Depression and heart disease: evidence of a link, and its therapeutic implications

The impact of depression in heart disease

Depression and heart disease affect millions of people worldwide. Studies have shown that depression is a significant risk factor for new heart disease and that it increases morbidity and mortality in established heart disease. Many hypothesized and studied mechanisms have linked depression and heart disease, including serotonergic pathway and platelet dysfunction, inflammation, autonomic nervous system and hypothalamic-pituitary-adrenal axis imbalance, and psychosocial factors. Although the treatment of depression in cardiac patients has been shown to be safe and modestly efficacious, it has yet to translate into reduced cardiovascular morbidity and mortality. Understanding the impact and mechanisms behind the association of depression and heart disease may allow for the development of treatments aimed at altering the devastating consequences caused by these comorbid illnesses.

Depression as modifiable coronary risk factor in the emergency department chest pain observation unit: a pilot

INTRODUCTION

Depression is a modifiable coronary risk factor (CRF) that is 2 times more prevalent in women.

OBJECTIVES

To describe the prevalence and severity of depression in women admitted with chest pain to an emergency department (ED) observation unit (ED-CPC) and to determine acceptance of a behavioral health referral.

METHODS

We conducted a prospective observational study at an urban tertiary care hospital ED. English speaking females >or=35 years admitted to the ED-CPC were eligible. A study nurse acquired consent of patients Monday to Friday, 9 AM to 5 PM between July 2006 and May 2007. A 16-item Quick Inventory of Depressive Symptomatology was administered to screen for depression. Those with severe depression were evaluated on site by a psychiatrist. Three- and 6-month follow-up telephone surveys were conducted for health services utilization.

RESULTS

Of 188 women screened, 114 (61%) were enrolled. Of these, 39 (34%) screened positive for depression; 17 were already under psychiatric care. Depressed women were likely to be younger (P = 0.02), nonwhite (P = 0.04), have lower incomes (P = 0.03), <or= high school education (P = 0.01), and nonprivate insurance (P = 0.01) as compared with nondepressed women. Both groups had comparable Framingham Risk Scores and CRFs except for higher obesity in the depressed (P = 0.01). At 6 months the depressed group had higher nonpsychiatric specialty referrals (RR = 2.2; CI = 1.2-4.2) and nondepressed patients had fewer ED visits for cardiac symptoms (RR = 0.89; CI = 0.8-0.9). Three-quarters (71%) agreed to participate in a future trial that referred these patients for psychiatric treatment.

CONCLUSION

Depression is common in CPC women offering an opportunity for further investigation and intervention in moderate-risk CPC patients.

Antidepressant study design affects patient expectancy: a pilot study

BACKGROUND

Response to antidepressant medication is higher in comparator versus placebo-controlled randomized controlled trials (RCTs). Patient expectancy is an important influence on clinical outcome in the treatment of depression and may explain this finding. The results are reported from a pilot RCT studying expectancy and depression outcome in placebo-controlled versus comparator treatment conditions.MethodOut-patients aged 18-65 years with major depressive disorder (MDD) were enrolled in this 8-week RCT. Subjects were randomized to placebo-controlled (escitalopram or placebo) or comparator (escitalopram or citalopram) administration of antidepressant medication. Subjects reported their expected likelihood and magnitude of depression improvement before and after randomization using questions from the Credibility and Expectancy Scale (CES). A regressed change model of post-randomization expectancy of improvement was fit to the data to determine whether subjects in the comparator group reported greater expectancies of improvement than subjects in the placebo-controlled group.

RESULTS

Twenty subjects with mean age 56.5+/-11.7 years, a baseline Hamilton Depression Rating Scale (HAMD) score of 24.2+/-5.3, baseline Beck Depression Inventory (BDI) score of 24.9+/-6.4 and baseline Clinical Global Impressions (CGI) - Severity score of 4.0+/-0.3 were enrolled in the study. Adjusting for other factors, the effect of group assignment on expected magnitude of improvement was significant and large (effect size 1.5). No group differences in expected likelihood of improvement were found.

CONCLUSIONS

Randomization to comparator versus placebo-controlled administration of antidepressant medication produced greater expectancies of how much patients would improve during the trial. This expectancy difference may explain the higher response and remission rates that are observed in comparator versus placebo-controlled trials.

The interaction of obesity and psychological distress on disability

BACKGROUND

Prior research has shown that psychological problems interact with various chronic medical conditions to amplify disability, but no study has investigated this effect in obesity. The aim of this study was to evaluate the synergistic interaction of psychological distress and obesity on functional disability in an adult community sample.

