Major Depression and Heart Disease: Treatment Trials

Cardiac disease and depression affect a significant number of individuals every year, and developing effective treatment for depression in cardiac disease could have a substantial impact on public health. Several studies have shown that depression increases cardiac morbidity and mortality and total costs of care and is associated with a poor psychosocial outcome. Psychopharmacological treatment trials have shown that tricyclic antidepressants have antiarrhythmic effects, prolong cardiac conduction, and cause orthostatic hypotension, but do not impair left ventricular function, even in patients with underlying left ventricular impairment. Tricyclic antidepressants are efficacious in treating depression but have a higher rate of cardiovascular complications than other antidepressants, with orthostatic hypotension being the most common complication. Recent small clinical trials with bupropion and selective serotonin reuptake inhibitors (SSRIs) indicate that they are efficacious and have a more benign cardiovascular side-effect profile, although large studies need to be performed to establish their safety and efficacy. Most psychosocial studies have focused on cardiac patients in general and not specifically on depressed cardiac patients. Studies of cardiac patients have shown that stress, social isolation, and lower income and educational levels are associated with a poorer cardiac outcome. A large meta-analysis of randomized, controlled trials of psychosocial interventions in nondepressed cardiac patients found that a diverse array of psychosocial interventions decreased morbidity and mortality. However, one recent psychosocial treatment trial of post-myocardial infarction (MI) patients has shown increased mortality in women in the intervention arm of the trial. There have been several recent studies showing that mental stress induces cardiac ischemia, that mental stress-induced cardiac ischemia is associated with a higher rate of adverse cardiac events than exercise-induced ischemia, and that with stress management training, patients show significant reductions in ischemic responses to mental stress. Currently, there are two large studies underway examining pharmacological and psychotherapeutic treatment of post-MI depressed and/or socially isolated patients. These large clinical trials are needed to determine if effective treatment of depression can modify the increased risk for mortality and morbidity associated with depression in cardiac disease. Hopefully, the development of effective treatment for depressed cardiac patients will decrease their morbidity and mortality and enhance their overall quality and enjoyment of life.