European Heart Journal Advance Access originally published online on May 5, 2007
European Heart Journal 2007 28(13):1661; doi:10.1093/eurheartj/ehm127
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Meta-analysis urges the development of new strategies to treat depression in order to improve cardiac prognosis
Internal Medicine and Psychiatry
University of Groningen
Hanzeplein 1 Gebouw 32 etc
PO Box 30.001
Groningen 9700 RB
Netherlands
Cardiology, Thoraxcenter
University Medical Center Groningen University of Groningen
PO Box 30.001
Groningen 9700 RB
The Netherlands
Tel: +31 50 3619005 Fax: +31 50 3619722 E-mail address: p.de.jonge{at}med.umcg.nl
With interest, we read the meta-analysis by Nicholson et al.1 on depression as an aetiological and prognostic factor in coronary heart disease (CHD). Focusing on the prognostic risk associated with depression, their results largely confirm findings from our meta-analysis, several years ago.2 We then already observed that in most studies, adjustment for left ventricular ejection fraction (LVEF) reduced the relative risk on cardiac events associated with depression. We addressed this relationship in the MIND-IT study cohort and found that LVEF is not only cross-sectionally associated with depression, but also predicts onset of depression following myocardial infarction.3 Nicholson et al. took this point further and quantified the level of confounding by LVEF and found that up to 48% of the estimated effects of depression are attenuated by LVEF. We agree that, as argued by the authors, treatment of depression is worthwhile, irrespective of its effects on cardiac prognosis. But perhaps it is time to test whether the concept of depression as developed in general psychiatry still holds in the context of CHD. Elsewhere, we have shown that only somatic depressive symptoms (such as fatigue, rather than negative self-image) were related to cardiac prognosis, even when cardiac disease severity was controlled for.4 We believe the association between these symptoms and cardiovascular prognosis consists of two components: (i) the effect of cardiac disease severity on cardiovascular prognosis and its covariance with somatic symptoms and (ii) an independent effect of somatic depressive symptoms.
If this is true, in order to improve cardiac prognosis, interventions need to focus on strategies that preserve LV function and on strategies that reduce the effects of somatic depressive symptoms themselves. In this light, the results presented by Nicholson et al. do not discard depression as a cardiac risk factor, but instead urge us to develop interventions for depression that are more integrated in cardiac aftercare, which might differ from guideline-based psychiatric treatment for depression in the general population.
References
- Nicholson A, Kuper H, Hemingway H. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146538 participants in 54 observational studies. Eur Heart J (2006) 27:2763–2774.
[Abstract/Free Full Text] - Van Melle JP, de Jonge P, Spijkerman TA, Tijssen JG, Ormel J, van Veldhuisen DJ, van den Brink RH, van den Berg MP. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosom Med (2004) 66:814–822.
[Abstract/Free Full Text] - Van Melle JP, de Jonge P, Ormel J, Crijns HJ, van Veldhuisen DJ, Honig A, Schene AH, van den Berg MP. Relationship between left ventricular dysfunction and depression following myocardial infarction: data from the MIND-IT. Eur Heart J (2005) 26:2650–2656.
[Abstract/Free Full Text] - de Jonge P, Ormel J, van den Brink RHS, van Melle JP, Spijkerman TA, Kuijper A, van Veldhuisen DJ, van den Berg MP, Honig A, Crijns HJGM, Schene AH. Symptom dimensions of depression following myocardial infarction and their relationship with somatic health status and cardiovascular prognosis. Am J Psychiatry (2006) 163:138–144.
[Abstract/Free Full Text]
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