Factors associated with the symptoms of depression in people with heart failureABSTRACT
Objective: Identify the factors associated with the symptoms of depression in people with heart failure.
Method: Cross-sectional study with a quantitative approach, conducted with individuals diagnosed with heart failure in follow-up at the cardiology outpatient clinic of a university hospital in the municipality of João Pessoa, Paraíba, Brazil. The data was collected from December 2021 to May 2022 using a sociodemographic and clinical characterization instrument and the Patient Health Questionnaire-9. Analysis by descriptive and inferential statistics.
Results: Of the 89 participants, 32.6% reported symptoms of depression. In the association between the variables, symptoms of depression were associated with sex (p=0.004), self-assessment of health (p=0.042), functional class (p<0.001), and hospitalization for heart failure (p=0.044).
Conclusion: Such findings can support new research and nursing interventions to provide comprehensive and quality care.
KEYWORDS:
Heart Failure; Cardiovascular Diseases; Depression; Adult Health; Health of the Elderly
HIGHLIGHTS
32.6% of respondents reported symptoms of depression.
There was a statistically relevant association with the variables sex, self-assessment of health, functional class, and hospitalization for heart failure.
A holistic and comprehensive assistance is essential.
RESUMO
Objetivo: Identificar os fatores associados aos sintomas de depressão de pessoas com insuficiência cardíaca.
Método: Estudo transversal com abordagem quantitativa, realizado com pessoas com diagnóstico médico de insuficiência cardíaca em seguimento no ambulatório de cardiologia de um hospital universitário do município de João Pessoa, Paraíba, Brasil. Os dados foram coletados no período de dezembro de 2021 a maio de 2022, utilizando-se um instrumento para caracterização sociodemográfica e clínica e o Patient Health Questionnaire-9. Análise por estatística descritiva e inferencial.
Resultados: Dos 89 participantes, 32,6% referiram presença de sintomas de depressão. Na associação entre as variáveis, os sintomas de depressão associaram-se ao sexo (p=0,004), autoavaliação da saúde (p=0,042), classe funcional (p<0,001) e internação por insuficiência cardíaca (p=0,044).
Conclusão: Tais achados podem embasar novas pesquisas e intervenções de enfermagem com o intuito de proporcionar uma assistência integral e de qualidade.
DESCRITORES:
Insuficiência Cardíaca; Doenças Cardiovasculares; Depressão; Saúde do Adulto; Saúde do Idoso
HIGHLIGHTS
32,6% dos entrevistados referiram sintomas de depressão.
Houve associação estatisticamente relevante com as variáveis sexo, autoavaliação da saúde, classe funcional e internação por insuficiência cardíaca.
É imprescindível uma assistência holística e integral.
RESUMEN
Objetivo: Identificar los factores asociados a los síntomas de depresión de personas con insuficiencia cardíaca.
Método: Estudio transversal con enfoque cuantitativo, realizado con personas con diagnóstico médico de insuficiencia cardíaca en seguimiento en el ambulatorio de cardiología de un hospital universitario del municipio de João Pessoa, Paraíba, Brasil. Los datos fueron recolectados en el período de diciembre de 2021 a mayo de 2022, utilizando un instrumento para la caracterización sociodemográfica y clínica y el Patient Health Questionnaire-9. Análisis por estadística descriptiva e inferencial.
Resultados: De los 89 participantes, el 32,6% informó la presencia de síntomas de depresión. En la asociación entre las variables, los síntomas de depresión se asociaron con el sexo (p=0,004), la autoevaluación de la salud (p=0,042), la clase funcional (p<0,001) y la hospitalización por insuficiencia cardíaca (p=0,044).
Conclusión: Tales hallazgos pueden fundamentar nuevas investigaciones e intervenciones de enfermería con el objetivo de proporcionar una atención integral y de calidad.
DESCRIPTORES:
Insuficiencia Cardíaca; Enfermedades Cardiovasculares; Depresión; Salud del Adulto; Salud del Anciano
HIGHLIGHTS
El 32,6% de los encuestados reportaron síntomas de depresión.
Hubo una asociación estadísticamente relevante con las variables sexo, autoevaluación de la salud, clase funcional e internación por insuficiencia cardíaca.
Es imprescindible una asistencia holística e integral.
INTRODUCTION
Heart failure is a complex syndrome characterized by the heart’s inability to pump enough blood to meet the body’s metabolic needs due to structural and/or functional cardiac changes1. Due to its high prevalence, it is currently considered one of the biggest challenges in the health field2. Estimates are that 23 million people are affected by the disease, with a projected increase of 46% by 2030 worldwide3.
In Brazil, approximately 6.5 million people have heart failure, which is the main cause of hospitalization in the Unified Health System (SUS)2,4. Between January and November 2022, there were about 200 thousand hospitalizations5. Studies on deaths from heart failure identified a mortality rate of up to 15% during hospitalizations6-7. The economic impact on health services exceeds 3 billion reais8.
The main symptoms of heart failure include dyspnea, pain, cough, fatigue, nausea, and constipation, which generally occur concurrently, worsening with the progression of the disease9-11. These symptoms are related to impairments in functional capacity and self-care management, interfering with the well-being and quality of life of patients12.
Living with chronic illness can provoke depressive symptoms, such as feelings of hopelessness, fear, sadness, sleep disturbances, and anxiety, which are frequently reported by these patients and are not favorable for the control and treatment of the disease. Researchers identified exacerbations and hospitalizations linked to a worse prognosis in patients with depressive symptoms12-13.
Factors such as the chronicity of heart failure, the requirement to adopt a healthy lifestyle, and changes in behaviors for disease control can be a daunting task for the patient and their families, potentially triggering stressful events and depressive symptoms12. The prevalence of depression in patients with heart failure can reach 70%14.
Health professionals, especially nurses, are essential in helping these individuals cope with the disease15. Nursing assistance occurs through the provision of comprehensive care, which utilizes a set of planned and personalized actions and interventions in an individual and humanized manner aimed at alleviating the symptoms of the disease and enhancing the physical and psychological well-being of the patient12.
However, studies that identify these factors and characterize the profile of these people are still scarce. Therefore, it is essential to understand and study this relevant topic to promote the knowledge of health professionals, especially nurses, involved in the care of patients with heart failure, as well as to support the creation of public policies aimed at reducing morbidity and mortality rates and improving the quality of life of these individuals. Thus, the objective of this study is to identify the factors associated with the symptoms of depression in people with heart failure.
METHOD
This is a cross-sectional study with a quantitative approach, conducted at the cardiology outpatient clinic of a university hospital in João Pessoa, Paraíba - BR, from December 2021 to May 2022. For data collection, the following inclusion criteria were established: being 18 years of age or older, having a diagnosis of heart failure, and being in outpatient follow-up at the institution for at least three months to capture patients adapted to the established therapy.
The individuals who presented clinical complications during the collection that made it impossible to carry out the research or cognitive deficits assessed by the Mini-Mental State Examination, whose cutoff points were used according to the participant’s education level, did not participate in the survey. 13 points for illiterates, 18 for low (one to four incomplete years) and medium education (four to eight incomplete years) and 26 for high education (more than eight years)16.
To define the sample calculation, data obtained from the hospital’s computerized registration system were used, referring to outpatient services offered to patients with heart failure from January to December 2021, resulting in a population of 211 patients. Taking into account a confidence level of 99% and a margin of error of 5%, based on the variables and instruments of the present study, the calculation was performed by software statistical R, based on the margin of error of the sample mean, totaling 89 participants.
Data collection occurred through individualized interviews in the outpatient clinic, using a semi-structured instrument developed by the researchers of this study, submitted to prior evaluation by master and doctoral judges in the field to obtain the sociodemographic and health profiles of the participants. For the understanding of the elderly person, the World Health Organization (WHO) classification was considered, which defines the elderly population as individuals aged 60 years or older.
The Patient Health Questionnaire (PHQ-9) instrument was developed by Robert L. Spitzer, Janet B. W. Williams, and Kurt Kroenke are validated in the general Brazilian population by Santos et al.17, being in the public domain. This unidimensional instrument was used to identify the presence of depressive symptoms, consisting of nine questions to assess the existence of major depression symptoms in the last two weeks, using the Likert scale from 0 to 3, and the tenth question to evaluate the interference of these symptoms in the performance of daily activities. This instrument’s score can vary from 0 to 27 points, with a cutoff point for screening depressive symptoms ≥ 917.
