Depression and Cardiovascular Disease

Dr. dr. Starry H. Rampengan, SpJP(K), FIHA, MSi, CHt,FICA, FACC, FAHA, FESC

Department Cardiology and Vascular Medicine/Internal Medicine

Faculty of Medicine, Sam Ratulangi UniversityManado

2013

• A figurative interdependence between the heart and sadness has long existed in language and in literature.

• In 1628, English physician William Harvey noted “every affection of the mind that is attended either with pain or pleasure, hope or fear, is the cause of an agitation whose influence extends to the heart”

• 1970s - epidemiologists start to associate/correlate heart disease and depression.

Global Burden of Disease

CAD & MDD will be the 1 &2 contributors to the burden of disease by the year 2020.

•Murray, CL “Alterantive projections of mortality and disability by cause 1990-2020:Global Burden Disease Study” Lancet May 1997 vol. 349, pp 1498-1504

Global Burden of Disease

WHO 2002 MEN WOMEN

Objectives:

• Review some of the literature regarding: -the course of depression following cardiac events

-depression as a risk factor for cardiac events -the links between depression and heart disease• Review evidence for treatment of depression in pts

with CHD• Review the ACC AHA guidelines• Discuss the professional recommendations with

ramifications relevant to local health care system and evironment

Major depressive disorder (MDD)

DSM-IV requires that five of the following are present:• Depressed mood most of the day• Anhedonia• Significant change in weight• Insomnia or hypersomnia• Psychomotor agitation or retardation• Fatigue or loss of energy• Feelings of worthlessness or guilt• Impaired concentration, indecisiveness• Recurring thoughts of death or suicide

Further, one of the symptoms must be either depressed mood or anhedonia.

The symptoms must be present nearly every day for 2 weeks, and occur through most of the day.

Symptoms must cause impairment of functioning.

S sleepI interestG guilt or worthlessnessE energyC concentrationA appetiteP psychomotor changesS SI

Biobehavioral variables and mortality or cardiac arrest in the Cardiac Arrhythmia Pilot Study (CAPS)

• 502 pts with >10PVC/hr or >5 NSVT episodes evaluated

• Results indicated that higher levels of depression and lower pulse rate reactivity were significant risk factors for death or cardiac arrest, after adjusting statistically for a set of known

clinical predictors of disease severity.

AJC 1990;66:59-62

Depression Following Myocardial Infarction: Impact on 6-month Survival

• To evaluate if MDD in patients hospitalized after MI would have an independent impact on mortality during 6month follow-up

• Prospective evaluation of 222 patients with MI using DIS• 78% male. Ages 24-88. EF 12-76%. 82 pts with previous MI.• Depression was a significant predictor of mortality with HR

5.74, p=0.0006. • Controlling for LVEF, Killip class, previous MI, HR 4.29,

p=0.013

JAMA 1993; 270(15) 1819-1825

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% M

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lity Depressed (n=35)

Nondepressed (n=187)

Depression and 18-Month Prognosis After Myocardial

Infarction • 18month follow-up showed that both DIS and BDI scores

consistent with depression were significantly related to 18month cardiac mortality, after controlling for other predictors of mortality including Killip class, PVCs, previous MI. (OR 3.64, p=0.012 and OR 7.82, p=0.0002 with adjusted OR6.64, p=0.0026)

• The deaths that occurred in 18month follow-up were concentrated among depressed patients with PVCs >10/hr.

Circ 1995; 91:999-1005.

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PVCs < 10/hour PVCs ≥ 10/hour

n = 112

n =56n =16

n =10

Depression and Long-term Mortality Risk in Patients with Coronary Artery Disease

• 1250 patients with CAD assessed for depression and followed for 15.2 years to evaluate the long-term mortality risk.

• Pts were enrolled at the time of LHC and followed at 6 and 12 months then annually with SDS.

Am J Cardiol 1996;78:613-617

• Higher depression scores were associated with increased risk of subsequent cardiac death (p=0.002) and total mortality (p<0.001) after controlling for initial disease severity and treatment.

• Pts with moderate to severe depression had a 69% greater odds of cardiac death and a 78% greater odds of mortality from all causes than nondepressed patients.

