Check All Heart Patients for Depression?

Heart Disease and Depression Are Common; New Recommendations Call for Universal Screening

By Kathleen Doheny
WebMD Health News

Reviewed By Elizabeth Klodas, MD, FACC

Sept. 29, 2008 -- Heart disease and depression are so common that all heart patients should be routinely screened for depression and referred for professional help if necessary, according to new recommendations issued by the American Heart Association.

The recommendations were spurred by growing evidence suggesting that depression is common among cardiac patients and that the condition can worsen patients' outcomes, making them more vulnerable to continuing or recurrent heart problems.

This is the Heart Association's first "call to action" addressing cardiac patients and depression, says Erika Froelicher, RN, MPH, PHD, professor of nursing and epidemiology and statistics at the University of California, San Francisco and co-chair of the writing group that created the recommendations.

"The call for action is for health care providers who deal with cardiac patients," she tells WebMD, and that includes doctors, nurses, and many other health care professionals.

The hope, she says, is that routine screening for depression will be done on every cardiac patient. "I believe a lot of depressed cardiac patients are overlooked," Froelicher says. "Unless you screen formally, you can miss a lot of people."

The American Psychiatric Association has endorsed the new recommendations, published in the Oct. 21 issue of Circulation: Journal of the American Heart Association.

Heart Disease & Depression: The Problem

Depression is about three times more common in patients after an attack than in the general population, and it can also occur with other types of heart problems. Many studies have found that depression is linked to a worse outcome in heart patients, who are more apt to have repeat heart attacks, for instance.

Heart Disease & Depression: The Recommendations

Among the new AHA recommendations:

  • Administer a two-item questionnaire, asking the patient: "Over the past two weeks, how often have you been bothered by any of the following problems? (1) Little interest or pleasure in doing things. (2) Feeling down, depressed, or hopeless."
  • If a patient answers in the affirmative to either question, screening with a more comprehensive questionnaire is recommended. The second questionnaire includes nine items, asking about feelings of hopelessness, changes in appetite or sleep habits, problems concentrating, and any instances of suicidal thoughts.

Patients who score high on the second questionnaire should be referred to a professional qualified in the diagnosis and management of depression. Cardiac care providers can also elect to refer patients to depression specialists if they answer in the affirmative on the initial two-question assessment.

In the advisory, the experts lay out the treatment options but leave it to health care providers to tailor the treatments to individual patients. Among the options to treat depression are antidepressant drugs, behavior or talk therapy, and physical activity recommendations.

If medications are required, the antidepressants Zoloft and Celexa are considered good first choices, the authors say, as research has shown they are generally safe for cardiac patients.

Heart Disease & Depression: A Patient's View

Dale Briggs, 62, of Fresno, Calif., had a heart valve replaced in 1994 because of a condition called mitral valve prolapse, a common heart valve disorder.

"My physical recovery was uneventful," he tells WebMD. Yet he began to experience anxiety and had trouble sleeping, among other problems. One day, sitting in his doctor's office, he saw a poster listing the signs of depression. There were 18 in all, he remembers.

"I had all of them except the one that said 'thoughts of suicide,'" he says.

He shared that with the doctor -- and told him "I am scared to death this valve is going to kill me." The physician put him on an antidepressant. That helped, he says.

"Then I discovered Mended Hearts," Briggs says. The national nonprofit organization, affiliated with the American Heart Association, offers resources and support for heart patients. Briggs began volunteering, and estimates he has talked to more than 1,000 cardiac patients in the hospital. He now serves as volunteer executive vice president of the organization.

Heart Disease & Depression: A Psychiatrist's View

The new recommendations "are terrific," says Michelle Riba, MD, associate chair of integrated medical and psychiatric services and associate director of the Depression Center at the University of Michigan, Ann Arbor. She helps direct a joint program between the depression center and the university's cardiovascular center, with the goal of meeting a heart patient's physical and psychological needs.

"This is definitely in line with what we have been trying to do at the University of Michigan."

SOURCES: Erika Froelicher, PHD, MPH, RN, professor of nursing and epidemiology and biostatistics, University of California, San Francisco; co-chair of the writing group for the recommendations. Lichtman, J. Circulation: Journal of the American Heart Association, Oct. 21, 2008, vol 118: pp 1-5. Dale Briggs, insurance consultant and heart valve patient, Fresno, Calif.; volunteer executive vice president, Mended Hearts Inc. Michelle Riba, MD, associate chair of integrated medical and psychiatric services, department of psychiatry, and associate director, University of Michigan Depression Center, Ann Arbor. Thombs, B. Journal of General Internal Medicine; January 2006, vol 21: pp 30-38.

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In the U.S., 1 in every 4 deaths is caused by heart disease. See Answer

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