Evidence Report/Technology Assessment

Number 123 

Post-Myocardial Infarction Depression 

Prepared for:

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0018

Prepared by:

The Johns Hopkins University Evidence-based Practice Center, Baltimore, MD 

Investigators 

David E. Bush, MD 

Roy C. Ziegelstein, MD 

Udita V. Patel, MSPH 

Brett D. Thombs, PhD 

Daniel E. Ford, MD, MPH 

James A. Fauerbach, PhD 

Una D. McCann, MD 

Kerry J. Stewart, ED 

Konstantinos K. Tsilidis, MPH 

Avani L. Patel, MPH 

Carolyn J. Feuerstein, BA 

Eric B. Bass, MD, MPH 

AHRQ Publication No. 05-E018-2 

May 2005
This report may be used, in whole or in part, as the basis for development of clinical practice

guidelines and other quality enhancement tools, or a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve the 

quality of health care, reduce its cost, address patient safety and medical errors, and broaden access 

to essential services. AHRQ sponsors and conducts research that provides evidence-based 

information on health care outcomes; quality; and cost, use, and access. The information helps 

health care decisionmakers—patients and clinicians, health system leaders, and policymakers—

make more informed decisions and improve the quality of health care services.
ii 

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without specific 

permission of copyrighted holders. 

Suggested Citation: 

Bush DE, Ziegelstein RC, Patel UV, Thombs BD, Ford DE, Fauerbach JA, McCann UD, Stewart 

KJ, Tsilidis KK, Patel AL, Feuerstein CJ, Bass EB. Post-Myocardial Infarction Depression. 

Evidence Report/Technology Assessment No. 123. (Prepared by the Johns Hopkins University 

Evidence-based Practice Center under Contract No. 290-02-0018.) AHRQ Publication No. 05-

E018-2. Rockville, MD: Agency for Healthcare Research and Quality. May 2005. 
iii 

Preface

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and new 

health care technologies. The EPCs systematically review the relevant scientific literature on 

topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to 

developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to release. 

 AHRQ expects the EPC evidence reports and technology assessments will inform individual 

health plans, providers, and purchasers as well as the health care system as a whole by providing 

important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H. 

Director Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

 

Kenneth S. Fink, M.D., M.G.A., M.P.H. Ernestine W. Murray, B.S.N., R.N., M.A.S. 

Director, EPC Program EPC Program Task Order Officer 

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

The authors of this report are responsible for its content. Statements in the report 

should not be construed as endorsement by the Agency for Healthcare Research and 

Quality or the U.S. Department of Health and Human Services of a particular drug, 

device, test, treatment, or other clinical service.
iv 

Acknowledgments 

We thank Karen A. Robinson, M.Sc., for her guidance with the literature process and the 

methodology; Sachin Agarwal, M.D., M.P.H., and Teerath Tampikopongse for assistance with 

review of the literature; Dhwani Mankad, M.D., M.P.H., for database management and review of 

literature; Christine Napolitano for literature retrieval and data management; and Brenda 

Zacharko for preparation of tables. 

We also thank our Task Order Officer, Captain Ernestine Murray, for her support with the 

project.
v 

Structured Abstract

Context: To improve outcomes of patients with myocardial infarction (MI), a number of 

treatments are typically recommended, including medications, revascularization procedures, 

behavior and lifestyle changes, and cardiac rehabilitation. Co-existent depression may influence 

the recovery of patients with MI in a number of important ways reviewed in this report. 

Objectives: Depression is manifested by a number of symptoms, including depressed mood, 

diminished interest or pleasure, and low self-esteem. These symptoms may occur in patients 

recovering from an MI and have the potential to adversely impact recovery. In this report, we 

examined the evidence addressing the following questions: 1) In patients with acute MI, what is 

the prevalence of depression during the initial hospitalization? 2) What percentage of patients 

with post-MI depression continue to have depression one or more months after initial hospital 

discharge? 3) What is the association of post-MI depression with outcomes or with surrogate 

markers of cardiac risk, independent of other predictors of post-MI outcomes? 4) Do post-MI 

patients with depression have better outcomes with depression treatment compared to those 

without depression treatment? 5) What are the performance characteristics (e.g., sensitivity, 

specificity, reliability and predictive value) of instruments or methods that are used to screen for 

depression following an acute MI? 6) Does the use of cardiac treatment for patients with acute 

MI differ for those with and without depression? 

Data Sources: The Johns Hopkins University Evidence-based Practice Center (EPC) team 

searched electronic databases for literature published through March 2004. The team identified 

additional articles by hand-searching the table of contents of 16 relevant journals for appropriate 

citations from October 2003 to April 2004, by querying experts, and by reviewing references in 

pertinent review articles identified during abstract review and in eligible articles during the 

article review process. 

