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The American Heart Association science advisory on depression and coronary heart disease: An exploration of the issues raised

July 1, 2010|Cleveland Clinic Journal of Medicine
J. Thomas Bigger, MD;Alexander H. Glassman, MD
Author and Disclosure Information

J. Thomas Bigger, MD
Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY

Alexander H. Glassman, MD
Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY

Correspondence: J. Thomas Bigger, MD, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, PH-9-103, New York, NY 10032; Jtb2@columbia.edu

Dr. Bigger reported that he has no financial relationships that could be perceived as a potential conflict of interest with this article. Dr. Glassman reported that he has received consulting fees and speaking honoraria from Pfizer Inc.

This work was supported by grant 5-UL1-RR024156 from the National Center for Research Resources, National Institutes of Health, and by the Suzanne C. Murphy Foundation.

ABSTRACT

The American Heart Association issued a science advisory on depression and coronary heart disease (CHD) in 2008. This paper reviews the purpose and content of the advisory and discusses reactions and new information that have followed the advisory’s release. Both the advisory and subsequent data support routine screening for depression in patients with CHD. Such screening can be done efficiently in primary care and cardiology settings and can effectively identify many depressed patients who would otherwise go undetected. Antidepressant drugs such as selective serotonin reuptake inhibitors are safe for use in patients with CHD, can reduce depression, and can improve adherence with medical therapy. Referral to a practice with the knowledge and resources to manage depression promotes successful management of depressed patients with CHD.

Psychotherapy

APA practice guidelines for major depressive disorder indicate that among psycho therapeutic approaches, CBT and interpersonal psychotherapy have the best-documented efficacy for treatment of major depressive disorder.22 CBT aims to solve problems related to dysfunctional emotions, behaviors, and cognition and is an umbrella term for various techniques that share a theoretical basis in behavioristic learning theory and cognitive psychology. Aaron T. Beck proposed that depressed people are quick to make negative evaluations of themselves and the world, and he designed treatment to reduce these negative cognitions.23 Interpersonal psychotherapy stems from the work of Harry Stack Sullivan, who believed that emotional reactions were triggered by interpersonal behaviors.24 Gerald Klerman and Myrna Weissman used this method to treat adults diagnosed with moderate or severe nondelusional clinical depression.25

CBT was used in ENRICHD,4 interpersonal psychotherapy in CREATE,19 and problem-solving therapy in the Coronary Psychosocial Evaluation Studies (COPES).26,27 Unintended therapy can also be a confounder in antidepressant drug trials; education and supportive care (eg, frequent visits or telephone calls with monitoring of depressive symptoms and counseling) are often provided for both the intervention and control (placebo) groups. If a study is blinded, education, supportive care, and attention will be identical for both groups and thus may reduce the likelihood of finding a difference between the drug and placebo, if one exists.

Psychotherapy can be helpful for depression, is preferred over antidepressant drugs by some patients, and can be combined with drugs to increase antidepressant efficacy. We still have much to learn about timing and choice of therapy, as well as about sequencing and combination of antidepressant drugs and psychotherapy.

Physical activity and exercise

Aerobic exercise28 and cardiac rehabilitation29 can reduce depressive symptoms in addition to improving cardiovascular fitness. Depression can serve as a barrier to participation in cardiac rehabilitation and exercise programs, but cardiologists can help depressed patients overcome this barrier by offering encouragement and follow-up contacts. Cardiologists also should enlist the help of spouses or other family members and friends to promote adherence. The prescription of exercise needs to be based on the cardiac status and exercise capacity of each individual.30

SUMMARY OF ADVISORY RECOMMENDATIONS

The AHA advisory1 summarized its recommendations as follows:

1. Routine screening for depression in patients with CHD should be considered in a variety of settings, including the hospital, the physician’s office, clinics, and cardiac rehabilitation centers. The opportunity to screen for and treat depression in cardiac patients should not be missed, as effective depression treatment may improve health outcomes.

2. Patients with positive screening results should be evaluated by a professional qualified in diagnosis and management of depression. Such a clinician can determine whether depression is present and needs treatment, as well as how to connect a patient to an effective care program in the local area.

3. Patients with heart disease who are being treated for depression should undergo careful monitoring for adherence to their medical care and for the efficacy and safety of drug therapy for their medical and mental health conditions.

4. Coordination of care among health care providers is essential for patients with coexisting medical and mental health issues.

COMMENTS ON THE ADVISORY

Since AHA advisories usually address evolving scientific issues, the knowledge base on these issues is constantly growing and a range of opinions and hypotheses are tenable, pending new information. Soon after the AHA science advisory on depression and CHD was issued, a systematic review on depression screening and patient outcomes in cardiac care was published.31 This review posed three key questions that are explored below.

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