Despite growing evidence of the association between depression and coronary artery disease, cardiovascular nurses and physicians tend to underrecognize depression in patients with acute myocardial infarction, according to a study in the May–June Psychosomatic Medicine. “Formal screening for symptoms of depression should be considered part of routine acute myocardial infarction care,” Roy C. Ziegelstein, MD, and his colleagues commented.

To examine the ability of health care providers to identify depressive symptoms in patients hospitalized for acute myocardial infarction, the researchers screened 88 patients using the Beck Depression Inventory (BDI). Then they compared the BDI scores to assessments by cardiovascular nurses, internal medicine residents or interns, and attending cardiologists, using a visual analog scale. BDI screening and at least one provider assessment were completed for 60 of the 88 patients.

The mean age of the patients was 66.5, and 40% were female. Researchers found a high prevalence of all cardiovascular risk factors, including hypertension, hyperlipidemia, and diabetes mellitus. Of the 60 patients with complete assessments, 18 had a BDI score of 10 or greater. Of those with a BDI score lower than 10, the average score was 3.5, whereas for those with a score of 10 or greater, the average score was 15.7.

According to the researchers, nurses reported spending almost twice as much time with patients as did internal medicine residents and more than twice as much time as did attending cardiologists. Overall, health care providers identified symptoms warranting further evaluation for depression as being present in 31 of 107 assessments, with considerable disagreement among providers. However, there was no correlation between BDI scores and health care provider assessments. The mean BDI score of patients deemed depressed was no different from the mean BDI score of those classified as not depressed. Accuracy of provider assessments was not affected by provider type, provider gender, or self-reported time spent with the patient.

The researchers concluded that “the ability of cardiovascular health care providers to recognize potentially significant symptoms of depression is poor when compared with the results of the BDI.”

THE AHRQ EVIDENCE REPORT

These findings are particularly startling in light of an evidence report issued in May by the Agency for Healthcare Research and Quality (AHRQ), stating that depression is common in patients hospitalized for acute myocardial infarction and that untreated depression can persist for at least several months after discharge. Patients with comorbid myocardial infarction and depression have poor quality of life in the year following discharge and also have an increased risk of death. Dr. Ziegelstein, along with David E. Bush, MD, and several other researchers who participated in the Psychosomatic Medicine study, also helped conduct the AHRQ study.

A team of reviewers, including clinicians and researchers from diverse specialties such as cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, was selected by the Johns Hopkins University Evidence-Based Practice Center in Baltimore to screen more than 4,000 possibly relevant articles. Of these, 86 met eligibility criteria and were included in the study.

Approximately 20% of patients hospitalized for myocardial infarction had major depression. Ten percent to 47% of patients reported potentially significant symptoms of depression. Most patients who were depressed during the initial hospitalization for myocardial infarction remained depressed one to four months later.

According to the researchers, post–myocardial infarction depression was associated with poor quality of life during the year after discharge, increased risk of death, and increased risk of cardiac readmission. In addition, psychosocial interventions and selective serotonin reuptake inhibitors (SSRIs) were effective in improving depression in myocardial infarction patients, but little evidence suggested that either decreased mortality or cardiac events.

“This report provides the scientific evidence clinicians need to know about the prevalence of depression in heart attack survivors, how depression affects these patients, and the need to treat the disease early,” said Carolyn M. Clancy, MD, Director of the AHRQ.

DO ANTIDEPRESSANTS REDUCE RISK OF HEART ATTACK OR DEATH?

If depression is associated with poor quality of life and an increased risk of death after myocardial infarction, can use of antidepressants thwart such adverse outcomes? Researchers at Stanford University School of Medicine in California argue that they could. “Our study provides much stronger evidence than we’ve ever had before that antidepressants are safe and may benefit” depressed patients who have had a heart attack, said Craig Barr Taylor, MD. He and his colleagues reported the results of their study in the July Archives of General Psychiatry.

Previously, in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study, which was published in JAMA, the researchers determined that cognitive behavioral therapy significantly reduced depression but had little effect on mortality rates. This prompted them to perform the present analysis on the effects of antidepressants among the study participants.

Dr. Taylor and his colleagues examined 1,834 patients with depression who were enrolled in the ENRICHD study. They found that during a mean follow-up of 29 months, 457 cardiovascular events occurred. Twenty-six percent of patients who did not receive antidepressants had a recurrent myocardial infarction compared with 21.5% of patients who did receive antidepressants. The risk of death or recurrent myocardial infarction, as well as the risk of all-cause mortality and recurrent myocardial infarction, was significantly lower in patients taking SSRIs, compared with patients who did not use SSRIs. For patients taking other antidepressants, “the comparable hazard ratios were 0.72, 0.64, and 0.73 for risk of death or recurrent myocardial infarction, all-cause mortality, or recurrent myocardial infarction, respectively, compared with nonusers,” said the researchers. After adjustment for baseline depression scores and cardiac risk factors, use of SSRIs was associated with a 43% lower risk of death, nonfatal myocardial infarction, and all-cause mortality.

“The results of this study, combined with the epidemiologic and other data, clearly demonstrate the need for a properly powered, prospective, randomized trial to determine whether SSRIs can alter cardiovascular outcomes post–myocardial infarction,” concluded Dr. Taylor and his colleagues.

In an accompanying editorial, Alexander H. Glassman, MD, of the New York State Psychiatric Institute, stated that in the ENRICHD trial, “only the most depressed patients, those known to be at higher risk for cardiac events, were offered antidepressants. In addition, there was no control over when the drug was started or stopped, and even the reported start and stop times were only estimates.

“However,” he noted, “the sample was large, the number of events reasonable, and the magnitude of the effect is hard to ignore…. [T]his observation of a 40% decrease in life-threatening outcomes has been in the literature for almost three years with no systematic follow-up and minimal medical or psychiatric awareness.”

According to Dr. Glassman, “Acknowledging the implications of major depressive disorder for cardiac morbidity and mortality would validate depression as a systemic disease with implications for the entire body, and reduce the stigma of this diagnosis for medical professionals, the public, and the patients themselves. The ENRICHD investigators have made a significant step in that direction.”

—Karen L. Spittler

Suggested Reading
Berkman LF, Blumenthal J, Burg M, 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.
Bush DE, Ziegelstein RC, Patel UV, et al. Post-Myocardial Infarction Depression. Evidence Report/Technology Assessment No. 123. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 290-02-0018.) AHRQ Publication No. 05-E018-1. Rockville, MD: Agency for Healthcare Research and Quality; May 2005.
Glassman AH. Does treating post-myocardial infarction depression reduce medical mortality? Arch Gen Psychiatry. 2005;62:711-712.
Taylor CB, Youngblood ME, Catellier D, et al. Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction. Arch Gen Psychiatry. 2005;62:792-798.
Ziegelstein RC, Kim SY, Kao D, et al. Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening? Psychosom Med. 2005;67:393-397.

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