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Frequently Asked Questions

Should patients with coronary heart disease be screened and treated for depression?

Introduction
Compared to the general population, depression is 3 times more likely to occur in patients after an acute myocardial infarction (MI), and almost 20% of such patients meet criteria for major depression.1 The risk in women appears to be even higher. Major depression in conjunction with chronic conditions is associated with more ambulatory care and emergency department visits, days lost due to illness, and functional disability. Major depression is also associated with earlier and more severe cardiac events after a MI, medical nonadherence, poor success rates in modifying cardiac risk factors, and a reduced quality of life. Based on this information, the American Heart Association (AHA) recently published a science advisory for the screening, referral, and treatment of depression in patients with coronary heart disease (CHD).1 Highlights from the September 2008 advisory paper regarding depression and CHD are summarized below. Clinicians are encouraged to review the full document on the American Heart Association’s website (www.americanheart.org) or by linking directly to the document (http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190769).

Screening/referral for depression
The Patient Health Questionnaire (PHQ-2) should be used as a minimum standard when screening for depression.1 This 2 question screening tool has the patient recall the last 2 weeks and answer “yes” or “no” to the following question and scenarios; Have you been bothered by any of the following problems? 1) Little interest or pleasure in doing things; 2) Feeling down, depressed, or hopeless. If either or both questions are answered “yes”, patients should be given the 9 question PHQ (PHQ-9). The PHQ-9 can usually be completed by the patient in less than 5 minutes and has been shown to have adequate sensitivity and specificity in screening for depression in patients with CHD. Patients with mild depressive symptoms can have follow up scheduled at a subsequent visit. Patients with high depression scores should have their responses reviewed with a physician or nurse and if needed be referred to a professional qualified to design and implement a suitable individualized treatment plan.

Literature review
Because many providers believe that depression is a “normal” response after an acute cardiac event, there can be a reluctance to treat depression after such an event.1 However, it is imperative that cardiologists take depression into account when treating patients with CHD. The goal is to target those patients in the most need of treatment and supportive services. Antidepressants, cognitive behavioral therapy (CBT), and physical activity are all options either alone or in combination when treating depression in patients with CHD.1 The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study demonstrated that depressed patients given a selective serotonin reuptake inhibitor (SSRI) in combination with either CBT or usual care had a 42% reduction in death or recurrent MI.2 Specifically, 2 SSRIs, sertraline and citalopram, have been shown to be safe and effective in the treatment of moderate, severe, or recurrent depression in patients with CHD.

The Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) enrolled 369 patients with major depressive disorder and either a recent acute MI or unstable angina.3 Patients were randomized to receive either sertraline 50 to 200 mg/day or placebo for 24 weeks. The primary outcome measure of change in left ventricular ejection fraction from baseline was not significantly different between the 2 groups. No statistically significant differences in all of the cardiovascular-related secondary endpoints were noted. The mental health secondary outcome measures included changes in the 17-item Hamilton Depression (HAM-D) score and the Clinical Global Impression Improvement (CGI-I) scale. These measures were compared in the total random sample, in a group with any prior history of major depressive disorder, and a more severe group with major depressive disorder which was defined as 2 prior depressive episodes plus a HAM-D score 18. The response rate using the CGI-I scale was greater in the sertraline group in the total random sample (67% vs. 53%, p=0.01), in the group with at least 1 prior episode of depression (72% vs. 52%, p=0.003), and in the more severely depressed group (78% vs. 45%, p=0.001). Changes in HAM-D scores also favored sertraline in the 2 subgroups with prior depression (p=0.009 and p=0.01). It was concluded that sertraline is safe and effective for the treatment of recurrent depression in patients with unstable angina or recent MI.

A 12-week trial evaluated citalopram and interpersonal psychotherapy (IPT) in reducing depressive symptoms in patients with coronary artery disease and major depression.4 Patients were randomized to receive citalopram 20 to 40 mg/day or matching placebo. The primary outcome measure was the change in the 24-item HAM-D score, and the secondary outcome was change in the self-reported Beck Depression Inventory II (BDI-II) score compared to baseline. After 12 weeks, citalopram recipients had significant improvement in HAM-D scores compared to placebo (p=0.005). HAM-D response rates (53% vs. 40%, p=0.03), remission rates (36% vs. 23%, p=0.01), and reduction in BDI-II scores (difference of 3.6 points, p=0.005) all favored citalopram over placebo. There was no evidence that IPT had significant benefit in the patient population studied. It was concluded citalopram should be considered as a first-line treatment for patients with CHD and depression.

Based on these trials, sertraline or citalopram are considered first-line therapy for the management of depression in patients with CHD.1,3,4 Patients should be observed closely for side effects, compliance, and efficacy after starting therapy. Tricyclic antidepressants and monoamine oxidase inhibitors (MAO-I) should generally be avoided in patients with CHD.1

Cognitive behavioral therapy may be an alternative for patients who can not tolerate an antidepressant or for those who may prefer nonpharmacological therapy.1 Patients with more severe depression may benefit from the combination of antidepressant therapy and CBT. Duration and frequency of CBT should be tailored to fit an individual’s needs. Aerobic exercise and cardiac rehabilitation can also improve depressive symptoms in patients with CHD. Providers should encourage physical activity and exercise whenever clinically appropriate. Spouses, partners, and/or family should also help encourage the patient to participate in rehabilitation.

Conclusion
Routine screening for depression in patients with CHD should be performed. Patients with a positive screen should be evaluated by an individual qualified in the diagnosis and management of depression. Patients being treated for depression should be monitored for adherence, efficacy, and safety. Lastly, coordination of care between healthcare providers is essential.

References

  1. Lichtman JH, Bigger JT, Blumenthal JA, et al. Depression and coronary heart disease. Recommendations for screening, referral, and treatment. A science advisory for the American Heart Association Prevention Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2008;118(17):1768-1775.
  2. Taylor CB, Youngblood ME, Catellier D, et al. Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction. Arch Gen Psychiatry. 2005;62(7):792-798.
  3. Glassman AH, O’Connor CM, Califf RM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002;288(6):701-709.
  4. Lesperance F, Frasure-Smith N, Koszycki D, et al. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian cardiac randomized evaluation of antidepressant and psychotherapy efficacy (CREATE) trial. JAMA. 2007;297(4):367-379.