• Pts with higher scores had a higher risk of cardiac death >5 yrs later (p<0.005)

• Compared with nondepressed pts, those with moderate to severe depression had an 84% greater risk at 5-10yrs later and a 72% greater risk after >10yrs.

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Effect of Depression on Late (8 years) Mortality After Myocardial Infarction

• Prospective observational study of 284 patients hospitalized with MI

• Any depression at the time of MI was not associated with mortality at 8 years.

• However, increased mortality was statistically significant in the short term (4 months).

AJC 2008;101:602-606

No Depression

Any Depression

YearsNumber at riskAny DepressionNo Depression

222960

169

018476

208

420050

150

616941

128

814734

113

Per

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age

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0%50

%10

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• Of note, this was a small observational study of 284 hospitalized pts over age 63 with multiple comorbidities.

Usefulness of Persistent Symptoms of Depression to Predict Physical Health Status 12 Months After an

Acute Coronary Syndrome• 425 pts hospitalized for ACS completed the BDI and SF-12 in

hospital, 6- and 12 months later.

• Only patients with persistent symptoms of depression were at risk for poorer physical health.

• Patients with newly developed depressive symptoms after ACS had a trend toward worse physical health, whereas patients with transient depressive symptoms were not at

increased risk.

AJC 2008;101:15-19

What about patients with no history of heart disease?

Depression Is a Risk Factor for Coronary Artery Disease in Men: The Precursors Study

• Observational study of 1190 male medical students enrolled from 1948 to 1964 followed for 40 years

• Incidence of depression was 12%. In multivariate analyses, these men were at greater risk for subsequent CAD (RR 2.12) and MI (RR 2.12).

• The increased risk associated with depression was present even for MIs occurring 10 yrs after the first MDE (RR 2.1)

• The association did not change when time-dependent smoking, EtOH, and coffee use were added to models, nor when BMI, FH of MI, baseline cholesterol, and time-dependent HL were added.

• In a model with the strongest RF, the risk of CHD from depression was still significant with RR of 1.7

Arch Int Med 1998;158:1422-1426

• Clinical depression was associated with a greater risk of total mortality according to both unadjusted and adjusted analyses.

• Clinical depression was significantly related to CVD mortality in unadjusted analyses, with a trend toward increased CVD mortality in adjusted analyses.

• The association of clinical depression with CVD mortality was stronger than the association of clinical depression with other

causes of death, exclusive of suicide.

Depression as an Antecedent to Heart Disease Among Women and Men in the NHANES I Study

• 5006 women and 2888 men who completed the CES-D were followed over 10 years.

• 17.5% of women were depressed and 9.7% of men were depressed.

• The mean poverty index was lower in depressed patients.

• Women had 187 nonfatal and 137 fatal events. Men had 187 nonfatal and 129 fatal events.

Arch Int Med 2000;160:1261-1268

• The RR of nonfatal CHD among women with scores of 23 or higher on CES-D was 2.09

• Adjusted RR with final model taking into consideration poverty, DM, HTN, smoking, and BMI was 1.73.

• The adjusted RR for nonfatal CHD in depressed men was 1.71.

• Adjusted RR for CHD mortality was 2.34.

• Adjusted all-cause mortality RR was 1.69.

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What is the connection between depression and cardiac events?

• Pathophysiologic changes

• Behavioral issues

• Medication Adherence

• Medication Side Effects

Candidate Mechanisms Linking Depression To Cardiovascular Morbidity & Mortality

• Physiological pathways

– Cardiovascular autonomic dysregulation

• E.g., low heart rate variability (HRV)

– Pro-inflammatory processes

• E.g., elevated CRP, IL-6

– Pro-coagulant processes

• E.g., elevated fibrinogen, PF4, BTG

– Shared genetic factors

• E.g., TNFA, IL1B, 5-HTT, 5-HT2A, 5-HT2B

Hypothalamic-Pituitary-Adrenal (HPA) axis in depression

Endothelium-Teflon Resistant

Tunica adventitia

Tunica media

Tunica intima

Endothelium

Subendothelial connective tissue

Internal elastic membrane

Smooth muscle cells

Elastic/collagen fibers

External elastic membrane

Ross, R. Nature, 1993; 362: 801-809. 1993;362:801-809.

LDL-small dense particlesLDL-small dense particles

LDLLDL

Mackness MI et al. Biochem J 1993;294:829-834.