METHODS

Cross-sectional data were obtained from the 2005 Canadian Community Health Survey, a nationally representative sample of 53,416 respondents aged 18 years or older. Our outcome measures were self-reported disability days and self-rated health. Our covariates of interest were non-specific psychological distress (Kessler K10 scale) and body mass index (BMI). Odds ratios of disability measures were estimated by psychological distress and weight status from logistic regressions, adjusted for sociodemographic and clinical variables.

RESULTS

Disability status was more frequent in individuals with obesity and psychological distress than in those with either obesity or psychological distress alone. Adjusted odds ratios increased progressively across BMI and psychological distress categories. Significant interactions were found for (a) obesity class I (BMI between 30.0 and 34.9 kg m(-2)) and high psychological distress; and (b) obesity class II-III (BMI > 35 kg m(-2)) and moderate to high distress.

CONCLUSION

The results suggest a strong association between psychological distress, obesity and disability. Addressing psychological distress in obese individuals might reduce the public health burden of comorbid obesity and psychological distress by tackling disability.

Expectancy and the Treatment of Depression: A Review of Experimental Methodology and Effects on Patient Outcome

Expectancies are a class of psychological and neurobiological processes that may be responsible for part of the improvement observed with psychiatric treatments. Patients' expectations can substantially affect the results of clinical trials, and managing them is an important part of clinical care. This review describes the history of research on expectancy effects in Major Depressive Disorder (MDD), the relationship between expectancies and placebo effects, and what is currently known about the mechanisms of action of expectancy. Meta-analyses of antidepressant trials show that placebo response rates are high (typically ~30%) and often larger than the difference in response rates between drug and placebo (typically ~10%). Some of the response to placebo is due to natural history, but a growing literature suggests that much of the improvement on placebo treatment is due to active neurobiological processes related to expectancy. Several studies have shown that higher expectation of therapeutic improvement leads to greater improvement in psychiatric symptoms, particularly in MDD. New research on the mechanisms of action of expectancy is therefore a priority that could lead to improved interventions. This review discusses the evidence to date and methodological considerations in the design of new studies.

Broken-Hearted Women: The Complex Relationship between Depression and Cardiovascular Disease

The importance of mind–body health relationships has been recognized for decades, but only recently has the wider medical and cardiovascular community become engaged in understanding and addressing the complex, bidirectional risk relationship between cardiovascular disease (CVD) and depression. Furthermore, it has become increasingly clear that there are incompletely understood sex differences in incidence and outcomes for both conditions that should guide treatment and future research efforts. This review will explore the role of depression in women as a risk factor for incident CVD, its impact on women already suffering from CVD, proposed psychobiologic mechanisms and links, and the implications of sex differences on diagnosis and treatment.

Effect of selective serotonin reuptake inhibitors on platelet activation: can they prevent acute myocardial infarction?

In recent years a large body of evidence from several longitudinal studies has emerged suggesting that depression is an independent risk factor for cardiovascular disease (CVD) and that the association between depression and increased CVD risk is not merely due to negative mood-driven behavior related with depression. Even though the underlying mechanisms are not well understood, several hypotheses and explanations have been proposed such as increased activation of the hypothalamic-pituitary-adrenal axis, abnormalities in the sympathoadrenal system, or abnormalities in platelet function. Platelet function abnormalities, including increased platelet reactivity, may predispose patients with depressive disorders to clotting diatheses and may explain their vulnerability to CVD. Serotonin secreted by platelets induces both platelet aggregation and coronary vasoconstriction. Even though serotonin itself is only a weak platelet agonist, it markedly enhances platelet reactions to a variety of other agonists. Several studies have shown that selective serotonin reuptake inhibitors (SSRIs) reduce platelet and whole blood serotonin concentrations after repeated doses, and could therefore exert an inhibitory effect on platelet activation. For that reason, it was hypothesized that SSRIs could have a protective effect against myocardial infarction (MI). Results from three currently available epidemiological studies assessing the risk of MI in patients treated with antidepressants, including SSRIs, are controversial with respect to a potential beneficial effect of SSRIs on CVD risk in depressed patients. However, there is evidence that exposure to SSRIs does not substantially increase the risk of CVD in patients. A recent randomized, double-blind, placebo-controlled, multicenter trial that evaluated the safety and efficacy of the SSRI sertraline in patients with major depression and acute MI or unstable angina suggested that sertraline is well tolerated and effective. Further epidemiological studies or longer-term clinical trials may shed more light on this issue, and answer the question conclusively, whether the effect of SSRIs on platelets or another mechanism translates into a decreased risk of CVD in depressed patients.

