The Burden Beneath the Chest: Depression and Clinical Outcomes in Heart Failure Patients — A Systematic Review and Meta-Analysis

Abstract

Background and Purpose: Heart failure (HF) is not only a disorder of hemodynamics; it carries a heavy psychological toll. Depression affects up to one-third of HF patients and may worsen adherence, functional status, and mortality. Despite growing recognition, the link between depression and HF prognosis remains under-emphasized in routine care. This systematic review and meta-analysis evaluated the association between depression and key clinical outcomes in HF, including hospitalization, mortality, and quality of life.

Methods: A structured search was conducted in PubMed, Scopus, Embase, and Cochrane Library databases from inception to January 2025. We included prospective and retrospective cohort studies and randomized controlled trial secondary analyses that assessed depression in HF patients and reported clinical outcomes. Two reviewers independently screened studies, extracted data, and assessed study quality using PRISMA guidelines and Newcastle-Ottawa Scale. Random-effects models were used to pool effect estimates.

Results: A total of 26 studies comprising ~18,900 HF patients met inclusion criteria. Depression was present in approximately 31% of patients at baseline. Meta-analysis demonstrated that depression was associated with significantly higher all-cause mortality (HR 1.48; 95% CI 1.30-1.69; p<0.001) and increased HF-related hospitalizations (HR 1.58; 95% CI 1.35-1.85; p<0.001). Depressed patients consistently reported worse functional capacity and lower quality-of-life scores, including Minnesota Living with Heart Failure Questionnaire ratings. Studies integrating early psychological assessment and multidisciplinary management showed improved adherence and reduced event rates, although interventional evidence remains limited.

Conclusions: Depression is a strong and independent predictor of mortality, hospitalization, and poor quality of life in HF patients. Findings highlight the need for systematic depression screening and integrated mental-cardiac care pathways in HF management. Future research should focus on targeted mental health interventions, timing of screening, and real-world implementation strategies to improve outcomes for this high-risk population.