EndotheliumEndothelium

Vessel Lumen-Teflon ResistentVessel Lumen-Teflon ResistentMonocyteMonocyte

oxidized LDLoxidized LDL

Macrophages Macrophages engulf LDLengulf LDL

Adhesion Modules-Adhesion Modules-increase monocytes increase monocytes

adherenceadherence

CytokinesCytokines

Atherosclerosis is an Inflammatory DiseaseLDL pro-inflammatory & HDL anti-inflammatory

Foam Cell-increase Foam Cell-increase ANGIOTENSIN II, ANGIOTENSIN II,

PAI, -pro-PAI, -pro-thrombotic state & thrombotic state &

decrease NOdecrease NOHDL Promote Cholesterol EffluxHDL Promote Cholesterol Efflux

HDL InhibitHDL InhibitOxidationOxidation

of LDLof LDL

Libby, P. et al. Circulation 2005;111:3481-3488

Plaque Morphology and Ischemic Impact

Pathophysiology in Motion

Autonomic dysregulation in depression

• sympathetic; parasympathetic activity: increased catecholamines (e.g. NE)lower threshold for ischemia, ventricular tachycardia, ventricular fibrillation, sudden death in CHD pts and may contribute to endothelial injury

• resting heart rate; heart rate variability• baroreceptor sensitivity • QT interval/impaired repolarization, variable repol

Psychosom Med 2005;67:S1:S29-33.

Procoagulant effects of depression

• Elevated catecholamines may also promote procoagulant processes by potentiating platelet activation through agonist effects, by increasing hemodynamic stress on vascular walls, or by inhibiting vascular eicosanoid synthesis.

Psychosom Med 2005;67:S1:S34-36.

Immunologic response

• Cytokines may lead to sickness-behavior (lethargia, anorexia, paresthesia, irritability, social withdrawal, impaired concentration, sleep problems, decreased libido; particularly TNF-alfa and IL-6 may induce depression, anxiety and memory impairment)

• In non-melancholic depression elevated levels of -IL-6 (mediates activation of the HPA axis), -NK cells (acute stage)-leucocytes/lymphocytes (acute stage)

• In melancholic depression:- decreased (in vitro) production of IL-2; IFN-g; IL-10 (acute stage), but normal cell counts

Schwarz . Dialogues in Clin Neurosciences 2003; 5: 139-153

Kop: Psychosom Med 2005; 67 [Suppl 1]: s37-s41

The relationship between central nervous system correlates of depression and immune system parameters is bidirectional, mediated by neurohormonal and parasympathetic pathways. Depressive symptoms primarily affect the transition from stable CAD to acute coronary syndromes via plaque activation and prothrombotic processes (solid line) and may adversely affect the initial response to injury at early stages of coronary atherosclerosis (dashed line).

SSRI therapy in patients with ischemic heart disease

• SSRIs reduce platelet activity. SSRI (sertraline) was associated with substantially less release of platelet/endothelial biomarkers: PF4, βTG, platelet/endothelial cell adhesion molecule 1, P selectin, thromboxane B2, 6-keto prostaglandin F1a, vascular cell adhesion molecule 1, and E selectin.

Jiang W, Davidson JRT. Am Heart J 2005; 150: 871-881

Sympathetic activity in major depressive disorder

• SSRI therapy abolished the excessive sympathetic activation, with whole body noradrenaline spillover falling from 518 +/- 83 to 290 +/- 41 ng/min (P = 0.008).

Barton et al. J Hypertens. 2007 Oct;25(10):2117-2124.

Copyright restrictions may apply.

Glassman, A. H. et al. Arch Gen Psychiatry 2007;64:1025-1031.

Heart rate variability (HRV) recovery following myocardial infarction in the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) and studies by Jokinen et al and

McFarlane et al

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n=416 n=11

n=12n=125

n=133 n=15

Patients WithoutDepression

PrescribedSertraline

Given Placebo

Patients With Depression

A

B

Jokinen et alSADHARTMcFarlane et al

Candidate Mechanisms Linking Depression To Cardiovascular Morbidity & Mortality

• Behavioral pathways

– Smoking

• High prevalence of smoking in depression & vice versa

• Depression decreases smoking cessation rates.

