Depression strikes one in five patients hospitalized for myocardial infarction, with severe consequences, including a threefold increased risk of cardiac mortality and significantly elevated mortality from all causes, a comprehensive evidence review has concluded.
The review, conducted by the federal Agency for Healthcare Research and Quality at the behest of the American Academy of Family Physicians, is destined to become the framework for evidence-based clinical practice guidelines, according to the AAFP.
Highlights of the review coordinated by the Johns Hopkins Evidence-Based Practice Center in Baltimore include:
▸ Evidence from 25 trials pointing to a prevalence of depression in one in five patients hospitalized for an MI.
▸ Data from three studies that depression during the initial MI hospitalization persists from 1–4 months in 60%–70% of patients.
▸ “Strikingly consistent” evidence that post-MI depression puts patients at an increased risk for death by cardiac causes (a threefold increased risk) and other causes.
▸ Conclusions from three studies showing that depressed post-MI patients are less likely than are others to take their prescribed medications or to comply with lifestyle modification.
▸ Findings that suggest psychosocial intervention and selective serotonin reuptake inhibitors (SSRIs) improve depression in post-MI patients, but not necessarily other outcomes.
The lengthy analysis pointed out a number of important gaps in scientific knowledge about depression and MI, such as the best way to measure depression in hospitalized MI patients and the true impact of interventions.
For example, SSRIs were found to improve some surrogate markers of cardiac risk, “but no studies of sufficient power address the question of whether this treatment improves survival,” the analysis said.
The Johns Hopkins team, led by David E. Bush, M.D., and Roy C. Ziegelstein, M.D., included clinicians and researchers from cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, as well as representatives from the AAFP, the nursing community, and private and government payers.
Six key questions were compiled, several with important subcategories. A literature review was conducted electronically and by hand of 16 specific journals and the electronic databases Medline, Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cumulative Index to Nursing and Allied Health Literature, the Psychological Abstracts, and Embase.
The intensive review unveiled the magnitude of evidence pointing to depression as an important impedance to a full recovery and a return to productive life in many MI patients.
Its conclusions suggest a pivotal role for family physicians, who may be in the best position to oversee “the whole patient” as he or she embarks on the long course of recovery, Lee A. Green, M.D., the AAFP representative to the review panel and a member of the family medicine faculty at the University of Michigan in Ann Arbor, said in a telephone interview.
Patients can survive heart attacks and their hearts can be fine, but they can be disabled by their depression, he said.
The severity of an MI may overshadow less evident aspects of health that should be identified early and managed with the best tools available.
Although the literature review shows that more research is needed to illuminate the best approaches to post-MI depression, it provides ample evidence of the worth of such research.
In the immediate future, the stark findings about the importance of depression following MI may lead to more communication among specialists, including family physicians, cardiologists, and psychiatrists, said Dr. Green.