Journals Club: Depression and heart disease

Dr Louise Newson brings us up to date with the latest research and guidance on depression and heart disease

Angiogram showing stenosis (Photograph: SPL)
Angiogram showing stenosis (Photograph: SPL)

Curriculum statement 13: Care of people with mental health problems

Curriculum statement 15.1: Cardiovascular problems Key trials

  • Depression is associated with increased morbidity and mortality in those with established cardiovascular disease (Future Cardiol 2010; 6(4): 547-56).
  • Patients with prominent physical symptoms of depression, such as fatigue, may be less likely to respond to active treatment and more likely to have worse cardiac outcomes than others (J Psychosom Res 2010; 68: 511-9).
  • Although RCTs of medication and non-pharmacologic treatments have not demonstrated that treating depression improves survival, there is evidence that treating depressed patients can reduce depressive symptoms and improve quality of life (Expert Opin Pharmacother 2011; 12: 85-98).
  • An analysis of more than 48,000 heart failure patients has shown that those with a history of depression had longer hospital stays and higher early post-discharge mortality compared with those without a history of depression (Am J Med 2009; 122: 366-73).

Evidence base

  • Many hypothesised 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 also psychosocial factors (Curr Psychiatry Rep 2010; 12(3): 255-64).
  • Although depression seems to be a marker of increased risk after the diagnosis of CHD, it is currently unclear whether depression can be considered as an independent risk factor and whether its treatment lowers CHD risk (Curr Atheroscler Rep 2010; 12(2): 105-9).
  • Antidepressant drugs, such as SSRIs, are safe for use in patients with CHD, can reduce depression and can also improve adherence with medical therapy (Cleve Clin J Med 2010; 77 Suppl 3: S12-9).

Guidelines

  • NICE guidance recommends that people with depression and also physical health problems should be treated using a 'stepped care' model (NICE. Depression with a chronic physical health problem. CG91. London, NICE, 2009).
  • The benefits of using a case management approach in primary care for people with depression and CHD are currently being studied (J Affect Disord 2010; 122(Suppl 1): S19).
  • Patients with cardiac disease should be screened for depression using the standard two questions (RCGP News, January 2011; 6).
KEY POINTS
  • Depression is very common in patients with CHD.
  • Patients with depression have a worse prognosis for CHD.
  • It is unclear as to whether treatment for depression actually improves the prognosis for CHD.
  • All patients with CHD should be screened for depression.
  • Contributed by Dr Newson, a GP in the West Midlands

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