Understanding psychological distress in heart failure dyads

This invited commentary refers to ‘Conjoint trajectories of anxiety and depression in patients with heart failure and their caregivers within three months post-discharge: exploring their interconnections with dyadic burdens using network analysis’ by B. Wan et al., https://doi.org/10.1093/eurjcn/zvaf126. Heart failure (HF) presents a serious global health challenge, affecting millions and demanding comprehensive, long-term care.1 Heart failure’s chronic nature, coupled with high readmission rates and mortality,1 highlights the necessity of a holistic approach to illness management.2 Crucially, the burden of HF extends beyond the patient, significantly impacting their caregivers, leading to the concept of the ‘dyad’—a unified patient–caregiver unit requiring integrated assessment and management.3,4 The manuscript titled ‘conjoint trajectories of anxiety and depression in patients with heart failure and their caregivers within three months post-discharge: exploring their interconnections with dyadic burdens using network analysis’ offers new insights into this complex dynamic.5 By using group-based trajectory modelling and network analysis, this prospective observational study explores the trajectories of anxiety and depression in HF dyads during post-discharge and investigates their interconnection with various components of dyadic burden. The authors in this study5 identified three distinct conjoint trajectories of anxiety and depression in HF dyads: a mild disorder group (27.4%), a moderate disorder group (58.9%), and a severe disorder group (13.7%) based on the severity of anxiety and depressive symptoms as referred individually by the two members of the dyad. In the mild disorder group, patients and caregivers reported no or mild symptoms; in the moderate disorder group, patients and caregivers reported mild to moderate symptoms; and in the severe disorder group, patients and caregivers reported the most severe anxiety and depressive symptoms. Through network analysis, the authors mapped the interconnections between these symptom levels and various dyadic burden components: anxiety and depression were significantly associated with physical symptoms, with the burden caused by such symptoms, and with caregiver burden. Although the authors identified significant socio-demographic differences among the three above-mentioned groups, a more detailed discussion of such heterogeneity could have enriched the discussion and implications for practice. Indeed, patients in the mild disorder group were older, with shorter hospitalization length, clinically less sick (with a higher percentage of patients in NYHA Class II), and with more educated (and male) caregivers than those in the other groups. The moderate disorder group interestingly included caregivers who were mainly female and less physically active. Instead, patients in the severe disorder group faced considerable socio-economic vulnerability—highlighted by a higher reliance on self-paid medical insurance, had the lower-educated caregivers—who were, on the other side, the most physically active compared with caregivers in the other groups. These differences must be taken into careful account as they reveal specific vulnerabilities that can influence how supportive interventions should be designed and/or delivered. The findings resonate with prior research on HF dyads, confirming and expanding earlier cross-sectional works. For instance, a previous cross-sectional study examined the association between anxiety, depression, and mutuality in HF dyads, finding that higher patient mutuality was associated not only with decreased patient anxiety and depression but also with higher caregiver depression.6 Another cross-sectional study reported that patient’s and caregivers’ psychological symptoms were associated with their own health-related quality of life and that caregivers’ anxiety and depression negatively influenced the patient’s health-related quality of life.7 What distinguishes Wan et al.’s work5 is the integration of both patient and caregiver psychological symptom trajectories into a unified model that link them to other relevant variables (i.e. physical symptoms and patient and caregiver burden) and the exploration of such phenomenon over time. One impactful finding from the network analysis of this study5 is the centrality of caregiver burden. The emergence of caregiver burden as the most influential core node within the network might contribute to shifting the paradigm for intervention focus. This finding strengthens existing literature8–10 by providing evidence that caregiver burden is not merely a consequence of caregiving, but it might even be a primary driver of psychological distress for both patients and caregivers. Indeed, the continuous demands of daily care, emotional support, time, and financial pressures can lead to caregivers feeling overwhelmed, which in turn negatively affects their own mental health and can directly compromise the patient’s psychological state and quality of care, creating a detrimental feedback loop.10–12 Therefore, this suggests that addressing caregiver burden goes beyond solely supporting caregivers—e.g. by providing access to health coaching, psychological counselling, or peer support groups,13–16 as it can be a powerful lever for improving the well-being of the entire dyad. Furthermore, the significant influence of core HF symptoms such as dyspnoea and difficulty sleeping in the network highlights their critical role beyond mere physical discomfort. These findings further highlight the link between physical symptoms and psychological distress.17,18 Dyspnoea, for example, can evoke feelings of impending doom, exacerbating anxiety and depression as well as the other way around where anxiety can lead to breathing agitation and worsening dyspnoea.19,20 Difficulty sleeping, often linked to dyspnoea,21 is strongly associated with anxiety and depression.22,23 Thus, the findings identified by Wan et al.5 reinforce the notion that effective management of physical symptoms is directly linked to alleviating psychological distress as well. The heterogeneity of anxiety and depression trajectories described by Wan et al.5 highlights the need to shift from static evaluations to dynamic, personalized assessments of the dyads even post-discharge. Given the centrality of caregiver burden, comprehensive caregiver support should be a key aspect in future interventions offering education, emotional resources, respite services, or care coordination assistance to ease their burden and eventually enhance patient outcomes.13,14,24–27 Furthermore, proactive management of key patients’ symptoms such as dyspnoea and sleep disturbances is essential, as alleviating them can lead to improvement in the psychological health of the dyad. The shift in recent research from focusing solely on the individual to examining the patient–caregiver dyad reflects a more inclusive and comprehensive approach to care, acknowledging that illness affects not just the patient but also those closely involved.28,29 Building on this perspective, it could also be valuable to further extend the focus by including the broader social networks and communities in which the dyad is embedded (e.g. friends, support groups, and other informal or formal relationships), which might also play an important role in coping and care.30–32 Overall, Wan et al. offer an insightful contribution to the literature on dyadic mental health in heart failure. By identifying distinct co-joint trajectories of anxiety and depression and uncovering the central role of caregiver burden and key HF symptoms within a complex network, the study offers a new framework for understanding and addressing the multifaceted challenges faced by HF dyads and further challenging the one-size-fits-all models by revealing the heterogeneity of mental health experiences in HF. The identification of distinct dyadic trajectories highlights the need for longitudinal and person-centred approaches that account for individual variability over time. Future studies should explore tailored interventions considering the specific dyadic profiles without assuming uniformity in psychological responses. Clinically, the centrality of caregiver burden further supports the need to move beyond uniquely patient-centric care models and to systematically include caregiver assessment and support as a routine part of HF management. Integrating dynamic mental health screening tools post-discharge could allow healthcare providers to early identify and support dyads at higher risk of psychological distress. Giulia Locatelli (Conceptualization [lead], Writing—original draft [lead], Writing—review & editing [lead]) and Michela Luciani (Conceptualization [supporting], Writing—review & editing [equal])) No funding declared. No new data were generated or analysed in support of this research.