Download Treating depression in people with Coronary Heart Disease (CHD)

Primary Care Guidance:
Treating depression in people with
Coronary Heart Disease (CHD)
January 2011
Key learning points
• Depression is a risk factor for CHD
• Depression worsens cardiac prognosis
• Case finding of depression in people with CHD is advocated by QoF
• Co morbid depression is improved by medication and psychological treatments
• Evidence for depression treatment improving cardiac outcomes is currently unavailable
Introduction
Depression affects about 20% of people
with CHD and is linked to poor medical
outcome. This fact sheet presents current
knowledge about the links between CHD
and depression, and best clinical practice.
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 factors1.
• 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 fewer than 50%1.
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 have worse quality
of life.2
•Whilst the exact mechanisms are
unproven, depression is associated
with more 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
hypothalamic-pituitary-adrenal axis,
all of which could lead to worse cardiac
outcomes.3
•People who develop depression after
suffering an acute coronary syndrome
(ACS) are even more at risk of further
cardiac events or death4.
•Individuals with prominent physical
symptoms of depression, such as
fatigue, may be less likely to respond
to active treatment 5 and more likely
to have worse cardiac outcomes
than others.
Treatment improves
depression but not
cardiac outcome
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.6 In this model people with
depression are started on low intensity
treatments including guided self help,
physical activation and computerised
CBT. This stepped care model is
appropriate for use in people with CHD.
At the mild end of the spectrum appropriate
physical activation may improve mood and
physical outcomes.
Antidepressant medication and cognitive
behavioural therapy (CBT) is more suitable
for people with moderate depression,
though they have been shown to have
only modest effect in people with CHD.7
Intensity of treatments is increased to
include more intensive psychological
treatments and antidepressants,
depending on failure to respond to less
intensive treatments, patient preference
and history of previous response.
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 and the
improvements in depression in that
study were very small 8.
Combining therapies, case management
and collaborative care strategies involving
specialist services (see box) are reserved
for individuals with most severe and
treatment resistant depression.
Principles of
collaborative care
Pro-active, systematic and co-ordinated
care organised by a case manager who
liaises with both GP and specialist
The depression case manager
•Assesses needs of each patients
• Negotiates explicit treatment plan
based on best evidence treatment
and patient preference
• Co-ordinates delivery of care
• Participates in the delivery of care
(e.g. CBT or BA)
• Provides medication management
• Proactively follow-up patients to
maximise adherence
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.failed to respond to low intensity
psychological treatments (such as
guided self help)
Safety and efficacy have been
demonstrated in people with CHD using
citalopram 9 and in those with recent ACS
using sertraline 8,10. 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.
Mirtazapine and venlafaxine are considered
safe in CHD, and can be introduced if
SSRIs are ineffective or poorly tolerated.
Venlafaxine, however, may cause
hypertension in higher doses and blood
pressure monitoring is required.
Tricyclic antidepressants can be cardio-toxic,
particularly in overdose, should be avoided
as first line treatments and only ever used
with extreme caution in individuals with CHD.
Psychological treatment
Psychological interventions with behavioural
and/or cognitive components reduce
depression in people with CHD11 and are
increasingly available in cardiac rehabilitation
programmes and through the Improving
Access to Psychological Treatments
(IAPT) Programme. Research is currently
underway to assess the benefits of a case
management approach in primary care
for people with symptomatic CHD and
depression.12
Overall care
As depression may worsen cardiac
prognosis, even though there still is an
absence of evidence that depression care
improves cardiac prognosis, a case can
be made for screening patients with CHD
using the standard two question screen for
depression as advocated within QoF and
then instituting treatment (see box below).
Case finding for
depression
•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?
Treatment approaches for concurrent
depression often need to address a wide
range of individual needs such as addressing
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 co morbid physical
problems (e.g. diabetes, hypertension,
hyperlipidaemia etc). Some patients who
fit the above criteria will be housebound
and practices will need systems of case
management and perhaps collaborative care
processes in place as advocated by NICE
for people with depression and physical
illness.6
People involved in
creating this resource
Co-authored by Professor Andre Tylee*
and Dr Chris Dickens**
We wish to acknowledge for their helpful
comments and advice:
The Forum
The Forum for Mental Health in
Primary Care is jointly hosted by
the Royal College of General
Practitioners and the Royal
College of Psychiatrists.
It aims to encourage communication,
collaboration and creativity between
individuals and organisations who
work to enable day-to-day mental
health in everyone.
Find out more from the Forum
website: http://www.rcgp.org.uk/
mental_health.aspx
Design by First Step Trust Design
& Print Salford. First Step Trust 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
• Dr Elizabeth Barley
• Prof Carolyn Chew-Graham
• Prof Linda Gask
Glossary
• Dr Mark Haddad
• Dr Paul Walters
CHDCoronary heart disease
• Dr David Shiers
QoF Quality outcome framework
* Professor Andre Tylee Head of Section of Primary Care Mental
Health, Health Services and Population Research Department,
Institute of Psychiatry
ACSAcute coronary syndrome
CBTCognitive behavioral therapy
** Dr Chris Dickens Senior Lecturer in Psychological Medicine,
Greater Manchester Collaboration for Leadership in Applied
Health Research and Care
A ‘yes’ to either question is considered
a positive test.
IAPTImproving access to
psychological therapies
programme
A ‘no’ response to both questions
makes depression highly unlikely.
SSRISelective serotonin reuptake
inhihitor
Useful Resources
NICE Depression in Chronic Health Problems (2009) http://guidance.nice.org.uk/CG/WaveR/23
Forum http://www.rcgp.org.uk/mental_health.aspx
References
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2
3
4
5
Rugulies R. Depression as a predictor of coronary heart
disease: a systematic review and meta-analysis of the
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Barth J et al. Depression as a Risk Factor for Mortality in
Patients With Coronary Heart Disease: A Meta-analysis.
Psychosom Med 2004; 66:802-813.
Carney RM et al. Depression as a risk factor for cardiac
mortality and morbidity: a review of potential mechanisms.
J Psychosom Res 2002; 53:897-902.
Dickens CM et al. New onset depression following
myocardial infarction predicts cardiac mortality.
Psychosom Med 2008; 70:450-455.
Huijbregts KM et al. Negative association of concomitant
physical symptoms with the course of major depressive
disorder: a systematic review. J Psychosom Res 2010;
68:511-519.
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9
NICE. The treatment and management of depression in
adults with chronic physical health problems. 2009.
Thombs BD et al. Depression screening and patient
outcomes in cardiovascular care: a systematic review.
JAMA 2008; 300:2161-2171.
Berkman LF et al. Effects of treating depression and low
perceived social support on clinical events after myocardial
infarction: the Enhancing Recovery in Coronary Heart
Disease Patients (ENRICHD) Randomized Trial.
JAMA 2003; 289:3106-3116.
Lesperance F et al. Effects of citalopram and interpersonal
psychotherapy on depression in patients with coronary artery
disease: the Canadian Cardiac Randomized Evaluation of
Antidepressant and Psychotherapy Efficacy (CREATE) trial.
JAMA 2007; 297:367-379.
Glassman AH et al. Sertraline treatment of major depression
in patients with acute MI or unstable angina.
JAMA 2002; 288:701-709.
11
Welton NJet al . Mixed treatment comparison meta-analysis
of complex interventions: psychological interventions in
coronary heart disease. Am J Epidemiol 2009;
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12
Tylee A et al. Programme to improve care for people with
coronary heart disease (CHD) and depression or distress
(UPBEAT) Journal of Affective Disorders Volume 122,
Supplement 1, April 2010, Page S19.
10