An open-label preliminary trial of sertraline for treatment of major depression after acute myocardial infarction (the SADHAT Trial). Sertraline Anti-Depressant Heart Attack Trial

A meta-analysis on the association between SSRIs and blood pressure in patients with CVD and depression

OBJECTIVE

This meta-analysis aimed to explore the association between selective serotonine reuptake inhibitors (SSRIs) and blood pressure in patients with cardiovascular disease (CVD) and depression.

METHOD

This study was registered on PROSPERO (CRD42022368655) and conducted in accordance with PRISMA 2020. The databases included PubMed, Web of Science, and EMBASE. The inclusion date was from the inception date through Oct. 26, 2022.Review Manager version 5.3 and Stata version 12.0 were used for data analysis.

RESULTS

This meta-analysis included six studies, and a total number of 149 patients with CVD and depression . In the group analysis, SSRIs treatment had no effect on the systolic blood pressure (SBP) (MD = 1.01, 95%CI:-2.88, 4.90, P = 0.61) and diastolic blood pressure (DBP) (MD = 0.64, 95%CI:-1.03, 2.31, P = 0.45). In the subgroup analysis, SSRIs treatment had no effect on SBP for patients with hypertension (MD = -8.02, 95%CI:-16.84, 0.81, P = 0.08), and patients with other CVD (MD = 3.18, 95%CI:-1.15, 7.52, P = 0.15). For patients with hypertension, SSRIs treatment significantly lowered DBP (MD = -5.75, 95%CI:-10.84, -0.67, P = 0.03). But SSRIs treatment had no impact on DBP for patients with other CVD (MD = 1.41, 95%CI:-0.36, 3.18, P = 0.12). Subgroup analysis of the treatment period and the country had no significant impact on SBP and DBP. In the sensitivity analysis, there was no significant change after omitting one study in both SBP and DBP group analysis. Egger's test showed no publication bias of SBP (P = 0.183) and DBP group analysis (P = 0.392).

CONCLUSION

SSRIs help to lower DBP in hypertensive patients with depression. The potential pathophysiological mechanisms may lie in serotonin function, sympathetic activation and genetic heterogeneity. Further clinic and experimental researches need to be conducted on SSRIs and blood pressure.

The negative effects of social bond disruption are partially ameliorated by sertraline administration in prairie voles

Negative social experiences influence both depression and cardiovascular dysfunction. Many individuals who experience negative mood states or cardiovascular conditions have limited social support. Therefore, investigation of drug treatments that may protect against the consequences of social stress will aid in designing effective treatment strategies. The current study used an animal model to evaluate the protective effect of sertraline administration on behavioral and cardiovascular consequences of social stress. Specifically, male prairie voles (Microtus ochrogaster), which are socially monogamous rodents that share several behavioral and physiological characteristics with humans, were isolated from a socially-bonded female partner, and treated with sertraline (16 mg/kg/day, ip) or vehicle during isolation. Unexpectedly, sertraline did not protect against depression-relevant behaviors, and it was associated with increased short- and long-term heart rate responses. However, sertraline administration improved heart rate variability recovery following a behavioral stressor, including increased parasympathetic regulation, and altered long-term neuronal activity in brain regions that modulate autonomic control and stress reactivity. These results indicate that sertraline may partially protect against the consequences of social stressors, and suggest a mechanism through which sertraline may beneficially influence neurobiological control of cardiac function.

Choosing among second-generation antidepressant treatments for depressed patients with cardiac diseases

Objectives: The present paper aimed to assist physicians in the accurate choice among second-generation agents (SGAs) for patients with cardiovascular disease (CVD). Methods: We reviewed the published pharmacokinetic (PK) and pharmacodynamic (PD) clinical data that report potential -or absence of- drug interactions between second-generation agents (SGAs) and CVD drugs most commonly used in cardiology, including antiplatelet drugs and anticoagulants, statins, beta-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics and the antiarrhythmic drugs amiodarone and digoxin. We also reviewed the cardiovascular safety profile that has been published for each class of SGAs and side effects reported by patients with CVD. Results: Most relevant PK/PD data about SGAs and CVD drugs are based on small studies or detailed case reports. In many cases, the drug interactions are at most assessed in healthy volunteers so that the clinical relevance of findings needs further investigation in patients with CVD. Case reports of serious, sometimes fatal reactions due to concomitant administration of certain drugs require careful consideration. The major cardiac side effects of SGAs include HR increase, postural hypotension and slight prolongation of the intraventricular conduction time and QT interval. On normal dosage of antidepressants, both advanced heart block and ventricular arrhythmias could occur in patients with severe heart disease, together with clinically important loss of myocardial contractile force. Conclusions: Data reported in the present review should help physicians about their decision-making processes that govern SGAs use in CVD patients.

Cardiovascular Safety of Psychiatric Agents: A Cautionary Tale

Psychiatric agents are among the most commonly prescribed medications. Despite the advent of newer generation agents, patients receiving them still experience cardiovascular (CV) side effects. However, these agents may have heterogeneous properties, calling for an individualized approach based on efficacy and also on the particular side effect profile of each specific agent. Proarrhythmic effects arising from drug-induced long-QT syndrome and consequent potentially life-threatening polymorphic ventricular arrhythmias in the form of torsade de pointes, the metabolic syndrome contributing to atherosclerosis and acute coronary syndromes, and drug-induced orthostatic hypotension raise major concerns. Of course, it is also crucial that fear of potential CV adverse effects does not deprive psychiatric patients of appropriate drug therapy. Modification of CV risk factors in psychiatric patients together with optimal management of their CV diseases and appropriate selection of psychotropic agents with greater efficacy and least CV toxicity are of paramount importance in mitigating CV risks and enhancing safety. Identifying patients at high risk of CV complications and close monitoring of all patients receiving these agents are crucial steps to prevent and manage such complications. All these issues are herein reviewed, relevant guidelines are discussed, and schemas are depicted that illustrate the interrelated connections among the psychotropic agents and their CV effects.

Depression and the Heart: A Systematic Overview of Definition, Measurement, Consequences and Treatment of Depression in Cardiovascular Disease

Depression is an independent risk factor in the pathogenesis of cardiovascular disease and it is a prevalent disorder after cardiovascular disease associated with negative outcome in terms of mortality and morbidity. It is a dangerous condition requiring adequate screening and treatment, however, it often remains undiagnosed and thus untreated. Non-psychiatric healthcare workers, like nurses, general practitioners, physiotherapists and cardiologists are the health providers most closely involved in the management of patients with cardiovascular disease. They can play an important role in screening cardiovascular patients for depressive symptoms and in referring them for treatment. The purpose of this article therefore is to provide an evidence-based framework, aiming to educate non-psychiatric healthcare providers on depressive disorder in the context of chronic cardiovascular disease. In this paper, an overview of the definition, prevalence and consequences of depression will be discussed. Moreover, an overview of measurement methods and treatment modalities for depression will be provided. In addition, a step-by-step guide is provided in order to help non-psychiatric healthcare providers in dealing with depressed patients.

