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| Subscribe to Clinical Compass™ | VOLUME 3, ISSUE 3 - JANUARY 29, 2008 | ||||||||||||||||||||||||
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Helping the Heart and Mind of Patients with Depression and Cardiovascular Disease by Mary Ann Stephens, PhD Heart disease is the number one cause of death in the United States and is a major cause of disability. Almost 700,000 people die of heart disease in the U.S. each year, accounting for 29% of all U.S. deaths. The most common heart disease in the U.S. is coronary heart disease (CHD), which can lead to myocardial infarction (MI). Recent data, however, reports that the CHD death rate in 2005 (the most recent year for which data are available), has decreased by 25.8% since 1999,(1) and American Heart Association (AHA) analysts project a 36% decrease in CHD death rate when the 2008 data are released in a few years.(2) Further, the survival rate for U.S. patients hospitalized with MI is approximately 90% to 95%, reflecting a significant increase related to improvements in emergency medical response and treatment strategies.(3) The shift from managing acute coronary events to long-term care has clinical implications for both primary care and psychiatry. Depression is common following acute coronary syndrome (ACS) and is associated with an increased risk of mortality. Prevalence of major depression among hospitalized patients with CHD has ranged from 17-27%; these patients have a two- to three-fold increased risk of future cardiac events compared to patients without depression.(4) Furthermore, depression aggravates the course of multiple cardiovascular symptoms and is associated with lower adherence to prescribed medications and secondary prevention measures.(5-6) Depression is frequently undiagnosed and untreated in patients with cardiovascular disease. It is estimated that less than 25% of cardiac patients with major depression are diagnosed with depression, and only half receive treatment for depression.(7) A number of reasons have been given as to why this occurs, such as commonly shared symptoms (fatigue, insomnia), and depression being attributed to a normal reaction to CHD. Another reason is that physicians may be reluctant to prescribe antidepressant medications to patients with CHD because of potential adverse effects. There have been several trials evaluating whether antidepressant treatments are safe or effective in patients with CHD, specifically in those who have experienced an MI. The largest trial, the Sertraline Antidepressant Heart Attack Trial (SADHART),(8) was designed to evaluate the safety and efficacy of sertraline hydrochloride for treatment of MDD in ACS. There were no adverse cardiovascular effects of sertraline detected. Sertraline was both safe and effective in post-MI depression, and there was a reduction in death and recurrent myocardial infarction. Sertraline performed better in patients with recurrent depression and those with more severe depression. Further analysis showed that sertraline inhibits platelet endothelial markers more than placebo in depressed patients after coronary events, reducing the chance of forming dangerous blood clots that can lead to a new heart attack.(9) A more recent study in patients with comorbid depression and CHD, the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy(CREATE),(10) evaluated the short-term efficacy and tolerability of citalopram, a first-line selective serotonin-reuptake-inhibitor (SSRI) and interpersonal psychotherapy (IPT), a short-term, manual-based psychotherapy focusing on the social context of depression. The study demonstrated the efficacy of citalopram in conjunction with either weekly clinical management or IPT. Similar to SADHART, there were more clear benefits of SSRIs for patients with recurrent episodes of major depression than for first episodes. Based on these results and those of previous trials, the SSRIs citalopram or sertraline plus clinical management should be considered as a first-line treatment for patients with CHD and major depression. These data, while still preliminary, show promise for patients with depression after MI, especially those with prior episodes. Such patients should be carefully watched and aggressively treated due to their elevated cardiac risk. Given this risk factor of depression in developing CHD or experiencing future cardiac events, it is imperative that primary care physicians and psychiatrists educate themselves on the detection and treatment of depression in patients with CHD, and provide these patients with resources to prevent future cardiac events. February is American Heart Month. Learn more about CHD and helping your patients understand, prevent, and recognize symptoms for early intervention at: www.americanheart.org. Do you have feedback for the author? Click here to send us an email. References
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