The collected data was compiled and stored in the Microsoft Office Excel 2010 program, with double entries containing the encoding and dictionary of all variables. Subsequently, it was imported into the Statistical Package for the Social Sciences (SPSS) version 24.0 for descriptive statistical analysis and inference program. The Pearson Chi-Square test or Fisher’s Exact test was used to identify the association between the variables. The significance level used for the statistical analyses was 5% (p≤0.05).
The present research was approved by the Research Ethics Committee of the Lauro Wanderley University Hospital of the Universidade Federal da Paraíba with opinion no. 4.865.295.
RESULTS
Of the 89 participants, 47 (52.8%) were male; 51 (57.3%) elderly; 66 (74.2%) self-declared non-white; 54 (60.7%) married or in a stable union; 24 (27.0%) with five to eight years of education; 83 (93.3%) practicing some religion; 89 (84.3%) not working; 53 (59.6%) retired; 78 and 75 (87.6% and 84.3%, respectively) with individual and family income of one to three minimum wages; 44 (49.4%) who lived with one to two people; and 63 (70.8%) from municipalities in the interior.
Regarding the clinical profile, 58 (65.2%) self-assessed their health as fair; 54 (60.7%) did not engage in physical activity; 60 (67.4%) participated in some leisure activity; 87 (97.8%) were not current smokers, but 60 (67.4%) had smoked previously; 84 (94.4%) did not consume alcoholic beverages currently, but 50 (56.2%) had consumed them previously; 86 (96.6%) had some comorbidity, of which 65 (73.0%) had systemic arterial hypertension; 71 (79.8%) were eutrophic; 38 (42.7%) had a normal Body Mass Index; 89 (100.0%) were using medications; 74 (83.1%) were receiving nutritional follow-up; and 60 (67.4%) did not have a caregiver.
Regarding the characteristics related to the disease of this population, 24 (27.0%) reported having 1 to 2 years or more than 10 years of diagnosis; 49 (55.1%) were classified as NYHA II; 63 (70.8%) had already been hospitalized for heart failure; 60 (67.5%) had a left ventricular ejection fraction of 40% or less; and 80 (89.9%) did not have a pacemaker. Regarding the symptoms of depression, 29 (32.6%) reported their presence (Table 1).
In the association between depression symptoms and sociodemographic variables, an association with sex was observed (p=0.004) (Table 2).
Association between sociodemographic characteristics and depression symptoms in patients with heart failure. João Pessoa, PB, Brazil, 2022
In Table 3, there is an association between depression symptoms and self-assessment of health (p=0.042).
Association between health conditions and depression symptoms in patients with heart failure. João Pessoa, PB, Brazil, 2022
The symptoms of depression were associated with the functional class variables (p<0.001) and hospitalization for heart failure (p=0.044) (Table 4).
Association between disease-related characteristics and depression symptoms in patients with heart failure. João Pessoa, PB, Brazil, 2022
DISCUSSION
In a cross-sectional observational study conducted with patients undergoing outpatient and inpatient treatment for heart failure in the wards of two hospitals in Rio de Janeiro - RJ, it was observed that 39.6% of the hospitalized group and 32.7% of the outpatient group exhibited symptoms of depression, data similar to that obtained in this research12.
New pathophysiological findings demonstrate that, in the context of this heart disease, inflammatory changes, neuro-humoral mechanisms, and low cerebral flow may be associated with the onset of these symptoms12. However, beyond that, the very condition that this syndrome imposes, as well as the changes that occur due to the treatment to which the patient is subjected, can affect that person’s quality of life (QoL) and, consequently, increase the risk of developing depression11,18.
More depressed individuals demonstrate a worse ability for self-care. Thus, there is a strong obstacle to therapeutic adherence, which creates a cyclical event in which there is a worsening of the heart failure condition and a decline in quality of life12. This was demonstrated by the research above, which identified that patients with heart failure with depression symptoms scoring equal to or greater than 18 had their quality of life more affected in all dimensions and worse total scores12.
