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Screening pulmonary hypertension patients for depression

Pulmonary arterial hypertension (PAH) is a rare and debilitating disease characterised by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance, leading to right ventricular failure and death (1–4). As there is no cure, the primary goal of disease management is to alleviate symptoms and prolong survival. Although treatment of patients with PAH with agents such as prostanoids, endothelin receptor antagonists and phosphodiesterase inhibitors have been shown to improve exercise capacity (5,6), many patients still experience diminished quality of life, severe limitations in mobility requiring lifestyle modifications, and a potential for social isolation. The physical burden imposed by PAH may result in loss of work, adding to the worry about paying for expensive therapies. Despite improvements in the treatment of PAH, patients still suffer from the uncertainty of this progressive disease. Thus, patients with PAH can accumulate a number of life stressors which have been associated with the development of depression (7). As a result of diminished quality of life, decreased mobility, social isolation, financial burdens, unemployment and an uncertain prognosis, patients with PAH may be more vulnerable to developing depression. This perspective provides rationale for the importance of routine screening of PAH patients for depressive symptoms. According to the World Health Organization (WHO), depression is the leading cause of disability as measured by Years Living with a Disability, and organisations such as the Institute of Medicine emphasise that depression screening and treatment should be a priority for US medicine in the 21st century (8). This is particularly true for PAH patients for the reasons noted above. Importantly, data from the REVEAL registry(9), a multicenter observation cohort study of WHO Group I PAH, shows that of the most frequent comorbid conditions experienced by PAH patients (including hypertension, thyroid disease and obesity), clinical depression is the single most clinically significant condition that predicts medical disability in patients with PAH (10).