Treatment of affective disorders in cardiac disease

Patients with cardiovascular disease (CVD) commonly have syndromal major depression, and depression has been associated with an increased risk of morbidity and mortality. Prevalence of depression is between 17% and 47% in CVD patients. Pharmacologic and psychotherapeutic interventions have long been studied, and in general are safe and somewhat efficacious in decreasing depressive symptoms in patients with CVD. The impact on cardiac outcomes remains unclear. The evidence from randomized controlled clinical trials indicates that antidepressants, especially selective serotonin uptake inhibitors, are overwhelmingly safe, and likely to be effective in the treatment of depression in patients with CVD. This review describes the prevalence of depression in patients with CVD, the physiological links between depression and CVD, the treatment options for affective disorders, and the clinical trials that demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population. Great progress has been made in understanding potential mediators between major depressive disorder and CVD—both health behaviors and shared biological risks such as inflammation.

The interface of depression and cardiovascular disease: therapeutic implications

Patients with major depression are at an increased risk for developing cardiovascular disease, respond more poorly to treatment, and exhibit worse outcomes, including increased morbidity and mortality. This article reviews the relationship between depression and heart disease, with an emphasis on epidemiology, biological substrates that likely underlie this relationship, and implications for treatment.

Effects of antidepressant medication on emotion regulation in depressed patients: an iSPOT-D report

BACKGROUND

Antidepressant medication (ADM) is thought to reduce depressive symptoms by altering emotion-generative brain systems. However, it is unknown whether successful ADM treatment is associated with changes in psychobehavioral strategies used to regulate emotions. We examined depressive symptoms and emotion regulation strategies before and after ADM in the international Study to Predict Optimized Treatment in Depression (iSPOT-D).

METHODS

The study enrolled 1008 adult patients with MDD (18-65 years old) from 18 primary and psychiatric care sites worldwide. Patients were randomly assigned to an 8-week course of escitalopram, sertraline, or venlafaxine-extended-release. We examined whether ADM is associated with changes in suppression, usually associated with maladaptive outcomes, and reappraisal, usually associated with adaptive outcomes. We also tested whether changes in emotion regulation predict changes in depressive symptoms following ADM.

RESULTS

We observed more adaptive emotion regulation (decreased use of suppression and increased use of reappraisal) following ADM. Furthermore, the largest improvements in emotion regulation were associated with the best treatment outcomes.

LIMITATIONS

Because we assessed acute outcomes, it is not yet known if the effects of ADM on emotion regulation would persist over time.

CONCLUSIONS

ADMs are associated with acute, adaptive changes in the psychobehavioral strategies used to regulate emotions.

Treatment of depression in cardiovascular disease

BACKGROUND AND OBJECTIVES

Depression in patients with Cardiovascular Disease (CVD) is extremely common, with a prevalence of 17-47%, and is associated with increased risk of morbidity and mortality. Treatment of depression has been hypothesized to reduce cardiac mortality. Pharmacologic and psychotherapeutic interventions have been studied and appear to be safe and in some studies effective in reducing depressive symptoms in patients with cardiac disease. The impact on cardiac outcomes remains unclear. This review briefly focuses on the prevalence of depression in patients with CVD, the physiological links between depression and CVD, and largely is concerned with the clinical trials that seek to demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population.

METHODS

PubMed and PsycINFO databases were searched through July 2012. Publications were included if they were in English, a review article, or a clinical trial in the CVD population with comorbid depression. The search was completed with key words of antidepressants, CVD, coronary artery syndrome, SSRIs, depression, treatment of depression, post-MI (where MI is myocardial infarction), major depression, and cardiac disease. Trials were included if the patients were above the age of 18, both male and female genders, and had cardiac comorbidity. No trials were excluded.

RESULTS

A total of 61 articles and/or book chapters were included. The majority were from North America and Europe. There were 7 clinical trials of tricyclic antidepressants (TCAs), one of TCAs and bupropion, and 10 trials of selective serotonin reuptake inhibitors (SSRIs). We also evaluated five trials involving psychotherapeutic techniques and/or collaborative care.

CONCLUSIONS

There is considerable evidence from randomized controlled clinical trials that antidepressants, especially SSRIs, are safe in the treatment of major depression in patients with CVD. Although efficacy has been demonstrated in some, but not all, trials for both antidepressants and certain psychotherapies, large, well-powered trials are urgently needed. There are virtually no data available on predictors of antidepressant response in depressed patients with CVD. Whether successful treatment of depression is associated with a reduction in cardiac morbidity and mortality remains unknown.

Serum contents of endocannabinoids are correlated with blood pressure in depressed women

BACKGROUND

Depression is known to be a risk factor for cardiovascular diseases but the underlying mechanisms remain unclear. Since recent preclinical evidence suggests that endogenous agonists of cannabinoid receptors (endocannabinoids) are involved in both cardiovascular function and depression, we asked whether endocannabinoids correlated with either in humans.

RESULTS

Resting blood pressure and serum content of endocannabinoids in ambulatory, medication-free, female volunteers with depression (n = 28) and their age- and ethnicity-matched controls (n = 27) were measured. In females with depression, both diastolic and mean arterial blood pressures were positively correlated with serum contents of the endocannabinoids, N-arachidonylethanolamine (anandamide) and 2-arachidonoylglycerol. There was no correlation between blood pressure and endocannabinoids in control subjects. Furthermore, depressed women had significantly higher systolic blood pressure than control subjects. A larger body mass index was also found in depressed women, however, it was not significantly correlated with serum endocannabinoid contents.

CONCLUSIONS

This preliminary study raises the possibility that endocannabinoids play a role in blood pressure regulation in depressives with higher blood pressure, and suggests an interrelationship among endocannabinoids, depression and cardiovascular risk factors in women.

