New Guidelines Examine Post-MI Depression, Second-Generation Antidepressants
Two new guidelines on depression and medications for depression have found that as many as 65 percent of patients experience symptoms of depression after a heart attack, and there is no significant difference in the effectiveness of second-generation antidepressants versus first-generation antidepressants for the treatment of major depression disorders.
Depression in Patients After Heart Attack
The AAFP Guideline for the Detection and Management of Post-Myocardial Infarction Depression found that of the 65 percent of patients who experienced depression after a heart attack, as many as 22 percent suffer from major depression.
According to Perry Dickinson, M.D., a member of the AAFP's Post-Myocardial Infarction Depression Clinical Practice Guideline Panel, which produced the guideline, depression is common in patients who have experienced a myocardial infarction, or MI. "Primary care doctors need to have some sort of screening process for depression in patients who have had myocardial infarctions and should treat depression when it appears," he said.
Dickinson, who is a professor in the Department of Family Medicine at the University of Colorado, Denver, said evidence shows that treatment improves patient outcomes for depression, but more research is needed to determine if treating depression also helps patients recover from heart attacks.
"They certainly do better with their depression symptoms," he said. "We don't have enough evidence yet to make it clear that it improves their cardiac outcome."
The guideline, which appears in the January/February Annals of Family Medicine, makes four recommendations.
According to Perry Dickinson, M.D., a member of the AAFP's Post-Myocardial Infarction Depression Clinical Practice Guideline Panel, which produced the guideline, depression is common in patients who have experienced a myocardial infarction, or MI. "Primary care doctors need to have some sort of screening process for depression in patients who have had myocardial infarctions and should treat depression when it appears," he said.
Dickinson, who is a professor in the Department of Family Medicine at the University of Colorado, Denver, said evidence shows that treatment improves patient outcomes for depression, but more research is needed to determine if treating depression also helps patients recover from heart attacks.
"They certainly do better with their depression symptoms," he said. "We don't have enough evidence yet to make it clear that it improves their cardiac outcome."
The guideline, which appears in the January/February Annals of Family Medicine, makes four recommendations.
- Patients who have had or are having an MI should be screened for depression at regular intervals, including during hospitalization.
- Patients diagnosed with depression should be treated to improve their depression symptoms, and systems should be put in place to ensure follow-up and monitoring of patients' treatment response and adherence to treatment.
- Psychotherapy may be beneficial for treatment of depression in post-MI patients.
- Selective serotonin reuptake inhibitors, or SSRIs, are preferable to tricyclic antidepressants for treatment of depression in these patients.
SSRIs are preferred, Dickinson said, because tricyclics can affect heart rate and heart rhythm.
Second-Generation Antidepressants
At the same time, new guidelines from the American College of Physicians, or ACP, indicate that there is no significant difference in effectiveness or side effects among second-generation antidepressants, which comprise SSRIs, serotonin norepinephrine reuptake inhibitors and selective serotonin norepinephrine reuptake inhibitors, for the treatment of major depression disorder.
The ACP report found that the three types of second-generation drugs demonstrated side effects similar to those seen with use of first-generation antidepressants, although SSRIs were associated with an increased risk for nonfatal suicide attempts.
The new guidelines recommend that when physicians choose pharmacologic therapy to treat patients with acute major depression, they should select second-generation antidepressants based on adverse effect profiles, cost and patient preference.
According to the guidelines, physicians should assess patient status, therapeutic response and adverse effects of therapy on a regular basis, beginning within one to two weeks of initiation of therapy. Patients should be monitored for agitation, irritability or other unusual changes in behavior because these symptoms typically indicate that the depression is worsening. In addition, the risk of suicide is greater during the first two months of treatment.
The ACP guidelines also state that physicians should modify treatment if a patient does not respond sufficiently to pharmacotherapy within six to eight weeks of treatment.
Physicians should continue treatment for four to nine months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had multiple episodes of depression, an even longer duration of therapy may be beneficial.
The ACP report found that the three types of second-generation drugs demonstrated side effects similar to those seen with use of first-generation antidepressants, although SSRIs were associated with an increased risk for nonfatal suicide attempts.
The new guidelines recommend that when physicians choose pharmacologic therapy to treat patients with acute major depression, they should select second-generation antidepressants based on adverse effect profiles, cost and patient preference.
According to the guidelines, physicians should assess patient status, therapeutic response and adverse effects of therapy on a regular basis, beginning within one to two weeks of initiation of therapy. Patients should be monitored for agitation, irritability or other unusual changes in behavior because these symptoms typically indicate that the depression is worsening. In addition, the risk of suicide is greater during the first two months of treatment.
The ACP guidelines also state that physicians should modify treatment if a patient does not respond sufficiently to pharmacotherapy within six to eight weeks of treatment.
Physicians should continue treatment for four to nine months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had multiple episodes of depression, an even longer duration of therapy may be beneficial.
Related ANN Coverage
AAFP Performance Improvement Initiative
Just-released METRIC Module Tackles Depression
(11/21/2008)
AHA Issues 'Science Advisory' on Treating Depression in Patients With CHD
(11/5/2008)
Primary Care Docs Show Mixed Results in Adhering to Depression Guidelines
(10/19/2007)
Additional Resources
U.S. Preventive Services Task Force: Screening for Depression -- Recommendations and Rationale
American Heart Association Statements and Practice Guidelines
AAFP Performance Improvement Initiative
Just-released METRIC Module Tackles Depression
(11/21/2008)
AHA Issues 'Science Advisory' on Treating Depression in Patients With CHD
(11/5/2008)
Primary Care Docs Show Mixed Results in Adhering to Depression Guidelines
(10/19/2007)
Additional Resources
U.S. Preventive Services Task Force: Screening for Depression -- Recommendations and Rationale
American Heart Association Statements and Practice Guidelines