Study Selection: Paired investigators reviewed the abstracts of identified citations to select 

studies that addressed the questions, reported on human subjects, and were written in English. 

Some questions had additional eligibility criteria. During the abstract review process, emphasis 

was placed on identifying all articles that could have original data that might address the 

questions. 

Data Collection and Analysis: Paired reviewers confirmed the relevance of each article to the 

research questions and abstracted data in a serial manner; the quality of each eligible study was 

assessed independently by each reviewer. 

Main Results: The search identified 86 articles with original data that addressed the questions. 

Results were as follows: 1) The evidence indicated that the prevalence of major depression is 

about 20 percent in patients hospitalized for MI and that of potentially significant symptoms of 

depression an additional 10 to 47 percent. 2) Few studies reported the prevalence of depression 

in patients at the time of the hospitalization and then re-assessed those same patients at follow-
vi 

up, but the studies indicated that most patients with depression during the initial MI 

hospitalization remain depressed 1 to 4 months later. 3) Post-MI depression is associated with a 

significantly increased risk of subsequent death, and of cardiac re-admission and poor quality of 

life during the first year. There is limited evidence that post-MI depression is associated with 

surrogate markers of cardiac risk. 4) In post-MI patients with depression, psychosocial 

intervention improves depression but not other outcomes. In post-MI patients with depression, 

selective serotonin re-uptake inhibitors (SSRIs) improve depression and some surrogate markers 

of cardiac risk, but no studies of sufficient power address the question of whether this treatment 

improves survival. 5) There is insufficient data to adequately assess the performance 

characteristics of instruments or methods used to screen for depression during the initial MI 

hospitalization, but most commonly used screening instruments or rating scales have adequate 

sensitivities and specificities when used within 3 months after initial hospitalization. 6) Patients 

with post-MI depression exhibit lower adherence to prescribed medications and secondary 

prevention measures compared to those without depression. The literature was too limited or 

heterogeneous to make conclusions about whether there are significant differences in cardiac 

medication prescription or cardiac procedure use in post-MI patients based on the presence or 

absence of depression. 

Conclusions: Evidence is consistent that in patients with MI, depression is common at the time 

of the hospitalization and persists for at least several months after hospital discharge without 

treatment. Post-MI depression is associated with a significantly increased risk of subsequent 

death, and of cardiac re-admission and poor quality of life during the first year. Strong evidence 

exists to indicate that both psychosocial interventions and SSRIs are effective in improving 

depression in MI survivors, but there is no evidence that either decreases mortality or cardiac 

events. Although it is not clear whether the frequency of prescription of cardiac medications or 

use of cardiac procedures is different based on the presence of depression, there is relatively 

strong evidence that those with post-MI depression have lower adherence to prescribed 

medications and secondary prevention measures than those without depression. 
vii

Contents 

Evidence Report 

Chapter 1. Introduction

Overview of Post-Myocardial Infarction Depression............................................................... 3 

Conceptual Framework............................................................................................................. 3 

Prevalence of Post-MI Depression............................................................................................ 4 

Depression and Risk of Coronary Heart Disease...................................................................... 4 

Possible Mechanisms Linking Post-MI Depression and Adverse Outcomes........................... 4 

Arrhythmias .............................................................................................................................. 5 

Hemostasis ................................................................................................................................ 5 

Inflammation............................................................................................................................. 5 

Quality of Life........................................................................................................................... 5 

Other Possible Mechanisms...................................................................................................... 6 

Response to Treatment for Depression..................................................................................... 6 

Patient Adherence and Provider Bias ....................................................................................... 6 

Screening and Diagnostic Approaches ..................................................................................... 6 

Therapeutic Approaches ........................................................................................................... 7 

 

Chapter 2. Methods 

Recruitment of Experts and Peer Reviewers ............................................................................ 9 

Target Population...................................................................................................................... 9 

Identifying the Key Questions .................................................................................................. 9 

Key Questions..................................................................................................................... 9 

Analytic Framework ............................................................................................................... 11 

Literature Search Methods...................................................................................................... 11 

Sources.............................................................................................................................. 11 

Search Terms and Strategies............................................................................................. 11 

Organization and Tracking of Literature .......................................................................... 12 

Title Review............................................................................................................................ 12 

Abstract Review...................................................................................................................... 12 

Inclusion and Exclusion Criteria ...................................................................................... 12 

Abstract Review Process .................................................................................................. 13 

Article Review ........................................................................................................................ 13 

Qualitative and Quantitative Data Abstraction................................................................. 13 

Evidence Tables................................................................................................................ 14 

Grading of the Evidence ......................................................................................................... 14 

Peer Review ............................................................................................................................ 14

Chapter 3. Results 

Literature Search and Abstract Review .................................................................................. 15 

Articles Eligible for Review ................................................................................................... 15 
viii

Key Questions 1 and 2 ............................................................................................................ 15 

Question 1. In patients diagnosed with and hospitalized for acute myocardial 

infarction (MI) what is the prevalence of depression during initial 

hospitalization for MI?

