Depressive Disorders and Cardiovascular Medicine Lawson Wulsin, MD Copyright © World Psychiatric Association

Introduction Major depression occurs 15-30% of ACS pts Depression triples post MI risk for death by 6 mos Screening for depression is not yet standard practice in most heart centers Depression reduces adherence to chronic regimens Depression reduces attendance at cardiac rehab Rudisch 2003; Glassman 1998; DiMatteo 2000; Copyright © World Psychiatric Association2

Depression as Risk for CV Morbidity and Mortality Depression independently raises the risk for the development of CHD (Coronary heart disease, impaired perfusion of the cardiac muscle because of narrowing of the coronary arteries or spasm of the coronary arteries leading to ischemia) In CHD pts, depression doubles the risk for CVD (Cardiovascular disease, any disease of the cardiovascular system, including hypertension, coronary heart disease, congestive heart failure, rheumatic heart disease, peripheral vascular disease, and stroke. CVD events and all-cause mortality Dose-response relationship between severity of depression and severity of CHD Linking mechanisms: –Smoking –Poor adherence –Platelet activation –Autonomic imbalance –Chronic low-grade inflammation 3Copyright © World Psychiatric Association

CVD as Risk for Depressive Disorders Vascular depression hypothesis –Decreased perfusion of limbic system contributes to late-onset depression risk High rates of “silent strokes” in depressed elderly 4Copyright © World Psychiatric Association

Assessment Depression often overlooked in CVD pts Recommend screening all CHD and CHF pts PHQ 2 screen PHQ 9 for any positive screen Referral to mental health specialist for all patients with complex depressive disorders 5Copyright © World Psychiatric Association

Depressive Disorders and Heart Surgery 20% of CABG pts experience major depression within 1 month Depression predicts poor outcome at 1 yr after CABG Heart transplantation regimens require effective treatment of depression to maintain the regimen 6Copyright © World Psychiatric Association

Treatment Options What’s good for the heart is good for the brain –Exercise, fish oil, relaxation training, stress management Citalopram Sertraline Beta blockers do not, in general, cause depression Avoid tricyclic antidepressants in pts with CAD –Risk for arrhythmia following acute coronary syndrome 7Copyright © World Psychiatric Association