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David L. Hare, Samia R. Toukhsati, Peter Johansson, Tiny Jaarsma, Depression and cardiovascular disease: a clinical review, European Heart Journal, Volume 35, Issue 21, 1 June 2014, Pages 1365–1372, https://doi.org/10.1093/eurheartj/eht462
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Abstract
Cardiovascular disease (CVD) and depression are common. Patients with CVD have more depression than the general population. Persons with depression are more likely to eventually develop CVD and also have a higher mortality rate than the general population. Patients with CVD, who are also depressed, have a worse outcome than those patients who are not depressed. There is a graded relationship: the more severe the depression, the higher the subsequent risk of mortality and other cardiovascular events.
It is possible that depression is only a marker for more severe CVD which so far cannot be detected using our currently available investigations. However, given the increased prevalence of depression in patients with CVD, a causal relationship with either CVD causing more depression or depression causing more CVD and a worse prognosis for CVD is probable. There are many possible pathogenetic mechanisms that have been described, which are plausible and that might well be important.
However, whether or not there is a causal relationship, depression is the main driver of quality of life and requires prevention, detection, and management in its own right. Depression after an acute cardiac event is commonly an adjustment disorder than can improve spontaneously with comprehensive cardiac management. Additional management strategies for depressed cardiac patients include cardiac rehabilitation and exercise programmes, general support, cognitive behavioural therapy, antidepressant medication, combined approaches, and probably disease management programmes.
Comments
We thank Dr Sharp for his comments that are not dissimilar to the issues raised in a recent article by Thombs and Ziegelstein from which he quotes1. Of course, having advocated screening for depression in cardiac patients, we obviously disagree.
Screening in low-risk primary care settings seems only to increase the detection of depression by less than 30%, especially when using non- specific psychological screening tools rather than specific diagnostic cut -points for depression2. However, on Bayesian principles, one would expect the screening of cardiac patients to be far more beneficial. There are extensive data showing that patients with cardiac disease have a much higher prevalence of depression than the general population.
In agreement with Dr Sharp, we believe that programmes of care for preventing the burden of depression are very important and that a range of management strategies need to be considered.
Certainly there are no randomised trials that show screening for depression improves clinical outcomes. This however is analogous to the situation of hyperlipidaemia: there are no randomised trials demonstrating that screening for hyperlipidaemia results in improved clinical outcomes. However, we attempt to detect hyperlipidaemia because we have evidence that subsequent treatment of the lipid abnormality results in improved clinical outcomes. Similarly, we have randomised trial data demonstrating that treating depression in cardiac patients results in improved clinical outcomes.
Although there are no randomised trials demonstrating that treating depression reduces cardiac events, there are randomised trial data showing that treating depression results in less depression.
In medical practice it would seem that there are two basic over- arching aims: firstly to prevent premature death and secondly to improve quality of life. Depression is clearly a major driver of one's quality of life. Therefore reducing depression would seem to be a major task of medical practice.
Thus screening for depression is really a parallel situation to screening for hyperlipidemia: the former leading to interventions that can improve quality of life and the latter leading to interventions that reduce cardiovascular events.
Therefore the screening of cardiac patients for depression should be strongly supported.
1. Thombs BD, Ziegelstein RC. Depression Screening in Patients with Coronary Heart Disease: Does the Evidence Matter? Journal of Psychosomatic Research 2013, doi: 10.1016/j.jpsychores.2013.10.008
2. Gilbody S, Sheldon T, House A. Screening and case-finding instruments for depression: a meta-analysis. CMAJ 2008; 178(8):997-1003
Conflict of Interest:
None declared
In their recent review, Hare et al. (1) present an informative overview of the astonishing prevalence of depression in people with cardiovascular disease, describe the relationship between CVD and depression and provide a helpful summary of the major outcome trials for interventional therapies to treat depression in people with CVD.
Within their review, Hare et al. advocate the use of screening tools to assist in the detection of depression in people with CVD. Whilst numerous instruments have demonstrated validity and reliability in the identification and diagnosis of depression in people with CVD, there is no meaningful evidence of any benefit of broad-based screening. Rather, meta -analysis of RCTs testing depression screening found that this strategy did not lead to increased detection or positively alter the management of patients with depression in primary care (2). Further, systematic reviews on depression screening within CVD care settings have concluded that there is no evidence that depression screening would benefit patients with CVD (3,4).
Despite the known prevalence and the availability of evidence-based interventions, fewer than 25% of people with CVD and depression receive a diagnosis and, of this group, only half ever receive an appropriate intervention (5). Further, with the increased emotional and behavioural needs of people with CVD it is unfeasible that demand for evidence-based psychological therapies can be met from existing models of service provision (6). National guidelines advocate the implementation of a collaborative, stepped care approach and recognise the potential utility of low-intensity, non-pharmacological interventions in helping improve access to evidence-based psychological therapy (7). Such programmes have previously demonstrated efficacy in reducing depression (8) and feasibility of using nurses as case managers (9).
Whilst there is broad agreement within mental health services on the merits of adopting a collaborative care model (CCM) to facilitate ready access to psychological support and intervention, services continually fail to identify and appropriately respond to the emotional and behavioural needs of people with CVD.
Reviewing extant clinical outcome studies serves to remind readers of the magnitude of the problem of depression in people with CVD and highlight the availability of evidence-based interventions. However, it is less helpful to recommend the use of screening approaches which do not yield any demonstrable benefit to the management of depression in people with CVD (10). Instead, increased attention ought to be given to how evidence-based CCMs can be implemented within CVD care settings using innovative improvement methodology to enhance the accuracy of diagnosis of psychopathology in people with CVD, monitor the progress of patients accessing services using validated patient reported outcome measures, create mechanisms to allow for the intensification of psychological support as required, and increase the number of staff receiving evidence- based training in the identification of emotional distress and the delivery of psychological interventions.
(1) Hare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression and cardiovascular disease: a clinical review. European Heart Journal 2013 November 25. (
2) Gilbody S, House A, Sheldon T. Screening and case finding instruments for depression. Cochrane Database Syst Rev 2005(4).
(3) Thombs BD, Roseman M, Coyne JC, de Jonge P, Delisle VC, Arthurs E, et al. Does evidence support the American Heart Association's recommendation to screen patients for depression in cardiovascular care? An updated systematic review. PLoS One 2013;8(1):e52654.
(4) Thombs BD, de Jonge P, Coyne JC, Whooley MA, Frasure-Smith N, Mitchell AJ, et al. Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA 2008 Nov 12;300(18):2161-2171.
(5) Musselman DL, Evans DL, Nemeroff CB. The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Arch Gen Psychiatry 1998 Jul;55(7):580-592.
(6) Lovell K, Richards D. Multiple access points and levels of entry (MAPLE): Ensuring choice, accessibility and equity for CBT services. Behavioural and Cognitive Psychotherapy 2000;28(04):379.
(7) National Collaborating Centre for Mental Health (UK). Depression in adults with chronic health problems. 2010.
(8) Huffman JC, Mastromauro CA, Sowden G, Fricchione GL, Healy BC, Januzzi JL. Impact of a Depression Care Management Program for Hospitalized Cardiac Patients. Circulation: Cardiovascular Quality and Outcomes 2011 March 01;4(2):198-205.
(9) Morgan MAJ, Coates MJ, Dunbar JA, Reddy P, Schlicht K, Fuller J. The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: a randomised trial. BMJ Open 2013 January 01;3(1).
(10) Thombs BD, Ziegelstein RC. Depression Screening in Patients with Coronary Heart Disease: Does the Evidence Matter? J Psychosom Res 2013(0).
Conflict of Interest:
None declared