Patients often diagnosed with depression after acute MI

WASHINGTON — Patients who had an acute MI often experience depressive symptoms, but it is up to their physician to take the proper steps in signaling the problem and referring them for appropriate evaluation and treatment, an expert said at the American College of Cardiology Scientific Session.

“Depression after a cardiac event is very common, and it is considered a big risk factor,” Kim G. Smolderen, PhD, psychologist and assistant professor of implementation science in the department of biomedical and health informatics at University of Missouri–Kansas City, said in a presentation. “It is often persistent after an acute [MI] has occurred. One in five experiences a major depressive disorder. One in three experiences clinically relevant depressive symptoms that are impactful enough to interfere with an optimal recovery of [MI].”

Smolderen referenced a study in the Journal of General Internal Medicine from 2006, in which 20% of the patient sample who were referred for angiography and diagnostic cardiac catheterization had major depressive symptoms. Researchers also found that less than 50% of all patients with heart disease will have at least a few symptoms of depression, and many will have a major depressive episode at some point in the course of their heart disease.

Kim G. Smolderen

Depression screening

Physicians can use Patient Health Questionnaire-9 (PHQ-9) as a two-step screener in identifying patients with high risk for depression. The questionnaire focuses on all symptoms that are characteristic for a major depressive disorder. If a patient answers “yes” to the first two questions, which addresses the amount of interest a patient has in activities and whether they feel down or hopeless, the physician can move on to the remaining seven questions. Smolderen said from there, a physician can refer the patient for further workup and treatment.

In a study conducted by Smolderen and a colleague, to be published in Circulation, over 4,000 patients (mean age, 57 years) from the TRIUMPH registry were given the PHQ-9 survey after acute MI. She said 19% of patients screened positive for depression, and of those, only 30% received treatment.

In the VIRGO study, also to be published in Circulation, the cohort was slightly younger (mean age, 47 years) and mostly women. Of the more than 3,000 patients, 69% had no significant depressive symptoms, 13% were treated for depressive symptoms, 12% had untreated transient depressive symptoms and 6% had untreated persistent depressive symptoms.

The General Hospital Psychiatry published a study in 2011 that combined 25 years of research. Smolderen said it confirms that depression is associated with an adverse prognosis after acute MI. Not only is it predictive of cardiac mortality and CV events, but it is also associated with a poor quality-of-life outcome.

MI linked to depression

“Acute [MI] is considered a major life event that causes stress in people,” Smolderen said. “You’re confronted with the possibility of dying, confronted with real disability and maybe a future with more disability. You also may see that your family and work roles can be compromised or that you need to redefine some of those roles. That’s a lot to digest after you’ve had your [MI].”

Smolderen discussed how determining whether depression is a byproduct of MI or causal is too “simplistic,” as there are a lot of data that can suggest either way. If an adjustment is made for disease severity and all functional indicators of heart function, there is still an association with CV outcomes.

When determining whether depression is causal, Smolderen said it is likely a “multidirectional relationship,” and one of the explanations for the association between depression and adverse outcomes is dysregulation of the autonomic nervous system, as expressed by low heart rate variability, for example. “Inflammation is another path that has been suggested,” Smolderen said. “Increased platelet reactivity, endothelial dysfunction and then, of course, a lot of the health behaviors among depressed patients are also potential pathways, like smoking, diabetes, sedentary lifestyle, hypertension and less medication adherence are potential explanations.”

When revisiting the results of the TRIUMPH study, Smolderen said, “If we look at how these people do in terms of their mortality a year following their admission, then we see that the mortality risk in depressed patients is only restricted to people with untreated depression.”

In results from the VIRGO study, treating depression affected patients in a positive way. “The quality-of-life improvement among untreated patients was less than as opposed to those who didn’t have depression or whose symptoms were treated,” Smolderen said.

The American Heart Association previously released a science advisory in 2008, which suggests screening for depression with the two-step protocol. “Unfortunately, there’s been a bit of criticism on this statement because the opponents mentioned that there was insufficient clinical trial evidence to suggest that treating depression actually also improves outcomes.” Smolderen said.

Depression treatment

She referenced the COPES trial published in the Archives of Internal Medicine in 2010. In the randomized controlled trial, researchers administered depression treatment along with multicomponent intervention, which included a social worker, psychologist, psychiatrist, clinical nurse specialist and problem-solving therapy, allowing physicians to adjust a patient’s treatment based on their needs. Smolderen said patients in the trial were satisfied with the treatment they received, and researchers noted that patients had better survival and improved depressive symptoms after 9 months of treatment.

“Depression and stress following an acute [CV] event are very impactful for the patient and can be impactful for their recovery trajectory as well as their [CV] prognosis,” Smolderen said, “We can successfully treat depression, and that’s also what we should try and do; however, we still see that psychological comorbidities in this population are poorly recognized.”

Smolderen said the lack of treatment for this patient population can be contributed to deficient services. “Often it is a lack of resources to organize screening or mental health care follow-up after that,” she said. “There’s still not a consensus as to how we should assess and follow-up on these comorbidities, so there’s a need to test high-quality, lower-cost intervention programs that are sustainable in this setting. It is important to keep in mind that just administering a screening instrument is not going to help your patient. It is only going to help if there is a care system where you can send the patient for follow-up care.” – by Darlene Dobkowski

Reference:

Smolderen KG. I can do what after my heart attack? Presented at: American College of Cardiology Scientific Session; March 17-19, 2017; Washington, D.C.

Disclosure: Smolderen reports receiving research grants from Merck.