Download Depression and Heart Disease

DEPRESSION AND HEART DISEASE
A synopsis based on the WPA volume “Depression and Heart Disease”
(Glassman AH, Maj M, Sartorius N, eds. – Chichester: Wiley, 2010)
Incidence of depression after myocardial
infarction
• The incidence of DSM-III major depressive disorder after
myocardial infarction has been found to be 16% (Schleifer et al.,
1989; Frasure-Smith et al., 1993). Studies based on selfadministered questionnaires have reported rates up to 50%.
From Jiang W, Xiong GL. Epidemiology of the comorbidity between depression and
heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N
(eds). Chichester: Wiley, 2010.
Depression and survival after myocardial
infarction
• Patients with major depression after myocardial infarction are 5
times more likely to die from cardiac events by 6 months than
non-depressed patients. At 18 months, cardiac mortality
reaches 20% in patients with major depression vs. 3% in nondepressed patients (Frasure-Smith et al., 1993, 1995).
• Patients with a Beck Depression Inventory score ≥10 after
myocardial infarction are almost 7 times more likely to die by 18
months than those with a score <10 (Frasure-Smith et al., 1995).
From Jiang W, Xiong GL. Epidemiology of the comorbidity between depression and
heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N
(eds). Chichester: Wiley, 2010.
The cumulative mortality is significantly higher in depressed than in non-depressed patients
following myocardial infarction (MI) (Lesperance at al., Circulation 2002;105:1049-1053). From
Glassman AH, Bigger JT. Depression and cardiovascular disease: the safety of antidepressant
drugs and their ability to improve mood and reduce medical morbidity. In: Depression and Heart
Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Depression and cardiac events in patients with
stable coronary heart disease
• In patients with stable coronary heart disease, the DSM-IV diagnosis of
major depression is the best predictor of cardiac events at 1 year. The
relative risk is 2.2 times higher in patients with major depression than
in non-depressed patients (Carney et al., 1988).
• Among patients hospitalized for unstable angina, those with a Beck
Depression Inventory ≥10 had a rate of death or myocardial infarction
one year after assessment 5 times higher than their non-depressed
counterparts (Lesperance et al., 2000).
From Jiang W, Xiong GL. Epidemiology of the comorbidity between depression and
heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Depression as a risk factor for development of
coronary heart disease
• Clinical depression is associated with an almost 2-fold higher risk of
subsequent coronary heart disease. This association remains
significant after adjustment for smoking, alcohol use and coffee
consumption (Ford et al., 1998).
• A meta-analysis of 28 studies comprising almost 80,000 subjects
found that depression was associated with increased risk of
cardiovascular diseases, in particular for acute myocardial infarction
(RR = 1.6) (van der Kooy et al., 2003).
From Jiang W, Xiong GL. Epidemiology of the comorbidity between depression and
heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Behavioural mechanisms linking depression and heart
disease - I
Mechanism
Comment
Effect on heart disease
Sleep disturbance
Common in depression; may be
exacerbated by heart disease
symptoms
Leads to autonomic hyperactivity
which is linked to obesity, diabetes,
hypertension, and the metabolic
syndrome
Physical inactivity
Common in depression
Increases cardiovascular morbidity
and mortality
Cigarette smoking
Individuals with depression are
Increases cardiovascular morbidity
more likely to smoke, and
and mortality
depressed smokers are less likely to
quit
From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression
and heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Behavioural mechanisms linking depression and heart
disease - II
Mechanism
Comment
Effect on heart disease
Poor hygiene
Inattentiveness to self care is more
common in depression; depression is
associated with decreased salivary
flow and cariogenic diet. Some
antidepressants cause xerostomia
and gingivitis
Periodontal disease (especially
gingivitis) has been associated with
increased cardiovascular morbidity
and mortality
Adherence to treatment
Patients with depression are less
likely to adhere to medical therapy
and risk reducing behaviors
Poor adherence to medical therapy is
associated with increased
cardiovascular morbidity and
mortality
From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression
and heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Psychological mechanisms linking depression and heart
disease - I
Mechanism
Comment
Effect on heart disease
Attitudes about treatment
Depression may be associated with
negative attitudes toward treatment.
Individuals with depression may
perceive more, and have greater
concern about, medication side
effects
Attitudes about treatment appear
important to therapeutic effect; even
poor adherers to placebo in
cardiovascular disease trials have
increased mortality
Social isolation
Depression is associated with less
social support and greater social
isolation
Decreased social support and social
isolation are associated with
increased cardiovascular morbidity
and mortality
From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression
and heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Psychological mechanisms linking depression and heart
disease - II
Mechanism
Comment
Effect on heart disease
Cardiovascular stress response
Some studies show that depression
Autonomic hyperactivity at baseline
is associated with heightened, and
and in response to stressors may
some with attenuated, cardiovascular increase cardiovascular risk
reactivity to physiological stress
Self-efficacy
Depression is often associated with
low self-efficacy
Low self-efficacy is associated with
greater symptom burden and
physical limitation; worse quality of
life; poor adherence; and possibly
increased cardiovascular morbidity
and mortality
From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression
and heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Biological mechanisms possibly underlying the
association between depression and heart disease
• Autonomic nervous system dysregulation (low heart rate variability is a powerful predictor
of mortality in patients with coronary heart disease; depressed patients have a decreased
heart rate variability than non-depressed controls).
• Blood clotting and endothelial dysfunction (depression is associated with enhanced
platelet activation, increased plasma levels of pro-thrombogenic factors and reduced
endothelial dependent vasodilatation).
• Inflammation (depression is associated with increased levels of pro-inflammatory cytokines
and inflammatory acute phase proteins; activation of the inflammatory system is linked to
ischemic cardiovascular events in patients with coronary heart disease).