Depression and cardiac disease: a review

Depression is highly prevalent in cardiac patients, with 20% to 40% of patients meeting criteria for major depressive disorder or experiencing an elevation in depressive symptoms. These depressive symptoms are often chronic and persistent, and they have been associated with the development and progression of coronary artery disease, worse health-related quality of life, poor physical functioning, recurrent cardiac events, and a 2- to 2.5-fold increased risk of mortality. Impaired adherence to health behaviors and adverse physiological effects of depression, including inflammation, endothelial dysfunction, platelet hyperactivity, and autonomic nervous system abnormalities, may link depression with adverse cardiac outcomes. Pharmacologic and psychotherapeutic interventions appear to be safe and effective at reducing depressive symptoms in patients with cardiovascular disease and may impact cardiac outcomes. Unfortunately, depression often is unrecognized and untreated in this population, despite the availability of brief screening tools that can be used for this purpose. We recommend the routine screening of cardiac patients for depression when there are adequate mechanisms for management and referral, such as available consulting psychiatrists or care management programs that facilitate the delivery of pharmacologic and psychotherapeutic treatments in this vulnerable population.

Meta-analysis of selective serotonin reuptake inhibitors in patients with depression and coronary heart disease

The occurrence of depression in patients with coronary heart disease (CHD) substantially increases the likelihood of a poorer cardiovascular prognosis. Although antidepressants are generally effective in decreasing depression, their use in patients with CHD is controversial. We carried out a meta-analysis to evaluate the health effects of selective serotonin reuptake inhibitors (SSRIs) versus placebo or no antidepressants in patients with CHD and depression. Observational studies and randomized controlled trials (RCTs) were searched in MEDLINE, EMBASE, PsycINFO, Cochrane Controlled Clinical Trial Register and other trial registries, and references of relevant articles. Primary outcomes were readmission for CHD (including myocardial infarction, unstable angina, and stroke) and all-cause mortality; the secondary outcome was severity of depression symptoms. Seven articles on 6 RCTs involving 2,461 participants were included. One study incorrectly randomized participants, and another was a reanalysis of RCT data. These were considered observational and analyzed separately. When only properly randomized trials were considered (n = 734 patients), patients on SSRIs showed no significant differences in mortality (risk ratio 0.39, 95% confidence interval 0.08 to 2.01) or CHD readmission rates (0.74, 0.44 to 1.23) compared to controls. Conversely, when all studies were included, SSRI use was associated with a significant decrease in CHD readmission (0.63, 0.46 to 0.86) and mortality rates (0.56, 0.35 to 0.88). A significantly greater improvement in depression symptoms was always apparent in patients on SSRIs with all selected indicators. In conclusion, in patients with CHD and depression, SSRI medication decreases depression symptoms and may improve CHD prognosis.

The relationship between depression, anxiety, and cardiovascular outcomes in patients with acute coronary syndromes

Depression and anxiety occur at high rates among patients suffering an acute coronary syndrome (ACS). Both depressive symptoms and anxiety appear to adversely affect in-hospital and long term cardiac outcomes of post-ACS patients, independent of traditional risk factors. Despite their high prevalence and serious impact, mood and anxiety symptoms go unrecognized and untreated in most ACS patients and such symptoms (rather than being transient reactions to ACS) persist for months and beyond. The mechanisms by which depression and anxiety are linked to these negative medical outcomes are likely a combination of the effects of these conditions on inflammation, catecholamines, heart rate variability, and endothelial function, along with effects on health-promoting behavior. Fortunately, standard treatments for these disorders appear to be safe, well-tolerated and efficacious in this population; indeed, selective serotonin reuptake inhibitors may actually improve cardiac outcomes. Future research goals include gaining a better understanding of the combined effects of depression and anxiety, as well as definitive prospective studies of the impact of treatment on cardiac outcomes. Clinically, protocols that allow for efficient and systematic screening, evaluation, and treatment for depression and anxiety in cardiac patients are critical to help patients avoid the devastating effects of these illnesses on quality of life and cardiac health.

Efficacy and tolerability of antidepressants for treatment of depression in coronary artery disease: a meta-analysis

OBJECTIVE

Depression occurs in 18% to 45% of patients with coronary artery disease (CAD) where it is associated with an increased risk of acute coronary events and mortality. Our objective was to quantitatively summarize the data on the efficacy and tolerability of antidepressant (AD) treatment for depression in CAD.

METHODS

We performed a meta-analysis of randomized, placebo-controlled, double-blind trials with a database search of the English literature (to March 2008) and manual search of references.

RESULTS

Four clinical trials with ADs (mirtazapine, citalopram, fluoxetine, and sertraline) of a 9- to 24-week duration involving 798 subjects (402 ADs, 396 placebo) with documented CAD and meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for depression were included. ADs were superior to placebo for decreasing Hamilton Depression Rating Scale (HDRS) scores (402 ADs, 396 placebo; weighted mean difference 1.41, 95% CI 0.53 to 2.29, P = 0.002) and Beck Depression Inventory (BDI) scores (373 ADs, 369 placebo; weighted mean difference 2.27, 95% CI 0.60 to 3.94, P = 0.008). The proportion of patients (216 ADs, 213 placebo) who responded (a 50% or more reduction in HDRS scores, OR 1.72, 95% CI 1.17 to 2.54) and remitted (HDRS of 8 or less at final assessment, OR 1.80, 95% CI 1.18 to 2.74), were also significantly higher with AD, compared with placebo, with no significant differences between the 2 groups for overall dropouts (OR 0.84, 95% CI 0.42 to 1.68) or dropout owing to adverse events (OR 1.30, 95% CI 0.75 to 2.25). The combined studies were homogeneous except for overall dropout rate (P = 0.01).

CONCLUSION

Treatment with ADs for depression in CAD results in significant therapeutic effects without substantially increased rates of discontinuation.

Depression and the cardiovascular system: increasing evidence of a link and therapeutic implications

This review explores the epidemiological evidence for the relationship between depression and cardiovascular disease from a mechanistic standpoint. It is important to examine the biological, behavioral and social mechanisms to improve outcomes for depressed cardiac patients. A number of plausible biobehavioral mechanisms linking depression and cardiovascular disease have been identified. Tricyclic antidepressants have various effects on the cardiovascular system, while selective serotonin reuptake inhibitors are not associated with adverse cardiac effects and should, therefore, be the preferred choice for the treatment of most patients with comorbid depression and cardiovascular disease.

Review of cardiovascular risk factors in women

BACKGROUND

Although cardiovascular disease (CVD) is the leading cause of death in women in the United States, a knowledge gap persists regarding the mechanisms and management of CVD in women. Before treatment can be optimized, the role of cardiovascular risk factors must be elucidated.

OBJECTIVE

This review provides an updated assessment of cardiovascular risk factors in women, with a focus on cardiometabolic risk.

