Dangerous depression in cardiac patients: What can we do about it?

A few decades ago, the description of risk factors for coronary heart disease (CHD) focused mainly on smoking, lipids, and hypertension. These factors were said to account for about 50% of incidence of CHD. The remaining risk panorama was in those days said to be largely ‘unknown’. The results of more recent research have filled most of that knowledge gap, and there has been an increasing emphasis on the importance of psychosocial factors, contributing to increased risk for both primary and recurrent events, as demonstrated in many studies and varying designs, and including many different populations. Depression, anxiety, stressful life events, lack of social support, financial and vocational stress, straining family situations, and low socioeconomic status (SES) have been shown to be independent risk factors for CHD. The INTERHEART case–control study assessed risk factors for myocardial infarction (MI) in populations across the world.1 Psychosocial stress was assessed by four simple questions about stress at work and at home, financial stress, and major life events in the past year. Additional questions assessed locus of control and presence of depression. People with MI (cases) reported higher prevalence of all four stress factors. Depression in the past year was more frequent in cases than controls. The differences were consistent across regions, in different ethnic groups, and in men and women.2 Psychosocial risks can be classified into the following categories: Acute emotional states, such as anger and anxiety, which can act as triggers for acute cardiac events. Long-lasting but variable emotions and strain, such as depression, vocational stress, family stress, conflicts, financial stress, bereavement, and lack of social support. Chronic, stable, response tendencies, such as so-called type D personality, entailing a combination of irritability, excessive worrying, and lack of communicative skill in social situations. Classifying psychosocial risk factors is helpful in determining appropriate interventions. This paper by Rao et al.3 addresses an important clinical issue – the need to identify and manage depression, anxiety, and stress in coronary patients, in order to increase adherence to secondary prevention and improve cardiac prognosis. Specifically, the study assessed predictors of depression and anxiety in cardiac rehabilitation (CR) programs, the impact of CR on moderate depression, anxiety and stress symptoms, and the relationship between moderate depression, anxiety and stress symptoms, and CR adherence. It reports a retrospective cohort study of close to 6000 patients entering CR programs in several Australian hospitals. The results showed that anxiety and stress were the strongest predictors of depression, and that patients with moderate depression, anxiety, or stress symptoms were significantly less likely to adhere to CR compared with those with normal, mild symptoms. Depression and stress at entry were stronger predictors of anxiety than socio-demographic and cardiovascular risk factors, diagnoses, and quality of life. The result implies that symptoms of poor emotional well-being must be taken seriously in the prediction of adherence to potentially life-saving rehabilitation and secondary prevention programs. Rehabilitation and prevention usually have a focus on individual characteristics and behaviour, such as health behaviours/lifestyle, adherence to medication, depression, anxiety, stress behaviours, and communication skills. If the social context of the patient is considered, CR programs can not address them directly; however, they can be addressed indirectly by supporting coping skills in the patient in dealing with his/her everyday life. Rao et al. demonstrate how depression is interrelated with other negative emotional states, and the authors emphasize, like a number of other studies, the importance of detecting, diagnosing, and treating depression in cardiac patients in order to decrease risk and improve prognosis. Of special interest is the assessment of the impact of depression on adherence to CR programs, a finding that adds urgency to the need for depression interventions. An important aspect of the Rao et al. study is the focus on participation and adherence to CR. They found that depressed patients were less likely to adhere to CR programs. A prospective cohort study by Olsen et al. described a somewhat different picture.4 They compared the prevalence of anxiety and depression related to CR participation among patients who had been treated with percutaneous coronary intervention (PCI). Self-rated anxiety and depression was assessed by the Hospital and Anxiety Depression Scale at the time of PCI and at three-year follow-up. The authors compared the level of depression and anxiety between PCI patients participating in CR programs with patients who did not participate. CR participants exhibited more anxiety and depression at baseline than non-participants; however, both groups had a higher level of anxiety and depression than the general population. Both groups improved in emotional well-being over three years, but improvements were not related to participation or non-participation in CR. No measure of adherence was reported in this study; therefore, a direct comparison with the Rao et al. study is difficult. Patients with anxiety may be more willing to participate in CR programs, but may run the risk of dropping out, unless they are carefully monitored and followed. At least two conclusions can be drawn from the Olsen et al. study: patients in distress may be more prone to attend CR programs (and should, indeed, be encouraged to do so), and there is a considerable ‘spontaneous recovery’ of depression and anxiety, which makes it more difficult to evaluate the effects of depression interventions. An interesting finding in the study by Olsen et al. was that anxiety is prevalent among female and younger patients, whereas depression is related to older age and cardiovascular co-morbidity. Thus, age and gender should be considered when it comes to offering the best psychological interventions. It may be that one shoe does not fit all patients. The good news, from a clinical point of view, is that most patients do better when time goes by. The European Guidelines on Cardiovascular Disease Prevention in Clinical Practice,5 as well as the American Heart Association Prevention Committee,6 advise that depression in cardiac patients should be diagnosed and treated as part of routine clinical practice. So, what is known about effective interventions? Lavoie et al.7 prospectively assessed the association between prescribed antidepressant medication and major adverse cardiovascular events (MACE). Antidepressant treatment was associated with a 30% reduced risk of MACE, and the authors conclude that antidepressants could be cardio-protective. However, this is a prospective observational study and not a randomized clinical trial (RCT). A recent review examined evidence related to the efficacy, tolerability, and safety of antidepressants for people with depression and with chronic physical health problems.8 Effectiveness studies suggest a neutral or beneficial effect on mortality for antidepressants in participants with recent MI. Antidepressants are efficacious and safe, and the SSRIs are probably the antidepressants of first choice given their demonstrable effect on quality of life and their apparent safety in cardiovascular disease. However, the effects on cardiovascular disease are small or inconclusive, and more RCTs are needed. A Canadian RCT evaluated the effects of a nurse-based psychosocial support program for male and female MI patients.9 Participants with symptoms of