Screening and Management of Depression in Patients With Cardiovascular Disease

Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD. (J Am Coll Cardiol 2019;73:1827–45) © 2019 by the American College of Cardiology Foundation. M ajor depressive disorder, commonly referred to simply as depression, affects 1 of 5 adults during their lifetime and is the second leading cause of disability in the United States (1,2). Depression is a major cause of morbidity and poor quality of life among patients with cardiovascular disease (CVD) (3) and is also considered an independent risk factor for major adverse cardiovascular events (4). Epidemiological studies suggest that fewer than 20% of individuals with depression are adequately treated (5). These rates are even lower in patients with CVD; in a study of those admitted to cardiac inpatient services, only 11% of patients with depression received adequate antidepressant therapy (6). To improve identification of patients with depression, the U.S. Preventive Services Task Force (USPSTF) recently issued recommendations to screen for depression in the general adult population while emphasizing that patients with CVD are at an increased risk of depression (7). Similar to these recommendations, the American Heart Association (AHA) issued an advisory in 2008 to screen all patients with coronary artery disease (CAD) for depression (8). However, the uptake of the USPSTF recommendations in clinical practice remains poor. While screening for depression has increased gradually since 2009, it is estimated that only 3% of patients in ambulatory care settings were screened for depression in 2015 (9). Standardized screening pathways for depression in CVD patients offer the potential for early identification and improved management of both CVD and depression (10–12). In this review, we discuss a practical approach for the screening and management of depression in patients with CVD. IMPACT OF DEPRESSION IN CVD PREVALENCE OF DEPRESSION IN PATIENTS WITH CVD. Prevalence of depression varies according to the type and severity of CVD. Approximately 15% to 20% of patients with CAD have depression; up to twothirds of patients with myocardial infarction (MI) develop depression either during index hospitalization or in follow-up (13). Compared with the general population, patients with MI are at 3-fold higher risk of depression (14). In a prospective cohort study examining the prevalence of depression in approximately 1,000 patients undergoing coronary artery bypass graft (CABG) surgery, 38% of patients met criteria for depression, with 26% having mild depression and 12% moderate-to-severe depression (15). Depression is also present in 20% of patients with peripheral artery disease (PAD) (16,17) and heart failure (18). Patients with New York Heart Association (NYHA) functional class IV have nearly 4-fold higher rates of depression compared with NYHA functional class I heart failure (18). A pooled analysis of 5 studies