Depressive Disorders and Cardiovascular Medicine

Lawson Wulsin, MD

Copyright © 2011. World Psychiatric Association

Introduction• Major depression occurs 15-30% of ACS pts

• Depression triples post MI risk for death by 6 mos

• Screening for depression is not yet standard practice in most heart centers

• Depression reduces adherence to chronic regimens

• Depression reduces attendance at cardiac rehab

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Depression as Risk for CV Morbidity and Mortality• Depression independently raises the risk for the development of CHD

(Coronary heart disease, impaired perfusion of the cardiac muscle because of narrowing of the coronary arteries or spasm of the coronary arteries leading to ischemia)

• In CHD pts, depression doubles the risk for CVD (Cardiovascular disease, any disease of the cardiovascular system, including hypertension, coronary heart disease, congestive heart failure, rheumatic heart disease, peripheral vascular disease, and stroke. 

• CVD events and all-cause mortality• Dose-response relationship between severity of depression and severity of

CHD• Linking mechanisms:

– Smoking– Poor adherence– Platelet activation– Autonomic imbalance– Chronic low-grade inflammation

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CVD as Risk for Depressive Disorders• Vascular depression hypothesis

– Decreased perfusion of limbic system contributes to late-onset depression risk

• High rates of “silent strokes” in depressed elderly

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Assessment• Depression often overlooked in CVD pts

• Recommend screening all CHD and CHF pts

• PHQ 2 screen

• PHQ 9 for any positive screen

• Referral to mental health specialist for all patients with complex depressive disorders

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Depressive Disorders and Heart Surgery• 20% of CABG pts experience major depression within 1 month

• Depression predicts poor outcome at 1 yr after CABG

• Heart transplantation regimens require effective treatment of depression to maintain the regimen

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Treatment Options• What’s good for the heart is good for the brain

– Exercise, fish oil, relaxation training, stress management

• Citalopram

• Sertraline

• Beta blockers do not, in general, cause depression

• Avoid tricyclic antidepressants in pts with CAD– Risk for arrhythmia following acute coronary syndrome

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