IJCS | Volume 31, Nº4, July / August 2018

419 Guerra et al. Screening: depression in heart failure Int J Cardiovasc Sci. 2018;31(4)414-421 Original Article consistency of the scales show that the BDI-II, HAM-D, and PHQ-9 proved to be useful tools for application in patients with HF. We observed in this study a possible agreement advantage of the HAM-D with the BDI-II, the gold- standard instrument. This is probably due to the number of items in both questionnaires. The significant agreement among the scales indicates an evaluation of the intensity of the symptoms in the same direction, i.e., the greater the score, the greater the severity. 37,40 Apossible explanation for the difference in prevalence identified in the PHQ-9 scale may be due to its self-rating features since they portray an individual’s subjective response (as how he perceives his health and symptom). Although the instrument has already been tested in various levels of health care attention and different cultural contexts, 1 still limited research has been carried out in Brazil using the PHQ-9 to screen for depression in outpatients with HF. A study carried out in Minnesota applied the PHQ-9 scale to evaluate the occurrence of depression in a sample of 425 outpatients with HF and identified a prevalence of 42.1% (n = 179), 38 which is in line with our findings. Self- and interviewer-rating scales should take into account several aspects, including the individual’s educational level and time availability for the assessment, as well as the objective of the evaluation. The BDI-II and HAM-D scales are instruments used in more than 50% of the studies; 10 the sensitivity and specificity of these instruments is approximately 0.84 and 0.72, respectively, 37,39 which is also in line with our results. A review 9 has assessed the scales HAM-D, BDI-II, Zung Self-Rating Depression Scale, Geriatric Depression Scale of Yesavage, andMontgomery-Åsberg Depression Rating Scale (MADRS). The results showed relevance in the identification of signs and symptoms of depressive disorders, directing the attention to mental health interventions in the elderly. We observed that the patients in the present study had important clinical comorbidities (diabetes, dyslipidemia, obesity, CRF, and hypertension), which were not associated with depression. In a study conducted by Aguiar et al. (2010) in hospitalized patients with HF (n = 43), patients with depression (55.8%, n = 24) according to the HAM-D scale did not differ from non- depressed ones in regards to gender, age, anemia, and renal function, factors that are known to influence the occurrence of clinical manifestations. Depression is an important risk factor associated with HF, 2 a syndromic clinical condition. When depression is not specified, it is mistaken and underdiagnosed in these individuals, 35 probably due to the superposition of symptoms of HF (dyspnea, weight change, sleep, fatigue) and the neurovegetative symptoms of depression (insomnia, psychomotor slowing, and decreased energy, concentration, and appetite). 36 A study conducted by Freedland et al. 32 in a sample of 682 patients with HF showed that 245 (36%) patients had clinically significant depression (according to the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] criteria), while 436 (64%) were classified as non-depressed. Patients with depression also were not significantly affected by the presence of other important comorbidities, such as diabetes or kidney disease, or by the presence of only one of these conditions. These results are aligned with those of our study and differ in some aspects from the observations described in the literature. However, considering that depression emphasizes the clinical manifestations and worsens the progression of patients with HF, more attention should be dedicated to this condition, including to its screening. The importance of this initiative has been increasing in clinics specialized in HF, since studies have documented that the treatment of depression promotes improvement of the symptoms and quality of life of the patients. 2 Limitations This study presents limitations due to its experimental, observational, and cross-sectional design, which did not allow us to establish the variables predicting depression in HF. However, through the data presented, it becomes evident the importance of this discussion, because different depression scales are applied in this population. This research demonstrates a need for further work on the screening of depression in outpatients in practices specialized on HF, due to the relevant prevalence of and damage from this association. It is important to highlight the need to deepen the knowledge of the association of depressionwith the sociodemographic and clinical characteristics present in this population for the development of preventive work in outpatients with HF. Conclusions Based on the results of this study on the prevalence of depression associated with HF, we found the following: