Depression and Coronary Heart Disease

There are exciting findings in the field of depression and coronary heart disease. Whether diagnosed or simply self-reported, depression continues to mark very high risk for a recurrent acute coronary syndrome or for death in patients with coronary heart disease. Many intriguing mechanisms have been posited to be implicated in the association between depression and heart disease, and randomized controlled trials of depression treatment are beginning to delineate the types of depression management strategies that may benefit the many coronary heart disease patients with depression

Emotional predictors and behavioral triggers of acute coronary syndrome

Mounting evidence suggests that depression, anxiety, and hostility/anger may each be an independent risk factor for acute coronary syndrome (ACS) occurrence. Data specific to the role of these negative emotional states in predisposing to imminent ACS risk are limited, however. Additionally, a number of studies have indicated that certain situational triggers (such as intense physical exertion) and behavioral triggers (such as acute anxiety or anger) are predictive of imminent occurrence of an ACS. Despite these findings, the use of emotional or behavioral information to identify persons at high risk for imminent ACS onset is not yet practical. Further research is needed to facilitate such patient identification

Anger Expression and Risk of Coronary Heart Disease: Evidence From the Nova Scotia Health Survey

Background Whereas some studies have found that anger increases the risk of incident coronary heart disease (CHD), others found anger to be protective. Prior studies did not account for different types of anger expression, which may be associated with opposing levels of cardiovascular risk. This study examines whether distinct types of anger expression differentially predict incident CHD. Methods We conducted a population-based, observational prospective study of 785 randomly selected Canadian men and women (50% each) aged 46 to 92 years and free of CHD in 1995. Using videotaped interviews, trained coders rated 3 types of anger expression: constructive anger (discussing anger to resolve the situation), destructive anger justification (blaming others for one's anger), and destructive anger rumination (brooding over an anger-inducing incident). The association between anger expression type per SD and incident CHD was estimated using Cox proportional hazards models adjusted for sex, age, cardiovascular risk factors, depressive symptoms, hostility, and anxiety. Interactions of anger expression type and gender were also tested. Results There were 115 incident CHD events (14.6%) during 6,584 person-years of follow-up. The association between clinically assessed constructive anger expression and CHD varied by gender (P for interaction = .02); higher levels were associated with a lower risk of incident CHD in men only (hazard ratio 0.58, 95% CI 0.43-0.80, P < .001), whereas higher levels of destructive anger justification was associated with a 31% increased risk of CHD in both sexes (hazard ratio 1.31, 95% CI 1.03-1.67, P = .03) and predicted CHD incidence independent of covariates and depressive symptoms, hostility, and anxiety. Conclusions Decreased constructive anger in men and increased destructive anger justification in men and women are associated with increased risk of 10-year incident CHD

Mental Disorders and Coronary Heart Disease Risk: Could the Evidence Elude Us While We Sleep?

Although provocative findings from large epidemiological studies suggest that mental disorders and elevated psychiatric symptoms are independent risk factors for the incidence and recurrence of coronary heart disease (CHD), other studies do not replicate this somewhat startling finding.1–3 This research has been characterized by incomplete adjustment for confounders, wide variation in the assessment of mental disorders, and inconsistent inclusion of multiple mental disorders and overlapping symptom clusters. For incident CHD, the most convincing evidence comes from prospective studies linking a diagnosis of depression or the presence of elevated depressive symptoms with later occult CHD.3 Although there have been tantalizing glimpses of associations of other types of mental disorders, such as alcohol/substance use disorder, anxiety, and schizophrenia, with incident CHD, there are a paucity of studies examining this risk. Indeed, we conducted a preliminary search of the prospective epidemiological literature on the association of mental disorders with incident CHD and found that, of 123 results retrieved, approximately 60% focused uniquely on depression, 10% on alcohol/substance use disorder, 11% on anxiety or posttraumatic stress disorder, and 14% on psychosis or schizophrenia. Thus, outstanding questions about the nature and consistency of the association of specific types of mental disorders—other than depression—and incident CHD remain

Depression and cardiovascular disease: Selected findings, controversies, and clinical implications from 2009

We systematically searched published empirical research on depression and cardiovascular disease (CVD) and found 494 unique articles published in 2009. Several particularly notable and provocative findings and controversies emerged from this survey of the 2009 literature. First, multiple large observational studies found that antidepressant use was associated with increased risk of incident stroke, CVD, or sudden cardiac death. Second, four randomized controlled trials on depression interventions in CVD patients reported important efficacy results that should guide future trials. Finally, the vigorous debate on whether patients with CVD should be routinely screened (and subsequently treated) for depression continued in 2009 even as some observed that routine screening for CVD in depressed patients is more evidence-based and appropriate. This article reviews these selected provocative findings and controversies from our search and explores their clinical implications

Evidence Searching for Evidence-Based Psychology Practice

There is an increased awareness of evidence-based methodology among psychologists, but little exists in the literature about how to access the research. Moreover, the prohibitive cost of this information and limited time are barriers to the identification of evidence to answer clinical questions. This article presents an example of a question worked though in an evidence-based way. Methods are highlighted, including distinguishing background and foreground questions, breaking down questions into searchable statements, and adapting statements to suit both the question being asked and the resource being searched. A number of free, evidence-based resources are listed. Knowing how and where to access this information will enable practitioners to more easily use an evidence-based approach to their practice

Don't worry, be happy: positive affect and reduced 10-year incident coronary heart disease: The Canadian Nova Scotia Health Survey

AIMS: Positive affect is believed to predict cardiovascular health independent of negative affect. We examined whether higher levels of positive affect are associated with a lower risk of coronary heart disease (CHD) in a large prospective study with 10 years of follow-up. METHODS AND RESULTS: We examined the association between positive affect and cardiovascular events in 1739 adults (862 men and 877 women) in the 1995 Nova Scotia Health Survey. Trained nurses conducted Type A Structured Interviews, and coders rated the degree of outwardly displayed positive affect on a five-point scale. To test that positive affect predicts incident CHD when controlling for depressive symptoms and other negative affects, we used as covariates: Center for Epidemiological Studies Depressive symptoms Scale, the Cook Medley Hostility scale, and the Spielberger Trait Anxiety Inventory. There were 145 (8.3%) acute non-fatal or fatal ischaemic heart disease events during the 14 916 person-years of observation. In a proportional hazards model controlling for age, sex, and cardiovascular risk factors, positive affect predicted CHD (adjusted HR, 0.78; 95% CI 0.63-0.96 per point; P = 0.02), the covariate depressive symptoms continued to predict CHD as had been published previously in the same patients (HR, 1.04; 95% CI 1.01-1.07 per point; P = 0.004) and hostility and anxiety did not (both P > 0.05). CONCLUSION: In this large, population-based study, increased positive affect was protective against 10-year incident CHD, suggesting that preventive strategies may be enhanced not only by reducing depressive symptoms but also by increasing positive affect

Diagnosing medication non-adherence in a patient with myocardial infarction

Background: Medication non-adherence continues to be a major challenge facing the healthcare system. A case is presented of a 48-year-old man with myocardial infarction who was found to be non-adherent to multiple medications. Conceptual models are reviewed along with current approaches for assessment and treatment of medication non-adherence. Design: Case report and literature review. Discussion: A theoretical model for medication non-adherence built on the Theory of Planned Behavior is presented. Empirical evidence is reviewed for determinants of non-adherent behavior such as health beliefs and self-efficacy. Current methods to assess medication non-adherence, including self-report, pill count, biological drug levels, pharmacy refill, and electronic bottles are summarized along with their limitations. Finally, an individualized approach for assessment is described using the case presented and the conceptual framework outlined above. Follow-up for the patient and potential interventions to improve medication adherence are discussed. Conclusion: Despite the challenges, a conceptual framework for medication non-adherence can guide assessment and treatment. Further research for innovative and effective methods to detect and treat medication non-adherence is urgently needed to aid clinicians in treating this pervasive behavioral problem

How Should We Treat Depression in Patients with Cardiovascular Disease?

Among patients with cardiovascular disease (CVD), depression is highly prevalent and is associated with worse cardiovascular prognosis and lower quality of life. Treatments for depression in CVD patients produce modest, but clinically significant reductions in depressive symptoms and show promise for improving cardiovascular prognosis. While tricyclics should generally be avoided, antidepressants from multiple other classes appear to be safe in cardiac patients. A strategy of engaging patients in choosing medications or psychotherapy and then intensifying treatment to therapeutic goal appears to be more effective at reducing depression than single mode interventions. Recommendations for screening all CVD patients for depression may be premature given increased costs associated with screening and gaps in knowledge about the risk-benefit ratio of depression treatment in mild and moderately depressed patients