The addition of citalopram to the clinical management of depression in people with established coronary artery disease decreases the symptoms, reported Dr. François Lespérance and his associates in the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy trial.
In contrast, attending interpersonal psychotherapy—a semistructured, short-term psychotherapy program that focuses on the social context of depression and is considered especially relevant to coronary artery disease (CAD) patients—does not improve depressive symptoms beyond the benefit provided by clinical management alone, the researchers said.
This does not imply that other forms of psychotherapy, particularly cognitive-behavioral therapy, would not be helpful in CAD patients, they noted.
The CREATE trial is the first randomized controlled trial designed to assess the short-term efficacy of citalopram and interpersonal psychotherapy in CAD. It involved 284 patients with stable CAD who were treated for an episode of major depression at any of nine academic centers across Canada between 2002 and 2006.
All of the study subjects participated in clinical management, which encompassed weekly 20-minute sessions with a psychotherapist who discussed depression and medication use, provided reassurance, and encouraged the patients to adhere to treatment.
For half of the subjects, this clinical management was the only psychotherapeutic intervention offered. The other half participated in additional interpersonal psychotherapy of 50-minute weekly sessions with a therapist who addressed problems common in CAD patients and known to exacerbate CAD morbidity and mortality, such as interpersonal conflicts, life transitions, grief, loss, and social isolation.
Similarly, half of the study subjects were randomly assigned to receive daily citalopram and half to receive a placebo pill, said Dr. Lespérance, of the University of Montreal, and his associates.
After 12 weeks of treatment, citalopram was found to be superior to placebo in reducing depressive symptoms, as assessed by independent clinical ratings and by patient self-report, the investigators said (JAMA 2007;297:367–79).
Citalopram (Celexa), a selective serotonin reuptake inhibitor, was most effective for recurrent episodes of major depression and less so for first episodes.
In contrast, interpersonal psychotherapy was no more effective at reducing depressive symptoms than was clinical management, its control condition, either by independent clinical ratings or by patient self-report. “Although interpersonal psychotherapy was designed to address interpersonal issues and improve interpersonal functioning, CAD patients with low levels of support or poor daily functioning may have difficulty dealing directly with the combination of cardiac and interpersonal issues that sessions entail, and may do better with the lower demands of regular medical management,” the researchers noted.
Taken together, the study findings indicate that citalopram plus clinical management “should be considered for the initial acute-phase treatment for major depression in patients with CAD,” Dr. Lespérance and his associates said.
In an editorial comment accompanying the report, Dr. Alexander H. Glassman of the New York State Psychiatric Institute and Dr. J. Thomas Bigger Jr. of Columbia University, New York, said the CREATE study's results provide further evidence for the antidepressant efficacy of SSRIs for patients with heart disease.