Perspective:

The following are 10 points to remember about depression and cardiovascular disease (CVD):

1. CVD and depression are two of the most common causes of disability. Furthermore, both conditions frequently occur together and are projected to increase over the next several decades.

2. Up to two thirds of patients hospitalized for acute coronary syndromes (ACS) have mild depression. Patients with heart failure (HF) also have high rates of depression (generally >20%).

3. It is currently not clear that depression is a risk factor for CVD, as opposed to a risk marker. However, the presence of depression appears to double the risk for CVD, including myocardial infarction. The INTERHEART study found that psychosocial factors (depression, stress, life events, and locus of control) were one of four major factors that contribute to ACS risk. Plausible biologic mechanisms include changes in the autonomic nervous system, platelet receptors and function, coagulopathic factors such as plasminogen activator inhibitor-1 and fibrinogen, proinflammatory cytokines, endothelial function, neurohormonal factors, and genetic linkages such as with the serotonin transporter mechanism. Depression is associated with poor adherence to medical treatment.

4. Depression is also associated with survival after MI and HF. After MI, patients with depression have been observed to have a three-fold increase in mortality after adjustment for age, sex, smoking status, clinical severity, and left ventricular ejection fraction.

5. Depression is also associated with reduced quality of life in both ACS and HF patients. Depression is associated with reduced adherence to lifestyle modification and medication adherence in CVD patients.

6. Cardiac rehabilitation programs have been observed to improve depressive symptoms in cardiac patients. It is likely that exercise training is helpful in the management of depression among cardiac patients.

7. Trials that have evaluated deferent interventions to treat depression in CVD patients have had mixed results. Studies to date have not observed a reduction in cardiac events with cognitive behavioral therapy (CBT), antidepressant medications, or interpersonal psychotherapy. However, most have noncardiac outcomes as the primary endpoints. Antidepressant medications (most commonly used are those in the selective serotonin reuptake inhibitor [SSRI] class), have been demonstrated to improve depression in cardiac patients, particularly those with recurrent or severe depression. The intervention in the ENRICHD study was actually a combination of CBT and SSRI, with subgroup analysis suggesting that perhaps there was more effect on reducing CV events in those who actually received the SSRI.

8. In general, SSRI medications have demonstrated good efficacy in the treatment of depression and have a good safety profile for cardiac patients. However, safety concerns exist for higher doses and in patients who are over 65 years of age, have low serum potassium or magnesium levels, have congestive HF, or are on other medications that could potentially inhibit cytochrome-2C19 metabolism, such as omeprazole. In general, tricyclic antidepressants are not used as first-line therapy in cardiac patients because of the potential increased risk of ventricular arrhythmias.

9. Several questions exist, which have been validated in cardiac patients and can be used to screen for depression. An American Heart Association Science Advisory suggested that the Patient Health Questionnaire (PHQ) might be the most useful. The PHQ2 comprises two items that inquire about the patients’ mood and experience of anhedonia in the last 2 weeks. The PHQ9 expands upon the PHQ2 to include seven additional Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV( depression symptoms.

10. Currently, screening for depression is not routinely performed by CV care providers. The European Guidelines on CVD prevention in clinical practice suggest that depression should be detected, and that patients with clinically significant depression should be offered treatment. The European Society of Cardiology guidelines for the diagnosis and treatment of HF suggest that routine screening for depression with a validated questionnaire is good practice.