ORLANDO — Depression is not a proven risk factor for coronary artery disease events, but the data available now are compelling enough to warrant screening patients with coronary disease for depression and treating it when it's diagnosed.
“Depression is a very complicated phenomenon, and we're very early in our clinical experience to definitively prove that effective treatment will reduce the risk of coronary artery disease,” Dr. David S. Sheps said at a conference on cardiovascular disease epidemiology and prevention sponsored by the American Heart Association. “We're now where we were with serum lipids [and coronary artery disease] in the early 1970s, before we had results from the Lipid Research Clinics trials to show that reducing cholesterol affected events.”
Despite the limited proof, Dr. Sheps and other experts who spoke at the meeting called for screening myocardial infarction patients and others with proven coronary disease for depression and treating these patients when depression is diagnosed.
“Even if depression were not a risk factor in the strictest sense, it's a very debilitating disease and it deserves treatment. We miss a lot of patients [with depression] and so we should screen more effectively,” said Dr. Sheps, professor of medicine and associate chief of cardiovascular medicine at the University of Florida, Gainesville.
Physicians should treat depression “not to prevent coronary artery disease events but to improve patient[s'] quality of life,” agreed Dr. Mary A. Whooley, a physician and epidemiologist at the University of California, San Francisco. A randomized trial is needed to prove that treating depression improves cardiovascular outcomes, she said in an interview. But this type of proof is not needed for physicians to treat depression in patients right now because patients get other benefits from treatment.
Dr. Whooley, as well as Dr. Lawson Wulsin, recommends a two-step screening approach for diagnosing depression in patients with coronary disease or in any patient with suggestive symptoms in a primary care practice. Step 1 is to use a two-item questionnaire, the Patient Health Questionnaire (PHQ)-2. The two questions asked are: During the past month, have you often been bothered by feeling down, depressed, or hopeless? During the past month, have you been bothered by little interest or pleasure in doing things?
A “yes” to either of these two questions suggests that depression may be present, and as a screening tool the questionnaire is 96% sensitive for not missing a possible case, said Dr. Wulsin, a professor of psychiatry and family medicine at the University of Cincinnati.
Step 2 in confirming a diagnosis is to use the PHQ-9, a nine-question tool that also is scored based on the frequency of several depression symptoms, such as poor appetite, trouble falling asleep, and trouble concentrating. This follow-up questionnaire takes about 2 minutes for a patient to complete, said Dr. Whooley. It can miss diagnosing about half of the patients who actually have depression, so a negative result on the PHQ-9 should be followed by a clinical interview. But if a patient has positive findings on the PHQ-9, with a score of 10 or higher, then the specificity is 90%, and the patient can be considered to be depressed without need for further confirmation, Dr. Whooley said.
Once diagnosed, a major issue is how to treat, especially in patients with coronary disease that might become exacerbated by certain antidepressant drugs. The top options are sertraline (Zoloft), citalopram (Celexa), and bupropion (Wellbutrin) for patients who are intolerant of a selective serotonin reuptake inhibitor (SSRI), said Dr. Whooley. Citalopram and sertraline are the SSRIs that are least likely to inhibit cytochrome P450 enzymes, and hence they minimize potential interactions with other drugs that patients with coronary disease might take. Bupropion can be associated with minor increases in blood pressure, but it's an especially good first-line choice if the patient smokes and is trying to quit.
'Even if depression were not a risk factor [for CAD] in the strictest sense … it deserves treatment.' DR. SHEPS