RESULTS
The study sample consisted almost exclusively of men (98.7%), the mean age was 71.3 years, and participant ages ranged from 60 to 92 years. A considerable number of individuals in this sample identified themselves as belonging to an ethnic minority (39.2%). As defined by NYHA and relative-risk score criteria, the sample included a large number of patients with significant physical limitations and medical-illness burden. The prevalence of self-reported depression, according to the GDS, was 41.8%, and the prevalence of self-reported anxiety, according to the GAI, was 25.3%. Notably, of those identified as having either depression- or anxiety-related symptoms (N = 73), 90.4% had symptoms of depression.

Of those screening positive for depression or anxiety on the GDS or GAI, 57.5% were recognized as having depression, and 60.3% had received some form of mental health treatment during the 18-month period of the EMR review. Of the 73 patients screening positive for depression and/or anxiety on the GDS and/or GAI, 42.5% had a diagnosis of depression or anxiety documented in the medical record, 57.5% had at least 1 progress note with a notation for depression or anxiety, 58.9% had received an antidepressant or antianxiety medication, and 34.2% had obtained specialty mental health care. For patients who screened negative on both the GDS and GAI (N = 85), 9.4% had a diagnosis of depression or anxiety documented in the medical record, 28.2% had at least 1 progress note with a notation for depression or anxiety, 21.2% had documentation of receiving an antidepressant or antianxiety medication, and 8.2% had documentation that they had received specialty mental health care.
Sample Characteristics and Group Comparisons Based on Self-Reported Depression/Anxiety

A follow-up examination was conducted to explore the number and percentage of patients with recognition of depression or anxiety (diagnosis or progress notation) in the medical record that also had a documented mental health treatment (psychotropic medication or specialty mental health visit). Of those with a depression or anxiety diagnosis, 92.3% had received treatment for depression or anxiety. For patients without a documented diagnosis of depression or anxiety, 24.4% had received mental health treatment.

Prediction of Recognition of Depression and/or Anxiety (diagnosis and/or medical-record notation) (N = 158)

Logistic regression procedures were used to predict documentation of recognized depression and/or anxiety in the medical record. Recognition, dichotomized as either present or absent, represented whether or not patients were diagnosed with or had a specific notation for depression and/or anxiety in the medical record during the 12 months prestudy and 6 months poststudy assessment. Higher GDS total scores (odds ratio [OR] = 1.18, 95% confidence interval [CI] = 1.02 to 1.38) were significantly related to increased recognition in the medical record. Notably, age, ethnicity, relative-risk score, HF severity, GAI total score, and number of outpatient encounters (pre- and post-assessment) were not significantly related to documentation of recognition in the medical record.

A follow-up logistic regression predicting documentation of treatment for depression and/or anxiety in the medical record revealed that the presence of a positive primary care depression screen was significantly associated with increased odds of receiving mental health treatment (p

< .05, OR = 3.37, 95% CI = 1.14 to 9.90). The GDS total score (OR = 1.14, 95% CI = 0.97 to 1.33) and GAI total score (OR = 1.09, 95% CI = 0.99 to 1.20) approached, but did not reach, clinical significance in the model (p values of .11 and .07, respectively).

DISCUSSION
Symptoms of anxiety and, especially, depression are highly prevalent in ambulatory HF patients, with over 45% of our sample reporting clinically significant symptoms on the GDS and/or GAI. Although these conditions have significant overlap in symptomatology, research indicates that both conditions offer unique contributions and warrant investigation, especially among chronically ill patients.  In the present study, the prevalence of depression and anxiety was notable but largely fell under the depression spectrum. Specifically, over 90% of the depressed or anxious subgroup was accounted for by clinical cutoff scores obtained from the GDS.

This study represents the first known prospective investigation to examine rates of recognized and treated depression and anxiety in ambulatory HF patients. Our findings are consistent with known rates of poor recognition in chronically ill patients and in HF inpatients. These results are somewhat consistent with a recent, large-scale Veterans Health Administration (VHA) study that found limited recognition but diverged from this larger study, which found poor follow-up care using standardized depression screenings. Despite the high-quality EMR system and formalized requirements for annual depression screening provided by the VHA, we found that many HF patients with significant symptoms of depression and/or anxiety went unrecognized. On a positive note, the use of primary care–based depression screening measures was significantly related to the attainment of mental health treatment. Specifically, patients with a positive depression screen (during the 18-month medical-record-review period) were over 3 times more likely to either obtain psychotropic medications or use mental health services. Results also indicated that patients with higher scores on the GDS were more likely to be recognized, suggesting that providers are able to more easily identify higher levels of depression severity.

As depression (and anxiety to a lesser extent) screening is becoming more widely accepted and used in health care settings, it is becoming increasingly clear that additional efforts are needed to improve the sensitivity of routine mental health screening. Our findings suggest that positive depression screens are important for subsequent receipt of care. However, despite the known high sensitivity of the VHA 2-item depression screening measure, the practical application of this method may not effectively identify patients willing to self-report depressive symptoms. For example, most mental health screenings identified in this study occurred during a preventive medicine note provided by a nurse, who was also charged with completing other physical health screenings. It is likely that many patients who received the depression screen may not have accurately reported their mental health state or may have been overlooked by providers who are charged with meeting multiple, competing demands.

Improvements in the recognition of depression (and, especially, anxiety) are needed and might best be addressed through formal mental health training of frontline practitioners to improve education about and skills in detecting mental health issues in the medically ill. Targeted efforts aimed at practitioners might include (1) education on the high prevalence of depression and anxiety in the medically ill and known effective treatments for these conditions to increase practitioners’ ability to address patient concerns and comfort in openly discussing depression and anxiety in a medical, rather than mental health care, setting; (2) provider training and education about differential diagnoses, especially related to depressive and anxiety symptoms and their overlap with the physical symptoms common to HF (e.g., fatigue, decreased physical activities); and (3) system-level changes to increase the real-world effectiveness of depression screening practices. For example, changes might include increased numbers of mental health specialists available for assessment and triage, more focused mental health screening appointments (rather than embedding a 2-item screening questionnaire within a larger battery of medical screening questions), and increased time for providers to address mental health concerns during routine office visits, there by decreasing competing demands.