Does Treating Post–Myocardial Infarction Depression Reduce Medical Mortality?

Glassman AH. — Fri, 01 Jul 2005 00:00:00 GMT

Depression and cardiovascular disease are 2 of the most common public health problems in the Western world and are strongly comorbid. The increased mortality associated with major depressive disorder (MDD) after myocardial infarction (MI) is equal to or greater than any medical predictor of risk. Even though the evidence is strong, physicians rarely think of depression as a medical risk factor and are unlikely to examine for it in patients after MI, whereas screening for heart failure, arrhythmia, or diabetes is a standard of care. Evidence linking depression and cardiac death comes from epidemiologic studies that screen all MI or unstable angina cases, not just patients seeking treatment, and, therefore, includes many mild cases. Even mildly elevated depression symptoms increase risk of cardiac death, although the risk increases with depression severity. Physicians who recognize depressed mood after MI frequently dismiss it as an understandable and temporary response to a stressful event. If they do treat post-MI depression, typically they treat only the most symptomatic cases. Even if physicians recognize that mortality is increased with less severe depression, there is no definitive evidence that treating depression reduces the risk of dying. In fact, little has been established about how or even whether to treat MDD in patients after MI.

Effects of Antidepressant Medication on Morbidity and Mortality in Depressed Patients After Myocardial Infarction

Taylor C, Youngblood ME, Catellier D, et al. — Fri, 01 Jul 2005 00:00:00 GMT

Background

Depression after myocardial infarction (MI) is associated with higher morbidity and mortality. Although antidepressants are effective in reducing depression, their use in patients with cardiovascular disease remains controversial.

Objective

To undertake a secondary analysis to determine the effects of using antidepressants on morbidity and mortality in post-MI patients who participated in the Enhancing Recovery in Coronary Heart Disease study.

Design

Observational secondary analysis.

Setting

Eight academic sites.

Patients

The Enhancing Recovery in Coronary Heart Disease clinical trial randomized 2481 depressed and/or socially isolated patients from October 1, 1996, to October 31, 1999. Depression was diagnosed using a structured clinical interview. This analysis was conducted on the 1834 patients enrolled with depression (849 women and 985 men).

Intervention

Use of antidepressant medication.

Main Outcome Measures

Event-free survival was defined as the absence of death or recurrent MI. All-cause mortality was also examined. To relate exposure to antidepressants to subsequent morbidity and mortality, the data were analyzed using a time-dependent covariate model.

Results

During a mean follow-up of 29 months, 457 fatal and nonfatal cardiovascular events occurred. The risk of death or recurrent MI was significantly lower in patients taking selective serotonin reuptake inhibitors (adjusted hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.38-0.84), as were the risk of all-cause mortality (adjusted HR, 0.59; 95% CI, 0.37-0.96) and recurrent MI (adjusted HR, 0.53; 95% CI, 0.32-0.90), compared with patients who did not use selective serotonin reuptake inhibitors. For patients taking non–selective serotonin reuptake inhibitor antidepressants, the comparable HRs (95% CIs) were 0.72 (0.44-1.18), 0.64 (0.34-1.22), and 0.73 (0.38-1.38) for risk of death or recurrent MI, all-cause mortality, or recurrent MI, respectively, compared with nonusers.

Conclusions

Use of selective serotonin reuptake inhibitors in depressed patients who experience an acute MI might reduce subsequent cardiovascular morbidity and mortality. A controlled trial is needed to examine this important issue.

JAMA Psychiatry: Myocardial Infarction Topic Collection

Does Treating Post–Myocardial Infarction Depression Reduce Medical Mortality?

Effects of Antidepressant Medication on Morbidity and Mortality in Depressed Patients After Myocardial Infarction