Chagas disease as a mechanistic model for testing a novel hypothesis

The association between depression and cardiovascular disease is well documented. Nevertheless, the process through which they are linked remains unknown, as does the direction of this relationship. Studies have suggested both that depression is a risk factor for heart disease and that heart disease is a risk factor for depression. A number of studies have established that a relationship exists between depression and inflammation, with alterations in the levels of inflammatory markers (IL-1, IL-6, TNF-alpha and others). Depressive symptoms have also been identified in many diseases characterized by inflammatory processes e.g. rheumatoid arthritis, bronchial asthma, diabetes, tuberculosis and cardiovascular diseases. In this brief viewpoint, we explain and propose how to use Chagas disease, a disorder characterized by inflammatory processes and leading to cardiovascular and autonomic problems, as a model for studying the directionality of the relationship between heart disease and depression.

Impaired parasympathetic function increases susceptibility to inflammatory bowel disease in a mouse model of depression

Clinical and experimental evidence indicates that intestinal inflammatory conditions can be exacerbated by behavioral conditions such as depression. The recent demonstration of a tonic counterinflammatory influence mediated by the vagus nerve in experimental colitis provides a potential link between behavior and gut inflammation. Here we show that experimental conditions that induced depressive-like behaviors in mice increased susceptibility to intestinal inflammation by interfering with the tonic vagal inhibition of proinflammatory macrophages and that tricyclic antidepressants restored vagal function and reduced intestinal inflammation. These results show that reserpine-induced monoamine depletion and maternal separation, 2 models for depression, produced a vulnerability to colitis by a mechanism involving parasympathetic transmission and the presence of gut macrophages. The tricyclic antidepressant desmethylimipramine protected against this vulnerability by a vagal-dependent mechanism. Together these results illustrate the critical role of the vagus in both the vulnerability to inflammation induced by depressive-like conditions and the protection afforded by tricyclic antidepressants and rationalize a clinical evaluation of both parasympathomimetics and tricyclic antidepressants in treatment of inflammatory bowel disease.

Sleep-disordered breathing, cognitive functioning, and adherence in heart failure: linked through pathology?

Heart failure (HF) is well recognized as a condition resulting from chronic neurohormonal activation. Sleep-disordered breathing (SDB) as a neurohormonal disorder is less recognized. In SDB, whether obstructive or central in nature, nightly repetitive cycles of hypoxia-reoxygenation produce intense sympathetic activation and deprive the body of much needed sleep. Both HF and SDB are associated with fatigue, cognitive impairment, and challenges for adherence to prescribed therapies. Together, the combination of HF and SDB can have particularly ominous consequences for cognitive functioning, decision making, adherence and, ultimately, outcomes. The suboptimal adherence seen in patients with both HF and SDB may result from a neurohormonal synergism that exists between the 2 conditions.

Depressive symptoms and the risk of atherosclerotic progression among patients with coronary artery bypass grafts

BACKGROUND

Depressive symptoms have been associated with increased risk of coronary artery disease and poor prognosis among patients with existing coronary artery disease, but whether depressive symptoms specifically influence atherosclerotic progression among such patients is uncertain.

METHODS AND RESULTS

The Post-CABG Trial randomized patients with a history of coronary bypass graft surgery to either an aggressive or a moderate lipid-lowering strategy and to either warfarin or placebo. Coronary angiography was conducted at enrollment and after a median follow-up of 4.2 years. Depressive symptoms were assessed at enrollment with the Centers for Epidemiologic Studies Depression scale (CES-D) in 1319 patients with 2496 grafts. In models that adjusted for age, gender, race, treatment assignment, and years since coronary bypass graft surgery, a CES-D score > or =16 was positively associated with risk of substantial graft disease progression (OR 1.50, 95% CI 1.08 to 2.10, P=0.02) and marginally associated with a 0.11-mm (95% CI -0.22 to 0.01 mm, P=0.07) decrease in minimum lumen diameter, but not with risk of graft occlusion (P=0.30). Additional adjustment for past medical history, blood pressure, and renal function did not materially alter these results. This association was virtually absent among participants randomly assigned to aggressive lipid-lowering therapy.

CONCLUSIONS

These findings suggest that depressive symptoms are associated with a higher risk of atherosclerotic progression among patients with saphenous vein grafts and that aggressive lipid lowering can minimize this increased risk. Whether depressive symptoms increase progression in other types of coronary atherosclerosis and whether aggressive lipid lowering attenuates such progression will require additional study.

