Psychological Distress and Cardiovascular Disease

Screening Issues

In recognition of the high prevalence of depression in patients with CHD, an American Heart Association (AHA) science advisory in 2008 recommended routine screening for depression in patients with CHD, with follow-up evaluation for diagnosis and treatment of depression by qualified professionals for positive cases [26]. In 2014, an AHA scientific statement recommended elevating depression to the level of a risk factor in ACS patients [27]. The recommendation for screening was initially met with some concern as being premature [28], when past supporters spoke out against the routine screening of depression in cardiac patients [29]. The dissenting authors claimed that there was a lack of scientific evidence supporting the efficacy of treatment for depression in cardiac patients, and that potential negative effects of routine screening and follow-up treatment were unknown. They argued the following: limited data from randomized controlled trials and/or evidenced-based reviews exist demonstrating improved outcomes in cardiac patients based on screening and referral [30]; antidepressants are not yet recognized to be effective in cardiac populations and there is a lack of evidence related to potential harms [28]; concerns exist about the potential for mass screening to increase health care resource use at the expense of other health care needs [29]; and routine screening may cause unnecessary negative social stigma related to false-positive findings [31].

Although clinical trials of depression treatment in cardiac patients have not demonstrated an increase in survival, treatment has been shown to be effective in reducing depression symptoms, improving patient satisfaction with depression care and improving health related quality of life [32–34]. Further, recent studies described the AHA recommendation as well accepted by cardiac unit staff, not heavily resource intensive, feasible, and accurate [35,36]. Bigger and Glassman [37] published a recent analytical review of the AHA advisory and concluded that the advisory is supported by the literature. A salient point regarding the depression screening debate is that screening without proper follow-up for further diagnosis and potential treatment may be harmful [28,29,31]. Despite concerns of the potential negative impact of depression screening in cardiac patients raised in the literature, the preponderance of the literature indicates that its benefits are likely to outweigh its risks [32,34,36,38–40].

Outcomes of Depression Treatment

Answers to questions about improvement in cardiovascular and all-cause mortality outcomes with depression treatment remain elusive in the literature. However, data show an improvement in depressive symptoms and quality of life for depressed patients receiving some types of treatment [33,41–45]. The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study was a landmark study of MI patients with a 6-month treatment intervention of cognitive behavioral therapy (CBT) plus pharmacologic intervention if indicated for depression [33]. Patients were followed for an average of 29 months post-MI. A significant improvement was seen in depressive symptoms and social isolation in the treatment group; however, there was no improvement in event-free survival [33]. When outcome measures are restricted to mortality alone, subsequent trials of antidepressant medications for treatment of depression in cardiac patients have shown them to be ineffective [46]. However, CBT and other supportive stress management strategies are effective in decreasing depressive symptoms and improving the quality of life in patients suffering with depression and CVD [46].