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Am Fam Physician. 2001;64(4):573

See article on page 641

The battle against heart disease has frequently taken center stage among the major public health concerns of the past 20 years. The importance of early detection and aggressive treatment of cardiovascular risk factors such as hypertension, elevated cholesterol levels and diabetes have played a significant role in the reduction of myocardial events experienced by patients in the United States. Family physicians have been at the forefront of these efforts—in patient treatment as well as patient education.

In this issue of American Family Physician, Guck and colleagues1 wisely point out that depression is a significant risk factor for the development and progression of heart disease. The authors underscore the fact that patients with depression following myocardial infarction are 3.5 times more likely to experience an additional cardiac event than their counterparts who are not depressed.2,3 Yet somehow, this startling bit of data has escaped public awareness. It is particularly important to diagnose and treat depression in patients who have had a myocardial infarction because there is an association with progression of the disease.

Prior to a patient's first myocardial infarction, depression appears to be a risk factor for the development of heart disease. Clearly, the work of Guck and colleagues1 suggests that early aggressive treatment of depression may play a significant role in the primary prevention of heart disease.

Family physicians have traditionally played a leading role in the diagnosis and management of depression.4 During the past 30 years, we have waged a hard-fought battle to promote public awareness of depression as a biologic illness and not a character flaw or weakness. Thanks to these efforts, public understanding of depression as a biologic entity has been greatly enhanced.

Yet, depression continues to be a significant public health problem.5 It is responsible for immense suffering, enormous loss of productivity and, all too commonly, loss of life. Unfortunately, significant obstacles stand in the way of effectively managing depression in patients.6 Third-party payers are increasingly denying payment to family physicians for treating depression, regardless of how effective (or even lifesaving) the treatment may be.

Now, Guck and colleagues1 have given yet another reason to aggressively diagnose and treat this endemic illness. Future research may uncover other diseases for which depression is a significant risk factor. In the meantime, physicians must re-double their efforts to treat what remains one of the most significant medical problems in patient populations. Finally, we must work to remove financial disincentives from the healthcare system that threaten our patients' access to primary care treatment of depression.

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