Should heart failure patients with depression choose therapy or medication?
Both behavioral activation psychotherapy and antidepressants reduced depressive symptoms by nearly 50%, with no statistically significant difference between the two treatments. However, behavioral activation recipients experienced 27% to 38% fewer emergency department visits and 17% to 36% fewer days hospitalized compared to medication recipients. A randomized comparative effectiveness trial of 416 adults with heart failure and depression at a single academic health system, published in JAMA Network Open, found behavioral activation delivered better physical health outcomes.
Behavioral activation is a manualized treatment that promotes engagement in personalized pleasurable activities selected by the patient, without adding to medication burden. The medication arm used a collaborative care model, with care managers coordinating between patients, psychiatrists, and primary care physicians to administer antidepressants.
What the data show:
- Depression reduction: Both treatments produced nearly 50% reduction in depressive symptoms at 3, 6, and 12 months, with no statistically significant difference between treatments
- Physical health: Behavioral activation recipients showed a small improvement in physical health-related quality of life at 6 months compared to medication recipients
- Emergency department visits: 38% reduction at 3 months, 30% at 6 months, and 27% at 12 months for behavioral activation versus medication
- Hospitalizations: 17% fewer days hospitalized at 3 months, 19% at 6 months, and 36% at 12 months for behavioral activation versus medication
- Study scope: 416 patients (208 behavioral activation, 208 medication) with heart failure and depression, a population in which roughly 50% experience depressive symptoms
This comparative effectiveness randomized clinical trial compared behavioral activation psychotherapy with antidepressant medication management in 416 adults with heart failure and depression, and found both treatments equally effective for depression while behavioral activation added physical health benefits, including reduced healthcare utilization.
Dr. Kumar’s Take
This study addresses a real clinical dilemma: how do I treat depression in patients whose medical condition is already serious and whose medication list is already long? Depression is common in heart failure and often goes undiagnosed and untreated, so knowing that two very different approaches both work is genuinely useful. What makes the therapy arm interesting to me is not the depression scores, which were essentially the same in both groups, but the difference in emergency visits and hospital days. Heart failure patients face complex regimens and real risk of drug interactions, so an equally effective option that does not add another pill is worth putting on the table. I would offer this as a choice rather than a directive, because both arms got patients better.
Study Snapshot
This comparative effectiveness randomized clinical trial enrolled 416 adults with heart failure and depression at Cedars-Sinai Health System, a not-for-profit academic health system in California serving more than 2 million people from diverse demographic, socioeconomic, cultural, and geographic backgrounds. Participants were inpatients and outpatients with New York Heart Association class II, III, or IV heart failure, a PHQ-9 score of 10 or higher, and a confirmed DSM-5 depressive disorder diagnosis. They were randomly assigned 1:1 to behavioral activation psychotherapy (BA) or antidepressant medication management (MEDS). Treatment consisted of an introductory session followed by 12 weekly sessions, then monthly for 3 months, then contact as needed for an additional 6 months, delivered by video or telephone. The trial ran from 2018 to 2022 with 1-year follow-up, and data were analyzed as intention-to-treat. Outcomes included depressive symptoms, physical and mental health-related quality of life, heart failure-specific quality of life, caregiver burden, healthcare utilization, and mortality at 3, 6, and 12 months.
Results in Real Numbers
This randomized clinical trial enrolled 416 adults with heart failure and depression (mean age 60.7 years, 243 [58%] male), with 208 patients randomized to behavioral activation psychotherapy and 208 randomized to antidepressant medication management. At baseline, mean PHQ-9 depression scores were 14.54 in the behavioral activation group and 14.31 in the medication group. Both treatments produced nearly 50% reduction in depressive symptoms at all time points, with mean scores of 7.53 at 6 months and 7.62 at 12 months for behavioral activation, and 8.09 at 6 months and 7.98 at 12 months for medication. The difference between groups was not statistically significant at either 6 months or 12 months.
