Download Treating Depression in People with Coronary Heart Disease

Mental Health
Living well for longer
2014 update
Primary Care Guidance: Treating Depression
in People with Coronary Heart Disease (CHD)
Key learning points
atients with long-term conditions, such as
»PCHD,
have a high prevalence of co-morbid
depression and anxiety.
o-morbid depression leads to reduced
»Cquality
of life and outcomes for the individual,
and to increased healthcare use and costs.
epression in people with CHD may go
»Dundiagnosed
and thus untreated: case-
finding is a useful strategy in the primary
care consultation.
with CHD and depression should
»Pbeeople
offered psychological treatment and/or
antidepressants, depending on severity of
the depression and patient preferences.
ollaborative care is an evidence-based
»Cframework
that has been shown to be
effective for the treatment of people with
depression and a long term physical illness.
Introduction
Depression affects about 20% of people with CHD, which
may be associated with psycho-social issues around loss 1,
and is linked to poor quality of life, outcomes and health
service use. This fact sheet presents current knowledge
about the links between CHD and depression, and best
clinical practice.
Compared to people with CHD and no
depression, those with depression are twice
as likely to have further coronary events.
Depression
in healthy
people
increases
their risk of
subsequently
developing
CHD by
60%.
Depression increases
the incidence of CHD
in healthy people
• Depression in healthy people increases
their risk of subsequently developing
CHD by 60%, even after taking into
account all the other known cardiac
risk factors 2,3.
• There is a dose effect with clinical
depression having a bigger risk of
developing CHD than depressive
symptoms alone, although the latter
increase the risk by just under 50% 2.
Depression worsens
cardiac prognosis
• Compared to people with CHD and no
depression, those with depression are twice
as likely to have further coronary events or
die, and to have worse quality of life 4-6.
• Whilst the exact mechanisms are
unproven, depression is associated with
increased likelihood of smoking, less physical
activity, poorer diet, and reduced adherence
to treatments or rehabilitative programmes.
• Depression is also associated with increased
platelet stickiness, reduced heart rate
variability due to autonomic dysfunction,
circulating inflammatory factors and
dysregulation of the hypothalamicpituitary-adrenal axis, all of which
could lead to worse cardiac outcomes 7,8.
• People who develop depression after
suffering an acute coronary syndrome
(ACS) are at even greater risk of further
cardiac events or death 9-11.
• Individuals with prominent physical
symptoms of depression, such as fatigue,
may be less likely to respond to active
treatment 12 and more likely to have
worse cardiac outcomes than others 13.
Depression often goes
undetected and unmanaged
Patients’ tendency to use normalising
attributional styles that see depression as
a normal consequence of ill health, along
with professionals’ conceptualisations
of depression as justifiable and difficult
to manage, especially in older adults,
are implicated with under-detection and
inadequate treatment of depression in
patients with long-term conditions, such
as cardiac disease, in primary care 14,15.
Barriers to optimal depression care in LTC care
can partly be explained by the time limited
nature of primary care where clinical decision
making is often centred around prioritising
competing patient demands. This is especially
true in health care settings like the NHS where
the management of LTCs is driven by guidelines
and treatment algorithms that focus on single
diseases. In these time-limited and highly
structured environments, competing demands
on health professionals’ time often leads to
prioritisation of physical health problems.
It should also be acknowledged that
many people presenting to surgeons have
depression, coronary heart disease or both.
These conditions can reduce or delay people’s
ability to recover from surgery.
The importance of
case-finding
The use of case-finding questions (see box
below) should be part of usual practice for
GPs in consultations with people with long
term conditions such as cardiac disease, or
where the GP has a clinical suspicion that
depression may be present.
Severity of depression should then be assessed
using a schedule such as the PHQ9. When
depression is detected, the GP should assess
the risk of self-harm and suicide.
Treatment improves
depression but not
cardiac outcomes
Recent NICE guidance directing the treatment
of depression in people with physical health
problems proposed that such people be treated
using a “stepped care” model 16. In this model,
people with depression are started on low
intensity treatments including guided self-help,
physical activation and computerised CBT.
Intensity of treatments is increased to include
more intensive psychological treatments and
antidepressants, depending on failure to respond
to less intense treatments, patient preference
and history of previous response. Ultimately
combining therapies, case management and
collaborative care strategies involving specialist
services are reserved for individuals with most
severe and treatment resistant depression. This
stepped care model would be appropriate for
use in people with CHD.
At the mild end of the spectrum appropriate
physical activation may improve mood and
physical outcomes.
Case-finding questions
?
During the past month, have you often been
bothered by feeling down, depressed, or hopeless?
During the past month, have you often been
bothered by having little interest or pleasure in
doing things?
A ‘yes’ to either question is considered a positive test.
A ‘no’ response to both questions makes depression highly unlikely.
Antidepressant medication and cognitive
behavioural therapy (CBT) would be more
suitable for people with moderate depression,
though they have been shown to have only
modest effect in people with CHD 17.
These treatments have not yet been associated
with any improvement in cardiac outcome or
survival, though only one study was designed
adequately to examine cardiac outcomes. In
that study, the improvements in depression
were very small 18.
Antidepressant drugs
SSRIs remain the first choice for treating
people with moderate to severe depression,
or in people with mild to moderate depression
who have:
i) a history of previous episodes of moderate
to severe depression, or
ii)failure to respond to low intensity
psychological treatments (such as guided
self help).
