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Depression and heart disease: What do we know, and where are we headed?

Cleveland Clinic Journal of Medicine. 2009 January;76(1):59-70 | 10.3949/ccjm.75a.08011
January 1, 2009|Cleveland Clinic Journal of Medicine
Leo Pozuelo, MD;George Tesar, MD;Jianping Zhang, MD, PhD;Marc Penn, MD, PhD;Kathleen Franco, MD;Wei Jiang, MD
Author and Disclosure Information

Leo Pozuelo, MD
Section Head, Consultation Psychiatry, Department of Psychiatry and Psychology; Associate Director, Bakken Heart-Brain Institute; and Department of Cardiovascular Medicine, Cleveland Clinic

George Tesar, MD
Chairman, Department of Psychiatry and Psychology, Cleveland Clinic

Jianping Zhang, MD, PhD
Department of Psychiatry, Zucker Hillside Hospital, North Shore Long Island Jewish Health System, Glen Oaks, NY

Marc Penn, MD, PhD
Director, Bakken Heart-Brain Institute; Director, Cardiac Intensive Care Unit; Department of Stem Cell Biology and Regenerative Medicine; and Department of Biomedical Engineering, Cleveland Clinic

Kathleen Franco, MD
Department of Psychiatry and Psychology, Cleveland Clinic; Associate Dean, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Wei Jiang, MD
Associate Professor, Medicine, Psychiatry, and Behavioral Sciences, Duke University Medical Center, Durham, NC; Investigator, Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART)-CHF study

Address: Leopoldo Pozuelo, MD, Department of Psychiatry and Psychology, P57, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail pozuell@ccf.org

ABSTRACTDepression and heart disease have an intricate association and perhaps a causal relationship. We review the current status of depression and heart disease and provide an algorithm for diagnosing and treating depression in cardiac patients that internists and cardiologists can use in their daily patient encounters.

KEY POINTS

  • Depression is a risk factor for new cardiac disease and has a detrimental impact in established cardiac disease.
  • Numerous mechanistic pathways have been implicated.
  • In clinical trials, drug therapy and psychotherapy have not clearly decreased the rate of cardiac death in depressed cardiac patients, but they did improve depression, adherence to drug therapy, and quality of life.
  • Clinicians should routinely screen for depression in cardiac patients and should not hesitate to treat it.
  • Eligible patients should routinely be referred to cardiac rehabilitation programs.

Will treating depression help in other types of heart disease?

The SADHART-CHF trial is examining whether 12 weeks of sertraline therapy is better than placebo in preventing death and improving cardiac outcomes in patients with chronic heart failure and comorbid major depressive disorder. It was to be completed in the fall of 2008. The results and experience of this study will help in designing future interventional trials to reduce the risk of depression in cardiovascular diseases.

We also await the results of a National Heart, Lung, and Blood Institute (NHLBI) trial, “Bypassing the Blues,” which is studying the treatment of depression after cardiac bypass surgery. This study should provide further insights into management of the depressed cardiac patient. Further prognostic studies in cardiac patients are also needed using the PHQ-9 and its shorter version, PHQ-2.

Current and future guidelines

For years our European colleagues have been ahead of us in recognizing depression screening and stress management as key to cardiac disease-prevention strategies.126 The NHLBI nicely outlined recommendations on the assessment and treatment of depression in cardiovascular patients.127 The just-published AHA Science Advisory should further encourage clinicians to screen and treat depression in the patient population.1 As our knowledge grows, we look forward to future evidence-based guidelines for depressed cardiac patients.

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