AHA Issues 'Science Advisory' on Treating Depression in Patients With CHD

For decades, research has demonstrated a link between depression and coronary heart disease, or CHD. Various studies have found that the prevalence of depression in patients hospitalized for certain cardiac problems and in community-dwelling patients with CHD is considerably higher than in their counterparts without CHD. Accordingly, the American Heart Association, or AHA, recently issued a "science advisory" on screening, referral and treatment of depression in patients with CHD.

Published in the journal Circulation, the consensus statement, which has been endorsed by the American Psychiatric Association, may offer guidance to family physicians and others who interact with patients with CHD who experience depression.

The AHA advisory recommends routine screening for depression in patients who have CHD. At a minimum, clinicians should ask patients two questions from the Patient Health Questionnaire, or PHQ, to identify those who are currently depressed. The questions ask patients to report how often in the previous two weeks they have been bothered by the following problems:

A positive response to either or both questions should trigger administration of the full nine-item PHQ screening instrument. According to the AHA document, use of this instrument can yield a provisional depression diagnosis and a severity score that physicians can use to select treatment and monitor these patients.

For patients who have mild symptoms of depression, follow-up at a subsequent visit is recommended. If a patient has high depression scores, a physician or nurse should promptly review the PHQ results with the patient. In addition, says the advisory, patients who have screening scores that indicate a high probability of depression "should be referred for a more comprehensive clinical evaluation by a professional qualified to evaluate and determine a suitable individualized treatment plan." These individuals also should be evaluated for other mental disorders that are associated with adverse outcomes in patients who have CHD.

The AHA advisory recognizes three types of treatment options: antidepressant drugs, cognitive behavioral therapy and physical activity. Previous research has shown that in primary care populations, these options may be used together to minimize relapse rates in patients with depression. However, the advisory notes, "There is no evidence that treatments for depression are differentially effective in cardiac versus other patients." Moreover, "There is as yet no direct evidence showing that treatment of depression improves cardiac outcomes; patients may remain at increased risk for major cardiac events and mortality even when treated for depression."

Two selective serotonin reuptake inhibitors, sertraline and citalopram, have been shown to be safe for patients who have CHD. Although these drugs should be considered first-line antidepressants for patients with CHD, says the advisory, if patients have tolerated a different antidepressant in the past, they can continue to take it or resume its use. However, tricyclic antidepressants and monoamine oxidase inhibitors have cardiotoxic side effects, so they are usually contraindicated in these patients.

Cognitive behavioral therapy and physical activity and exercise also can be useful in reducing depression in patients who have CHD. The advisory notes "many patients with moderate to severe depression may respond better to the combination of an antidepressant and psychotherapy than to either treatment alone." For these patients, the referral to a qualified psychotherapist is recommended.

Because patients with depression may be unwilling to participate in cardiac rehabilitation and exercise programs, physicians should encourage them and provide follow-up. Physicians also can enlist the patient's spouse, partner or other family members to provide encouragement.

Finally, the advisory stresses the importance of coordinating care among health care professionals treating patients with combined medical and mental health issues. Patients who experience depression may need additional clinical management to ensure that they comply with cardiac treatment regimens and to promote lifestyle and behavioral changes.