Sertraline is effective and the drug of choice
for people with CHD 18,19. Citalopram and
escitalopram should only be used in people
with heart disease following an ECG to rule
out QT prolongation, and should be avoided
in people taking other medications known
to prolong the QT interval. The maximum
dose used for citalopram is 40mg and for
escitalopram, 20mg; and this should be halved
in the elderly and people with hepatic disease.
Other SSRIs are likely to be as efficacious and
safe though potential for drug interactions,
side-effects and patient preference may affect
choice of drug.
Sertraline, (and probably other SSRIs) may
also reduce future cardiac events, irrespective
of whether they improve depression, probably
as the result of their anti-platelet effect.
Psychological treatments
Psychological interventions with
behavioural and/or cognitive components
reduce depression in people with CHD 20.
NICE 16 suggests that a psychological
intervention should be delivered within
a collaborative care framework for
people with long term physical
conditions. This model involves a multiprofessional approach to care, structured
management plans, scheduled followups and enhanced inter-professional
communication 21. In depressed patients
with poorly controlled diabetes and /or
coronary heart disease, collaborative care
involving nurse case managers working
closely with GPs can significantly improve
control of both the medical disease and
depression 22,23.
Overall care
Treatment approaches for concurrent
depression often need to address a wide
range of individual needs such as possible
stigma or social isolation; problem solving,
inter personal relationship therapy or
coping strategies for associated life events
and difficulties (which may precede or
follow coronary events), and lifestyle
behavioural modification such as smoking
cessation, good diet, and exercise (the
latter two of which may help depression
as well as CHD). People with CHD may also
have erectile dysfunction and other
comorbid physical problems (e.g. diabetes,
hypertension, hyperlipidaemia etc). Some
patients who fit the above criteria will
be housebound and practices will need
systems to identify and manage such
vulnerable patients. n
Lifestyle
behavioural
modification
such as a
good diet,
and exercise
may help
depression as
well as CHD.
Mirtazapine is considered safe in CHD, and
can be introduced if SSRIs are ineffective or
poorly tolerated.
Venlafaxine is contraindicated in people at
high risk of cardiac arrhythmias and may
cause hypertension in higher doses. Caution
is indicated when using venlafaxine in CHD,
and blood pressure monitoring is advised.
Tricyclic antidepressants can be cardiotoxic, particularly in overdose, should
be avoided as first line treatments.
They should only ever be used with
extreme caution in individuals with CHD.
Useful Resources
IAPT 2008. Long term conditions positive practice guide. Department of Health. |
http://www.iapt.nhs.uk/silo/files/longterm-conditions-positive-practice-guide.pdf
NATIONAL INSTITUTE OF CLINICAL EXCELLENCE 2009. Depression in adults with a chronic physical health problem:
treatment and management. NICE | http://guidance.nice.org.uk/CG91
SIGN guidelines – non-pharmaceutical management of depression | http://www.sign.ac.uk/guidelines/fulltext/114/index.html Naylor C, Parsonage M, McDaid D, Knapp M, Fossey M, Galea A. Long-term conditions and mental health.
The cost of co-morbidities. King’s Fund and Centre for Mental Health, 2012. |
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf
Royal College of Psychiatrists. Improving Physical and Mental health |
http://www.rcpsych.ac.uk/mentalhealthinfo/improvingphysicalandmh.aspx
Drug Safety Update: Citalopram and escitalopram: QT interval prolongation—new maximum daily dose restrictions
(including in elderly patients), contraindications, and warnings | http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON137769
Authors
Professor Andre Tylee
Professor of Primary Care Mental Health and
Academic Director of Mood, Anxiety and
Personality at the Institute of Psychiatry and
the South London and Maudsley Foundation
Trust, Kings Health Partners.
Professor Chris Dickens
Professor of Psychological Medicine, Institute
of Health Research and Lead for the Mental
Health Research Group at the University of
Exeter; Honorary Consultant in Psychological
Medicine, Devon Partnership NHS Trust
Professor Carolyn Chew-Graham
GP and Professor of General Practice Research,
Keele University; Curriculum Advisor, Mental
Health, RCGP
To cite: Tylee A, Dickens C, Chew-Graham
C. Primary Care Guidance: Treating
Depression in People with Coronary Heart
Disease (CHD) – 2014 update; Royal College
of General Practitioners & Royal College of
Psychiatrists; 2014.
This factsheet is one of a series of practitioner
resources originally developed by the Primary
Care Mental Health Forum (Royal College
of General Practitioners & Royal College
of Psychiatrists) which have been updated
with the support of NHS England and Public
Health England.
Acknowledgements
Mrs Scarlett McNally, Royal College of Surgeons of England, for her review and helpful comments.
Dr David Shiers for his review and general support.
Endorsements
Royal College of General Practitioners (RCGP)
This publication was designed by FST
Design & Print Salford. First Step Trust
(FST) is a national charity providing
employment and training opportunities
for people excluded from ordinary
working life because of mental health
conditions and other disadvantages.
www.firststeptrust.org.uk
Royal College of Psychiatrists (RCPsych)
Royal College of Surgeons (RC Surgeons)
UK Faculty of Public Health (FPH)
Rethink Mental Illness
Charity No: 1077959. Company registration number: 3730562.
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