Physician's Weekly Article - Screening for Depression in Cardiac Patients

       A scientific advisory statement has been published to help physicians in the screening, diagnosis, and treatment of depression among cardiac patients.

      Published studies have shown that 15% to 20% of patients with myocardial infarction (MI) meet the Diagnostic and Statistical Manual of Mental Disorders criteria for major depression and even more experience depressive symptoms. The current literature has also documented an association between depression among patients with coronary heart disease (CHD) and higher health care costs, impaired quality of life, poor adherence to medication and lifestyle guidelines, and a doubling of the mortality rate. Despite its high prevalence, the detection and treatment of depression among CHD patients have been suboptimal. To address this issue further, the American Heart Association has released a science advisory for clinicians which recommends systematic screening for depression in CHD patients. The new advisory, which was published in the October 21, 2008 issue of Circulation, was also endorsed by the American Psychiatric Association.

      “Depression worsens the prognosis for CHD patients because it can lead to poorer adherence to critical prevention guidelines,” explains J. Thomas Bigger, Jr., MD, an author of the new advisory. “Compliance with cardiac drugs that are recommended by AHA/ACC guidelines reduce mortality by about 50%, but these benefits won’t be realized if patients fail to adhere to their cardiac medications and lifestyle recommendations. Depression can substantially reduce compliance with cardiac drugs regimens, causing patients to lose the benefits of known therapies.”

      A Helpful Screening Algorithm

      Dr. Bigger says that screening for depression is critical among patients, especially those with CHD. “Depression can’t be managed if clinicians aren’t aware that patients have it,” he says. The scientific advisory statement helps guide physicians in screening cardiac patients for depression and created an algorithm for clinicians (Figure). The statement recommends that clinicians use the Patient Health Questionnaire (PHQ)-2 to identify currently depressed patients because the survey can be administered quickly and easily (Table). If the answer is “yes” to one or both questions, it is then recommended that all 9 items in the PHQ be answered. Patients with screening scores that indicate a high probability of depression—meaning a PHQ-9 score of 10 or higher—should be referred for a more comprehensive clinical evaluation by a professional qualified to evaluate and determine a suitable individualized treatment plan for depression. “Furthermore,” Dr. Bigger says, “the statement recommends early and repeated screening for depression in heart patients.”

      Implications for Physicians & Patients

      According to research, the risks of not treating depression during or soon after acute coronary syndromes and the benefits of depression treatments have not been widely appreciated by cardiologists. “Depression has a substantial impact on adherence to life-saving cardiovascular drugs recommended in clinical guidelines, but too few physicians make this connection,” says Dr. Bigger. “The key is to develop and utilize depression screening/treatment systems for CHD patients that are both efficient and effective. The hope is that the recommendations made in the scientific advisory statement can enable physicians to optimize outcomes for patients.”

      Typically after an acute coronary event, MI patients and those with CHD will experience a peak in depressive symptoms. Some physicians, according to Dr. Bigger, may have been averse to routinely screening their patients for depression because they feel that it is a “normal” reaction to a stressful life event. “Other clinicians believe that the symptoms often diminish over time or they simply don’t have the training required to properly treat a cardiac patient with a positive diagnosis of depression.”

      Recent data have demonstrated that sertraline and citalopram are very safe and moderately effective antidepressant therapies for patients with CHD, and the scientific advisory recommends that these agents be used as first-line therapies for this patient group. Patients with recurrent depression who previously tolerated and responded well to another antidepressant may continue taking it unless it is contraindicated because coronary heart disease has developed.

      “The biggest barrier to managing coincident heart attack and depression is the need for coordination between cardiology/medical personnel and mental health personnel,” says Dr. Bigger. “These groups need to form an integrated management team to optimize benefits for patients. Cardiologists should communicate with the physicians who are responsible for providing therapies for mental health to make them aware of cardiovascular developments and new therapies as well as to seek their advice on patient management. Additionally, depressed patients may benefit from close family monitoring and support of compliance-strengthening procedures. More frequent office visits, phone calls, e-mails, and other messaging modalities should be used to improve adherence to the cardiac therapeutic regimen as well as to improve clinical and behavioral outcomes.”

      J. Thomas Bigger, MD, FAAN, FAASM, has indicated to Physician’s Weekly that he has worked as a consultant for Merck & Co, Inc and that he has received research support from the NHLBI, the NIH, and the Dana Foundation.