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Heart Disease & Depression

From heartwire - a professional news service of webmd

September 30, 2008 — Clinicians should routinely screen their patients with heart disease for signs of depression, refer those in whom it's suspected to a qualified mental health professional, and monitor the management of any patient receiving treatment for both disorders, according to a new advisory issued by the American Heart Association (AHA) and endorsed by the American Psychiatric Association [1].

Their document, the authors say, represents the AHA's first standalone set of recommendations to confront the well-recognized links between the psychiatric disorder and cardiovascular disease, which frequently exist together.

"There is currently no direct evidence that screening for depression leads to improved outcomes in cardiovascular populations," cautions the report's authors, led by Dr Judith H Lichtman (Yale University, New Haven, CT), who, along with Dr Erika Froelicher (University of California, San Francisco), co chaired the report's writing group. But there is abundant evidence that treating depression in patients with coronary heart disease (CHD) can help them, notes the report, which was published online September 29, 2008 in Circulation and scheduled for the journal's October 21 issue.

Even without such indications, though, "there's certainly compelling evidence that untreated depression is associated with worse outcomes and that there's almost a dose-response effect," Lichtman told heartwire. "And even if we don't understand all the mechanisms, there really is a large body of evidence showing that people who are depressed are less likely to follow through on a variety of things that are important for risk-factor management and certainly associated with recovery and outcomes, like medication adherence or going to rehab."

The report says that to maximize opportunities for identifying depressed patients, screening can be performed in the range of settings CHD patients are seen in, such as the clinician's office, the hospital, clinics, and rehabilitation centres.

The "pretty quick, pretty simple" screening

For most patients, the initial screening could "at a minimum" consist of the two-question Patient Health Questionnaire (PHQ-2). If either answers points to the possibility of depression, the nine-item PHQ-9 would then be administered.

The PHQ-2 asks the patient "have you been bothered" in the past two weeks by "little interest or pleasure in doing things" or "feeling down, depressed, or hopeless." The PHQ-9 asks similar questions with the goal of identifying symptom frequency.

"For patients with mild symptoms, follow-up during a subsequent visit are advised," the report notes; also, patients with scores indicating a high likelihood of depression should be referred for a more comprehensive evaluation by an appropriate specialist.

Lichtman said that the PHQ forms are suggested instruments but not required. "There are a number of screening devices available.

We wanted to present one that was pretty quick, pretty simple, pretty easy, that you didn't have to purchase to use and would give a quick indication, with the idea that if someone comes up positive, [the provider] refers them for more comprehensive evaluation by someone who is qualified.

" The two questions on the initial PHQ, she said, "give a reasonable indication of whether or not there's something that needs to be pursued more thoroughly."

Dr Karina W Davidson (Columbia University and Mount Sinai School of Medicine, New York, NY), who isn't connected with the new report, said that the PHQ screening questionnaires are validated tools and "an efficient, evidence-based way of finding possible cases and referring them on for further assessment and treatment."

Performing the screening, she told heartwire, is well worth the minimal extra time and effort it takes.

The PHQ questions can point to patients with depressive symptoms that independently increase mortality and the risk of major adverse cardiovascular events.

Such patients are just the kind cardiologists and other cardiac-care professionals would want to be targeting with follow-up calls, monitoring, and reminders to get into a cardiac rehabilitation program, Davidson said.

"These are questions that are perfectly appropriate for a nurse or other allied health professional to be doing on the floor," she said.

According to an editorial on the recommendations published online the same day [2], "We should no longer ignore depression in the cardiac patient.

One cannot expect a detailed evaluation of coexisting illnesses in the busy cardiology office; however, recognition of a key co morbidity, such as depression, can lead to the delivery of higher-quality care."

Noting that current guidelines actually do recommend evaluation for symptoms of depression in patients with established cardiac disease, the editorialist, Dr Viola Vaccarino (Emory University, Atlanta, GA), writes that "the availability of simple instruments, such as those described in the AHA advisory, makes this task easier and makes it possible to integrate the management of depression into routine cardiac care."

Treatment and follow-up

The AHA report strongly advises that patients found to have depression be referred to providers qualified to treat depression and also that "coordination of care between healthcare providers is essential" in patients with both cardiovascular and psychiatric diagnoses.

As for treatment, the selective serotonin reuptake inhibitors sertraline and citalopram "are the first-line antidepressants drugs for patients with CHD," the report states.

It notes that patients who fared well on other medications can generally resume taking them but cautions that tricyclic antidepressants and monoamine oxidise inhibitors can be cardiotoxic and so are contraindicated in many CHD patients.

Cognitive behaviour therapy, notes the report, can be an alternative to drug therapy "for cardiac patients who cannot tolerate antidepressants or who may prefer a nonpharmacologic or counselling approach to treatment"; some patients will respond best to a combination of pharmacologic therapy and psychotherapy.

Davidson has some advice for cardiac-care providers whose patients are also diagnosed with depression.

Typically, she said, such providers "are used to ensuring that patients truly understand the seriousness of their diagnosis.

The opposite approach is needed with depression," she said. A patient with depression who is not anticipating a psychiatric diagnosis "won't really appreciate hearing that now they've got yet another disease. . . . What often works better is to say, you're telling me that you're upset, or sad, or alarmed.

So I'm going to find you help for that."

Also, Davidson said, "patients have strong preferences for the type of treatment they will accept for depression. It's unlike the choice, for example, of PCI [percutaneous coronary intervention] vs. CABG [coronary artery bypass graft], where the doctor's recommendation about what is best for that case is usually accepted by the patient.

Those who have strong beliefs against psychiatric medication will not accept it, even if it's recommended." The same is true for psychotherapy, she said. "I would strongly urge cardiologists to ask the patient which they prefer, medicine or talking, and then prescribe the patient's preference."

Disclosures for the writing committee members are listed in the article.



1. Lichtman JH, Bigger Jr JT, Blumenthal JA, et al. Depression and coronary heart disease. Recommendations for screening, referral, and treatment. A science advisory from the Prevention Committee of the American Heart Association Cardiovascular Nursing Council, Clinical Cardiology Council, Epidemiology and Prevention Council, and Interdisciplinary Council on Quality of Care and Outcome Research. Circulation 2008; DOI:10.1161/CIRCULATIONAHA.108.190769. Available at: