depression as a risk factor of heart disease?

Photo: Darrel Regier, M.D.

Darrel Regier, M.D., former APA director of research, discusses APA’s involvement with the AHA’s recommendation to consider depression as a major risk factor for heart disease.

Sylvia Johnson

Despite publication of numerous studies and meta-analyses showing a link between depression and cardiovascular disease, the American Heart Association (AHA) has yet to formally recognize depression as a risk factor for a poor prognosis in patients with heart disease.

On March 25 in the journal Circulation, a statement was issued by the AHA in response to a systemic literature review, which could lead to depression being considered as a major risk factor in heart disease among adults in the United States.

A 12-person panel was organized by the AHA to determine if depression should be elevated to the status of risk factors—along with diabetes, high blood pressure, and smoking—for patients with coronary heart disease (CHD).

“Many studies have found that depression predicts increased mortality [for patients with heart disease],” Robert Carney, Ph.D., a panel member and a professor of psychiatry at Washington University School of Medicine, stated during an interview with Washington University BioMed Radio. “But this was the first time that it was formally done, in this way, by the American Heart Association.”

According to the AHA, an estimated 15.4 million U.S. adults have CHD, and approximately 20 percent of patients hospitalized for CHD meet criteria for a DSM diagnosis of major depression.

“There is growing recognition among cardiologists that psychosocial factors are associated with [negative cardiac] outcomes,” commented Judith Lichtman, Ph.D., M.P.H., lead author and cochair of the National AHA Writing Committee. Lichtman, who is an associate professor at the Yale School of Public Health, said that the goal of the panel was to review studies to evaluate the evidence linking the risk of depression on outcomes for patients with CHD.

The panel was charged with sifting through more than 1,000 studies that indicated an association between depression and CHD. A total of 53 studies were selected for review that met the following inclusion criteria: a prospective design, more than 100 patients were included, established assessment instruments were used to define major depression or depressive symptoms, and nonfatal cardiac events and all-cause mortality, cardiac mortality, or a combination of both were reported. Studies that did not have a nondepressed comparison cohort were excluded.

After years of evaluating the selected studies, the panel issued the following scientific statement: “Our review identified heterogeneity in the published findings from these studies in terms of the demographic composition of the samples, the definition and measurement of depression, [and] the length of follow-up. . . . Despite this heterogeneity, the preponderance of evidence supports the recommendation that the AHA should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.”

The former head of the APA Office of Research, Darrel Regier, M.D., who is now an APA consultant, said he is pleased with the AHA panel’s recommendation. “The integration of mental health with the rest of general medicine is illustrated by this linkage between depression and cardiovascular disease,” Regier told Psychiatric News. “I am glad that the AHA is making another step to elevate depression to a major risk category for cardiovascular disease.”

Regier explained that in 2008 APA was asked by the AHA to endorse a scientific manuscript concerning the impact for depression on heart disease, which was intended to initiate the process to highlight depression as a risk factor in cardiovascular disease. After publication of the manuscript and APA’s endorsement, the AHA advisory committee decided that there was not enough sound evidence to make such a recommendation.

Shortly after the disappointing news, said Regier, the AHA convened another panel, in which APA was asked to participate. Lawson Wulsin, M.D., a professor of psychiatry and family medicine at the University of Cincinnati, was recommended by APA to sit on the panel.

Regier told Psychiatric News that though the extensive literature review conducted by the AHA had many setbacks, the final outcome will definitely payoff for the field of psychiatry.

“The AHA recommendation emphasizes that depression is a whole-body illness. This is very important to consider in terms of future reimbursements for treating depression. It’s not just treating a mental health condition; it’s also reducing the risk of heart disease.” ■

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