With appropriate screening, nurses can help improve the identification of depression in this patient population.

MR. ROBERT GAINS*, a 45-year-old truck driver, arrives for a post-hospitalization follow-up appointment with the nurse practitioner (NP) at his cardiologist’s office after insertion of an internal cardio defibrillator to manage recently diagnosed congestive heart failure (CHF). During his visit, Mr. Gains appears fatigued, angry, and sad. He reports weight loss, a decreased appetite, lack of energy, and not feeling like himself.

The NP refers Mr. Gains to his primary care provider for further assessment. The provider makes a diagnosis of depression, prescribes an antidepressant, and refers the patient for cognitive behavior therapy.

Depression: Prevalence and impact

The World Health Organization (WHO) describes depression as a common mental health disorder characterized by a reduced interest or enjoyment in usual activities, accompanied by feelings of sadness or heaviness, reported by a patient based on their personal cultural context. According to WHO, depression affects 5% of the world population.

Birk and colleagues report that depression affects approximately one in five adults, with higher prevalence among those with cardiovascular disease. The researchers also note that depression occurs nearly twice as often in adults with multiple chronic comorbidities such as diabetes, respiratory disease, or hypertension. Jha and colleagues note that depression and chronic conditions exert a reciprocal influence, such that patients with coexisting depression and cardiovascular disease experience a bidirectional relationship associated with a greater risk of suboptimal clinical outcomes.

CHF, a chronic, progressive cardiovascular condition, occurs when the heart no longer pumps blood effectively to the body. As a result, blood can back up into dependent body cavities or spaces such as the lungs, legs, and abdomen, causing symptomatic shortness of breath, fatigue, edema, decreased appetite, and activity intolerance. Rashid and colleagues explain that, likewise, depression can lead to feelings of fatigue, low energy, altered sleep, and appetite changes. The overlap of these symptoms, according to Rashid and colleagues, increases the risk of underdiagnosing depression in patients with CHF.

Linking depression and heart disease

Behavioral and physiological factors link depression and cardiovascular disorders. Jha and colleagues describe depression as a mental health disorder characterized by neurotransmitter dysregulation in the brain that influences behavioral functions, whereas cardiovascular disorders encompass conditions affecting the ventricles, atria, coronary arteries, or valves. CHF, the condition diagnosed in Mr. Gains, specifically involves the ventricles. Huang and colleagues note that heart failure relates to a decreased pumping function of the ventricles, with causation frequently linked to other cardiovascular diseases such as coronary artery disease or myocardial infarction.

Multiple biological and behavioral pathways further complicate the association between CHF and depression. Jha and colleagues and Johnstad observe that depression creates significant challenges in sustaining health-related routines, including nutrition, physical activity, and medication adherence. Patients experiencing depression also may face co-occurring concerns such as substance use disorders, changes in eating patterns, and lack of motivation. Cultural norms, environmental stressors, and access to resources can influence these experiences. Ultimately, decreased energy levels or impaired daily functioning contribute to shifts in behaviors, such as weight changes and tobacco use, which place patients with cardiovascular conditions at increased risk of worsening disease.

Beyond these behavioral factors, Jha and colleagues note that cardiovascular disorders and depression can trigger autonomic dysfunction, leading to tachycardia, hypertension, arrhythmias, and endothelial dysfunction. These physiological stressors eventually result in structural remodeling of the heart, which directly causes or exacerbates CHF.

Recognizing depression in patients with CHF

In Mr. Gains’ case, his report of weight changes, decreased energy, and fatigue could indicate either depression or CHF. Although his sadness and anger are more indicative of depression, the other signs and symptoms could result from either condition.

According to Jha and colleagues, a lack of consistent depression screening in patients with CHF can lead to poor prognosis and outcomes. Huang and colleagues report that depression, one of the most frequent comorbidities associated with heart failure, can increase the risk of heart failure by at least 20% and that the co-occurrence of the two conditions increases mortality. Based on American Heart Association (AHA) and U.S. Preventive Services Task Force (USPSTF) guidelines, consistent depression screening of patients with cardiovascular conditions should be standard of care.

Based on an analysis of data from the 2012 and 2013 National Ambulatory Medical Care Survey, Akincigil and Matthews found that only 4.2% of adults are screened for depression via the electronic health record (EHR) in the primary care setting. Of those screened, 47% received a diagnosis of depression. To adhere to AHA and USPSTF guidelines, Wilhem and colleagues recommend that clinics leverage the EHR to document findings when staff screen patients with CHF for depression in the clinic. Reliable depression screening, documentation in the EHR, and appropriate referrals support quality patient care.

Application to practice

Although Mr. Gains receives a referral to his primary care provider for depression screening and treatment, the cardiovascular team could have integrated the use of the Patient Health Questionnaire-2 (PHQ-2) into the EHR for preliminary screening. Wilhelm and colleagues implemented such a quality improvement change to better screen for depression in cardiovascular patients. (See Screening at work.)