Pathways to depression: the impact of neighborhood violent crime on inner-city residents in Baltimore, Maryland, USA

Crime and neighborhood disorder may negatively impact the health of urban residents. Neighborhoods with high levels of violent crime may also increase residents' risk of experiencing violence. Most studies supporting the assertion that neighborhood disorder impacts mental health have used residents' own ratings of their neighborhoods. The present study examines the relationships among block-group level crime, perceived neighborhood disorder, violence experienced in the neighborhood, and depression. The sample comprising the current and former drug users (n=786) nested in 270 block groups within Baltimore, Maryland, USA. Using path analysis, we tested the hypothesis that neighborhood violent crime has a direct impact on experiences of violence. Also, we hypothesized that neighborhood violence had a direct and indirect impact on depressive symptoms. Results support a model in which violence is associated with psychological distress through perceptions of neighborhood disorder, and through experiences of violence. We conclude that community and structural level interventions are needed to decrease neighborhood crime and improve residents' perception of their neighborhood.

Depression and ischemic heart disease: what have we learned from clinical trials?

PURPOSE OF REVIEW

Discuss the interplay of depression and ischemic heart disease. Studies demonstrate high prevalence of depression and its negative impact among patients with ischemic heart disease.

RECENT FINDINGS

Results extend previous findings among men, demonstrating a significant increase in mortality and cardiovascular events among depressed women. Sertraline, citalopram and mitrazapine have been shown to be safe and well tolerated in patients with ischemic heart disease. Sertraline and citalopram have demonstrated efficacy for treating depression in such patients. Mirtazapine did not have significant efficacy on post-myocardial infarction depression. Cognitive-behavioral therapy and interpersonal therapy have not been found to have a significant treatment effect. Treating depression may have an impact on cardiovascular morbidity and mortality, but this has not yet been adequately studied. Studies to date lack sufficient statistical power to fully examine the impact of interventions for depression on cardiovascular outcomes.

SUMMARY

Cardiologists encounter depression among 25-30% of their patients with ischemic heart disease. Depression is an independent risk factor for poor prognosis among ischemic heart disease patients, at a level comparable to several conventional cardiac risk factors. Adequate treatment of depression may improve the poor prognosis of depressed patients with ischemic heart disease.

Psychosocial aspects of pulmonary hypertension: a review

Pulmonary arterial hypertension (PAH) is characterized by progressive and sustained elevation of pulmonary-artery pressure, which ultimately leads to right-ventricular failure and death. The diagnosis carries with it an uncertain and historically very bleak prognosis. Although new oral and chronic parenteral (intravenous and subcutaneous) treatments have had a significant positive medical impact on the physical functioning of individuals with PAH, patients often struggle with new short- and long-term psychosocial challenges. The purpose of the current article is to 1) provide a brief review of PAH and its treatment; 2) summarize the limited literature examining the psychosocial adjustment of those with a PAH diagnosis; and 3) provide pertinent information extrapolated from the larger literature on chronic illness that might inform us on the psychosocial challenges faced by the patient diagnosed with PAH.

Presence of depression and anxiety before and after coronary artery bypass graft surgery and their relationship to age

BACKGROUND

Scientific literature on depression and anxiety in patients with coronary heart disease (CHD) consistently reports data of elevated anxiety and depression scores indicating clinically relevant quantities of these psychopathological conditions. Depression is considered to be a risk factor for the development of CHD and deteriorates the outcome after cardiac rehabilitation efforts. The aim of our study was to evaluate the presence of clinically relevant anxiety and depression in patients before and after coronary artery bypass grafting (CABG). Additionally we evaluated their relationship to age because of the increasing number of elderly patients undergoing CABG surgery.

METHODS

One hundred and forty-two consecutive patients who underwent CABG in our hospital were asked to fill in the "Hospital Anxiety and Depression Scale - German Version (HADS)" to measure depression and anxiety scores two days before and ten days after CABG surgery. Differences between these pre- and post-surgical scores were then calculated as means for changes, and the amount of elevated scores were appraised. In order to investigate the relationship between age and anxiety and depression, respectively, Spearman correlations between age and the difference scores were calculated. In addition, ANOVA procedures with the factor "age group" and McNemar tests were calculated. Therefore the sample was divided into four equally sized age groups.

RESULTS

25.8% of the patients were clinically depressed before and 17.5% after surgery; 34.0% of the patients were clinically anxious before and 24.7% after surgery. This overall change is not significant. We found a significant negative correlation between age and the difference between the two time points for anxiety (Spearman rho = -.218; p = 0.03), but not for depression (Spearman rho = -.128; p = 0.21). ANOVA and McNemar-Tests revealed that anxiety scores and the number of patients high in anxiety declined statistically meaningful only in the youngest patient group. Such a relationship could not be found for depression.

CONCLUSION

Our data show a relationship between age and anxiety. Younger patients are more anxious before CABG surgery than older ones and show a decline in symptoms while elderly patients show hardly any change.