A study conducted by the Brazilian Institute of Geography and Statistics (IBGE) with 60,202 (2013) and 90,846 (2019) people from all over Brazil identified a higher prevalence of self-reported depression in females, with an increase from 7.6% to 10.2% between 2013 and 201919. In contrast, a cross-sectional observational study conducted in two basic health units in Pindamonhangaba - SP found that, despite the higher prevalence of depression in males, only women exhibited more severe depression symptoms11.
According to the WHO, the female population shows higher rates of emotional disorders, as they face various difficulties in daily activities and in taking care of the home and family20. Moreover, women also tend to identify the presence of symptoms and seek professional help more than men, which contributes to the diagnosis of psychological disorders, especially depression19.
Self-assessment of health is considered an important subjective indicator, which considers the individual’s physical and emotional components, as well as their well-being and satisfaction with their own life. In a cross-sectional study conducted with health workers in the municipality of Diamantina - MG, there was a higher prevalence of negative self-assessment of health among individuals with a medical diagnosis of some disease or who had multimorbidities21.
In this research, self-rated health was associated with depression symptoms, demonstrating a low positive perception of health among those with depressive symptoms. This can be justified due to the numerous changes that occur in the life of the patient with heart failure due to the clinical condition of this pathology and also the treatment itself, which imposes limits and changes that are not always considered pleasant for those who need to undergo14.
In light of this, one realizes the importance of understanding health self-assessment and using it in the work process of health professionals, especially in the care of patients with heart failure, to better understand the diagnosis and enable acceptance of these people’s new life conditions.
The New York Heart Association (NYHA) was used in this research for the functional class, based on the individual’s tolerance to exercise1. In this study, an association was observed between the functional class variable and depressive symptoms, highlighting a high frequency of depressive symptoms in those who presented high functional impairment. The literature indicates that the higher the functional class, the worse the symptoms and the consequences in the patient’s daily activities13.
Regarding hospitalization, it is known that such a situation is not unpleasant. Therefore, it is understood that there is a strong relationship between hospitalizations and the onset of depression13. When the hospitalized patient presents as depressed, it is expected that there will be a worsening of the symptoms of the syndrome, mainly fatigue, and dyspnea, and the risk of mortality becomes 60% higher in patients with heart failure associated with depression22-23.
A cross-sectional and descriptive study conducted in the emergency department and cardiology wards of a public hospital in the state of Pernambuco with 133 patients revealed that 54 individuals with a length of stay of less than 7 days already exhibited minimal to mild symptoms of depression, while 16 respondents showed moderate to severe depressive symptoms24.
In this context, it is clear how fundamental nursing professionals are. They work fully not only in hospital care but also in the health education of patients to optimize their self-care practice25. Therefore, nurses must have the technical and scientific foundation to act effectively in preventing harm and promoting health for this population.
However, the study’s cross-sectional design has limitations, as it is not possible to establish a cause-and-effect relationship between the obtained variables. Therefore, longitudinal studies can be conducted to more closely observe the association of depressive symptoms in the health-disease process of patients with heart failure.
CONCLUSION
The results of this study showed that 32.6% of respondents reported symptoms of depression, where an association was observed with the variables of sex, self-assessment of health, functional class, and hospitalization due to heart failure.
The results of this study become relevant for nursing, as well as for other areas of health, as they provide the sociodemographic and clinical profile of this population and identify associations with symptoms of depression. This allows for new discussions about public policies and actions for the prevention, treatment, and rehabilitation of this population at different levels of health care.
In this way, one also realizes the indispensability of these findings to support new research and subsidize interventions, especially those carried out by nursing, to reduce the presence of depressive symptoms in patients with heart failure through comprehensive care, thus providing a better quality of life and greater adherence to the treatment of this pathology.
ACKNOWLEDGMENTS
A thank you to the National Council for Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), which, through the notice 01/2022, significantly contributed to the execution of this research.
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HOW TO REFERENCE THIS ARTICLE:de Melo DA, Frazão MCLO, Ferreira GRS, da Silva CRR, Viana LRC, de Lima RB, et al. Factors associated with the symptoms of depression in people with heart failure. Cogitare Enferm [Internet]. 2025 [cited “insert year, month and day”];30. Available from: https://doi.org/10.1590/ce.v30i0.97808
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Associate editor: Dra. Susanne Elero Betiolli
