Treatment of anxiety and depressive disorders in patients with cardiovascular disease
Davies SJC, Jackson PR, Potokar J and Nutt DJ;
Commented by , 24 May 2004
Background
Anxiety and depressive disorders are common in the general population and even more common in patients with coronary heart disease and hypertension. Further, untreated psychiatric disorder worsens the prognosis of patients with cardiovascular disease. Are these psychiatric and medical disorders biologically linked, and if so, are treatments for anxiety/depression safe in the cardiologically compromised?
Objectives
- To review evidence for a link between psychiatric morbidity and cardiovascular disease.
- To review evidence for efficacy for psychotherapeutic treatments; and for safety and efficacy for serotonin specific re-uptake inhibitors (SSRIs) in patients with co-morbid anxiety/depression and cardiovascular disease.
Method
The authors researched Medline (1966 to August 2003) and Embase (1980 to October 2002) for all relevant English language articles. They first entered terms and text words “myocardical infarction”, “angina”, “hypertension”, “stroke”, “cerebrovascular”, and “post stroke”; then entered terms and text words “SSRIs”, “serotonin re-uptake inhibitors”, and individual drug names.
Results
- The authors found several studies showing anxiety and depression following a diagnosis of cardiovascular disease/myocardial infarction. However, prospective studies also showed excess incidence of cardiovascular disease and/or poorer outcome in patients with depression and anxiety disorders, eg., excess sudden death in patients with established anxiety.
- The authors found substantial evidence supporting non-pharmacological treatments, eg., cognitive behaviour therapy for depression and anxiety disorders in three different populations:
- the general population
- those with chest pain with normal cardiac investigations
- those with depression post myocardial infarction
- Post myocardial infarction, antidepressants used in depressed patients resulted in significantly lower mortality. They identified nine randomised controlled trials showing improved outcome with SSRIs over placebo.
There are few trials comparing tricyclics with SSRIs in patients with cardiovascular disease: tricyclics tend to be avoided because of their potentially serious side effects of postural hypotension and cardiac arrhythmias.
Five double blind trials have studied outcome of SSRIs used in depressed patients with cerebrovascular disease; all gave a positive outcome for SSRIs compared to placebo; no published studies showed a contrary trend.
Discussion
This systematic review of published data in peer-review journals came to the clear conclusion that SSRIs are safe and effective in treating psychiatric morbidity in patients with cardiovascular disease. Evidence that SSRIs may improve survival after myocardial infarction in depressed patients is less strong. This is important to General Practitioners and Psychiatrists in clinical practice given the high co-morbidity.
The authors speculate that SSRIs exert beneficial effects in cardiovascular disease by reducing platelet activation and/or restoring heart rate variability.