– Physical inactivity

• Depression is inversely associated with exercise, participation in cardiac rehabilitation

– Poor diet and obesity

– Nonadherence to prescribed medications

Depression and Medication Adherence in Outpatients With Coronary Heart Disease

Findings From the Heart and Soul Study

• 14% of depressed pts vs 9% of nondepressed pts reported not taking their medications as prescribed (OR 2.8, p<0.001)

• Twice as many depressed pts as nondepressed pts reported forgetting to take their medications (OR2.4, p<0.001)

• 9% depressed pts and 4% nondepressed pts reported deciding to skip their medications (OR 2.2 p=0.009)

Archives 2005;165:2508-2513

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Depressed (n=204) Not Depressed (n=736)

Not as Prescribed(P <.001)

Forgot to Take(P <.001)

Decided to Skip(P <.01)

Reason for Nonadherence

Course of Depressive Symptoms and Medication Adherence After Acute Coronary Syndromes

• Depression was associated with medication nonadherence in a gradient fashion.

• 15% of nondepressed pts, 29% of mildly depressed pts, and 37% of mod-severely depressed pts took ASA <80% of the time.

• Change in depressive symptoms over the study period were linearly related to changes in adherence.

JACC 2006;48:2218-22

Beta-Blockers and Depression After Myocardial Infarction

• 381 pts, 127 without BB and 254 matched pts with BB at discharge after MI

• There were no significant differences in BDI at baseline, 3, 6, or 12 months after MI.

JACC 2006;48:2209-14

• Does treatment of depression, then, improve outcomes in patients with CAD?

Sertraline Treatment of Major Depression in Patients With Acute MI or Unstable Angina

SADHART

• 369 pts with MDD randomized to sertraline (50-200mg/day) or placebo for 24 weeks

• Pts were hospitalized with ACS in the past 30 days and met DSM-IV criteria for MDD.

• The study involved 7 countries from 04/1997-04/2001.

• Primary outcome was change from baseline EF. • Secondary measures included cardiovascular adverse

events, HAM-D scores, CGI-I scores

JAMA 2002;288(6) 701-709

SADHART: Safety Outcomes

• No difference between drug and placebo in:

– LVEF

– Blood pressure

– Resting ECG (HR, QRS, QT)

– 24-Hour Holter ECG

• VPCs

• HRV (time & frequency domain)

SADHART: Efficacy

Severe Recurrent MDD Subgroup*Severe Recurrent MDD Subgroup*

OutcomeOutcome

SertralineSertraline

(n=50)(n=50)

PlaceboPlacebo

(n=40)(n=40) pp

HAM-D, mean (SD)HAM-D, mean (SD) -12.3 (0.9)-12.3 (0.9) -8.9 (1.0)-8.9 (1.0) .01.01

All Randomized PatientsAll Randomized Patients

OutcomeOutcome

SertralineSertraline

(n=186)(n=186)

PlaceboPlacebo

(n=183)(n=183) pp

HAM-D, mean (SD)HAM-D, mean (SD) -8.4 (0.4)-8.4 (0.4) -7.6 (0.4)-7.6 (0.4) .14.14

HAM-D: Hamilton Rating Scale for Depression

* 2 prior episodes plus HAM-D score 18.

SADHART• Sertraline had no significant effect on mean LVEF,

incidence of PVCs, or QTc interval.

• The incidence of severe CV adverse events was 14.5% with sertraline and 22.4% with placebo.

• CGI-I but not HAM-D favored sertraline.

• In the groups with preexisting depression, both CGI-I and HAM-D measures were significantly better in those assigned to sertraline.

SADHART

• Sertraline appears to be a safe medication for use following ACS.

• In patients with recurrent depression and CAD, sertraline was efficacious in the treatment of depression.

Effects of Treating Depression and Low Perceived Social Support on Clinical Events After

Myocardial Infarction ENRICHD

• 2481 MI patients at 8 centers enrolled from 10/1996 to 04/2001.

• Pts had major or minor depression by DSM IV criteria.

• Randomized to usual medical care or CBT based therapy with primary endpoints of death or nonfatal MI.

JAMA 2003;289(23) 3106-3116.

ENRICHD: Intervention

• Cognitive behavior therapy– Behavioral activation, cognitive restructuring, social skills

training, social network.

