Depression in Patients With CAD

Pragle AS, Salahshor S
Identifying and managing depression in patients with coronary artery disease. JAAPA 2018;31:12-18.

The following are key points to remember regarding depression in patients with coronary artery disease (CAD):

  1. Clinically significant depression occurs in 20-40% of patients with CAD. Untreated depression significantly increases morbidity and mortality following an acute cardiac event. Depression in patients with CAD is frequently underdiagnosed and undertreated. Depression decreases patient adherence to recommendations such as daily aspirin and cardiac rehabilitation; effective treatment of depression can improve cardiac outcomes.
  2. Risk factors for depression in patients with CAD include female sex, younger age, social isolation, diabetes, prior depression history, and previous cardiac event.
  3. Useful tools include Beck Depression Inventory, Hamilton Depression Rating Scale, Patient Health Questionnaire PHQ-9, Diagnostic and Statistical Manual of Mental Disorders Cross-Cutting Level 1, Columbia Suicide Assessment Screen, and Zero Suicide online assessment toolkit.
  4. Major depression diagnosis requires 5 of 9 key symptoms for >2 weeks and must include 1 of the first 2: depressed mood, diminished interest or pleasure in almost all activities, low self-esteem, sleep disturbance, changes in appetite, loss of energy, difficulty with concentration, psychomotor retardation or agitation, and suicidal ideation.
  5. Mild depression can be effectively treated with psychotherapy. Moderate or severe depression requires psychotherapy and antidepressant treatment. Patients with suicidal ideation should be hospitalized immediately.
  6. Psychosocial intervention (psychotherapy) can be provided by psychologists or clinical social workers. Cognitive behavior therapy is the most effective non-pharmacologic treatment modality for moderate to major depression. Others include interpersonal therapy, supportive stress management, and problem-solving depression care.
  7. Pharmacologic intervention should be considered in those with severe depression, chronic or recurrent depression, psychotic features, response to prior antidepressant therapy, family history of depression, or inability to participate in psychotherapy. Sertraline and citalopram have few cardiac adverse reactions. Citalopram can cause bradycardia and should be avoided in conditions such as congenital long QT syndrome. Fluoxetine is used for mild to major depression 90 days post-myocardial infarction in those tending toward hostility. Bradycardia risk is low; it may decrease QRS width and decrease dysrhythmias. Mirtazapine has a low risk of orthostatic hypotension or conduction abnormalities. It showed no increase in adverse reactions or hospital admissions in MIND-IT (The Myocardial Infarction and Depression-Intervention Trial). Tricyclic antidepressants are generally contraindicated due to adverse cardiac reactions including conduction abnormalities, orthostatic hypotension, and tachycardia.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement

Keywords: Coronary Artery Disease, Depressive Disorder, Major, Depression, Cognitive Therapy, Cardiac Rehabilitation, Psychotherapy, Risk Factors, Social Isolation, Appetite, Self Concept, Suicidal Ideation, Hostility, Mianserin, Diagnostic and Statistical Manual of Mental Disorders, Antidepressive Agents, Antidepressive Agents, Tricyclic, Fluoxetine, Citalopram, Sertraline, Bradycardia, Hypotension, Orthostatic, Tachycardia, Long QT Syndrome, Myocardial Infarction

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