Severity, duration of depression associated with risk of death among patients with coronary heart disease

Among patients with both major depression and acute coronary syndrome, those with more severe depression within a few weeks of hospitalisation for a cardiac event and those whose depression does not improve within six months appear to have more than double the risk of dying over a seven-year period, according to a report in the September issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

About one-fifth of individuals experience major depression in the first few weeks following a heart attack, according to background information in the article. Depression is associated with an increased risk of death after acute coronary syndrome, a term for cardiac events such as heart attack or unstable angina (chest pain).

Alexander H. Glassman, MD, of Columbia University Medical Center and New York State Psychiatric Institute, New York, observed participants in a study assessing the safety and effectiveness of antidepressants following heart attack (the Sertraline Antidepressant Heart Attack Randomized Trial, or SADHART) to establish features of major depression associated with long-term risk of death. A total of 361 participants who were hospitalised for acute coronary syndromes between 1997 and 1999 and determined to have major depression were tracked through September 2007.

During a median (midpoint) of 6.7 years of follow-up, 75 participants (20.9 percent) died. Severity of depression during hospitalisation for acute coronary syndromes was strongly associated with a significantly increased risk of death. Regardless of whether they took antidepressants, those whose depression had improved substantially at six months had significantly lower death rates – 33 of 211 patients (15.6 percent) who were very much or much improved died, compared with 42 of 148 patients (28.4 percent) whose depression showed little or no improvement.

Risk of death during the study period did not appear to be associated with whether patients had previous episodes of depression, whether their depression developed before or after their cardiac event or whether they took antidepressants during the first six months following hospitalisation.

"Depression is a syndrome with multiple pathways to a similar clinical picture. In patients with active coronary heart disease, it seems likely that the association with depression is a two-way street, and each can aggravate the other," they conclude. "Because persistent depression increases mortality and decreases medication adherence, physicians need to aggressively treat depression and be diligent in promoting adherence to guideline cardiovascular drug therapy."

(Source: JAMA/Archives: Archives of General Psychiatry: September 2009)