Depression in Patients with Coronary Heart Disease

https://doi.org/10.1016/j.amjmed.2008.09.010Get rights and content

Abstract

Approximately 20% of patients with coronary heart disease (CHD) have major depression and 20% have minor depression at any given point in the course of their illness. Depression causes significant psychological and social morbidity, and is a risk factor for further cardiac morbidity and mortality. Although there are many possible biological and behavioral mechanisms, the causal pathways through which depression increases the risk for cardiac events and death are not well understood. Despite the morbidity associated with depression, and the devastating impact it has on the quality of life of patients with CHD, it is underdiagnosed and often left untreated. This article describes screening techniques for use in primary care and cardiology settings, and discusses the safety and efficacy of available treatments for depression in patients with CHD.

Section snippets

Prognostic importance

Depression doubles the risk for cardiac events, including cardiac mortality, in the 12 months following the initial diagnosis of CAD.18, 19, 20 Depression is also a significant predictor of mortality and cardiac events in patients undergoing coronary artery bypass graft surgery.21, 22, 23 In 1 study,21 moderate-to-severe depression just prior to surgery was associated with an adjusted mortality hazard ratio (HR) of 2.4. Even mild depression was associated with an increased risk for mortality,

Mechanisms

There is compelling evidence that the autonomic nervous system (ANS) is dysregulated in patients with CHD and depression.36 Heart rate variability (HRV) is often used to study cardiac ANS modulation. Low HRV is a powerful, independent predictor of mortality in patients with CHD.37, 38, 39, 40 Low HRV suggests excessive sympathetic and/or inadequate parasympathetic modulation of heart rate,41 which may promote myocardial ischemia, ventricular tachycardia, ventricular fibrillation, and even

Risk stratification for comorbid depression in coronary heart disease

Which patients are at risk for depression following an ACS? Many of the predictors of depression in the medically well also predict incident depression in patients with heart disease. Female sex, younger age, personal and family history of depression, low social support, and stressful life events are associated with depression in patients with a recent ACS.81, 82, 83, 84 Among patients who are not depressed after hospital discharge, those who had frequent angina during hospitalization or

Screening

Identification of depression in patients with CHD can be quite a challenge. Many patients experience a few mild depressive symptoms, but most will improve without treatment. Some of the criterion symptoms of a major depressive disorder, such as fatigue, weight change, and insomnia, may reflect the underlying heart disease in addition to, or instead of, depression. To meet the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition criteria for major depression, however, patients

Treatment

Little is known about the efficacy or safety of most antidepressants in patients with established CHD. One of the reasons for this gap in knowledge is that heart disease is an exclusion criterion in most randomized, placebo-controlled clinical trials of antidepressants; thus there is a paucity of randomized, placebo-controlled clinical trials of antidepressants in patients with heart disease.87 As a result, antidepressants are often selected for patients with CHD based on data about cardiac

Depression treatment and medical outcomes

Can successful treatment of depression reduce risk for cardiac morbidity and mortality? The Enhancing Recovery in Coronary Heart Disease (ENRICHD) study was a multicenter, randomized, controlled clinical trial designed to determine whether treating depression and addressing inadequate social support following acute MI reduces the risk for recurrent infarction and death.112 The ENRICHD trial enrolled 2,481 patients (1,084 women and 1,397 men) with major or minor depression and/or low perceived

Summary

Although we do not yet know whether treating depression can reduce the risks for cardiac mortality and morbidity, we do know that depression is associated with significant psychological, social, and functional impairment in patients with CHD.10, 11, 12, 13, 14, 15, 16, 17 There is evidence that treating depression, at least in psychiatric patients, improves quality of life and daily functioning.115 We recommend that depression be assessed and treated in patients with heart disease to improve

Author disclosures

The authors who contributed to this article have disclosed the following industry relationships:

Robert M. Carney, PhD, received an honorarium from Forest Laboratories, Inc.; and receives Zoloft (sertraline hydrochloride) from Pfizer Inc for use in a National Institutes of Health (NIH)–funded clinical trial.

Kenneth E. Freedland, PhD, has no financial arrangement or affiliation with a corporate organization or manufacturer of a product discussed in this article.

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