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Depression treatment in patients with coronary artery disease: a systematic review

Gita Ramamurthy¹, Edgardo Trejo¹, Stephen V Faraone¹

¹Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York (Drs Ramamurthy and Faraone); and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts (Dr Trejo).

The Primary Care Companion for CNS Disorders

|February 11, 2014

Insights

Depression treatment in coronary artery disease (CAD) patients showed no significant impact on cardiac outcomes. However, persistent depression post-acute coronary syndrome may benefit from interventions, with caution advised for certain antidepressants.

Area of Science:

Cardiology
Psychiatry
Clinical Trials

Background:

Depression is associated with adverse outcomes in patients with coronary artery disease (CAD).
The impact of depression treatment on CAD prognosis remains unclear.
This review focuses on medical and mood outcomes of depression treatment in CAD patients.

Purpose of the Study:

To systematically review 25 years of research on depression treatment in CAD patients.
To evaluate the effects of antidepressants and psychotherapy on cardiac and mood outcomes.
To identify potential benefits or risks of depression treatment in this population.

Main Methods:

Systematic review of prospective trials from 1986-2011.
Searches included terms for depression, CAD, antidepressants, psychotherapy, and revascularization.
Included English-language randomized controlled trials with at least 50 depressed CAD patients.

Main Results:

Ten trials were included in the review.
Antidepressant and/or psychotherapy did not significantly improve CAD outcomes overall.
A trend towards worse CAD outcomes was observed with bupropion treatment; most studies were underpowered.

Conclusions:

Depression often remits spontaneously after acute coronary syndrome (ACS).
Persistent depression post-ACS predicts adverse CAD outcomes.
Interventions like the Coronary Psychosocial Evaluation Studies may benefit persistent depression; caution with noradrenergic antidepressants is advised.

Read full analysis

Abstract

Objective:

Depression has been linked to adverse coronary artery disease outcomes. Whether depression treatment improves or worsens coronary artery disease prognosis is unclear. This 25-year systematic review examines medical outcomes, and, secondarily, mood outcomes of depression treatment among patients with coronary artery disease.

Data Sources:

We systematically reviewed the past 25 years (January 1, 1986-December 31, 2011) of prospective trials reporting on the medical outcomes of depression treatment among patients with established coronary artery disease using keywords and MESH terms from OVID MEDLINE. Search 1 combined depression AND coronary artery disease AND antidepressants. Search 2 combined depression AND coronary artery disease AND psychotherapy. Search 3 combined depression AND revascularization AND antidepressants OR psychotherapy.

Study Selection:

English-language longitudinal randomized controlled trials, with at least 50 depressed coronary artery disease patients, reporting the impact of psychotherapy and/or antidepressants on cardiac and mood outcomes were included.

Data Extraction:

Data extracted included author name, year published, number of participants, enrollment criteria, depression definition/measures (standardized interviews, rating scales), power analyses, description of control arms and interventions (psychotherapy and/or medications), randomization, blinding, follow-up duration, follow-up loss, depression scores, and medical outcomes Results: The review yielded 10 trials. Antidepressant and/or psychotherapy did not significantly influence coronary artery disease outcomes in the overall population, but most studies were underpowered. There was a trend toward worse coronary artery disease outcomes after treatment with bupropion.

Conclusions:

After an acute coronary syndrome, depression often spontaneously remitted without treatment. Post-acute coronary syndrome persistence of depression predicted adverse coronary artery disease outcomes. Antidepressant and/or psychotherapy, particularly as part of the Coronary Psychosocial Evaluation Studies intervention, may improve prognosis in persistent depression among post-acute coronary syndrome patients. Noradrenergic antidepressants should be prescribed cautiously in patients with coronary artery disease.

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