The recovery period following an acute myocardial infarction (AMI) can be a confusing time. A heart attack is an impactful, unexpected event for patients that can leave them with many questions. Most patients would consider this a stressful period, and while much of this stress naturally diminishes, a significant amount of patients continue to experience emotional symptoms that may impair their daily functioning. Symptoms of depression manifest in about one-third of patients who suffered an AMI, and about one in five suffers from a major depressive disorder.¹ Anxiety is also very common, with estimates ranging from 30-40% of hospitalized patients following an AMI.² Symptoms do not necessarily lead to a clinical diagnosis such as a generalized anxiety disorder or posttraumatic stress disorder, but in 5% and 15% of patients respectively, a clinical diagnosis of a generalized anxiety disorder or post-traumatic stress disorder has been noted.^3,4

While having a mental health condition like depression or an anxiety disorder may be impactful in and of itself, dealing with the aftermath of an AMI presents an additional challenge. It may also compromise the cardiac rehabilitation trajectory following an AMI. Adhering to an exercise regimen or medications becomes more difficult when one is also affected by a mental health condition. In fact, it may leave patients more vulnerable to less optimal outcomes post AMI as compared with patients who do not battle depression or anxiety. For depression, a 22% increased risk of premature all-cause death has been observed.⁵ Less data are available for the risk associated with anxiety, but estimates thus far have quantified a more than 30% increased risk of the combined endpoint of all-cause mortality, cardiac mortality, and cardiac events associated with symptoms of anxiety post-AMI.² The exact mechanisms underlying these associations are still largely unknown, but are most likely multifactorial and include biological, behavioral, and social pathways.

In the past decade, much of the research in this context has concentrated on depression in AMI. Far less literature has focused on how to recognize and treat anxiety disorders in patients with AMI. While trials were not able to demonstrate a survival benefit by treating depression in patients with AMI, randomized controlled trials do show that depression can be safely and effectively treated in patients with AMI, thereby improving quality of life.^6,7 Options are also available to treat conditions like generalized anxiety disorder or post-traumatic stress disorder.^8,9

Improved recognition and follow-up are vital in ensuring patients receive the treatment necessary to alleviate their depression and anxiety symptoms.¹⁰ In the past 10 years, there has been much debate as to whether or not the time after an AMI is the appropriate setting for intensify screening efforts to detect depression.¹¹

The American Heart Association does underscore in its scientific advisory statements the importance of screening of coronary disease patients for depressive symptoms, including patients who have suffered an AMI, and provides specific instructions as to how such a screening and treatment referral process can be set up.^12,13 The availability of reliable and valid self-report screening instruments, such as the Patient Health Questionnaire 9-item version,^14,15 have made it easier to support these screening efforts. Concerns have traditionally been voiced about the use of resources and potential harmful effects of screening given the lack of evidence supporting an association between treatment of depression and improved survival after AMI.¹¹ Recently, however, the US Preventive Services Task Force issued an advisory wherein it recommends screening for depression in the adult population, particularly in adults with chronic diseases.¹⁰ Its justification for doing so is based on compiled evidence that demonstrates the availability of reliable depression screening instruments, the substantial benefits associated with detection and treatment of depression, and the minimal to non-existent risks associated with screening.

Key elements that allow for a screening program to be successful, though, include the involvement of primary care providers and adequate institutional support for a dedicated depression case manager or a collaborative care program to ensure successful referral and continuation of care. In fact, programs designed with a more integrated vision of care in mind have proven successful in treating depressive symptoms in patients with stable coronary disease and AMI. The Bypassing the Blues trial is such an example,¹⁶ in which treatment of depression was provided through an 8-month telephone based collaborative care program delivered by a multidisciplinary team consisting of a psychiatrist, nurse, and primary care physician for patients who had undergone coronary artery bypass grafting. Compared with usual care (i.e., patient and primary care physician being informed about depression status but no further treatment advice unless suicidality detected), patients in the intervention group had better outcomes in terms of quality of life, physical functioning, and mood symptoms. The COPES (the Coronary Patients Evaluation Study) and the CODIACS (Comparison of Depression Interventions after Acute Coronary Syndrome) trials were studies conducted in survivors of AMI with persistent symptoms of depression (symptoms that persisted beyond 3 months following the AMI).^17,18 In both trials, patients that experienced persistent depressive symptoms were randomized to usual care or a stepped care depression protocol. Key elements of the stepped care protocol were a choice of treatment (problem solving therapy and/or pharmacotherapy) and continuous monitoring of depressive symptoms with the purpose of adapting the care as necessary. In both studies, patients experienced both greater relief of depressive symptoms and greater satisfaction with their treatment. The COPES trial also had a signal towards better 6-month prognostic outcomes (reduced risk of major adverse cardiac events) for those who received the stepped care protocol. These intervention studies have been instrumental in identifying successful components of integrated depression care in a cardiology specialty care setting.

