Some elderly patients cope surprisingly well with heart failure, but psychiatric problems, unfortunately, are quite common in this population. Dementia, delirium, and other forms of cognitive dysfunction are frequently encountered, particularly in hospitalized patients with moderate to severe CHF. Alcohol abuse and cigarette smoking contribute to the development of heart disease and may persist after the onset of CHF. Substance abuse may be difficult to treat, but if left untreated can cause severe complications. Major depression and other depressive disorders are especially prevalent among patients in NYHA class III or IV heart failure. Depression is strongly associated with functional impairment in CHF, although the direction of this relationship is not yet clear. It is also associated with poor QOL and there is growing evidence that it may increase the risk of mortality in these patients. Fortunately, depression can often be treated successfully with antidepressant medications and psychotherapy. Anxiety and social isolation are also problematic for some patients, and both are also amenable to treatment. In recent years, there have been impressive advances in the medical care of elderly patients with heart failure. Improving their psychosocial care should be a much higher priority in this decade than it has been in the past.