The validity and reliability of the PHQ-2 (with two questions) and PHQ-9 (with nine questions) self-report questionnaires have led to successful use in a variety of medical settings among many populations. The AHA recommends first-line PHQ-2 screening with follow-up PHQ-9 screening. Wilhelm and colleagues suggest that cardiology practices add the PHQ-2 to existing EHR systems, if possible. Trained staff members can administer the screening before the provider arrives in the room. The provider can then examine the results, assess the patient, and make referrals for further evaluation and treatment as needed. The referring provider can then choose a psychometrically sound tool of their choice to further assess and treat depression, such as the PHQ-9.

Integrating screening tools into the EHR allows for easy access and readily available results.

Nursing implications

Despite the increased risk for depression faced by patients with CHF, depressive symptoms may go unrecognized or misdiagnosed, even overlapping with cardiac symptoms. Moradi and colleagues found that depression affects 21.6% of patients with heart failure, with over 64 million people having varying symptoms of heart failure and depression.

According to Rustad and colleagues, psychosocial stressors, life transitions, and newly diagnosed chronic illness can play a role in increased depressive symptoms among patients with cardiovascular conditions, thus warranting assessment in the clinical setting. Using Mr. Gains as an example, a trained clinician in a cardiovascular or heart-failure care setting might assess psychosocial and clinical factors relevant to his emotional well-being. The nurse might determine that Mr. Gains’ sadness and anger stem from depression, even though his heart condition may account for other symptoms.

Although strong evidence supports depression screening in patients with cardiovascular conditions, several real-world barriers can limit consistent implementation. Wilhelm and colleagues noted time constraints during cardiology visits, competing clinical priorities, limited staff training in mental health assessment, and patient reluctance to disclose depressive symptoms as factors contributing to underuse of structured screening.

Wilhelm and colleagues also reported that integrating brief, validated tools into routine clinical workflows, such as embedding depression screening within nursing intake or EHR-driven prompts, can reduce time burden and improve feasibility. In addition, targeted staff education and clearly defined referral pathways may increase clinician confidence in addressing positive screens. Normalizing screening as part of routine cardiovascular care can help reduce stigma and improve patient reception. Wilhelm and colleagues noted that addressing these barriers through workflow integration and interprofessional collaboration can enhance the sustainability and effectiveness of depression screening in cardiology care settings.

Rashid and colleagues found that structured depression screening is particularly important in this population, as symptoms such as fatigue, sleep changes, or reduced energy can be related to both heart failure and depression. Clinical evidence supports depression screening in patients with heart failure. Wilhelm and colleagues, for example, report a high prevalence and decreased recognition of depression symptoms in CHF. Rustad and colleagues note the diagnostic challenge due to symptom overlap, and Certo Pereira and colleagues demonstrated an association between identifying depression symptoms with instruments such as the PHQ screening tool and improved heart failure outcomes. Given this evidence, integrating a structured depression screening process into cardiovascular and heart failure care may help identify symptoms that would otherwise remain unnoticed.

However, screening alone isn’t sufficient. When screening yields elevated scores, referral pathways enable comprehensive assessment, psychosocial support, and evidence-based treatment.

Rashid and colleagues note that depression remains underrecognized in patients with CHF, but by screening for depression and treating it, patients can achieve a higher quality of life with better self-care. Evidence, including from Jha and colleagues, indicates that co-occurring depression and cardiovascular disease can compound complications experienced by patients with CHF. According to Certo Pereira and colleagues, incorporating a structured depression screening process into cardiovascular practice strengthens the holistic care provided to patients with CHF. In addition, interprofessional collaboration aids the referral process, which allows for appropriate and targeted individual assessment and treatment, thus improving patient outcomes.

Positive impact

Mr. Gains follows up with his primary care provider for 6 months after his depression diagnosis. His treatment adherence and therapy participation lead to improved mood. He reports increased energy levels and work enjoyment and says that he no longer feels the same degree of sadness he did 6 months ago. This improvement demonstrates the impact of early screening and coordinated care. The care team commends Mr. Gains for continuing his depression medication and routine primary follow-up appointments.

Nurses should confer and coordinate with providers in primary care settings to routinely screen all patients with cardiovascular disease for depression using a reliable and validated screening tool. Providing patients with education on depression-related risks may enhance treatment adherence and improve clinical outcomes. Additionally, ongoing education for nurses regarding the relationship between depression and cardiovascular disease may strengthen screening practices and better address the needs of this patient population. More research will help determine the most beneficial educational processes and tools.

*Names are fictitious.

Maranda Fain is an assistant professor at Troy University in Troy, Alabama.

References

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Birk JL, Kronish IM, Moise N, Falzon L, Yoon S, Davidson KW. Depression and multimorbidity: Considering temporal characteristics of the associations between depression and multiple chronic diseases. Health Psychol. 2019;38(9):802-11. doi:10.1037/hea0000737

Certo Pereira J, Presume J, Araujo I, et al. Depression and heart failure—The incidence of depressive symptoms assessed by the PHQ9 and their association with HF outcomes. Eur Heart J. 2023;44(Suppl_2):ehad655.2381. doi:10.1093/eurheartj/ehad655.2381

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Key words: congestive heart failure, cardiovascular disease, depression, screening tools