1. Post Myocardial Infarction Depression and Subsequent Cardiac Events By Mitchell Kee

2. Background 20% of patients post myocardial infarction (MI) develop depression 20% of patients post myocardial infarction (MI) develop depression 2-2.5 fold increase 2-2.5 fold increase risk of mortality risk of mortality (all causes) (all causes) Risk of cardiac mortality is also increased Risk of cardiac mortality is also increased

3. Previous Studies Inconclusive Inconclusive Some suggest that treatment for depression can Some suggest that treatment for depression can Protect the heartProtect the heart Have no effectHave no effect Be CardiotoxicBe Cardiotoxic CBT had no improved prognosis as compared to normal care CBT had no improved prognosis as compared to normal care

4. This Study Prior studies Prior studies Little improvement of prognosis with antidepressantsLittle improvement of prognosis with antidepressants No effect on the depression in these studiesNo effect on the depression in these studies This study = Does effective treatment for depression affect cardiovascular prognosis This study = Does effective treatment for depression affect cardiovascular prognosis

5. What do we want to know? Will Responders after 24 weeks have lower risk of cardiovascular events? Will Responders after 24 weeks have lower risk of cardiovascular events? Is the increased risk in nonresponders an effect of refractory depression on the heart? Is the increased risk in nonresponders an effect of refractory depression on the heart?

6. Method Recruit patients admitted with MI Recruit patients admitted with MI Exclude those with Exclude those with MI not reason for hospitalisationMI not reason for hospitalisation Dis. likely to affect short term survivalDis. likely to affect short term survival Previous history of psychiatric illnessPrevious history of psychiatric illness In another clinical trialIn another clinical trial

7. Procedure Selected patients screened for depression at 3 months Selected patients screened for depression at 3 months Treatment vs. normal care Treatment vs. normal care No information for normal care patients No information for normal care patients

8. Subjects In total In total 90 - double-blind mirtazapine/placebo for 8 weeks90 - double-blind mirtazapine/placebo for 8 weeks 100 received usual care100 received usual care

9. Course of Action Hamilton Depression scale Hamilton Depression scale If unresponsive switch to citalopram (open) If unresponsive switch to citalopram (open) After 24 weeks - classed as responders and nonresponders After 24 weeks - classed as responders and nonresponders Responders = 50% drop in HAM-D or HAM-D <9 Responders = 50% drop in HAM-D or HAM-D <9

10. Results 45 - mirtazapine (M). 45 - mirtazapine (M). 15 nonresponders (NR), given Citalopram (C)15 nonresponders (NR), given Citalopram (C) 45 - placebo (P) 45 - placebo (P) 25 – NR, given C25 – NR, given C Overall 70 - drugs (either C or M) Overall 70 - drugs (either C or M) 100 - no drugs 100 - no drugs After 24 weeks After 24 weeks 40% - R40% - R 60% - NR60% - NR

11. Cardiac events (24wk-18mth) Cardiac events (24wk-18mth) 25% NR25% NR 7% R7% R 11% U11% U Depression after 18 months Depression after 18 months 10% R10% R 33.3% U33.3% U 60% NR60% NR Results

12. What does this mean? Responders vs. untreated = similar results Responders vs. untreated = similar results Clearly presence of treatment not main factorClearly presence of treatment not main factor Nonresponders Nonresponders Higher chance of recurrence of depressionHigher chance of recurrence of depression Higher chance of cardiac eventHigher chance of cardiac event

13. So? Subtype of post MI depression Subtype of post MI depression Increases chance of further eventIncreases chance of further event Refractory to normal treatmentRefractory to normal treatment Persistent depression is responsible for most eventsPersistent depression is responsible for most events

14. Conclusion Persistent depression Persistent depression Increases reactivity of plateletsIncreases reactivity of platelets Increases ANS activityIncreases ANS activity Increased immune system reactionsIncreased immune system reactions These increase chance of cardiac event These increase chance of cardiac event

15. Thank you for your attention Thank you for your attention

16. source nonresponse to treatment for depression following mzocardial infarction: association with subsquent cardiac events source nonresponse to treatment for depression following mzocardial infarction: association with subsquent cardiac events Amerian Journal of Psychiatry september 2007Amerian Journal of Psychiatry september 2007