In a prospective cohort study of 142 outpatients with advanced heart failure followed for a mean of 3 years, 29% of subjects with a depression diagnosis at baseline were significantly more likely to experience the combined end point of death or transplantation (hazard ratio 2.54, 95% confidence interval 1.16 to 5.55). After adjustment for a range of sociodemographic and clinical characteristics, patients with depressive disorders were still significantly more likely to reach the combined end point (hazard ratio 2.41, 95% confidence interval 1.24 to 4.68). Depressed patients also had more heart failure related hospitalizations (1.5 +/- 1.8 vs 0.6 +/- 1.4, p = 0.04) and clinic visits (2.4 +/- 1.7 vs 1.7 +/- 1.8, p = 0.04) over the first year of follow-up.