– Up to 6 months of CBT with trained therapist

• Sertraline added for severely depressed patients and for those who did not respond sufficiently to CBT within 6 weeks

ENRICHD: Overall Effects onDepression and Social Support

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InterventionUsual care

ENRICHD Social Support Instrument (ESSI) scores reported for patients with low social support only; Hamilton depression scores reported for depressed patients only.

The Efficacy of the ENRICHD Intervention Depended on Initial Severity of Depression

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Intervention

RL*=1.35

p<0.006

RL=1.80

p<0.0008 RL=2.58

p<0.0015

(N=346) (N=313) (N=200)

*Relative Likelihood of Remission

The ENRICHD Intervention Did NotImprove Reinfarction-Free Survival

The ENRICHD Intervention Did Improve Late Survival (>6 Months)

Late survivaldepended onwhether depressionimproved over thecourse of theintervention.

Carney et al., Psychosom Med 2004;66(4):466-474.

ENRICHD

• Improvements in psychosocial outcomes favored treatment at 6 months.

• There was no difference in event-free survival.

• Of note, treatment with anti-depressants was 4.8% to 20.6% in the usual care group and 9.1% to 28% in the treatment arm.

Effects of Citalopram and Interpersonal Psychotherapy on Depression in Patients With Coronary Artery Disease

CREATE

• 284 patients with CAD and DSM-IV criteria for MDD with HAM-D scores >20.

• Pts randomized to (1) 12 weekly sessions of interpersonal psychotherapy plus clinical mgmt vs clinical mgmt only and (2) 12 weeks citalopram or matching placebo

JAMA 2007;297(4) 367-379

CREATE

• Citalopram was superior to placebo in reducing 12 week HAM-D scores (p=0.005)

• No benefit was seen of IPT over clinical mgmt (p=0.06)

• Similar to the results of SADHART, response to SSRI was more pronounced in pts with a history of recurrent depression.

Impact of Cardiac Rehabilitation on Depression and Its Associated Mortality

• 522 patients enrolled in cardiac rehab and a control group not enrolled evaluated over 4 years

AJM 2007;120:799-806

Effect of Cardiac Rehab on Depression in 552 patientsEffect of Cardiac Rehab on Depression in 552 patients

17%17%

6%6%

15%

20%

10%

0

BeforeBefore AfterAfter

5%

Milani RV, Am J Med 2007

BeforeBefore

AfterAfter

Cardiac Rehab Improves Depression

Actuarial cumulative hazard plot for survival timebased on depression status upon completion of cardiac rehabilitation

Milani RV, Am J Med 2007

DepressedDepressed

Non-Non-depresseddepressed0

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Depression is Associated with Decreased Survival

Prevalence of Prevalence of DepressionDepression Before and After Cardiac Rehab Before and After Cardiac Rehab

23%23%

19%19%

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YoungYoung ElderlyElderly

106%6%4%4%

BeforeBefore

AfterAfter

Lavie CF, Arch Int Med, 2006

Psychological Distress is Common

Evidence for Depression as an Independent Risk factor for CAD

GOOD1. Strength of Association2. Prediction3. Consistency4. Dose-response Effect FAIR5. Specificity6. Biological Plausibility

INSUFFICIENT EVIDENCE7. Cardiac risk reduction in

response to treatment for depression.

Wulsin, L.R; Harv Rev Psychiatry. March/April 2004Wulsin, L.R; Harv Rev Psychiatry. March/April 2004

Criteria for Major Depression Depressed mood Diminished interest or pleasure

5 or more of the following Sx present for > 2 weeks: Fatigue or loss of energy Diminished ability to concentrate Insomnia or hypersomnia Weight loss or weight gain Feelings of worthlessness or excessive guilt Psychomotor agitation or retardation Recurrent thoughts of death or suicidal ideation

or attempt

One or the other required

When to suspect depression in cardiac pts

Symptoms: chronic tiredness, wt loss, insomnia, recent onset of irritability or anger

Impairment: reduced social contact, poor ADLs, reduced interest, difficulty coping with recent losses and stresses

Medical Management Problems: chronic anxiety, poor medication compliance or risk factor modification

What are the treatment recommendations

regarding depression in patients with CHD?