Intervention studies targeting anxiety in coronary patients have not been widely tested. The UNWIND (UNderstanding the benefits of exercise and escitalopram in anxious patients WIth coroNary heart Disease) study is currently being conducted whereby patients with coronary disease experiencing elevated anxiety symptoms and/or a diagnosed anxiety disorder will be randomized to 12 weeks of aerobic exercise, escitalopram, or placebo (follow-up assessments and meeting with study physician and placebo pill). Outcomes with regards to anxiety symptoms, inflammatory markers, heart rate variability, and vascular endothelial function will be compared.¹⁹ In the past, intervention studies have been conducted targeting general stress in patients with coronary artery disease. One good example of this was a study done in female patients with coronary disease, randomizing them to a group-based stress reduction program over the course of a year versus usual care. What researchers found over a mean observation period of 7 years was that women who participated in the stress reduction program had better survival.²⁰

Despite these successful trials targeting patients' mood and stress levels, there are several questions and challenges to be addressed to allow for a wider adoption and implementation of these programs into routine cardiovascular care. The sustainability and cost-effectiveness of the programs that have been tested will require further evaluation. In addition, identifying the groups that would benefit most from these programs is key. Working with patients to identify an individualized and tailored treatment plan and further standardization of the assessment and monitoring of patients' mood symptoms following an AMI are key areas to focus on in the future.

References

1. Thombs BD, Bass EB, Ford DE, et al. Prevalence of depression in survivors of acute myocardial infarction. J Gen Intern Med 2006;21:30-8.
2. Roest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med 2010;72:563-9.
3. Roest AM, Zuidersma M, de Jonge P. Myocardial infarction and generalised anxiety disorder: 10-year follow-up. Br J Psychiatry 2012;200:324-9.
4. Gander ML, von Kanel R. Myocardial infarction and post-traumatic stress disorder: frequency, outcome, and atherosclerotic mechanisms. Eur J Cardiovasc Prev Rehabil 2006;13:165-72.
5. Meijer A, Conradi HJ, Bos EH, et al. Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis. Br J Psychiatry 2013;203:90-102.
6. Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized trial. JAMA 2003;289:3106-16.
7. Joynt KE, O'Connor CM. Lessons from SADHART, ENRICHD, and other trials. Psychosom Med 2005;67:S63-6.
8. Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev 2013:CD003388.
9. Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev 2007:CD001848.
10. Siu AL, US Preventive Services Task Force, Bibbins-Domingo K, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA 2016;315:380-7.
11. Thombs BD, Roseman M, Coyne JC, et al. Does evidence support the American Heart Association's recommendation to screen patients for depression in cardiovascular care? An updated systematic review. PLoS One 2013;8:e52654.
12. Lichtman JH, Bigger JT, Blumenthal JA, et al. Depression and coronary heart eisease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation 2008;118:1768-75.
13. Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 2014;129:1350-69.
14. Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med 2007;22:1596-602.
15. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA 1999;282:1737-44.
16. Rollman BL, Belnap BH, LeMenager MS, et al. Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial. JAMA 2009;302:2095-103.
17. Davidson KW, Bigger JT, Burg MM, et al. Centralized, stepped, patient preference-based treatment for patients with post-acute coronary syndrome depression: CODIACS vanguard randomized controlled trial. JAMA Intern Med 2013;173:997-1004.
18. Davidson KW, Rieckmann N, Clemow L, et al. Enhanced depression care for patients with acute coronary syndrome and persistent depressive symptoms: coronary psychosocial evaluation studies randomized controlled trial. Arch Intern Med 2010;170:600-8.
19. Blumenthal JA, Feger BJ, Smith PJ, et al. Treatment of anxiety in patients with coronary heart disease: rationale and design of the UNderstanding the benefits of exercise and escitalopram in anxious patients WIth coroNary heart Disease (UNWIND) randomized clinical trial. Am Heart J 2016;176:53-62.
20. Orth-Gomer K, Schneiderman N, Wang HX, Walldin C, Blom M, Jernberg T. Stress reduction prolongs life in women with coronary disease: the Stockholm Women's Intervention Trial for Coronary Heart Disease (SWITCHD). Circ Cardiovasc Qual Outcomes 2009;2:25-32.

Keywords: Acute Coronary Syndrome, Secondary Prevention, Angina, Stable, Heart Failure

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