Management of Depression in Patients with Comorbid Cardiovascular Disease

Evidence suggests that depression commonly occurs in patients with cardiovascular disease and is associated with a poor prognosis including increased risk of cardiac mortality. Proposed pathophysiologic mechanisms include decreased heart rate variability, altered sympathetic and parasympathetic activity, increased ventricular instability, and abnormal platelet reactivity. Other proposed mechanisms involve the interference of depression with medication adherence and cardiac risk factor reduction. Despite this evidence, depression during cardiovascular disease is commonly unrecognized and inadequately treated. Tricyclic antidepressants (TCA) are efficacious for treating depression in this population but cause serious cardiac side effects and should be avoided in patients with significant cardiovascular disease. More recent studies with bupropion and the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline) indicate that they are acceptable alternatives to TCAs with regard to cardiac risk in depressed patients with heart disease, although larger studies are needed to validate their safety and efficacy in this special population. There are 3 studies currently being conducted to investigate the effect of antidepressant therapy and/or psychotherapy on cardiac morbidity and mortality in post–myocardial infarction patients with depression and/or low social support. These studies will hopefully answer the long-posed question of whether appropriate treatment of depression can improve cardiac prognosis.