Depression in Post-MI Patients: An Opportunity for Primary Care
Am Fam Physician. 2009 Nov 1;80(9):917.
The American Academy of Family Physicians (AAFP) Guideline for the Detection and Management of Post-Myocardial Infarction Depression highlights the importance of identifying and treating depression in patients who have recently experienced myocardial infarction (MI).1 To initiate this work, the AAFP Commission on Public Health and Science requested an evidence review from the Agency for Healthcare Research and Quality,2 and convened the panel to produce the guideline. The findings emphasize the role family physicians play in managing the follow-up and ongoing care of patients after acute MI.
The panel found that depression is common in patients following MI. According to the literature, the prevalence of depression in the post-MI period can range from 41 percent acutely to 60 percent at one month.1 There is substantial evidence that post-MI depression is independently associated with cardiac mortality, although the association with cardiac event rates is less clear. Evidence shows that treating post-MI depression improves depression and quality-of-life outcomes; however, there are only trends pointing to improvement in cardiac outcomes.
Based on these findings, the panel recommends screening for and treating depression in the post-MI period, as well as implementing systems to ensure monitoring and follow-up. Screening should be performed using a standardized measure, but there is insufficient evidence to recommend a specific measure. Selective serotonin reuptake inhibitors are the preferred treatment over tricyclic antidepressants, and psychotherapy should be considered as a potential treatment option.1
Since the panel completed its work, two papers have been published that elaborate on the link between depression and the post-MI period. One study found that behavioral factors, particularly physical inactivity, are associated with depressive symptoms and adverse cardiac events.3 Another study found no clear evidence to support improved cardiac outcomes in post-MI patients treated for depression.4 However, the authors did find positive trends, and acknowledged substantial difficulty in ensuring adequate treatment and follow-up. Together, these reports suggest that patients with post-MI depression may benefit from self-management support that emphasizes physical activity and regular, scheduled follow-up.3,4 There is no evidence of harm in addressing and treating depression in post-MI patients.
The prevalence of depression in post-MI patients underscores the importance of treating the whole person. Because family physicians care for patients before, during, and after acute hospitalizations for MI, we are in a position to recognize and treat depression in this population. Ongoing research may demonstrate how health information systems can facilitate depression screening in post-MI patients and in patients with other chronic diseases.5
Although single-disease guidelines are helpful, they do not adequately address many of the comorbid conditions seen in primary care. This guideline aims to help physicians identify and treat two prevalent, comorbid conditions. More guidelines addressing other comorbid diseases would be helpful in improving patient care.
1. Post-Myocardial Infarction Depression Clinical Practice Guideline Panel. AAFP guideline for the detection and management of post-myocardial infarction depression. Ann Fam Med. 2009;7(1):71–79.
2. Bush DE, Ziegelstein RC, Patel UV, et al. Post-myocardial infarction depression. Evidence report/technology assessment no. 123. AHRQ publication no. 05-E018-2. Rockville, Md.: Agency for Healthcare Research and Quality; 2005.
3. Whooley MA, de Jonge P, Vittinghoff E, et al. Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. JAMA. 2008;300(20):2379–2388.
4. Thombs BD, de Jonge P, Coyne JC, et al. Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA. 2008;300(18):2161–2171.
5. Schwenk TL, Green LA. The Michigan Clinical Research Collaboratory: following the NIH Roadmap to the community. Ann Fam Med. 2006;4(suppl 1):S49–S54.
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