Study Limitations and Need for Additional Research
Two methodological decisions should be further discussed. First, the current study focused on symptoms of depression and anxiety rather than a diagnosis as obtained from a semistructured clinical interview. As such, results must be interpreted with this methodological decision in mind. The decision to assess symptoms rather than diagnoses was based on literature that suggests the importance of treating elevated mental health symptoms, as well as the current assessment and care practices in the primary care setting, which often focus on symptom-based patient concerns. Second, the decision to separate recognition and treatment of depression and/or anxiety in the medical record has both strengths and limitations. As a strength, it offers an objectified classification strategy for analyses and clearly separates treatment from diagnosed or noted depression/anxiety. As a limitation, this classification strategy minimizes the role of recognition, which is likely inherent in many of the medical records reviewed for this study.

Results from this study are also limited by our reliance on documentation of depression and anxiety in the VA and the potential for biased participation favoring nondepressed/nonanxious HF patients. Our reliance on VA data, which did not include any information from outside providers, may underestimate recognition and treatment of depression and anxiety. Data also suggest that some patients may have been diagnosed by their provider without documentation (patients with treatment who did not have documentation of a condition). However, the VHA’s use of EMR for provider communication and workload documentation, and the need to record clinical findings for accurate patient records, suggests that many providers routinely document their work. Study results may have also been affected by limited participation of depressed and anxious HF patients. However, the study attempted to address this concern using recruitment methods including unsolicited recruitment letters and telephone calls, as well as telephone-based screening, to increase the recruitment of depressed and/or anxious HF patients.

With the recent, targeted efforts to embed mental health services within VHA primary care practices, future work might assess potential improvements in recognition and treatment as these programs become established. The VHA’s use of a comprehensive EMR will likely afford many opportunities to assess mental health practices in the primary care setting and the resulting impact of this large initiative on patient health factors. Other work is needed that focuses on the role of mental health treatments for the medically ill and on increasing the number of medically ill patients who receive evidence-based mental health treatments.

Disclosure of off-label usage: The authors have determined that, to the best of their knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration–approved labeling has been presented in this article.

REFERENCES

1. Katon W, Lin EHB, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry. 2007;29:147–155.
2. Koike A, Unutzer J, Wells KB. Improving the care for depression in patients with comorbid medical illness. Am J Psychiatry. 2002;159:1738–1745.
3. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54:216–226.
4. Brenes GA. Anxiety and chronic obstructive pulmonary disease:prevalence, impact, and treatment. Psychosom Med. 2003;65:963–970.
5. Jiang W, Alexander J, Christopher E, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161:1849–1856.
6. Kunik ME, Roundy K, Veazey C, et al. Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest. 2005;127:1205–1211.
7. MacMahon KM, Lip GY. Psychological factors in heart failure:a review of the literature. Arch Intern Med. 2002;162:509–516.
8. Rutledge T, Reis VA, Linke SE, et al. Depression in heart failure:a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48:1527–1537.
9. Dimatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment:meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101–2107.
10. Cully JA, Graham DP, Stanley MA, et al. Quality of life in patients with chronic obstructive pulmonary disease and cormorbid anxiety or depression. Psychosomatics. 2006;47:312–319.
11. Koenig HG. Differences between depressed patients with heart failure and those with pulmonary disease. Am J Geriatr Psychiatry. 2006;14:211–219.
12. Rumsfeld JS, Havranek E, Masoudi FA, et al. Depressive symptoms are the strongest predictors of short term declines in health status in patients with heart failure. J Am Coll Cardiol. 2003;42:1811–1817.
13. Sullivan M, Simon G, Spertus J, et al. Depression-related costs in heart failure care. Arch Intern Med. 2002;162:1860–1866.
14. Desai MM, Rosenheck RA, Craig TJ. Case-finding for depression among medical outpatients in the Veterans Health Administration. Med Care. 2006;44:75–181.

Jeffrey A. Cully, Ph.D., Daniel E. Jimenez, Ph.D., Tracey A. Ledoux, Ph.D., and Anita Deswal, M.D., M.P.H., F.A.C.C.
From the Houston Center for Quality of Care & Utilization Studies, Health Services Research and Development Service, Michael E. DeBakey Veterans Affairs Medical Center (all authors); Menninger Department of Psychiatry and Behavioral Sciences (Dr. Cully) and the Department of Medicine (Drs. Cully and Deswal), Baylor College of Medicine; Veterans Affairs South Central Mental Illness Research, Education & Clinical Center (Dr. Cully); and Winters Center for Heart Failure Research, Michael E. DeBakey Veterans Affairs Medical Center & Baylor College of Medicine (Dr. Deswal), Houston, Texas