METHODS

MEDLINE and Cochrane Library databases, and statistics from the National Health and Nutrition Examination Survey and the American Heart Association, were searched from 1990 to September 2008 using the following terms: cardiovascular risk factors, women, gender, cardiometabolic risk, abdominal obesity, and metabolic syndrome. Publications were classified as English-only original data, reviews, and clinical guidelines. Nonpublished data were excluded. Data were extracted by 2 reviewers independently.

RESULTS

Investigators performing multivariable predictive models have estimated that traditional risk factors account for approximately 70% of the variance in estimating cardiovascular events. However, substantial sex differences exist in the prevalence of traditional risk factors as well as in cardiovascular outcomes. Hypertension is more prevalent in men until the age of 59 years, but then contributes to greater morbidity in older women. Low levels of high-density lipoprotein and elevated triglyceride levels pose more of a threat to women, yet high levels of low-density lipoprotein pose equal risk for women and men. The CVD mortality rate is -3 times greater in people with diabetes than in those without diabetes. Among diabetic individuals, CVD mortality is slightly higher in women compared with men.

CONCLUSIONS

Increased knowledge of gender-specific risks for CVD has led to national campaigns to educate women. In addition to traditional risk factors, cardiometabolic risk is an important consideration in women. Controversy exists regarding the exact definitions and usefulness of the term metabolic syndrome, but it is clear that the presence of certain factors contributes to increased morbidity and mortality in affected individuals. Abdominal obesity links insulin resistance, dyslipidemia, and hypertension through complex endocrine pathways. Current research is identifying gene x gender interactions, and continued research is necessary to explore the relationship of sex steroids and cardiovascular risk in both men and women.

A Case of “Double” Depression under Outpatient Treatment Conditions

During his professional practice the author encountered a case of coexistence of "major depression" with psychic depressive attacks (dysthymic attacks) of so-called temporal epilepsy. Apart from major depression of medium intensity, other manifestations developed. These were independent of the time of the day, suddenly occurring within several seconds, developing without any cause, attacks of very strong dejection, sadness, breakdown, feeling of lacking sense and hopelessness of life with slight lessening of consciousness and strong groundless fear. Detailed psychiatric examinations, observations of the patient during such attacks and EEG records confirmed the diagnosis of dysthymic attacks of temporal epilepsy. The author treated the patient with sertraline starting at a low dose and increasing up to 100 mg daily - administered orally once daily in the morning, clonazepam in oral doses 1 mg in the morning, 1 mg at lunchtime, 2 mg in the evening, and carbamazepine 200 mg tablets from low doses to 400 mg administered once daily in the evening. Complete remission of major depression and complete regression of dysthymic attacks of "temporal epilepsy" were obtained.

Role of depression in heart failure--choosing the right antidepressive treatment

Major depression is a common feature of heart failure patients and possibly stems from their common biochemical background. Depression and heart failure co-morbidity has several clinical implications on the prognosis of these patients. Furthermore antidepressive drugs have known cardiovascular side effects, while their safety and efficacy in heart failure has not been fully elucidated yet. The right choice of antidepressive treatment in heart failure constitutes an issue of high importance as it can affect the clinical outcome of these patients. In this article we highlight the role of major depression in heart failure and demonstrate their common biochemical background. Moreover we review the acquired so far knowledge on the use of the various categories of antidepressants in heart failure by reference to the existing clinical studies on antidepressants efficacy and safety in heart failure. Even though certain conclusions cannot be drawn yet, evidence suggests that the use of selective serotonin reuptake inhibitors may have a beneficial effect on clinical outcome of heart failure patients.

A double-blind, placebo-controlled treatment trial of citalopram for major depressive disorder in older patients with heart failure: the relevance of the placebo effect and psychological symptoms

BACKGROUND

Little is known about the treatment of depression in older patients with heart failure. This study was developed to investigate the effectiveness of antidepressant treatment for major depressive disorder (MDD) in the elderly with heart failure.

METHODS

We enrolled 72 older outpatients with ejection fraction <50 and diagnosed with MDD by the structured clinical interview for DSM-IV. Thirty-seven patients, 19 on citalopram and 18 on placebo, initiated an 8-week double-blind treatment phase. Measurements were performed with the 31-item Hamilton Rating Scale for Depression (Ham-D-31), the Montgomery-Asberg rating scale (MADRS) and the Systematic Assessment for Treatment Emergent Effects (SAFTEE). A psychiatrist followed up the patients weekly, performing a consultation for about 20 min to field complaints after the measurements.

RESULTS

A trend toward superiority of citalopram over placebo in reducing depression was observed in MADRS scores (15.05+9.74 vs 9.44+9.25, P=.082) but not on HAM-D scores. The depressive symptomatology significantly decreased in both groups (P < .001). The high rate of placebo response during the double-blind phase (56.3%) led us to conclude the study at the interim analysis with 37 patients.

CONCLUSION

Citalopram treatment of MDD in older patients with heart failure is well-tolerated with low rates of side effects, but was not significantly more effective than placebo in the treatment of depression. Weekly psychiatric follow-up including counseling may contribute to the improvement of depression in this population. Scales weighted on psychological symptoms such as the MADRS are possibly better suited to measure depression severity and improvement in patients with heart failure.

Antidepressant drugs and cardiovascular pathology: a clinical overview of effectiveness and safety

OBJECTIVE

To review data examining the relationships between depression, antidepressants and cardiovascular disease.

METHOD

Structured searches of PubMed, Medline and Embase conducted in March 2008.

RESULTS

Depression and cardiovascular disease are closely associated clinical entities. Depression appears both to cause and worsen cardiovascular disease. Cardiovascular disease is in turn associated with a high incidence of depression. Depression is associated with increased mortality in cardiovascular disease, and after myocardial infarction (MI) and stroke. Many antidepressants have cardiotoxic properties. Tricyclic drugs are highly cardiotoxic in overdose and may induce cardiovascular disease and worsen outcome in established cardiovascular disease. Reboxetine, duloxetine and venlafaxine are known to increase blood pressure. Other antidepressants have neutral or beneficial effects in various cardiovascular disorders.

CONCLUSION

Sertraline, fluoxetine, citalopram, bupropion and mirtazapine appear to be safe to use after MI; the use of sertraline, and response to citalopram and mirtazapine may improve mortality. Paroxetine and citalopram appear to be safe to use in patients with established coronary artery disease. Limited data suggest that a variety of antidepressants are effective and safe to use after stroke.

Effect of selective serotonin reuptake inhibitors on platelet activation: can they prevent acute myocardial infarction?

