MedWire - ESC (Munich, Germany), September 3, 2008: Depression is a major contributor to adverse cardiovascular (CV) outcomes and this was the focus of several Oral Presentations made here on the last day of the European Society of Cardiology (ESC) congress. Highlights of a few of these are given in this report.
Cardiac depression scale accurately diagnoses depression
Professor David L. Hare, Austin Hospital, University of Melbourne, Australia
“Both major and minor depression can be accurately assessed using the cardiac depression scale (CDS),” said Professor Hare. This tool, which he helped develop, [1] consists of 26 statements that patients are asked to rate according to their level of agreement.
Professor Hare noted that the CDS has not been formally validated against the categories of major and minor depression set out by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. Therefore, a study was undertaken to investigate the diagnostic accuracy of the CDS for DSM-IV depression categories, he said. [2]
According to the DSM-IV criteria, the symptoms of depression are:
- depressed mood
- anhedonia (lack of interest or pleasure in usually enjoyable activities)
- increase/decrease in sleep
- change in appetite/weight
- change in psychomotor activity
- loss of energy
- trouble concentrating/making decisions
- thoughts of worthlessness or guilt
- thoughts about death or suicide
For depression to be diagnosed at least one of the two core symptoms (depressed mood and anhedonia) need to be present in addition to at least two of the other symptoms listed above. Major depression is said to be present if patients have at least one core symptom and five additional symptoms on most days, for 2 weeks or more. Minor depression is considered to be present if there is a core symptom plus at least two but less than five additional symptoms.
For the present study, Professor Hare and team administered the CDS and the Beck Depression Inventory (BDI) to 204 patients attending a cardiac outpatient clinic and compared the results with the findings of a Mini International Neuropsychiatric Interview (MINI). The latter (conducted by an interviewer who was unaware of the findings of the CDS or BDI assessments) showed that 14% and 12% of patients had major and minor depression, respectively, with ‘other’ identified in 2% of patients and no depression in 72%. Thus “any depression” was present in 28% of patients with cardiac disease.
The CDS was able to correctly diagnose both major and minor depression, with high specificity and sensitivity. The optimum CDS score for correctly diagnosing major depression was ≥ 95 points (100% sensitive, 81% specific), whereas diagnosing any type of depression (i.e., major, minor, other) the optimum score was ≥ 85 points (97% sensitive, 76% specific).
The CDS and BDI were comparable when diagnosing major depression, said Professor Hare, although he concluded that the CDS was better than the BDI for diagnosing mild depression.
Core depression symptoms related to mortality
Dr. Andrew Stewart, Austin Hospital, Melbourne, Australia
Comorbid depression is common in patients with heart failure (HF), said Dr. Stewart, noting that the prevalence ranges from 22-40%, although there is some evidence that it could be as high as 70% in patients who are hospitalized. He noted that depression is linked to worse symptom severity than having no depression, and that patients with HF and depression are more than twice as likely to use emergency department services.
Data also strongly suggest that cormorbid depression significantly increases the risk of mortality in patients with HF. Until now, however, studies have not looked at whether or not there are any particular symptoms that are linked to increased mortality more than others.
Dr. Stewart and colleagues used the CDS to examine if there are certain depressive symptoms linked to higher patient mortality in 374 patients who were newly diagnosed with HF. [3] The mean age of the patients was 68 years and 73% were male. The majority of patients (54%) had New York Heart Association (NYHA) class II HF, with NYHA class I in 23%, NYHA class III in 21%, and NYHA class IV in 2%. The mean duration of follow-up was 3 years and during this time, almost a quarter (23.5%) of patients died.
The presence of low mood and/or anhedonia was independently associated with increased mortality, said Dr. Stewart, although hopelessness and irritability were not.
Clinical benefits of antidepressants in patients recovering from ACS
Dr. Marianna Mazza, Institute of Psychiatry, Catholic University, Rome, Italy
Looking at whether treating depression is beneficial in patients with acute coronary syndromes (ACS), Dr. Mazza presented data from a meta-analysis involving over 3454 patients. [4] Of these, 3118 had received antidepressant treatment for at least 6 months and 336 had been given placebo. Treatment was predominantly with a selective-serotonin reuptake inhibitor (SSRI), such as sertraline, although some patients were treated with a mixed action antidepressant, mirtazapine, or cognitive behavioral therapy.
Dr. Mazza noted that a systematic literature review had been performed, looking for randomized clinical trials that compared the use of antidepressant medications versus placebo in patients with ACS. Eight papers, published up to November 2007, were deemed suitable for meta-analysis.
After 6 months of antidepressant therapy, patients treated for depression showed significant improvements in their depression symptoms, said Dr. Mazza. This was evidenced by a change in depression scores of 2.05 points, where a change of 3 points is usually considered to be clinically significant, she added.
Antidepressant treatment was also associated with a significantly lower rate of hospitalization, myocardial infarctions, repeat revascularizations, and deaths. Dr. Mazza said that antidepressant therapy “ was notably safe,” and there was no significant increase in the number of major adverse cardiac events reported.
However, she conceded that the study had many limitations, including the fact that almost 10 times as many patients received antidepressants as placebo, a range of instruments had been used within the studies to assess depression, different drugs and dosages were used, and that there were only eight studies included in the meta-analysis.
Nevertheless, Dr. Mazza concluded that these data suggest that antidepressant therapy is of significant benefit in patients with ACS and symptoms of depression and that its routine use should be considered in appropriate cases.
References- Hare DL, Davis CR. Cardiac Depression Scale: validation of a new depression scale for cardiac patients. J Psychosom Res 1996;40:379-386.
- Shi WY, Stewart AG, Hare DL. Both major and minor depression can be accurately assessed using the cardiac depression scale. Eur Heart J 2008;29 (Suppl.):745 [Abstract 4404].
- Stewart AG, Toia D, Hare DL. Core depression symptoms related to mortality in systolic heart failure patients. Eur Heart J 2008;29(Suppl.):744 [Abstract 4401].
- Mazza M, Lotrionte M, Biondi-Zoccai G, et al. Antidepressant drugs provide clinical benefits in patients recovering from acute coronary syndromes: evidence from a meta-analysis of 3,454 patients. Eur Heart J 2008;29(Suppl.):755-756 [Abstract 4446].
