American Heart Association urges depression screening for all heart patients

Heart patients are particularly vulnerable to depression and should be screened, and if necessary treated, to improve their recovery and overall health, according to a scientific advisory issued by the American Heart Association.

The advisory recommends heart patients be initially evaluated with a simple two-item assessment. If even one of the questions generates a "yes" response, it is recommended that a more in-depth screening be done with a total of nine questions.

Heart patients found to be suffering from depression can benefit from a number of treatment options, including behavioral therapy, physical activity, cardiac rehabilitation, antidepressant drugs, or combinations of these treatments.

"Depression and heart disease seem to be very much intertwined," said Judith H. Lichtman, co-chair of the statement and associate professor of epidemiology at the Yale School of Public Health. "You can't treat the heart in isolation from the patient's mental health."

The American Psychiatric Association has endorsed the statement-the first of its kind on the link between heart disease and depression. Some of its recommendations include:

• Routine and frequent screening for depression in patients with chronic heart disease in a variety of settings, including the hospital, physician's office and cardiac rehabilitation center.
• Help for patients with positive screening results by a professional qualified to diagnose and manage treatment for depression.
• Careful monitoring of patients to ensure adherence to their treatment plan.
• Coordination between health care professionals treating patients with combined medical and mental health diagnoses.

"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," said Erika Froelicher, RN, MA, MPH, PhD, a professor at the University of California San Francisco, School of Nursing and Medicine and co-chair of the writing group.

While there is no evidence that screening for depression leads to improved outcomes for people with cardiovascular complications, the advisory does state that depression is linked with increased morbidity and mortality, lower rates of cardiac rehabilitation and poorer quality of life.

Depressed cardiac patients have at least twice the risk of second events in the one to two years after a heart attack. Furthermore, studies have shown that more severe depression is associated with earlier and more severe second cardiac events, Froelicher said.

For example, one study found that 15 percent to 20 percent of hospitalized heart attack patients met the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for major depression. An even greater proportion showed more depressive symptoms than usual in the population, though not sufficient to meet these criteria. The study also found that some subgroups of patients, such as young women with heart disease, seem particularly vulnerable to depression.

"Studies show that depression is about three times more common in patients following a heart attack than in the general community," says Lichtman. "Because there has been no routine screening for depression in heart patients, we think there is a large group of people who could benefit from appropriate treatment."

Recent studies indicate that depressed patients are less likely to take their medicines as directed, improve their diets, exercise and attend cardiac rehabilitation sessions, all of which could contribute to a worse outcome, Lichtman said.

It's 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 said.

Other recommendations in the statement include:

• Patients who have depressive symptoms should be evaluated by a professional qualified in diagnosing and managing depression, and should be screened for other psychiatric disorders, such as anxiety.
• Treatment options include cognitive behavioral therapy, physical activity, cardiac rehabilitation, antidepressant drugs or combinations of those treatments.
• Selective serotonin reuptake inhibitor (SSRI) treatment soon after a heart attack is considered safe, relatively inexpensive and may be effective for treating depression.
• Routine screening for depression in coronary heart disease patients should be done in multiple settings, including the hospital, physician's office, clinic and cardiac rehabilitation center, to avoid missing the opportunity to effectively treat depression in cardiac patients and improve physical health outcomes.
• Coordination of care between health providers is essential for patients with combined medical and psychiatric diagnoses.

"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."

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Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. 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. Circulation. 2008 Sep 29;doi: 10.1161/CIRCULATIONAHA.108.190769   [Abstract | Full text ()]