Depression in cardiovascular disease: From awareness to action

Abstract

In this issue of Trends in Cardiovascular Medicine, Drs. Bradley and Rumsfeld [1] provide a clear, contemporary review of the phenomenology, assessment, and treatment of depression in patients with heart disease. Their article adds to a large volume of such reviews written over the last 15 years. It should be clear at this point that depression in cardiac patients is common, underrecognized, persistent, and deadly. Furthermore, it is also increasingly clear that psychotherapy and antidepressant medications are well tolerated and generally effective in treating depression in this population. The question is, now what? Certainly, increasing recognition of the prevalence and toxic effects of depression is a start. In addition to reviews such as this one, the American Heart Association has taken a lead role in highlighting the issue of depression in cardiac patients, first in 2008 by recommending systematic screening of all cardiac patients [2], and then in 2014 by declaring depression a risk factor for poor prognosis following an acute coronary syndrome [3]. However, despite being a good first step, depression screening alone is at best ineffective and at worst associated with increased patient distress and greater clinician burden [4,5]. Furthermore, asking front-line clinicians to assess patients for depression, initiate treatment, and monitor and adjust such treatment may feel well beyond the scope of practice for many cardiologists. This is especially true given that most cases of major depression—in cardiac and non-cardiac patients—often require long trials and multiple adjustments of treatment before patients have substantial symptomatic and functional relief [6]. Furthermore, there is evidence that patients with significant medical conditions may be more