Depression, Hostility, and Social Isolation in Patients with Coronary Artery Disease

Psychosocial risk factors such as depression, hostility, and social isolation are substantially more prevalent in patients with coronary artery disease (CAD) than is widely recognized. It has been demonstrated that patients with CAD who have these risk factors, individually or together, may have a substantially increased risk for recurrent ischemic events, as well as cardiac death, when compared with unaffected CAD patients. Numerous adverse physiologic changes that appear to occur as a consequence of these psychosocial risk factors have been identified, including increased platelet aggregation, hyperadrenergic states, elevated cortisol levels, abnormal endothelial function, and an increased propensity towards malignant ventricular arrhythmias. Each of these may explain the increased risk of recurrent coronary events (including death) among afflicted patients. Under-recognition, and hence under-treatment, remains a principal obstacle for improvements in the care of patients with CAD who have psychosocial risk factors. The diagnosis of psychosocial risk factors depends on systematic patient evaluation by experienced clinicians trained in the recognition of these disorders. All clinicians must be aware of the potential importance of these factors, their sometimes subtle presenting characteristics, and the available treatment options. The universal use of comprehensive cardiovascular rehabilitation offers the ideal conduit for such evaluation and management. Nonpharmacologic therapies for psychosocial risk factors include psychotherapy, stress-reduction techniques, and exercise therapy. Studies suggest that the reduction of social isolation among depressed patients with CAD may result in a reduced mortality rate in comparison with those without improvements in isolation. Pharmacologic therapies are mainly for the management of depression, and largely center on the use of selective serotonin reuptake inhibitors (SSRIs). Several SSRIs (paroxetine and sertraline) recently have been shown to be safe and effective for the treatment of depression in patients with ischemic heart disease. Whether use of antidepressants attenuate the increased cardiac risk from depression in the setting CAD remains to be proven; however, their use improves the quality of life in properly selected patients.