Sertraline for the treatment of depression in coronary artery disease and heart failure

Depression is a common co-morbid condition in patients with cardiac disease and has been identified as an independent risk factor for increased morbidity and mortality. SSRIs are established agents for the treatment of depression and are well tolerated in patients with cardiac disease. SSRIs are a heterogeneous group of antidepressants, which apart from their common mechanism of action, differ substantially in their chemical structure, metabolism and pharmacokinetics. This article reviews experimental and clinical evidence on the safety and efficacy of the most extensively studied SSRI, sertraline, in depressed patients with coronary artery disease and heart failure. Intervention with sertraline has the potential to provide depressed patients with cardiac disease relief from their depressive symptoms, improvement in quality of life and a potential benefit in their cardiovascular risk profile.

Relationship between depressive symptoms and long-term mortality in patients with heart failure

BACKGROUND

Depression is prevalent in patients with heart failure (HF) and is associated with short-term poor prognosis. However, the long-term effect of depression and the use of self-administered depression evaluation on HF prognosis remained unknown. The study sought to assess the association of depressive symptoms and long-term mortality of patients with HF and to explore the prognostic predictability of the Beck Depression Inventory (BDI) scale for patients with HF.

METHODS

Hospitalized patients with HF between March 1997 and June 2003 were recruited. All participants were given the self-administered BDI scale for depression assessment during the index admission. They were then followed for 6 months for the collection of vital status, and annually thereafter.

RESULTS

Total study population comprises 1006 patients. The mean BDI score was 8.3 +/- 7.1. The average days of follow-up were 971 +/- 730 and the vital status was obtained from all participants. During this period, 42.6% of the participants died. Depression (defined by BDI score > or = 10) was significantly and independently associated with reduced survival (adjusted hazard ratio 1.36, 95% CI 1.09-1.70, P < .001). Patients whose BDI scores were 5 to 9, 10 to 18, and > or = 19 were 21%, 53%, and 83% more likely to die, respectively, than patients whose BDI score was < 5 (P < .001).

CONCLUSIONS

Self-rated depression by BDI is independently linked with higher long-term mortality in patients with HF. Significant dose effect of depressive symptoms on higher mortality is noted.

Common genetic factors for depression and cardiovascular disease

There is increasing knowledge regarding the considerable comorbidity between depression and cardiovascular disease, which are two of the most common disorders in developed countries. The associated vulnerability is not unidirectional, as the presence of cardiovascular disease can also influence mood states. Although this may be the result of psychological factors, common biological mechanisms, including genetic ones, are thought to be responsible for this interaction; we can thus question whether variations in genes could be predisposing factors. Regarding the multiple interactions in the mechanisms between depression and cardiovascular system disorders, eg, dysfunctions in the hypo-thalamic-pituitary-adrenocortical and sympathoadrenal axis and the response to stress, the importance of the sero-tonergic and immune systems, or the impact on the renin-angiotensin system, several candidate genes are being investigated. However, despite the interest in unraveling the potential susceptibility genes for both disorders, most available studies have so far dealt with the impact of polymorphisms in relation to either depression or cardiovascular disease. A few recent studies have now examined the effects of gene-gene or gene-environment interactions, and are investigating the impact of "depression-related" variants on cardiac response to stress. The first promising results were obtained with the serotonin transporter, and it may be hypothesized that this polymorphism interacts via the impact of the S allele on depression and via the effect of the L allele on platelet activation. However, the role played by various other candidate genes remains to be determined, especially regarding the question as to whether they are indicative of common pathophysiological mechanisms, or for identifying a subgroup of patients with somatic disorders that are more closely related to psychiatric symptoms.

Joint effect of depression and chronic conditions on disability: results from a population-based study

OBJECTIVES

To estimate and compare the prevalence of functional disability in individuals with both chronic medical conditions and comorbid major depression and individuals with either chronic medical conditions or major depression alone and to determine the joint effect of depression and chronic conditions on functional disability. Evidence exists that major depression interacts with physical illness to amplify the functional disability associated with many medical conditions.

METHODS

We used data from the Canadian Community and Health Survey Cycle 2.1 (n = 46,262), a nationally representative survey conducted in 2003 by Statistics Canada. Depression, chronic conditions, and functional disability were assessed by personal/telephone interview.

RESULTS

Prevalence of functional disability was higher in subjects with chronic conditions and comorbid major depression (46.3%) than in individuals with either chronic conditions (20.9%) or major depression (27.8%) alone. With no chronic conditions and no major depression as reference and after adjusting for relevant covariates, the odds ratio of functional disability was 2.49 (95% confidence interval (CI), 1.91-3.26) for major depression, 2.12 (95% CI, 1.93-2.32) for chronic conditions, and 6.34 (95% CI, 5.35-7.51) for chronic conditions and comorbid major depression.