In recent years a large body of evidence from several longitudinal studies has emerged suggesting that depression is an independent risk factor for cardiovascular disease (CVD) and that the association between depression and increased CVD risk is not merely due to negative mood-driven behavior related with depression. Even though the underlying mechanisms are not well understood, several hypotheses and explanations have been proposed such as increased activation of the hypothalamic-pituitary-adrenal axis, abnormalities in the sympathoadrenal system, or abnormalities in platelet function. Platelet function abnormalities, including increased platelet reactivity, may predispose patients with depressive disorders to clotting diatheses and may explain their vulnerability to CVD. Serotonin secreted by platelets induces both platelet aggregation and coronary vasoconstriction. Even though serotonin itself is only a weak platelet agonist, it markedly enhances platelet reactions to a variety of other agonists. Several studies have shown that selective serotonin reuptake inhibitors (SSRIs) reduce platelet and whole blood serotonin concentrations after repeated doses, and could therefore exert an inhibitory effect on platelet activation. For that reason, it was hypothesized that SSRIs could have a protective effect against myocardial infarction (MI). Results from three currently available epidemiological studies assessing the risk of MI in patients treated with antidepressants, including SSRIs, are controversial with respect to a potential beneficial effect of SSRIs on CVD risk in depressed patients. However, there is evidence that exposure to SSRIs does not substantially increase the risk of CVD in patients. A recent randomized, double-blind, placebo-controlled, multicenter trial that evaluated the safety and efficacy of the SSRI sertraline in patients with major depression and acute MI or unstable angina suggested that sertraline is well tolerated and effective. Further epidemiological studies or longer-term clinical trials may shed more light on this issue, and answer the question conclusively, whether the effect of SSRIs on platelets or another mechanism translates into a decreased risk of CVD in depressed patients.

Safety and efficacy of sertraline for depression in patients with CHF (SADHART-CHF): a randomized, double-blind, placebo-controlled trial of sertraline for major depression with congestive heart failure

BACKGROUND

Sertraline, a selective serotonin-reuptake inhibitor, has demonstrated substantial mood improvement in patients with post myocardial infarction or with unstable angina. The impact of sertraline on the prognosis and depression of patients with chronic heart failure (HF) and comorbid major depressive disorder (MDD) is unknown.

METHOD

This is a prospective, randomized, double-blind, placebo-controlled study designed to assess the safety and efficacy of sertraline in the treatment of MDD in patients with HF. The study is designed also to examine the effects of treating depression on cardiac events and morbidity/mortality in patients with HF. Approximately 500 men and women who are >or=45 years of age with current MDD and chronic systolic HF, characterized by left ventricular ejection fraction or=II, comprise the study population. Eligible participants are randomized to either sertraline or placebo for a 12-week acute treatment phase. All patients, regardless of acute treatment phase completion, are followed routinely until the last subject completes 6-month follow-up. Quality of life and certain physiologic parameters, as well as pro-inflammatory and HF biomarkers, that may reflect the impact of sertraline in this particular population are measured at baseline and at the end of the acute treatment phase.

CONCLUSION

Because of the high prevalence of depression and its significant adverse impact on prognosis of patients with ischemic heart disease (IHD) and HF, the Safety and Efficacy of Sertraline for Depression in Patients with Chronic Heart Failure (SADHART-CHF) trial aims to assess the effects of sertraline on response of depression as well as on the cardiac prognosis of patients with HF.

High impact of depression in heart failure: Early diagnosis and treatment options

Depressive syndromes in chronic heart failure (CHF) are common and are associated with a poorer prognosis, particularly with increased morbidity and mortality. CHF as a severe physical disorder may increase the risk of developing depressive syndromes or vice-versa as an interaction of possible common psycho-organic etiological aspects. Depression in CHF is associated with impaired NYHA status and daily activities, resulting in enhanced hospitalisation rates and medical costs with a great impact on long-term health. Only a fraction of comorbid patients receives antidepressants. Therefore, identification of risk factors and prevention by optimizing cardiological and psychiatric therapeutic strategies appear essential for these patients. Early diagnosis and treatment of both CHF and depression may prevent further pathophysiological effects on the heart and brain. This review gives a comprehensive overview of the occurrence, risk factors and shared pathophysiology of depression in CHF, and focuses on improving insufficient diagnosis and therapy of depression. Special attention is given on the cardiac effects of psychopharmacological and alternate non-pharmacological antidepressant therapy in CHF. Recommendations are made for treating depression in CHF patients for a better prevention of this disabling physical and psychosocial condition.

Depression and heart disease: therapeutic implications

The consequences of depression and coronary artery disease (CAD) were reviewed in the literature. The comorbidity of depression and CAD results in an increased cardiovascular mortality. We reviewed possible explanations for this increased morbidity, which include: toxicity of tricyclic antidepressants that can cause cardiac arrhythmias, abnormalities in platelet function leading to increased platelet aggregation due to abnormalities in serotonin in the platelet (an abnormality that possibly causes depression in the central nervous system), diffuse atherosclerosis causing central nervous system abnormalities including depression (vascular depression), as well as the possibility that depressed patients are less compliant with their medications and physician-directed health recommendations. Recent reports of selective serotonin reuptake inhibitors (SSRIs) causing a reduced cardiovascular mortality may be related to serotonin platelet abnormalities in depressed patients that are effectively treated by SSRIs (SADHART and ENRICHD trial). It is possible that these trials reveal a mechanism of depression that also effects platelet function and can be improved with SSRI therapy, suggesting a preferential therapeutic pathway for the treatment of depressed patients with CAD.

The platelet of the patients with ischemic cardiopathy and cardiac valve disease showed a reduction of 8OH-DPAT binding sites

Depression is prospectively associated with increased risk of coronary artery disease in individuals initially free of clinical cardiovascular disease probably by an increased platelet activity. The serotonergic receptors mainly implied in depression are 5-HT1A and 5-HT2 receptors. Activation of 5HT2 receptor induces platelet aggregation. Drugs with 5-HT1A receptor agonist and 5-HT2A receptor antagonist effects reduced the receptor-mediated platelet aggregation. There are only indirect data about 5-HT1A receptors presence in platelet membranes, thus our aims were to study the characteristics of the platelet membranes 5-HT1A binding sites of both healthy volunteers and patients with cardiac valve disease and ischemic cardiopathy. The bound of the 5-HT1A selective agonist 3H-8OH-DPAT to the platelet membranes 5-HT1A binding sites of patients with cardiac valve disease and ischemic cardiopathy were compared with a control group of healthy voluntaries using radioligand binding methods. The patients with cardiovascular disease showed a reduction (-50.40%) (p<0.01) of the 3H-8OH-DPAT bound to the platelet membranes 5-HT1A receptors (1.652+/-0.79 fmol/mg protein) with respect to the control group (3.331+/-0.16 fmol/mg protein). 3H-8OH-DPAT binding to human platelet membranes is saturable, of high affinity, and seems selective for 5-HT1A receptors, and similar to that described in animal brain and in other human cells. Patients with ischemic cardiopathy and cardiac valve disease showed a reduction of the 8OH-DPAT bound to the platelet membranes. Taken together, these findings suggest that the 8OH-DPAT bound to the human platelet membranes is modulated by modifications produced by cardiovascular disease conditions.

