Major depression is a common co-existing illness in heart failure (HF). Depression and inadequate self-care are common and interrelated problems that increase the risks of hospitalization and death in patients with HF. Self-care in HF includes behaviors that maintain physical functioning and prevent acute exacerbations, such as following a low-sodium diet, exercising and taking prescribed medications, according to background information in the article

Kenneth E. Freedland, Ph.D., of the Washington University School of Medicine, St. Louis, and colleagues randomly assigned 158 outpatients with heart failure and major depression to cognitive behavior therapy (CBT) delivered by experienced therapists plus usual care (UC; n = 79) or UC alone (n = 79). Usual care was enhanced in both groups with a structured HF education program delivered by a cardiac nurse. The intervention treatment followed standard CBT manuals and a supplemental manual on CBT for cardiac patients. The intensive phase of the intervention consisted of up to 6 months of weekly 1-hour sessions. Sessions tapered to biweekly and then monthly between the end of intensive (weekly) treatment and 6 months post-randomization.

One hundred thirty-two (84 percent) of the participants completed the 6-month posttreatment assessments; 60 (76 percent) of the UC and 58 (73 percent) of the CBT participants completed every follow-up assessment. Six-month depression scores were lower in the CBT than the UC group. CBT did not improve HF self-care or physical functioning, but it did improve anxiety, fatigue, social functioning, and quality of life, and additional analysis suggested that the intervention might help to decrease the hospitalization rate in clinically depressed patients.

The authors note that major depression in heart failure may respond to CBT even if antidepressant therapy is unsuccessful.

"The results suggest that CBT is superior to usual care for depression in patients with HF," the researchers write. "Further research is needed on interventions to improve depression, self-care, physical functioning, and quality of life in patients with HF and comorbid major depression.
(JAMA Intern Med. Published online September 28, 2015. doi:10.1001/jamainternmed.2015.5220. Available pre-embargo to the media at

Editor's Note: This study was conducted with support from the National Heart, Lung, and Blood Institute. No conflict of interest disclosures were reported.

Editor's Note: Reframing Depression Treatment in Heart Failure

Patrick G. O'Malley, M.D., M.P.H., Deputy Editor, JAMA Internal Medicine, writes that the good news is that the CBT in this study "did significantly improve emotional health and overall quality of life, and the improvement in depressive symptoms associated with CBT was larger than observed in pharmacotherapy trials for depression in patients with heart disease."

"This is supportive evidence for a shift in practice away from so much pharmacotherapy and more use of psychotherapy to achieve better mental health and overall quality-of-life outcomes in patients with heart failure. In reframing how we think about the management of depression in patients with heart failure, we should be talking more and prescribing less."

Editor's Note: No conflict of interest disclosures were reported.

Media Advisory: To contact corresponding author Kenneth E. Freedland, Ph.D., call Judy Martin at 314-286-0105 or email To contact Editor's Note author Patrick G. O'Malley, M.D., M.P.H. email

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