Tools for Assessment of Depression in Clinical Practice

Patient Health Questionnaire (PHQ-9) and (PHQ-2)

Beck Depression Inventory (Self-report)

Zung Self-rating Depression Scale (self report)

Center for Epidemiologic Studies-Depression (self report)

Hamilton Depression Scale (Administered)

Depression and Coronary Heart DiseaseRecommendations for Screening, Referral, and

Treatment: A Science Advisory From the American Heart Association

Lichtman JH, Bigger JT, Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lespérance F, Mark DB, Sheps DS, Taylor CB, Froelicher ES.

Circulation 2008;118;1768-1775

AHA Recommendations• Routine screening for depression in patients

with CHD in various settings, including the hospital, physician’s office, clinic, and cardiac rehabilitation center.

• The opportunity to screen for and treat depression in cardiac patients should not be missed, as effective depression treatment may improve health outcomes.

Lichtman et al., Circulation 2008;118;1768-1775

Patient Health Questionnaire (PHQ-2)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

(1) Little interest or pleasure in doing things.(2) Feeling down, depressed, or hopeless.

Positive screen = “yes” to either question.

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613.

Patient Health Questionnaire (PHQ-9)

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613.

Over the past 2 weeks, how often have you been bothered by any of thefollowing problems?

(1) Little interest or pleasure in doing things.(2) Feeling down, depressed, or hopeless.(3) Trouble falling asleep, staying asleep, or sleeping too much.(4) Feeling tired or having little energy.(5) Poor appetite or overeating.(6) Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down.(7) Trouble concentrating on things such as reading the newspaper or watching television.(8) Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual.(9) Thinking that you would be better off dead or that you want to hurt yourself in some way.

AHA Recommendations• Patients with positive screens should be

evaluated by a professional qualified in the diagnosis and management of depression.

• Patients with cardiac disease who are under treatment for depression should be carefully monitored for adherence to their medical care, drug efficacy, and safety with respect to their cardiovascular as well as mental health.

Lichtman et al., Circulation 2008;118;1768-1775

AHA Recommendations• Monitoring mental health may include, but is

not limited to, the assessment of patients receiving antidepressants for possible worsening of depression or suicidality, especially during initial treatment when doses may be adjusted, changed, or discontinued.

Lichtman et al., Circulation 2008;118;1768-1775

AHA Screening Guideline

Meta-Analysis of the Adverse Effect of Depression on Patient

Adherence

Compared to nondepressed patients, the odds are 3 times greater that depressed patients would be nonadherent with medical treatment recommendations

DiMatteo MR, et al. Arch Intern Med. 2000;160(14):2101-2107.

Depression Is AssociatedWith ↑% Smoking

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% S

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p<0.001; Major>Nonep<0.01; Minor>None

N=4225

Adjusted for demographics, medical comorbidity, diabetes severity,diabetes type and duration, treatment type,HbA1c and clinic.

Katon et al, Diabetes Care, 2004

Summary

• MDD occurs in 15-23% of patients with coronary disease and is an independent RF for morbidity and mortality.

• RCTs in the 1990s and 2000s show RR of MI and CV mortality of 1.5-2 in pts with preexisting depression.

• In persons with established IHD, depression is associated with a 3-4 fold increase in the risk of subsequent CV morbidity and mortality.

• Treatment of depression in patients with CAD is safe and somewhat efficacious

• Rehabilitation is associated with a 50% decrease in depressive symptoms in pts with CHD

Bi-Directional ConclusionsPSYCHIATRY

Depression is associated with an increase in cardiac riskRecurrent depression worsens cardiac outcomesCBT improves mood but does not improve cardiovascular outcomes in depressed cardiac patientsSSRIs improves mood and appears safe in the cardiac patient

CARDIOLOGY/PRIMARY CARE20% of patients post MI will have symptoms of depression Understand the potential mechanisms of how depression may increase the risk for CHD eventsTreatment of depression leads to better clinical outcomes after a cardiac event

Wulsin, L.R; Harv Rev Psychiatry. March/April 2004Wulsin, L.R; Harv Rev Psychiatry. March/April 2004

MDD is an independent predictor of all cause mortality and CV death after

AMI complicated by heart failure

“Insanity: Doing the same thing

over and over again and expecting different results.”

Albert Einstein