depression and/or anxiety were offered regular telephone contacts and home visits by a nurse. The aim was to decrease depression and anxiety, and thereby reducing the risk of recurrence. The results showed no differences in depression/anxiety and recurrence between male participants and controls. The female patients, however, who received the intervention had a small but statistically significant increased mortality. Important clinical conclusions can be drawn from this study. The ‘psychosocial support’ content of the intervention was, intentionally, not well specified but left to the individual nurses to interpret. The nurses were, intentionally, not specialized cardiac nurses, in order to make possible a wider implementation, in case of positive results. Carefully specified and monitored treatment components, as well as specialized staff conducting the intervention, seem needed, in order to not do harm. Similar patterns were shown in the ENRICHD study, a multi-centre intervention study that evaluated the effects of combined individual and group cognitive therapy for post-MI patients exhibiting depression and/or social isolation.10 Outcome measures were depression, isolation, cardiac events, and mortality. Overall, the treatment yielded a small significant effect on depression but no differences in mortality between participants and controls. Also, in this study, the effects for women were significantly worse than those for men. Tele-health and Internet-based treatment programs are increasingly offered for a variety of lifestyle and psychological problems. The enthusiasm for using the Internet is based on the potential to deliver and implement interventions on a broad scale to people who may otherwise not be able to access treatment. However, before adopting this route with too much enthusiasm, RCTs will be needed to evaluate effects. One of the few well-designed and controlled studies so far conducted for medical problems and depression is the U-CARE Heart Randomized Controlled Trial.11 The aim of this study was to evaluate the effectiveness of an Internet-based cognitive behaviour therapy treatment to reduce self-reported symptoms of depression and anxiety among patients with a recent MI. There was a reduction in hospital anxiety and depression scale (HADS) depression scores over time in the total study sample but no difference between the study groups at follow-up. Treatment adherence was very low, which is a problem often encountered in Internet-based programs. The researchers conducted an interview study with participants, which showed, among other things, that many patients experienced a lack of personal communication with the therapists.12 However, despite the somewhat disappointing results of several attempts, with varying types of psychological treatment, a recent review showed that the general picture is promising. A recent review with the purpose to determine if interventions, which are specifically designed to assess or treat mental health symptoms, can effectively reduce risk of readmission following hospitalization for physical health conditions.13 The results indicated that there is some support for the use of mental health interventions after discharge as a mechanism for reducing physical health condition readmissions. Also, communities with a stronger, social-based public mental health infrastructure had significantly lower physical health readmission rates. Another review assessed the effectiveness of psychosocial interventions addressing both depression and social support for people with CHD and depression.14 Overall, the psychosocial intervention group had significantly lower levels of depressive symptoms, but no differences were found for mortality (all-cause and cardiac), MI, revascularization, anxiety, or quality of life. However, the number of studies eligible for the review were few. A Cochrane review published in 2011 observed marked variation in the psychological interventions tested across studies.15 They found no conclusive evidence that psychological interventions had effects on total mortality and cardiovascular morbidity, although a potential effect on cardiac mortality was observed. In an updated Cochrane review published in 2018, Richards et al.16 reported the effects of psychological interventions on cardiovascular mortality, total mortality, MI, and revascularization. The results were based on 35 RCTs with 10,703 participants from studies published up to April 2016. There was considerable variation in the types of interventions, treatment components, group or individual format, and length of treatment program, as well the psychological problems addressed (for instance, stress, depression, anxiety). In summary, psychological interventions were found to achieve small to moderate improvements in depressive symptoms, anxiety, and stress compared with usual-care controls. There was a small but statistically significant reduction in cardiovascular mortality, but no differences were observed for total mortality, non-fatal MI, or revascularization procedures. To conclude, psychological interventions can achieve better emotional well-being, and possibly effects on cardiac morbidity and mortality; however, which type of intervention is most effective remains to be assessed. More fine-tuned matching between patient characteristics and type of intervention is probably needed; however, generally, there is a substantial potential for psychological interventions for cardiac patients. The authors conclude that addressing psychological health should be a core component of standard CR and secondary prevention, which is in line with current European guidelines. Interestingly, psychosocial or psychological intervention focusing on stress management have most convincingly demonstrated effects on cardiac morbidity and mortality.17,18 These programs were group-based, of considerable length, and entailed more behavioural skills training. Is depression in cardiac patients different from depression in psychiatric patients, thus requiring other types of treatment components than ‘traditional’ depression treatment? What are the most effective treatment programs for the cardiac patient population? A review focusing on elderly cardiac patients with depression and apathy showed that apathy was independently associated with future CVD, stroke, and mortality.19 Treatment programs with emphasis on behavioral activation may affect both apathy and depression. Several types of interventions have demonstrated small but significant reductions in depression, but, so far, effects on cardiac endpoints have not been achieved. Large RCTs with a sufficient number of participants are needed. Primary prevention and public health strategies are important in order to empower individuals and create conditions for healthy and socially rewarding everyday lives. Depression in cardiac patients can be reduced, but it is still unclear if the interventions result in reduced cardiac risk. Despite that, patients should be screened for depression and other negative emotional states, since it may affect adherence to rehabilitation and secondary prevention programs. Also, from a human point of view, there is a value per se in helping patients to achieve better emotional well-being. Comprehensive CR programs may be sufficient for many patients in ameliorating depression and anxiety. Patients with depression should be particularly actively encouraged to participate in CR programs, such as physical exercise and educational programs. Organized and frequent monitoring and follow-up of patients is recommended. CR teams including different types of professions are key to success. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.

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