CONCLUSIONS

The results suggest that there is a joint effect of depression and chronic conditions on functional disability. Research and social policies should focus on the treatment of depression in chronic conditions.

Psychological Factors and Treatment Adherence Behavior in Patients With Chronic Heart Failure

BACKGROUND

Chronic heart failure adversely affects 300,000 Australians. Symptom stabilization and prognosis are partially determined by patients following medical and lifestyle recommendations.

METHODS

To test the hypothesis that depression, anxiety, and self-efficacy are independent predictors of such adherence, 115 predominantly male (70.6%) volunteers with a mean age of 63 years were recruited from a major teaching hospital in Australia.

RESULTS

Depression (Beck Depression Inventory score >10, 33.3%) failed to predict adherence. Trait anxiety (State-Trait Anxiety Inventory score >40, 31%) explained minimal variability regarding smoking and alcohol adherence. Self-efficacy strongly predicted adherence behavior.

CONCLUSIONS

Findings will assist cardiac nurses to prepare strategies to optimize adherence and quality of life while minimizing public health costs.

Depressive symptoms are prominent among elderly hospitalised heart failure patients

BACKGROUND

There are limited data on the prevalence of depressive symptoms in hospitalised elderly HF patients and demographic and clinical characteristics associated with depressive symptoms are not known.

METHODS

A sample of 572 HF patients (61% male; age 71+/-12 years; LVEF 34%+/-15) was recruited from 17 Dutch hospitals during HF admission. Depressive symptoms were assessed by the CES-D. Demographic, clinical variables and HF symptoms were collected from patient chart and interview.

RESULTS

Forty one percent of the patients had symptoms of depression with women significantly more often reporting depressive symptoms than men 48% vs. 36% (chi(2)=8.1, p<0.005). HF patients with depressive symptoms reported more clinical HF symptoms than patients without depressive symptoms. Even after deleting HF related symptoms (sleep disturbances and loss of appetite) from the CES-D scale, 36% of patients were still found to have symptoms of depression. Multivariable logistic regression analyses revealed that depressive symptoms were associated with female gender (odds 1.68, 95% CI 1.14-2.48), COPD (odds 2.11, 95% CI 1.35-3.30), sleep disturbance (odds 3.45, 95% CI 2.03-5.85) and loss of appetite (odds 2.61, 95% CI 1.58-4.33).

CONCLUSIONS

Depressive symptoms are prominent in elderly hospitalised HF patients especially in women. Depressive symptoms are associated with more pronounced symptomatology, despite the fact that other indices of severity of left ventricular dysfunction are similar.

Depression in coronary artery disease: novel pathophysiologic mechanisms and therapeutic implications

Depression is a common comorbid condition in patients with coronary artery disease and a well-documented risk factor for recurrent cardiac events and mortality. The exact mechanisms underlying the interplay between depression and ischemic heart disease remain poorly understood and the same is true for the most effective depression treatment for cardiac patients. This review summarizes current knowledge regarding the prognostic role of depression in patients with coronary artery disease, the pathophysiologic pathways involved, and the effects of antidepressant therapy on cardiovascular disease outcomes. With recent evidence suggesting that selective serotonin reuptake inhibitors may improve survival after myocardial infarction in patients with depression, diagnosis and treatment of this co-morbidity may be essential for the clinical management of coronary artery disease.

Depression in patients with advanced illness: An examination of Ontario complex continuing care using the Minimum Data Set 2.0

Objective: In this study, we examined the prevalence of depression, its recognition, and its treatment in continuing care patients with advanced illness (AI).

Methods: All data were obtained from the Ontario (Canada) provincially-mandated MDS 2.0 form for chronic care. Of 3,801 patients, 524 met our empiric definition of AI, which was predicated on a previously validated algorithm. The MDS-embedded Depression Rating Scale (DRS) was used to measure psychological well-being and a score of 3 or greater indicated potential depression.

Results: Twenty-nine percent of patients with AI scored greater than 3, making them nearly twice as likely to be potentially depressed as other patients (OR 1.8, 95% CI 1.5–2.2). Despite this patients with AI were less likely to have received antidepressants (28.9% vs. 38.2%), even among those with a diagnosis (45.3% vs. 58.4%). Using logistic regression, correlates of potential depression were identified and surprisingly patients with cancer were substantially less likely to be depressed (AOR 0.37, 95% CI 0.2–0.6). Further investigation revealed that cancer patients were more likely to be treated for depression and to be recognized as being within the terminal phase of illness.

