Change in Depressive Symptoms During the First Month of Discharge and 1-Year Clinical Outcomes in Patients Hospitalized for Heart Failure

Abstract

Background The patterns of depressive symptom change during the first month after discharge, as well as their prognostic implications, and predictors of persistent or new-onset depressive symptoms are not well characterized. Methods and Results We included patients hospitalized for heart failure undergoing Patient Health Questionnaire-2 before discharge and at 1 month after discharge in a multicenter prospective cohort. We characterized 4 patterns of change in depressive symptoms-persistent, new-onset, remitted depressive symptoms, and no depressive symptom-and examined the associations between the 4 patterns and 1-year clinical outcomes. We analyzed the factors associated with persistent or new-onset depressive symptoms. A total of 4130 patients were included. Among 1175 (28.5%) symptomatic patients and 2955 (71.5%) symptom-free patients before discharge, 817 (69.5%) had remission, and 366 (12.2%) had new-onset depressive symptoms, respectively. Compared with no depressive symptom, persistent depressive symptoms were associated with an increased risk of cardiovascular death (hazard ratio [HR], 2.10 [95% CI, 1.59-2.79]) and heart failure rehospitalization (HR, 1.56 [95% CI, 1.30-1.87]); new-onset depressive symptoms were associated with an increased risk of cardiovascular death (HR, 1.78 [95%CI, 1.32-2.40]) and heart failure rehospitalization (HR, 1.54 [95% CI, 1.29-1.83]). Remitted depressive symptoms were associated with a slightly increased risk of cardiovascular death but had no significant association with heart failure rehospitalization. Patients who were female or had poor socioeconomic status, stroke history, renal dysfunction, or poor health status had a higher risk of persistent or new-onset depressive symptoms. Conclusions Sex, socioeconomic status, clinical characteristics, and health status help identify patients with high risks of depressive symptoms at 1 month after discharge. Dynamic capture of depressive symptom change during this period informs long-term risk stratifications and targets patients who require psychological interventions and social support to improve clinical outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier (NCT02878811).

Keywords: death; depressive symptom; heart failure; postdischarge period; rehospitalization.

Figure 1. Patterns of depressive symptom change stratified by age, sex, and LVEF phenotype.

(A) Age (<65, ≥65), (B) sex (male, female), (C) LVEF phenotype (HFrEF, HFmrEF, HFpEF). No depressive symptom: PHQ‐2 <2 before discharge and <2 at 1 month; remitted depressive symptoms: PHQ‐2 ≥3 before discharge and <2 at 1 month; new‐onset depressive symptoms: PHQ‐2 <2 before discharge and ≥3 at 1 month; persistent depressive symptoms: PHQ‐2 ≥3 before discharge and ≥3 at 1 month. HFmrEF indicates heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; and LVEF, left ventricular ejection fraction.

Figure 2. Outcomes of patients stratified by patterns of depressive symptom change.

(A) Cardiovascular death, (B) all‐cause death, (C) heart failure rehospitalization, (D) all‐cause rehospitalization. No depressive symptom: PHQ‐2 <2 before discharge and <2 at 1 month; remitted depressive symptoms: PHQ‐2 ≥3 before discharge and <2 at 1 month; new‐onset depressive symptoms: PHQ‐2 <2 before discharge and ≥3 at 1 month; persistent depressive symptoms: PHQ‐2 ≥3 before discharge and ≥3 at 1 month. HF indicates heart failure; and PHQ‐2, Patient Health Questionnaire‐2.

Figure 3. Associations between 4 patterns of depressive symptom change at 1 month after discharge and clinical outcomes.

No depressive symptom: PHQ‐2 <2 before discharge and <2 at 1 month; remitted depressive symptoms: PHQ‐2 ≥3 before discharge and <2 at 1 month; new‐onset depressive symptoms: PHQ‐2 <2 before discharge and ≥3 at 1 month; persistent depressive symptoms: PHQ‐2 ≥3 before discharge and ≥3 at 1 month. *Counting hospitals as random effects and adjusting for age (<65, ≥65 years), sex (male, female), smoking status (current smoker, nonsmoker), education level (less than high school, high school or above), prior HF, New York Heart Association class (II, III, IV), hypertension, diabetes, prior myocardial infarction, stroke, anemia, systolic blood pressure (<120, 120–140, ≥140 mm Hg), LVEF phenotype (HFrEF, HFmrEF, HFpEF), N‐terminal pro‐B‐type natriuretic peptide (stratified into trichotomies), eGFR (<45, ≥45 mL/min per 1.73 m²), self‐report use of medications at 1 month after discharge (including renin‐angiotensin system inhibitors, β‐blocker, and spironolactone), and MACE within 1 month after discharge. eGFR indicates estimated glomerular filtration rate; HF, heart failure; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; KCCQ‐12; LVEF, left ventricular ejection fraction; OR, odds ratio; MACE, major adverse cardiovascular events; and PHQ‐2, Patient Health Questionnaire‐2.