Behavioral activation recipients showed better physical health outcomes than medication recipients. At 6 months, they had modestly higher physical health-related quality of life scores on the SF-12 (38.82 versus 37.12, P=0.04). Behavioral activation recipients had 38% fewer emergency department visits at 3 months (95% CI, 14% to 55%; P=0.005), 30% fewer at 6 months (95% CI, 14% to 40%; P=0.008), and 27% fewer at 12 months (95% CI, 15% to 38%; P=0.001) compared to medication recipients. They also spent 17% fewer days hospitalized at 3 months (95% CI, 8% to 25%; P=0.002), 19% fewer days at 6 months (95% CI, 13% to 25%; P=0.005), and 36% fewer days at 12 months (95% CI, 32% to 40%; P=0.001).
Who Benefits Most
Patients with heart failure and depression who are concerned about adding more medications to their regimen may benefit most from behavioral activation psychotherapy. The approach may be particularly valuable for individuals who are already taking multiple cardiac medications and want to avoid potential drug interactions or side effects.
Heart failure patients who frequently use emergency services or spend time in the hospital may find behavioral activation especially worth considering, given the reductions in both seen in this trial. Individuals who prefer active, behavioral approaches may also respond well to the emphasis on increasing pleasurable and rewarding activities rather than working through complex cognitive material.
Safety, Limits, and Caveats
Both treatments were effective for depression, so individual patient factors should guide the choice. The physical health-related quality of life advantage for behavioral activation was small, and the depression results were statistically indistinguishable between arms.
The trial was run at a single health system in California, which limits how far the findings extend to other settings. It tested behavioral activation specifically, so results may not apply to other forms of psychotherapy. Patients with cognitive impairment, bipolar, psychotic, or substance-induced disorders, imminent danger to self or others, or active depression treatment were excluded, so the findings do not speak to those groups. Sessions were delivered by video or telephone, and the trial overlapped the COVID-19 pandemic.
Practical Takeaways
- Both psychotherapy and antidepressants cut depressive symptoms by nearly half in this trial, with no significant difference between them
- Consider behavioral activation if you want to avoid adding more medications to your regimen or are concerned about drug interactions
- Behavioral activation was associated with fewer emergency department visits and fewer days in the hospital
- Discuss both options with your care team, weighing your overall medical condition, medication burden, and personal preference
- Expect treatment to run over months: the trial delivered 12 weekly sessions, then monthly sessions for 3 months, with benefits sustained at one year
What This Means for Heart Failure Care
This trial supports both psychotherapy and medication as effective treatments for depression in heart failure, which gives clinicians and patients a real choice rather than a single default. The better physical health-related quality of life and lower healthcare utilization with behavioral activation argue for building mental health interventions into cardiac care.
Related Studies and Research
Episode 31: Depression Explained, The Biology Behind the Darkness
Episode 32: Depression Recovery Roadmap: A Step-by-Step, Evidence-Based Plan
FAQs
Is therapy a reasonable alternative to medication for depression in heart failure patients?
In this trial, behavioral activation psychotherapy reduced depressive symptoms as much as antidepressant medication management, with better physical health-related quality of life and fewer emergency visits and hospital days.
Will treating depression help my heart failure symptoms?
Behavioral activation recipients had better physical health-related quality of life and spent fewer days hospitalized, which points to benefits beyond mood alone.
How does behavioral activation work for heart failure patients?
Behavioral activation is a manualized treatment that increases engagement in pleasurable and rewarding activities the patient chooses, aiming to improve mood, sense of control, and activity level without the complex cognitive work of cognitive behavioral therapy.
Bottom Line
Behavioral activation psychotherapy and antidepressant medication both reduced depression by nearly half in adults with heart failure, with no significant difference between them. Behavioral activation added better physical health-related quality of life, fewer emergency department visits, and fewer days in the hospital, which means patients with heart failure can reasonably be offered the choice.
