Assessment and treatment of depression in coronary artery disease patients

Depressive symptoms occur frequently among patients with coronary artery disease (CAD), with prevalence estimates ranging from 15 to 30%. Risk ratios for first and recurrent cardiac events related to depression are comparable to well-established CAD risk factors and range from 2 to 7. The commonly atypical nature of depression in individuals with CAD plays an important role in the under diagnosis of depression in these patients. This review indicates that presence of atypical and subclinical depression, as well as of clinical major depressive disorders, significantly increase the risk of cardiac events. Pathophysiological mechanisms include altered autonomic nervous system activity, increased tendency toward blood coagulation, and elevated low-grade inflammation. Evidence suggests that depression in CAD patients does not reflect anatomical CAD severity or use of anti-ischemic medications. In addition to these pathophysiological pathways, depression affects CAD progression via adverse health behaviors such as smoking, poor compliance, and reduced exercise levels. Initial screening for depressive disorders can be accomplished using questionnaires, but structured clinical interview are preferred for definite diagnosis of depression. Optimal treatment of depression in CAD generally involves both psychological and pharmacological interventions that affect both depression and its biological correlates relevant to CAD progression.