1. Depression, Vital Exhaustion and recurrent heart disease

2. Lecture 9 references Standard texts, Kop paper, and Krantz & Lundgren paper. Depression and CHD is very current topic and good reviews are just appearing. Psychosomatic Medicine has made a complete special issue on the topic available over the internet (free). Go to www.psychosomaticmedicine.org www.psychosomaticmedicine.org Kubzansky & Kawachi 2000. Going to the heart of the matter: do negative emotions cause coronary heart disease? J Psychosomatic Res., 48, 323-327 Review that includes depression. Carney, R M., Freedland, Miller, M (2002) Depression as a risk factor for cardiac mortality and morbidity:A review of potential mechanisms. J Psychosomatic Res., 53, 897-902. Thoughtful discussion that is worth reading.

3. Depression: what is it? DSM-IV Five of following for at least 2 weeks Sad mood most of day, most days Loss of interest & pleasure in usual activities Sleeping difficulties Change in activity level Change in eating patterns Fatigue Negative view of self Less efficient thinking Recurrent thoughts of suicide or death

4. Frasure-Smith et al, 1999. Gender, depression and one-year prognosis after myocardial infarction. Psychosomatic Med. 61, 26-37. (On web through library, worth reading). See also her paper on special issue of Psychosomatic Medicine referred to earlier Nancy Frasure-Smith major figure in proposing that depression makes reinfarction more likely. In this paper she combines her earlier studies to get large enough sample to examine effects of gender. Sample. Women 283, Men 613.

5. Frasure-Smith, 1999

6. Barefoot et al, 2000 Depressive symptoms and survival of patients with coronary artery disease. Psych. Med. 62, 790-795. 1250 patients with CAD seen between 1974 & 1980 followed up for up to 19.4 years. Measure Negative Affect. 6 item covering Sad, crying, suicidal thoughts, irritability, restlessness

7. High negative affect (overlaps with depression), associated with lower survival in younger patients

8. Vital Exhaustion (Ad Appels), see Kop Features lack of energy increased irritability demoralization Vital exhaustion is short term predictor of MI, Rotterdam Civil Servant study. 3877 healthy men followed up for 4.2 years.

10. More coronary events in “exhausted” patients who received angioplasty, Kop.

11. Mechanisms for Depression CHD link Reactivity. Studies just appearing. Contradictory evidence as to whether reactivity increased or decreased in depression. Consider role of anger/irritation. Anti-depressants Other Risk factors Heart disease severity Adherence and other behavioural mechanisms Autonomic tone Blood clotting processes. PF4 and BTG increased in depressed CHD patients Inflammatory processes. Evidence of increased inflammation related to chlamydia in exhausted patients with CAD (Appels 2000). See Kop in special issue of Psychosomatic Medicine.

12. Studies in Health populations Kuper Marmot & Hemingway (2002), Seminars in Vascular Medicine,2, 267-313 Psychological processpositive/no. of studies Type A / Hostility6/18 Depression15/22 Anxiety 4/8 Work characteristics10/13 (Social Support 6/9) Studies in Populations with Cardiovascular Disease Type A/Hostility 2/15 Depression 18/34 Anxiety 8/18 Work characteristics 2/4 (Social Support 14/21) Seen as positive support overall By K,M & H

13. Evidence from interventions

14. ENRICHD (2003). Treatment of depression and low perceived social support after myocardial infarction JAMA, 289, 3106-3116 Effects on Depression BDI at only 6 months Pre 6 month Usual Care 18.012.2 Intervention 17.79.1 ENRICHD trial of reduction of Depression and/or increase in Perceived Social Support. No effect on Recurrent MI but very little effects on Depression or Social Support

15. Appels, A et al., (2005) Effects of treating exhaustion in angioplasty patients on new coronary events. Psychosom Med 67, 217- 223 Effects on Exhaustion at 18 months No history of CAD Int. Cntrl % Not Exhausted 5638 Exhausted 4462 History of CAD Int. Cntrl % Not Exhausted 4747 Exhausted 5353 Reduction in Vital Exhaustion after Angioplasty. No effect on new coronary events but effect on Exhaustion restricted to sub-sample of patients

16. Johnston,M, Foulkes J, Johnston, D, Pollard, B, Gudmundsdottir, H (1999) Psychosomatic Medicine, 61, 225-233 Depression reduced in patients after MI by simple Counselling intervention

17. Johnston,M, Foulkes J, Johnston, D, Pollard, B, Gudmundsdottir, H (1999) Psychosomatic Medicine, 61, 225-233 Depression reduced in partners of MI patients who received counselling

18. Why no effects of interventions on CHD? Little effect on Depression Why? Perhaps depression different after MI> Martens et al (2006) Classic depressive cognitions absent in Post MI patients – somatic symptoms of depression present And When depression reduced studies too small to show effect on CHD recurrence Martens et al, 2006, Relative lack of depressive cognitions in post MI depression. J Affective Disorders, 94, 231-237

19. Depression: what is it? DSM-IV Five of following for at least 2 weeks Sad mood most of day, most days Loss of interest & pleasure in usual activities Sleeping difficulties Change in activity level Change in eating patterns Fatigue Negative view of self Less efficient thinking Recurrent thoughts of suicide or death