By Will Boggs MD
NEW YORK—Patients with cardiovascular disease should undergo screening to identify and manage depression, according to a JACC state-of-the-art review.
Depression, which affects 1 in 5 patients with coronary artery disease, peripheral artery disease, and heart failure, complicates the management of cardiovascular disease by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and medical therapies.
The American Heart Association recommends screening all patients with coronary artery disease for depression, and the US Preventive Services Task Force recommends screening the general adult population for depression, but only an estimated 3% of patients in ambulatory care settings underwent screening for depression in 2015.
Dr. James W. Murrough from Icahn School of Medicine at Mount Sinai, New York and colleagues discuss a practical approach for screening and managing depression in patients with cardiovascular disease in their April 16th Journal of the American College of Cardiology report.
Cardiologists should discuss the importance of depression screening with their patients with cardiovascular disease and then undertake screening of all those who agree.
While several depression screening instruments are available, the authors recommend the 2-item Patient Health Questionnaire (PHQ-2) for its ease of use, availability in multiple languages, and accessibility in the public domain (http://www.cqaimh.org/pdf/tool_phq2.pdf).
Patient who screen positive with the PHQ-2 can proceed immediately to respond to the additional 7 items of PHQ-9, which incorporates DSM-IV depression diagnostic criteria and other major depressive symptoms and is also available online (http://www.cqaimh.org/pdf/tool_phq9.pdf).
Positive screens should not be considered diagnostic. Rather, additional diagnostic assessments should be performed through structured instruments or clinician interviews by the primary care or mental health provider working with the patient's cardiologist.
In the meantime, patients who screen positive for depression should undergo immediate evaluation for acute suicidality, although how best to do this depends upon the availability of resources at the cardiology service and in the community.
Management of depression in patients with cardiovascular disease can include antidepressants (excluding tricyclic antidepressants and monoamine oxidase inhibitors because of their unfavorable cardiovascular safety profile), psychotherapy, and/or exercise, all of which can relieve depressive symptoms and improve quality of life.
The management strategy should be determined by a multidisciplinary team that includes primary care providers and mental health clinicians. This is particularly important for patients with severe major depressive episodes and for those at risk of harm to themselves or others.
The authors provide helpful algorithms to guide routine depression screening and a sequenced approach to management of depression in patients with cardiovascular disease.
Dr. Robert Carney from Washington University School of Medicine, St. Louis, Missouri, who has extensively researched links between depression and coronary artery disease, told Reuters Health by email, "Probably the well documented finding that depression increases the risk of mortality and cardiac morbidity may be the most significant point. However, the evidence that treating depression improves survival in these patients is not as strong as most of us would like. Nevertheless, there is reason to believe that it may, especially if optimal treatment is provided."
"Cardiologists may decide to screen for depression, and perhaps even begin treatment, but primary care docs will follow the patients longer and hopefully see them more often," he said. "Regardless of which treatment is initiated (psychotherapy or antidepressants), the likelihood of achieving remission with the first treatment is about 35%. Also, depression may recur or become more severe, and so ongoing follow up is needed."
"It is important to be aware that depression is common in these patients, and this is often not mentioned to cardiologists unless they ask," Dr. Carney said.
Dr. Benjamin I. Goldstein, director of research in the department of psychiatry at Sunnybrook Health Sciences Center, Toronto, Ontario, Canada, told Reuters Health by email, "Reducing depression symptoms can not only improve quality of life and functioning in the here and now, but it can also potentially improve cardiovascular disease outcomes through both direct (e.g., biological) and indirect (e.g., motivation to participate in cardiac rehabilitation, adherence with treatments) effects of depression on cardiovascular disease."
"While the current article focuses on depression, which is where the data are most abundant, similar themes apply to other serious and recurrent psychiatric disorders, such as bipolar disorder and schizophrenia," he said. "In addition to focusing on depression as a modifiable risk factor for poor outcomes among patients with established cardiovascular disease, we must also employ a preventive lens, and focus on depression as modifiable risk factor for the development of early cardiovascular disease."
Dr. Murrough did not respond to a request for comments.
J Am Coll Cardiol 2019.
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