Significance of results: These findings suggest that a high proportion of terminally ill patients had unmet needs for psychological support. As well, they suggest that cancer patients received better targeted end-of-life care, which resulted in an overall decrease in psychological distress when compared to other patients with similarly advanced illness.

Antidepressant therapy in patients with ischemic heart disease

Depressive disorders are common in patients with ischemic heart disease and have serious consequences in terms of the risk of further cardiac events and cardiac mortality. Among survivors of acute myocardial infarction, up to one fifth meet diagnostic criteria for major depression, and the presence of major depression carries a >5-fold increased risk for cardiac mortality within 6 months. This article reviews clinical trial data on the cardiac safety profiles of antidepressant agents with the aim of discussing clinical considerations in selecting the most appropriate treatment of comorbid depression in patients with ischemic heart disease. Tricyclic antidepressants are effective against depression but are associated with cardiovascular side effects including orthostatic hypotension, slowed cardiac conduction, antiarrhythmic activity, and increased heart rate. Selective serotonin reuptake inhibitors, by contrast, have benign cardiovascular profiles and are well tolerated in patients with cardiac disease. The safety of dual-acting serotonin and noradrenaline reuptake inhibitors has not been well studied. Intervention with a selective serotonin reuptake inhibitors has the potential to provide the depressed patient with ischemic heart disease relief from their depressive symptoms and may offer a potential improvement in their cardiovascular risk profile.

Depressive symptoms and mortality in men: results from the Multiple Risk Factor Intervention Trial

BACKGROUND AND PURPOSE

Depression may be a risk factor for cardiovascular disease (CVD) mortality. We evaluated long-term mortality risk associated with depressive symptoms measured at middle age among men at high risk for coronary heart disease (CHD).

METHODS

12,866 men without definite evidence of CHD at study entry but who had above average risk of CHD based on blood pressure, blood cholesterol levels, and/or cigarette smoking were recruited into the Multiple Risk Factor Intervention Trial (MRFIT). Survivors at the end of the trial were followed-up for mortality for an additional 18 years. Men who had completed the Center for Epidemiologic Studies Depression (CES-D) scale near the end of the trial (n=11,216) were used in a prospective analysis of post-trial all-cause and cause-specific mortality during 18-year follow-up after CES-D assessment.

RESULTS

Greater depressive symptoms measured at the end of the trial were associated with significantly higher risk of all-cause mortality and for cause-specific death, a higher risk of CVD, and, more specifically, stroke mortality (all P values <0.02) but not CHD mortality (P=0.48) in linear trend analyses. The significant associations were strongest for those reporting the greatest depression: hazard ratio (HR)=1.15 (95% CI, 1.03 to 1.28; P<0.01) for all-cause mortality for those in the highest depressive symptom quintile, HR=1.21 for CVD mortality (95% CI, 1.03 to 1.41; P<0.05), and HR=2.03 for stroke mortality (95% CI, 1.20 to 3.44; P<0.01) compared with those in the lowest quintile. These associations were adjusted for age, intervention group, race, educational attainment, smoking at baseline and visit 6, trial averaged systolic blood pressure, alcohol consumption, and fasting cholesterol, as well as the occurrence of nonfatal cardiovascular events during the trial.

CONCLUSIONS

Greater depressive symptoms are associated with an increase in the risk of all-cause and, more specifically, CVD mortality in men. Stroke but not CHD was the form of CVD with which depressive symptoms were associated.

Prognostic value of anxiety and depression in patients with chronic heart failure

BACKGROUND

Anxiety is often present with depression and may be one of its manifestations. Although the adverse effects of depression in patients with chronic heart failure (CHF) have been well studied, the relation between anxiety and CHF prognosis has not been addressed. In a secondary analysis of data collected for a published study of depression and prognosis in patients with CHF, we examined the relations among anxiety, depression, and prognosis.

METHODS AND RESULTS

We measured symptoms of anxiety with the Spielberger State-Trait Anxiety Inventory (STAI) scale and symptoms of depression with the Beck Depression Inventory (BDI) scale in 291 patients with CHF hospitalized as a result of cardiac events. We followed up these patients for all-cause mortality over 1 year. The mean scores for state anxiety (State-A) and trait anxiety (Trait-A) were identical at 33.5; the mean BDI score was 8.7+/-7.6. State-A and Trait-A scores correlated highly with each other (r=0.85; P<0.01) and with BDI score (State-A, r=0.52; Trait-A, r=0.59; P<0.01). Cox proportional-hazards model with and without confounding variables showed no relation between State-A or Trait-A and 1-year mortality. BDI scores, however, significantly predicted increased mortality during 1-year follow-up (hazard ratio, 1.04 for each 1-unit increase; P<0.01).

