Behavioral activation vs antidepressants: Which wins for heart failure patients with depression?

By Neha MathurJan 17 2024Reviewed by Lily Ramsey, LLM

In a recent article published in JAMA Network Open, researchers compared the efficacy of antidepressant medication management (MEDS) against behavioral activation psychotherapy (BA) among inpatients admitted to a hospital with heart failure (HF) and outpatients presenting to clinics for HF follow-up, both experiencing depressive symptoms.

They conducted a randomized controlled trial (RCT) between 2018 and 2022, including a one-year follow-up within Cedars-Sinai Health System in California, United States. 

Study: Comparative Effectiveness of Psychotherapy vs Antidepressants for Depression in Heart Failure. Image Credit: New Africa/Shutterstock.com

Background

The interplay of biological and psychosocial mechanisms gives rise to depression among ~50% of HF survivors.

As a result, HF patients with depression have poorer health-related quality of life (HRQOL) than patients with HF without depression. 

The patient's depressive symptom severity also increases the risks of decline in cognitive functions or death at six months; moreover, it is an independent factor associated with all-cause mortality.

Accordingly, the American Heart Association (AHA) recommends screening for depression in patients with HF and other heart diseases.

However, it is equally crucial to make treatments, such as antidepressant medications and psychotherapy, available for patients diagnosed with depression, which often is not the case.

Some notable evidence-based treatments for depression in patients with HF are cognitive behavioral therapy (CBT), e.g., BA, and antidepressant medications, also known as pharmacotherapy. 

However, limited access to these interventions and a lack of evidence for clinicians on which intervention to use for depression treatment in HF patients are some of the issues that require attention.

About the study

In the present study, researchers addressed these challenges facing clinicians, patients, and caregivers and compared the effectiveness of psychotherapy vs pharmacotherapy for patient-centered outcomes in an RCT.

The study cohort had a life expectancy of over six months post-HF, confirmed by their treating physician, and depressive disorder, based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.

The team randomly assigned participants to BA or MEDS in a 1:1 ratio. BA therapists, licensed social workers, and MEDS care managers took a 50-minute introductory session of participants, followed by 12 weekly sessions of BA or MEDS.

These sessions were run monthly for three months, followed by contact for six more months, as deemed necessary.

They delivered 50-minute BA and 15-minute MEDS sessions on telephone/video call, which was easy to access for HF patients, saved time, and improved adherence to the program; additionally, it improved mood and HRQOL without compromising efficacy.

This trial had multiple outcomes of interest, with depressive symptom severity at six months, measured by the patient health questionnaire 9-item (PHQ-9) being the primary outcome.

Secondary outcomes were physical/mental HRQOL and HF-specific HRQOL, measured using the short-form 12-item version 2 (SF-12) and Kansas City cardiomyopathy questionnaire, respectively.

The team also monitored caregiver burden, measured using the caregiver burden questionnaire for HF; additionally, they collected emergency department (ED) visits, readmissions, days of hospitalization, and mortality at three, six, and 12 months.

Results

Of 416 patients with HF enrolled in this RCT, 243 were male, and the median age of the study participants was 60.71 years. 

Both BA and MEDS groups had 208 patients whose mean (SD) PHQ-9 scores at baseline were 14.54 (3.45)and 14.31 (3.60), respectively.

Even at six months, their PHQ-9 scores were not statistically different (7.53 vs 8.09; P=0.88). Moreover, both BA and MEDS recipients experienced ~50% reduction in depressive symptoms at three, six, and 12 months.

On other measures, for instance, physical HRQOL at six months, 

BA recipients showed fewer improvements than MEDS recipients (mean SF-12 physical score: 38.82 vs 37.12; P=0.04).

They also had fewer ED visits and had to spend fewer days in the hospital at all three-time points, all statistically significant observations. 

However, there was no significant difference in hospital readmissions of BA group participants versus MEDA recipients. 

The authors attributed these differences to poor general health, a reliable risk factor associated with rehospitalization in patients with HF and depression.

It is also noteworthy that BA recipients are encouraged to be more physically active than MEDS recipients, which likely would have contributed to their tendency to have fewer ED visits and hospital days.

Conclusions

Overall, the present RCT confirmed that both interventions, BA and MEDS, reduced depressive symptoms in patients with HF and depression by almost 50%.

In addition, BA recipients experienced better physical HRQOL, made fewer ED visits, and had fewer days hospitalized. 

This data could inform clinicians and caregivers that they can choose both psychotherapy and pharmacotherapy to improve depressive symptoms in HF patients.