Redefining psychocardiology: Integrating depression management into heart failure care for enhanced long-term recovery and prognosis

Table 2 Current controversies in psychocardiology for heart failure

Controversy	Supporting rationale	Counterpoint/Limitation	Practical interpretation
Is depression a modifiable causal risk factor or mainly a prognostic marker in HF?	Observational studies consistently show associations with mortality, hospitalization, poor self-care, and reduced quality of life	Randomized trials have not consistently shown reductions in HF hospitalization or mortality after depression treatment	At present, depression in HF may be most appropriately framed as a clinically important prognostic marker and treatment target for symptom burden and self-management
Should routine depression screening be implemented in all HF settings?	Depression is common, under-recognized, and clinically meaningful; tools such as PHQ-2/PHQ-9 are feasible	Screening alone is insufficient if referral pathways, psychiatric support, and follow-up capacity are lacking; moreover, key validation data for common screening strategies were derived mainly from non-HF cardiovascular cohorts	Screening is reasonable only when linked to an actionable care pathway
Do antidepressants improve HF prognosis?	They may be appropriate for selected psychiatric indications, but evidence for HF-specific benefit remains limited	Large trials such as SADHART-CHF and MOOD-HF did not show reduced hard cardiovascular endpoints	Antidepressants should be used cautiously for psychiatric indications, not as established HF outcome-modifying therapy
Can collaborative care improve cardiovascular outcomes?	Collaborative models improve depressive symptoms and mental health-related quality of life	Effects on rehospitalization, physical function, and mortality remain inconsistent	Collaborative care is justified mainly for patient-centered benefits
Can digital health replace face-to-face psychocardiological care?	Telemonitoring, mobile applications, and AI may improve access, monitoring, and longitudinal follow-up	Evidence remains limited, and clinical utility, generalizability, equity, and implementation feasibility are not yet fully established	Digital tools should support, not replace, multidisciplinary human care
Are all HF phenotypes equally affected by depression?	Depression appears relevant across HF populations, including vulnerable and preserved EF groups	Mechanisms and effect sizes may differ by phenotype, socioeconomic context, and comorbidity burden	Precision-oriented psychocardiology is needed

HF: Heart failure; PHQ: Patient Health Questionnaire; AI: Artificial intelligence; CHF: Congestive heart failure.