ATLANTA – Psychiatrists treating depression associated with an acute coronary event should look to severity of a depressive episode, recurrence of major depression, and the onset of depression prior to hospitalization as predictors of drug benefit.
Most clinicians will typically consider severity in evaluating whether to treat depressed patients, but prior episodes of depression and the timing of the onset of the present episode are also important factors in assessing the possible success of drug treatment, Alexander H. Glassman, M.D., said at the annual meeting of the American Psychiatric Association.
These “two historic considerations, [which] most clinicians never use in deciding who to treat, have a very strong impact on who's going to have a drug response,” said Dr. Glassman, who is professor of clinical psychiatry at Columbia University, New York.
Even without proof of reduced mortality, depression associated with an acute coronary event can be safely and effectively treated, he said.
Dr. Glassman pointed to the results from the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART), which looked at the effects of sertraline versus placebo in patients who suffered from depression that was associated with acute MI or unstable angina (JAMA 2002;288:701–9).
Dr. Glassman was a member of the steering committee for SADHART and has been a consultant for Pfizer, which markets sertraline (Zoloft).
The trial included 369 patients who were given a 2-week single-blind placebo run-in and then randomly assigned to receive sertraline or placebo for 24 weeks.
The patients selected for SADHART were not seeking psychiatric treatment and, as a result, the sample had much milder depression and depressive episodes that were shorter than would normally be expected in a typical drug trial.
The effect of the drug was modest in the overall sample, but for those patients with recurrent depression–about half of the sample–the results were dramatically different, Dr. Glassman said at the meeting.
Of those patients with no prior episodes of depression, about 59% responded to the drug, compared with 55% on placebo.
In the case of patients with any recurrent depression, however, there was a very real difference, with 72% getting better on the drug versus 51% on placebo.
The SADHART study also showed that more than half of the cases of depression began before hospitalization for the coronary event. Of those patients whose depression began before hospitalization, 93% began more than a month before and could have contributed to the heart attack, Dr. Glassman said.
Similarly, the time of onset was also a predictor of drug response. The SADHART study showed that, of those patients who had depression onset in the hospital, there was no drug-placebo difference.
In the group with earlier onset of depression, though, 63% responded to the drug, compared with 46% on placebo, he said.
When the patient had both prior history of depression and onset before hospitalization, the drug was effective in 73% of patients, compared with 43% for placebo.
Even though the evidence that depression is a risk factor for cardiovascular events is overwhelming, specialists outside of psychiatry have been slow to pick it up.
Academic institutions are just beginning to recognize it as a risk factor, and in the general community hospital setting, recognition is poor, Dr. Glassman said.
There is more to the story, however: Those in other areas of medicine may be overlooking depression, but psychiatrists generally don't ask patients about their medical risk factors, he said.
“We see patients in our office all the time who are depressed, and I'll bet that the majority of people in this room can't tell if all their patients are smokers or not,” Dr. Glassman said.
