Minding the heart: Why are we still not closer to treating depression and anxiety in clinical cardiology practice?

Psychological comorbidities are common in patients with ischaemic heart disease (IHD) and other cardiovascular conditions, such as peripheral arterial disease, atrial fibrillation and cardiomyopathies, with as many as 20% of patients suffering from depression and/or anxiety. Not only a clinical diagnosis but also subthreshold levels have prognostic implications, as depression is a barrier for appropriate risk factor management, increases risk of non-adherence, refusal or drop-out from cardiac rehabilitation, readmission and premature death despite state-of-the-art treatment. Unfortunately, depression and anxiety tend to be overlooked and undertreated in cardiac patients, although depression alone in cardiac patients adds an extra cost of 33% compared with patients without depression. Both IHD and depression are associated with a high economic burden and will be among the top 10 contributors to the disease-burden worldwide in 2020. Paradoxically, despite this consistent evidence and recognition of depression, anxiety and psychosocial factors as risk factors by European and National Societies already in 2012, this has had little impact on changing clinical practice. Given that the number of patients with IHD has increased considerably due to better treatment options and ageing of the population, there is an urgent need to treat heart and mind in concert and not only the underlying somatic disease but also psychological comorbidity, in order to bridge this gap in clinical practice. The state-of-the-art Cochrane review by Richards et al. published in this issue may comprise an important piece of the puzzle in terms of helping us to understand why we are not closer to implementing screening for depression and anxiety combined with interventions targeting depression and anxiety in clinical practice. Although no randomized controlled trial (RCT) to date has examined the effectiveness of screening combined with intervention targeting depression and anxiety, the review by Richards et al. pinpoints other challenges, such as uncertainty about treatment effects due to low quality of evidence across different endpoints from cardiovascular morbidity and mortality to psychological outcomes. In addition, the heterogeneity between studies is significant and the level of quality varies from moderate to low and very low. Although the review demonstrates an effect of psychological interventions on cardiovascular mortality, no effects are seen on total mortality and major adverse cardiac events, such as myocardial infarction and revascularization procedures. In addition, only small to moderate improvements are seen in symptoms of depression, stress and anxiety, and these estimates are plagued by some uncertainty. This despite the inclusion of 35 randomized studies and 10,703 participants (median follow-up of 12 months) with data added from 14 new studies as compared with the previous Cochrane review in 2011. It is disappointing and of great concern to see that little has changed in the cardiovascular behavioural field in terms of demonstrated effects of psychological interventions since 2011, with the fear that the next update of this Cochrane review will show similar results. Although challenged health care budgets and hospital resources across the world combined with an increasing number of patients with complex chronic disease and multi-morbidities may constitute another piece of the puzzle why clinical practice has not changed, the time may be ripe for behavioural scientists and mental health professionals engaged in research and working in the cardiovascular field to take a step back and evaluate whether we are on the right path. If we take a critical look at the field, there has been a tendency to use a simplistic one-size-fits-all approach. However, the Cochrane review clearly demonstrates that this approach does not work, as patients are