Originally published in Journal Watch Psychiatry
by Steven Dubovsky, MD
And attaining remission significantly improves mortality risk in patients with acute coronary syndromes.
Depression is common after myocardial infarction (MI), and medical outcomes are worse in depressed patients. These researchers addressed long-term survival in a 6.7-year follow-up study of 361 patients with acute coronary syndromes (ACS) and major depression. The patients had participated in a randomized, controlled, industry-funded trial involving 6 months’ treatment with sertraline or placebo.
Randomization had been stratified by left ventricular ejection fraction, dichotomous depression severity (Hamilton Rating Scale for Depression score, <18 vs. ≥18), and depression recurrence (≥2 vs. ≤1 previous episodes). Patients with severe depression at baseline were 2.71 times more likely to have died during follow-up than those with less-severe depression. Recurrent depression, onset of depression before ACS onset, and sertraline treatment had no impact on long-term mortality. However, after adjustment for left ventricular ejection fraction and hypertension, patients whose depression had not improved at 6 months (measured by the Clinical Global Impressions Improvement [CGI-I] subscale) were 1.76 times more likely to have died during follow-up, regardless of their treatment assignment. A CGI-I score compatible with remission had the greatest protective effect.
Comment: The antidepressant itself had no impact on medical outcome, improvement in depression improved medical prognosis, and more-severe depression was associated with a worse prognosis. Mechanisms by which depression might affect the outcome of coronary heart disease include poor compliance with medical treatment, diet and exercise, heightened inflammatory state, and unstable autonomic tone. Whatever the cause, the results suggest that clinicians must not only recognize and treat depression in cardiac patients, but also treat it to remission. Simply prescribing an antidepressant is insufficient if it does not produce substantial improvement in depression.
Citation(s):
Glassman AH et al. Psychiatric characteristics associated with long-term mortality among 361 patients having an acute coronary syndrome and major depression: Seven-year follow-up of SADHART participants. Arch Gen Psychiatry 2009 Sep; 66:1022.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
Visit Journal Watch for more psychiatry articles.
