From the American Society of Hypertension
Treat Depressive Symptoms to Improve Cardiac Outcomes
As many as 1 in 4 patients with coronary artery disease (CAD) have concomitant major depression, and evidence shows that when the depression is successfully treated, the cardiac prognosis improves. New data now suggest that selective serotonin reuptake inhibitor (SSRI) therapy is both effective and safe in these patients.
The Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial (JAMA. 2007; 297:367-379) included 284 patients (mean age, 58.2 years; 25% women) with CAD who met the diagnostic criteria for major depression and who had baseline 24-item Hamilton Depression Rating Scale (HAM-D) scores of ≥20 (mean score, 29.7).
Patients were randomized to interpersonal psychotherapy plus clinical management or to clinical management alone. Clinical management consisted of weekly semistructured 20- to 25-minute visits, in which the patient was assessed but no specific psychotherapy was delivered. After 12 weeks, the group assigned to clinical management alone showed slightly better response (defined as ≥50% reduction from baseline HAM-D score) and remission (defined as HAM-D score ≤8) (Table).
Patients were then rerandomized to 12 weeks of citalopram (Celexa), 20 to 40 mg/day, or to placebo. Both groups also participated in clinical management sessions. At the end of this phase, citalopram showed a clear benefit over placebo (Table).
The authors of an accompanying editorial (pages 411-412) suggest that these results should encourage physicians to screen for depression in CAD patients and be quick to treat it with either citalopram or with sertraline (Zoloft), the other SSRI that had previously demonstrated efficacy in this clinical setting, most notably in the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) (JAMA. 2002; 288:701-709).
Although patients in both SADHART and CREATE responded better to SSRI therapy if they had a history of major depression, “general practitioners or internists don’t have time to figure out whether somebody has a past history of depression,” coeditorialist (and SADHART lead investigator) Alexander H. Glassman, MD, tells IMWR.
Dr Glassman points out, however, that “in no group did the drug do worse than placebo. It never makes the patient worse. However, if you look at people who get depressed for the first time after a heart attack and have never had a history of depression before, they really get better and, for the most part, stay better.”
He notes that these results do not necessarily apply to all SSRIs. “When we did SADHART, the average post-myocardial infarction patient in that study was taking 11 other drugs. When somebody is taking 11 other drugs, you have to have a very good reason for giving them another drug, because they’re sick of drugs,” advises Dr Glassman, who is chief of clinical psychopharmacology at the New York State Psychiatric Institute and professor at Columbia University in New York City.
In these patients, “The chances of getting a drug—drug interaction are really high, and you’ll never know what’s going on. If you have 2 drugs or 3 drugs, you can stop 1 drug and see if that’s what the cause is. But when you have 11 drugs, it’s just better to avoid it,” he says.
“Citalopram and sertraline have essentially no drug—drug interactions. So they’re the 2 best drugs,” Dr Glassman emphasizes. And both are now available in generic versions, which makes them even more attractive—“they’re cheap; they’re both safeand they both work.”
PHQ: Quick Screening Tool for Depression in CAD
Of the different, quick screening tools for depression, Dr Glassman says the Patient Health Questionnaire (PHQ) “is the one that I think is probably the easiest to use.”
The PHQ is basically a boiled-down version of the Primary Care Evaluation of Mental Disorders (PRIME-MD), which began as a 26-item questionnaire. “The PHQ is much more usable for primary care physicians than the 9-question variety of the PRIME-MD,” Dr Glassman says, noting that the PHQ covers “2 real crucial questions”:
1. In the past 2 weeks, have you had depressed mood; lost interest or pleasure in things; had problems with sleeping, eating, or concentrating; felt bad about yourself; felt tired or lacking in energy; moved or talked so slowly—or been so fidgety—that other people could have noticed; and/or thought you would be better off dead or of hurting yourself?
2. If you answered “yes” to any of the above, how have these problems affected your work, home life, or social interactions?
This test can be self-administered and takes less than 3 minutes for the patient to complete.
“The questions are really very simple, and it is very specific in picking up somebody who’s really depressed. It’s also relatively sensitive,” Dr Glassman notes. The PHQ has shown an overall accuracy of 85%, a specificity of 90%, and a sensitivity of 75% (JAMA. 1999; 282:1737-1744).
“In terms of just speaking ordinary English, everybody gets depressed. But it shouldn’t be persistent,” Dr Glassman emphasizes. “You get depressed, you get down for a few hours, a few days—not weeks or months. The 2 weeks [referred to in the first PHQ question] is probably pretty arbitrary, but it’s not unreasonable.”
He says that the PHQ picks up the other important thing about depression: “It isn’t just that you’re sad or blue, but it interferes with your ability to enjoy things. People don’t look forward to things that they ordinarily did, whether it’s a concert, or reading a book, or sitting with a beer can in front of a television set.”