Sertraline for the treatment of depression in coronary artery disease and heart failure

Depression is a common co-morbid condition in patients with cardiac disease and has been identified as an independent risk factor for increased morbidity and mortality. SSRIs are established agents for the treatment of depression and are well tolerated in patients with cardiac disease. SSRIs are a heterogeneous group of antidepressants, which apart from their common mechanism of action, differ substantially in their chemical structure, metabolism and pharmacokinetics. This article reviews experimental and clinical evidence on the safety and efficacy of the most extensively studied SSRI, sertraline, in depressed patients with coronary artery disease and heart failure. Intervention with sertraline has the potential to provide depressed patients with cardiac disease relief from their depressive symptoms, improvement in quality of life and a potential benefit in their cardiovascular risk profile.

Care Management of Poststroke Depression

Background and Purpose— Poststroke depression is a prevalent and disabling disorder, yet evidence regarding the effectiveness of treating poststroke depression is inconclusive. Our objective was to determine the effectiveness of the Activate-Initiate-Monitor care management program for the treatment of poststroke depression.

Methods— We conducted a prospective, randomized, outcome-blinded trial in 188 ischemic stroke survivors identified at the time of admission to one of 4 Indianapolis hospitals. Depression screening and enrollment occurred between 1 and 2 months poststroke. The Activate-Initiate-Monitor intervention was a care management program that included A ctivation of the patient to recognize depression symptoms and accept treatment, I nitiation of an antidepressant medication, and M onitoring and adjusting treatment. Usual care subjects received nondepression-related education and were prescribed antidepressants at the discretion of their provider. The primary outcome measure was depression response, defined as a Hamilton Depression Inventory score <8 (remission) or a decrease from baseline of at least 50% at 12 weeks.

Results— Intervention and usual care groups did not differ on any key baseline measures. Both depression response (51% versus 30%, P =0.005) and remission (39% versus 23%, P =0.01) were more likely in the Activate-Initiate-Monitor intervention than in the usual care group. This difference in depression scores was present by 6 weeks and persisted through the 12-week assessment. Serious adverse events did not differ between the 2 groups.

Conclusion— The Activate-Initiate-Monitor care management model is significantly more effective than usual care in improving depression outcomes in patients with poststroke depression.

Post-MI psychiatric syndromes: six unanswered questions

Depression, anxiety, and other psychological variables following acute myocardial infarction (MI) have been the subject of intense study over the last two decades. Through selective literature review and editorial commentary, we address six vital, unanswered questions concerning these psychological variables and their impact on coronary outcome. The picture that emerges is complex. Despite all that has been learned about the nature, consequences, and management of post-MI depression and related disorders, there remain many open issues. First, the prevalence, phenomenology, medical impact, and method of diagnosis of post-MI depression and other psychiatric syndromes remain unclear. In addition, at least four pathophysiologic mechanisms have been proposed to explain the link between depression and cardiac disease, but evidence of causation remains elusive. There have been increasingly well-designed treatment studies of post-MI depression, but the optimal agents and timing of treatment have yet to be defined. Finally, few recent studies of post-MI anxiety have been conducted. To make further progress, large, multicenter trials that use optimized screening tools, obtain data at several time points, consider multiple psychosocial variables, and correct carefully for medical/cardiac severity are required.

Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding?

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) represent a relatively new class of antidepressants. Several studies have reported bleeding disorders associated with the use of SSRIs, which are considered the result of a decrease in platelet serotonin leading to a defect in platelet aggregation. To what extent the use of SSRIs increases the risk of gastrointestinal bleeding is unclear.

METHODS

A comprehensive literature search for studies addressing SSRI use and upper gastrointestinal tract bleeding (UGIB) was conducted using Medline, EMBASE, and Cochrane databases with a recursive manual reference search up to May 2005. Any observational and interventional studies were systematically reviewed, and critical appraisal was conducted on available studies.

RESULTS

Published clinical evidence on the relationship between SSRI use and gastrointestinal bleeding is limited to observational studies without any clinical trials. Three cohort studies and one case-control study met inclusion criteria. These studies combined different affinity SSRIs in the class and had differing control groups with conflicting conclusions. Both a cohort study and a case-control study investigating the concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose aspirin found that combined use with an SSRI increased the risk of UGIB.

CONCLUSIONS

Only a few epidemiology studies have investigated the association between SSRIs and UGIB. They provide weak evidence to support the hypothesis of a link between SSRIs and UGIB at a population level. Available evidence shows that concurrent use of NSAIDs or aspirin with SSRIs greatly increases the risk of UGIB. The preventive strategy should be considered in those SSRI users at high risk, especially the elderly or those with a history of UGIB and taking nonselective NSAIDs or aspirin.

Depression in coronary artery disease: novel pathophysiologic mechanisms and therapeutic implications

Depression is a common comorbid condition in patients with coronary artery disease and a well-documented risk factor for recurrent cardiac events and mortality. The exact mechanisms underlying the interplay between depression and ischemic heart disease remain poorly understood and the same is true for the most effective depression treatment for cardiac patients. This review summarizes current knowledge regarding the prognostic role of depression in patients with coronary artery disease, the pathophysiologic pathways involved, and the effects of antidepressant therapy on cardiovascular disease outcomes. With recent evidence suggesting that selective serotonin reuptake inhibitors may improve survival after myocardial infarction in patients with depression, diagnosis and treatment of this co-morbidity may be essential for the clinical management of coronary artery disease.

Consultation-liaison psychiatry: how far have we come?

This article takes stock of how far the field of consultation-liaison psychiatry has come since its inception in the 20th century. In order to do this, we review its past in terms of its knowledge base in psychosomatic medicine and in terms of its practice at the bedside in the general hospital setting. We also offer a contemporary account of the field and finish with a subjective view of the opportunities and pitfalls faced during the next phase of consultation-liaison psychiatry in the 21st century.