• Neuroendocrine abnormalities (depression is associated with an increased activity of the
hypothalamic-pituitary-adrenal axis, with a consequent overstimulation of the sympathetic
nervous system).
From Monteleone P. The association between depression and heart disease: the role of biological
mechanisms. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Role of genetic factors in explaining the
association between depression and heart disease
• Twin and family studies provide evidence for a role of genetic
pleiotropy in the association between major depression and coronary
heart disease (i.e., genetic variants influence risk factors that
independently increase the risk for both major depression and
coronary heart disease). The actual genetic variants at the base of this
pleiotropy remain to be detected.
From de Geus E. The association between depression and heart disease: the role of genetic
factors. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester:
Wiley, 2010.
Antidepressants in post-myocardial (MI) infarction
• Selective serotonin reuptake inhibitors (SSRIs) are safe in the
immediate post-MI period and are effective antidepressants.
• Although evidence suggests that antidepressants are particularly
active in more severely depressed patients, it is premature to conclude
that there is no treatment effect in the less severely depressed post-MI
patients.
• There is strong suggestion that antidepressants in general, and SSRIs
in particular, reduce morbidity and mortality in post-MI depressed
patients.
From Glassman AH, Bigger JT. Depression and cardiovascular disease: the safety of
antidepressant drugs and their ability to improve mood and reduce medical morbidity. In:
Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Relative risk (95% CI) for cardiovascular events: sertraline vs. placebo (adapted from Glassman et
al., JAMA 2002;288:701-709). From Glassman AH, Bigger JT. Depression and cardiovascular
disease: the safety of antidepressant drugs and their ability to improve mood and reduce medical
morbidity. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester:
Wiley, 2010.
Effects of antidepressant drug use on clinical events over 30 months during the ENRICHD trial
(adapted from Taylor et al., Arch. Gen. Psychiatry 2005;62:792-798). From Glassman AH, Bigger
JT. Depression and cardiovascular disease: the safety of antidepressant drugs and their ability to
improve mood and reduce medical morbidity. In: Depression and Heart Disease. Glassman AH,
Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Psychotherapies for depression in postmyocardial infarction (MI) patients
• In the ENRICHD trial, individual cognitive psychotherapy was superior to usual
care for depression (Berkman et al., 2003).
• In the ENRICHD trial, patients who completed the 6-month cognitive
psychotherapy and whose depression improved had a lower risk of late mortality
than those who remained depressed despite completing the intervention (Carney
et al., 2004).
From Carney RM, Freedland KE. Psychotherapies for depression in people with heart disease. In:
Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Recognition and management of depression in
post-myocardial infarction (MI) patients
• Post-MI patients should be screened for the presence of depression
by a simple well-validated instrument (such as the Patient Health
Questionnaire).
• When a patient screens positive for depression, a primary care
provider familiar with managing depression should follow and
support him/her, with the regular supervision by a psychiatrist.
• There is a need to educate physicians and to establish a system to
identify, treat and follow up cardiac patients with depression.
From Glassman AH, Bigger JT. Depression and cardiovascular disease: the safety of
antidepressant drugs and their ability to improve mood and reduce medical morbidity. In:
Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.
Recommendations for clinicians providing care for
patients with comorbid depression and heart disease - I
• Sleep. Ask your patients about their sleep habits. Ask about why patients are
awakening, and see if changes in treatment or the timing of medications might
decrease the need to awaken during the night to pass urine or because of
breathlessness.
• Physical activity. Strongly encourage your patients to exercise at home and to
become involved (and stay involved) in structured exercise programs. Greater
involvement in exercise may improve symptoms of depression.
• Cigarette smoking. Ask every patient whether he/she smokes, and counsel about
smoking cessation if appropriate. Every clinician should become familiar with
medications that help patients quit, and should offer specific advice on how to
quit and/or set a quit date.
From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression
and heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Recommendations for clinicians providing care for
patients with comorbid depression and heart disease - II
• Medication adherence. Specifically address the issue of medication
adherence with every patient and try to decrease barriers to adherence.
Simplifying medication regimens, eliminating medications that are not
absolutely necessary, and prescribing low-cost alternatives may be helpful in
specific circumstances.
• Attitudes and beliefs about cardiac treatment regimens. Anticipate the
possibility that patients with depression may have greater levels of concern
and more negative attitudes and beliefs about medical treatment regimens.
Discuss the importance of each medication, what the goals of treatment are,
and how the patient’s particular health goals are more likely to be achieved by
adhering to a particular medical treatment.
From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression
and heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Recommendations for clinicians providing care for
patients with comorbid depression and heart disease - III
• Social isolation. Encourage patients to socialize with family and
friends; offer to engage family and friends on behalf of the patient,
encourage the patient to participate in group activities that may be
appropriate and desirable (sport clubs, hobbies, religious groups).
• Self-efficacy. Inquire about your patient’s confidence that he/she can
accomplish a given task or behaviour (e.g., participation in a cardiac
rehabilitation program, stopping smoking, following a proper diet). If
the patient’s confidence is low, consider specific counseling that
might enhance self-efficacy.
From Ziegelstein RC, Elfrey MK. Behavioural and psychological mechanisms linking depression
and heart disease. In: Depression and Heart Disease. Glassman AH, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.
Acknowledgements
This synopsis is part of the WPA programme aiming to raise the
awareness of the prevalence and prognostic implications of depression
in persons with physical diseases. The support to the programme of the
Lugli Foundation, the Italian Society of Biological Psychiatry, Eli-Lilly and
Bristol-Myers Squibb is gratefully acknowledged. The WPA is grateful to
Dr. Andrea Fiorillo, Naples, Italy for his help in the preparation of this
synopsis.