CONCLUSIONS

Although anxiety and depression are highly correlated in CHF patients, depression alone predicts a significantly worse prognosis for these patients.

Should selective serotonin reuptake inhibitors be prescribed to all patients with ischemic heart disease?

Recent studies have uncovered more and more evidence demonstrating the adverse relationship between depression and ischemic heart disease. One of the most significant mechanisms that may explain the adverse relationship is the increased platelet activity, otherwise known as aggregation, observed to occur in patients with depression or ischemic heart disease. Platelet activity is further elevated in patients with depression and ischemic heart disease. Selective serotonin reuptake inhibitors are antidepressants and also act like platelet inhibitors. The results of large-scale clinical trials suggest that the use of selective serotonin reuptake inhibitors may reduce cardiac events in post-myocardial infarction patients or in those with unstable angina that may be related to the effects of selective serotonin reuptake inhibitors on platelet aggregation.

Influence of depression and effect of treatment with sertraline on quality of life after hospitalization for acute coronary syndrome

Major depressive disorders complicate recovery from acute coronary syndrome in approximately 1 in 5 patients, and have been found to be associated with significant impairments of quality of life and functioning. The aim of the present analysis was to evaluate the efficacy of sertraline in improving quality of life and functioning in patients diagnosed with major depression who had recently been hospitalized for acute coronary syndrome. Three hundred sixty-nine patients hospitalized in the previous month for acute coronary syndrome (myocardial infarction, 74%; unstable angina, 26%) who also met criteria for major depressive disorder were randomized to 24 weeks of double-blind treatment with sertraline (50 to 200 mg/day) or placebo. Quality-of-life and functional status were assessed using the Quality of Life, Enjoyment, and Satisfaction scale (Q-LES-Q) and the Medical Outcomes Study SF-36. Data from the total sample, and the recurrent depression subgroup, were analyzed. Severe baseline impairment was found in the Q-LES-Q and all subscales of the SF-36. A multivariate regression analysis identified depression as the strongest predictor of baseline quality-of-life impairment (partial r, -0.37, p = 0.001). In the recurrent depression group, treatment with sertraline resulted in significantly greater improvement than placebo in the Q-LES-Q total score and SF-36 mental component summary score, as well as the SF-36 role limitations, emotional, and mental health factors. Depression has a substantial negative impact on quality of life and functioning in patients hospitalized for acute coronary syndrome. Sertraline was associated with clinically meaningful improvement in multiple quality-of-life domains in patients with acute coronary syndrome and recurrent depression.

Impact of a Collaborative Care Model on Depression in a Primary Care Setting: A Randomized Controlled Trial

To measure the effects of a collaborative care model that emphasized the role of clinical pharmacists in providing drug therapy management and treatment follow-up to patients with depression, we conducted a randomized controlled trial at a staff model health maintenance organization. We compared the outcomes of subjects treated in this collaborative care model (75 patients, intervention group) with subjects receiving usual care (50 patients, control group). After 6 months, the intervention group demonstrated a significantly higher drug adherence rate than that of the control group (67% vs 48%, odds ratio 2.17, 95% confidence interval 1.04-4.51, p=0.038). Patient satisfaction was significantly greater among members randomly assigned to pharmacists' services than among controls, and provider satisfaction surveys revealed high approval rates as well. Changes in resource utilization were favorable for the intervention group, but differences from the control group did not achieve statistical significance. Clinical improvement was noted in both groups, but the difference was not significant. Clinical pharmacists had a favorable effect on multiple aspects of patient care. Future studies of this model in other health care settings appear warranted.

Broken heart: depression in cardiovascular disease

Heart disease and depression are among the most common diseases seen in developed countries. The relation-ship between heart disease and depression has been the subject of both popular interest and scientific research. Sadness is often portrayed as a feeling of heaviness in the chest or as a "broken heart." Interestingly as we learn more about the expression of emotions, it appears that these perceptions may simply be the language representation of somatic feelings. Large, prospective, longitudinal studies that have examined the relationship between depression and development of coronary artery disease (CAD) have shown that depression is a risk factor for the development of CAD. Depression also increases mortality in patients with stable CAD or myocardial infarction compared with patients without depression. The recent Sertraline AntiDepressant HeARt attack Trial (SADHART) has shown that selective serotonin reuptake inhibitors like sertraline can be safely used in patients with depression following myocardial infarction. There is also intriguing evidence that treating depression with antidepressants may improve outcomes, including mortality.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.