Design and rationale for a randomized, controlled trial of interpersonal psychotherapy and citalopram for depression in coronary artery disease (CREATE)

OBJECTIVE

Recognition that depression is associated with increased morbidity and mortality in coronary artery disease (CAD) patients has augmented the need for evidence-based treatment guidelines. This article presents the design of a multisite, Canadian trial of the efficacy, safety, and tolerability of interpersonal psychotherapy (IPT), an empirically supported, depression-focused therapy, and the selective serotonin reuptake inhibitor citalopram, alone or in combination, in the treatment of major depression in CAD patients.

METHODS

Two hundred eighty stable CAD patients with a current major depressive episode of at least 4 weeks' duration, based on the Structured Clinical Interview for Depression (SCID), and who have a baseline score >19 on a centralized, telephone-administered, 24-item Hamilton Depression Rating Scale (HAM-D) will be randomly assigned to receive 12 weekly IPT sessions or 12 weekly sessions of standardized clinical management (CM). Patients are also randomly assigned to receive 20 to 40 mg per day of citalopram or pill-placebo. This results in a 2-by-2 factorial design with four groups: IPT plus pill-placebo, IPT plus citalopram, CM plus pill-placebo, and CM plus citalopram. This permits the evaluation of both IPT and citalopram. Blinded, centralized, 24-item, HAM-D telephone ratings constitute the primary outcome variable. The self-report Beck Depression Inventory-II is the secondary outcome. Analyses will involve the intent-to-treat principle with last observation carried forward for incomplete assessments.

RESULTS

Not applicable.

CONCLUSIONS

The results of this trial will contribute to the development of evidence-based clinical guidelines for managing depression in the context of CAD.

Management of psychiatric problems in critically ill patients

Critical care units have become essential elements in modern medicine. These units reflect the highest levels of scientific and technological advance in medicine. Within these units, however, lie significant psychiatric challenges for patients and staff. This article examines the identification and treatment of the most frequent psychiatric problems facing patients entering critical care units, including delirium, depression and anxiety. These conditions are important to address in order to decrease patient suffering and improve morbidity and mortality. The article also addresses some of the most common staff stressors encountered in working in these units. Managing these stressors makes the critical care unit a place where staff can flourish instead of burning out. Specific techniques may help the staff deal with the complex medical, psychological, and ethical issues found in these units in an empathic, compassionate, and well-balanced manner that allows ongoing work satisfaction.

Effectiveness of sertraline in treatment of depression in a consecutive sample of patients with acute myocardial infarction: six month prospective study on outcome

Background

A considerable proportion of patients suffer from depression following acute myocardial infarction. Information regarding this prevalence in Indian patients and response to treatment is lacking.

Method

Prevalence of major depression was studied in 50 consecutive in-patients with acute myocardial infarction following DSM-IV criteria. In a comparative study outcome of treatment with sertraline in terms of recovery from depression, change in Hamilton Depression Rating scale score and occurrence of cardiac events were ascertained for a 6-month period, which were compared with a group of patients who did not receive sertraline.

Results

Major depression was diagnosed in 34% of patients. Female patients were more affected than the males. Hamilton Depression Rating scale scores gradually decreased in both the groups over the study period; however it became significantly less for patients treated with sertraline. Significantly more number of patients who received sertraline recovered from depression. There were no dropouts due to non-response or side effects. Cardiac events were reported less in this group than those who continued only cardiac treatment as usual.

Conclusion

A considerable proportion of acute myocardial infarction patients have major depression. Sertraline is efficacious and safe in these patients. Antidepressant treatment might be associated with reduction of cardiac events.

Antidepressant therapy in patients with ischemic heart disease

Depressive disorders are common in patients with ischemic heart disease and have serious consequences in terms of the risk of further cardiac events and cardiac mortality. Among survivors of acute myocardial infarction, up to one fifth meet diagnostic criteria for major depression, and the presence of major depression carries a >5-fold increased risk for cardiac mortality within 6 months. This article reviews clinical trial data on the cardiac safety profiles of antidepressant agents with the aim of discussing clinical considerations in selecting the most appropriate treatment of comorbid depression in patients with ischemic heart disease. Tricyclic antidepressants are effective against depression but are associated with cardiovascular side effects including orthostatic hypotension, slowed cardiac conduction, antiarrhythmic activity, and increased heart rate. Selective serotonin reuptake inhibitors, by contrast, have benign cardiovascular profiles and are well tolerated in patients with cardiac disease. The safety of dual-acting serotonin and noradrenaline reuptake inhibitors has not been well studied. Intervention with a selective serotonin reuptake inhibitors has the potential to provide the depressed patient with ischemic heart disease relief from their depressive symptoms and may offer a potential improvement in their cardiovascular risk profile.

Psychosocial considerations in the European guidelines for prevention of cardiovascular diseases in clinical practice: Third Joint Task Force

The International Society of Behavioral Medicine (ISBM) was one of eight societies that comprised the Third Task Force of European and Other Societies on Prevention of Cardiovascular Disease in Clinical Practice (2003-2004). This task force considered published knowledge from diverse fields related to preventive cardiology including behavioral medicine to improve risk estimation and risk factor management. The scientific evidence supporting the guidelines included findings on low socioeconomic status, social isolation, psychosocial stress, hostility, depression and negative affect, the clustering of psychosocial and lifestyle risk factors, and lifestyle psychosocial interventions. Recommendations for promoting behavior change and management of psychosocial and lifestyle factors in clinical practice include strategies for promoting healthy lifestyle, improving health care provider-patient interactions, implementing multimodal interventions, and managing psychosocial risk factors.

Treatment of depression in the medically ill

Most studies on treatment methods in elderly depressive patients have included primarily patients in good physical health, excluding medical comorbidity, despite the fact that depression with medical comorbidity is the norm rather than the exception. In addition, depression is known to increase disability and mortality among the medically ill. This, therefore, becomes an extremely important issue. Although data are limited, the available evidence suggests that depression concomitant with medical illness can be treated. One or more of the selective serotonin reuptake inhibitors have demonstrated potential usefulness in depressed patients with ischemic heart disease, diabetes, dementia, and Parkinson's disease and in patients after stroke and after myocardial infarction. Large-scale trials are needed to assess not only the safety and effectiveness of agents for the treatment of depression in comorbid illness, but also the effects of depression on the course of the medical illness itself.

