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Am Fam Physician. 2007;76(8):1210

Background: Coronary artery disease (CAD) requiring hospitalization is a risk factor for depression, which has a prevalence of 17 to 27 percent in this population. Although it appears that depression leads to poorer outcomes, it is unknown whether treating depression in patients with CAD effectively improves symptoms. One trial showed that treatment improved depressive symptoms but did not impact CAD morbidity and mortality. Another trial showed that sertraline (Zoloft) is safe and somewhat effective, particularly in patients with more severe depression whose symptoms began before a cardiac event. Lespérance and colleagues evaluated the short-term effectiveness of the selective serotonin reuptake inhibitor citalopram (Celexa) and interpersonal psychotherapy in patients with CAD.

The Study: In the nine-center Canadian Cardiac Randomized Evaluation of Anti-depressant and Psychotherapy Efficacy trial, 284 patients with CAD and major depression were randomly assigned to one of four groups: interpersonal psychotherapy and citalopram, interpersonal psychotherapy and placebo, citalopram alone, or placebo alone; all participants received clinical management. Patients had stable CAD, defined as previous myocardial infarction or revascularization or angiography showing significant blockages, and had a baseline score of 20 or higher on the Hamilton Depression Rating Scale. Patients were excluded if they had a serious concomitant mental disorder. Citalopram was titrated up to a 20-mg daily dosage. Clinical management involved individual weekly visits at which reassurance and information on depression and medication were provided. Up to four of these visits could be conducted by telephone. Patients undergoing interpersonal psychotherapy were treated immediately after each clinical management session, addressing issues such as interpersonal conflicts and grief.

Results: Fifty-four patients discontinued treatment; more patients discontinued medication because of intolerance or lack of effectiveness than discontinued interpersonal psychotherapy. Of the patients undergoing interpersonal psychotherapy, 86 percent completed all 12 sessions. Citalopram reduced depression compared with placebo from baseline to 12 weeks. The mean reduction from baseline on the Hamilton Depression Rating Scale was 11.02 for citalopram and 8.44 for placebo. Some benefit was shown with clinical management and with interpersonal psychotherapy, but this did not reach the threshold of rejecting the null hypothesis. Subgroup analysis suggested that citalopram was effective for recurrent depression but not for first-time depression. Of the factors influencing responses, low perceived social support at baseline was associated with somewhat better results in patients undergoing clinical management than in patients undergoing interpersonal psychotherapy.

Conclusion: The authors conclude that, in the short term, citalopram is more effective than placebo in treating patients with depression and CAD; interpersonal psychotherapy is no better than clinical management.

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