Screen Heart Patients For Depression, New Guidelines

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Main Category: Heart Disease
Also Included In: Depression;  Psychology / Psychiatry;  Cardiovascular / Cardiology
Article Date: 30 Sep 2008 - 3:00 PDT

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New guidelines from the American Heart Association (AHA) recommend that heart patients should be screened for depression, and treated if necessary, because research shows they are at much higher risk, and it can severely affect prognosis of their heart condition and their quality of life.

The AHA's first scientific statement on depression and coronary heart disease is published in the September 29 issue of Circulation: Journal of the American Heart Association.

Co-chair of the writing group, Dr Erika Froelicher said:

"The statement was prompted by the growing body of evidence that shows a link between depression in cardiac patients and a poorer long-term outlook."

Froelicher is a professor at the University of California San Francisco, School of Nursing and Medicine.

Dr Judith H. Lichtman, associate professor of epidemiology at Yale University School of Medicine in New Haven, Connecticut, and also writing co-chair of the statement said there was currently no routine screening of heart patients, yet:

"Studies show that depression is about three times more common in patients following a heart attack than in the general community."

Lichtman said some recent studies found that depressed patients were less likely to follow medication instructions, or other advice such as improve their diets, exercise and attend rehabilitation, all of which can lead to worse outcomes. More research was needed, said Lichtman.

The recommendations have the support of the American Psychiatric Association and suggest heart patients should receive early and repeat screening for depression and follow up for both conditions should be co-ordinated for patients with both.

Screening entails asking the patient 2 questions, and then if depression is suspected, asking them a further 7 questions.

Dale Briggs, volunteer executive vice president of Mended Hearts Inc, a national non-profit organization affiliated to the AHA, and who experienced depression after receiving heart valve surgery, welcomed the new statement.

"I think it's long overdue. It is unfortunate that some patients aren't warned of the possibility of some depression after surgery," said Briggs.

Mended Hearts offers resources and support for heart surgery patients. One of the main support services is patient to patient support, for example where volunteers like Briggs visit new heart patients in hospital and relate their experience.

Briggs said he'd visited about 1,000 new heart patients since his own surgery and always alerts them to the risk of depression. He said he encourages them to talk to their doctor about treatment:

"I've had a number of people call me through the years and thank me for warning them about the possibility of depression," said Briggs.

Heart patients who are depressed have at least twice the risk of another heart event up to two years after their first heart attack, said Froelicher, quoting experts, and adding that research also shows that more severe depression is linked to earlier and more severe second heart events.

Froelicher mentioned a study that found 15 to 20 percent of hospitalized heart attack patients met the criteria for major depression as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Young women, and other subgroups, appear to particularly vulnerable.

The statement suggests that it is also "possible that biological changes associated with depression such as reduced heart rate variability and increases in blood factors that encourage clot formation could increase risk".

The statement also recommends that:

• Patients presenting with sympoms of depression should be evaluated by a professional qualified in diagnosing and managing depression.


• They should also be screened for other psychiatric disorders, such as anxiety.


• Treatments considered should include cognitive behavioral therapy (CBT), physical activity, cardiac rehabilitation, antidepressants, and combinations of these.


• Selective serotonin reuptake inhibitor (SSRI) treatment may be effective for treating depression soon after a heart attack and is considered safe and relatively inexpensive.


• To avoid missing the opportunity to effectively treat depression in heart patients and improve physical health outcomes, screening for depression should be routinely performed in a range of settings, including hospitals, doctors' surgeries and offices, clinics and cardiac rehabilitation centers.


• Coordination of care between health providers is essential for patients with both medical and psychiatric diagnoses.

"You can't treat the heart in isolation from the patient's mental health," said Lichtman, adding that:

"There is no direct evidence yet that treating depression improves coronary heart disease outcomes, but plenty of evidence shows that having depression worsens those outcomes. By understanding the prevalence of depression and learning more about the subgroups of heart patients at particular risk of depression, we can begin to understand the best ways to recognize and treat it."

"Depression and Coronary Heart Disease. Recommendations for Screening, Referral, and Treatment. A Science Advisory From the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research."
Judith H. Lichtman, J. Thomas Bigger, Jr, James A. Blumenthal, Nancy Frasure-Smith, Peter G. Kaufmann, François Lespérance, Daniel B. Mark, David S. Sheps, C. Barr Taylor, and Erika Sivarajan Froelicher.
Circulation published September 29, 2008.
doi:10.1161/CIRCULATIONAHA.108.190769

Click here for the full statement (PDF download).

Source: AHA.

Written by: Catharine Paddock, PhD.


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