Depression in chronic heart failure: novel pathophysiological mechanisms and therapeutic approaches

Depression is four to five times as common in chronic heart failure (CHF) patients as in the general population, may confer a higher risk of developing CHF in susceptible populations, and is significantly related to higher hospital readmission rates and increased mortality in established CHF. This effect may be mediated via the pathophysiological mechanisms that are shared between CHF and depression, including increased hypothalamic-pituitary-adrenal function, sympathoadrenal hyperactivity, diminished heart-rate variability and excessive pro-inflammatory cytokine activation. Each of these pathways of linkage represents a potential therapeutic target to improve outcome in CHF. This paper reviews the recent investigational observations that clarify the direct effects of antidepressants on immune functions, as well as the indirect effects of anticytokine pharmacological agents on depressive symptoms in CHF. With recent evidence suggesting that selective serotonin re-uptake inhibitors improve survival after myocardial infarction in patients with depression, diagnosis and treatment of this comorbidity may beneficially affect the functional capacity and prognosis of CHF patients.

Pharmacologic treatment of depression in patients with heart disease

The relationship between depression and cardiovascular disease is complex and multifaceted. There is a growing body of evidence that depression significantly and adversely affects cardiovascular health. Perhaps the most prominent finding is the documented increase in mortality rate in patients with depression after myocardial infarction. The critical questions of interest to both the clinician and researcher are whether there are safe and effective treatments for depression in patients with heart disease and whether treatment of depression reduces the increased risk of cardiac morbidity and mortality. Although the data are limited and are primarily from open or comparator trials, the tricyclics (TCAs) and selective serotonin reuptake inhibitors (SSRI) are effective for treatment of depression in patients with ischemic heart disease (IHD), and response rates are comparable with those reported in depressed patients without heart disease. In terms of safety, the TCAs are associated with documented adverse cardiovascular effects, including increases in heart rate, orthostatic hypotension, and conduction delays. Use of TCAs in patients with IHD carries a proven increased risk of cardiac morbidity and perhaps of mortality as well. The SSRI appear to be relatively safe and effective in the treatment for depression in patients with comorbid IHD.

Heart and mind: (1) relationship between cardiovascular and psychiatric conditions

The relationship of our emotions and psyche to heart disease is intriguing. In this article we have reviewed the evidence linking cardiovascular and neuropsychiatric disorders and the possible mechanisms and pathophysiology of this association. This review is derived from Medline searches (1966-2002) using the relevant search terms (psychiatric disease, cardiovascular disease, depression, anxiety, and pathophysiology). Finally, the possible role of using mood enhancing therapies (mainly antidepressants) and their safety in patients with cardiovascular disorders is briefly discussed. In a companion paper, the therapeutic aspects of these two conditions is highlighted.

Endocrine disturbances in depression

Depression is one of the most common psychiatric disorders. For a long time, clinicians suspected a causal link between depression and the endocrine system. The most frequently occurring endocrine abnormality in depressed subjects is hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis. CRH and AVP are likely to play a substantial role in the pathophysiology of this disorder, and their receptors appear to be a specific target for future antidepressant drugs. Depression also affects the hypothalamic-pituitary-GH (HPGH) and -thyroid (HPT) axes. Alterations in the reproductive system may also play a role in the pathology of depression. In addition, there is increasing evidence that leptin and neurosteroids, such as DHEA, are implicated in mood disorders.

An Open-Label Trial of Interpersonal Psychotherapy in Depressed Patients With Coronary Disease

High rates of depression have been reported in patients with coronary artery disease, and depression has been repeatedly shown to adversely affect cardiac morbidity and mortality. Despite these findings, little work has been devoted to evaluating effective antidepressant treatments for this subpopulation. This open-label trial assessed the efficacy and acceptability of interpersonal psychotherapy in depressed patients with stable coronary artery disease. Seventeen patients with coronary artery disease who met DSM-IV criteria for major depression received 12 weekly sessions of interpersonal psychotherapy. Outcome was assessed with the 17-item Hamilton Depression Rating Scale and the Beck Depression Inventory II. Ten patients received medication during the trial, and seven patients received interpersonal psychotherapy alone. The patients showed a significant reduction in scores on both the Hamilton depression scale and the Beck Depression Inventory II from baseline, with 53% of the patients meeting criteria for remission, as defined by scores of < or =7 and < or =14 on the Hamilton depression scale and the Beck Depression Inventory II, respectively. Medicated and unmedicated patients responded similarly to interpersonal psychotherapy. These data provide support for the potential use of interpersonal psychotherapy in depressed patients with coronary artery disease. The therapy was well tolerated and accepted by patients, with a high proportion achieving remission. Future randomized clinical trials are needed to establish its efficacy.

Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: results from the National Comorbidity Survey

Most health and work productivity studies have focused on individual conditions without considering comorbidity. We illustrate the implication of this neglect by examining the effects of comorbid mental disorders on role impairment (number of sickness absence and work cut-back days in the past month) among people with chronic physical disorders. A nationally representative household survey of 5877 respondents assessed current mental and physical disorders and role impairments. Four physical disorders were sufficiently common to be studied: hypertension, arthritis, asthma, and ulcers. All 4 physical disorders were associated with significant role impairments in bivariate analyses. However, further analysis showed that these impairments were almost entirely confined to cases with comorbid mental disorders. Effectiveness trials in workplace samples are needed to evaluate the cost-effectiveness of treating comorbid mental disorders among workers with chronic physical disorders.

An open-label study of nefazodone treatment of major depression in patients with congestive heart failure

OBJECTIVES

To evaluate the feasibility of screening and recruiting patients with major depression and congestive heart failure (CHF) in a tertiary care cardiology hospital and to obtain preliminary efficacy, tolerability, and safety data for nefazodone treatment of a major depressive episode in CHF patients.

METHOD

We conducted a 12-week, open-label trial of nefazodone given in dosages up to 600 mg daily. We assessed patients at baseline, 1, 2, 4, 8, and 12 weeks. Measures used were the 17-item Hamilton Depression Rating Scale (HDRS), the Clinical Global Impression Scale, the Beck Depression Inventory, Spielberger's State-Trait Anxiety Inventory, and the Minnesota Living with Heart Failure Questionnaire. We also obtained pre- and poststudy ECGs, 24-hour Holter monitor recordings, and plasma levels of norepinephrine.

RESULTS

After screening 443 CHF patients, 28 patients with major depression met study eligibility criteria. The 23 patients who completed 4 or more weeks of medication showed significant improvement on all depression scales and in quality of life. Of 19 subjects who completed the full 12-week trial, 74% experienced a decline of 50% or more on HDRS scores. The completers also showed a significant reduction in heart rate, an increase in QT intervals (but not in the QTc), and a marginally significant decrease in plasma norepinephrine. There were no changes in heart rate variability.

CONCLUSIONS

It is feasible to screen and recruit CHF patients with major depression for an anti-depressant trial. Nefazodone seems sufficiently safe, tolerable, and efficacious to justify a larger, placebo-controlled trial.