Question 1a. What is the prevalence of depression during initial hospitalization 

for MI in patients with and without a known history of depression as reported 

by study investigators? 

Question 2. What percentage of patients with post-MI depression continue to 

have depression (or depressive symptoms) one or more months after initial 

hospital discharge?

Introduction ...................................................................................................................... 15 

Results of Literature Search.............................................................................................. 16 

Characteristics of Studies ................................................................................................. 17 

Quality of Studies ............................................................................................................. 17 

Results of Studies ............................................................................................................. 18 

Key Question 3 ....................................................................................................................... 20 

Question 3. What is the association of various measures of depression with 

outcomes in patients with acute MI independent of other predictors of postMI outcomes? 

Question 3a. What is the association of post-MI depression with surrogate 

markers of cardiac risk independent of other predictors of post-MI 

outcomes? 

Introduction ...................................................................................................................... 20 

Results of Literature Search.............................................................................................. 20 

Characteristics of Studies ................................................................................................. 21 

Quality of Studies on Depression and Survival................................................................ 22 

Quality of Studies on Depression and Cardiac Events .................................................... 22 

Quality of Studies on Depression and Quality of Life ..................................................... 22 

Quality of Studies on Depression and Surrogate Markers of Cardiac Risk ..................... 22 

Results of Studies on Depression and Survival ................................................................ 22 

Results of Studies on Depression and Cardiac Events ..................................................... 24 

Results of Studies on Depression and Quality of Life...................................................... 25 

Results of Studies on Depression and Surrogate Markers of Cardiac Risk...................... 27 

Key Question 4 ....................................................................................................................... 28 

Question 4. Do post-MI patients with depression who received depression 

treatment have better outcomes than post-MI depression patients who did not 

receive depression treatment?

Introduction ...................................................................................................................... 28 

Results of Literature Search.............................................................................................. 29 

Characteristics and Results of Studies.............................................................................. 29 

Quality of Studies ............................................................................................................. 35 
ix

Key Question 5 ....................................................................................................................... 35 

Question 5. What are the performance characteristics (e.g., sensitivity, 

specificity, reliability, and predictive value) of instruments that are used to 

screen for depression (or depressive symptoms) following an acute MI? 

Question 5a. What are the performance characteristics of instruments that are 

used to screen for depression (or depressive symptoms) following an acute 

MI during hospitalization? 

Question 5b. What are the performance characteristics of instruments that are 

used to screen for depression (or depressive symptoms) following an acute 

MI within 3 months after hospitalization?

Introduction ...................................................................................................................... 35 

Results of Literature Search.............................................................................................. 36 

Characteristics of Studies ................................................................................................. 36 

Quality of Studies ............................................................................................................. 37 

Results of Studies ............................................................................................................. 37 

Summary of Studies.......................................................................................................... 38 

Key Question 6 ....................................................................................................................... 39 

Question 6. Does use of cardiac treatment for patients with acute MI differ for 

those with and without depression? 

Introduction ...................................................................................................................... 39 

Results of Literature Search.............................................................................................. 40 

Characteristics of Studies ................................................................................................. 40 

Quality of Studies ............................................................................................................. 40 

Results of Studies ............................................................................................................. 40 

Chapter 4 Discussion

Conclusions and Limitations................................................................................................... 43 

Future Research ...................................................................................................................... 47

References and Included Studies .................................................................................................. 51 

Figures 

Figure 1: Conceptual Model ......................................................................................................... 61 

Figure 2: Literature Search ........................................................................................................... 62 

Figure 3: Sensitivity and Specificity of Instruments used to Screen for Major and Minor 

Depression Following an Acute Myocardial Infarction ......................................................... 63 

Figure 4: Sensitivity and Specificity of Instruments used to Screen for Major Depression 

Following an Acute Myocardial Infarction ............................................................................ 64 

Tables 

Table 1: Summary of Studies on the Prevalence of Depression during Hospitalization for 

Acute Myocardial Infarction................................................................................................... 67 
x

Table 2: Summary of Studies on the Prevalence of Depression after Hospitalization for 

Acute Myocardial Infarction................................................................................................... 70 

Table 3: Summary of Studies on Relation of Depression to Survival after Myocardial 

Infarction................................................................................................................................. 74 

Table 4: Summary of Studies on the Relation of Depression to Cardiac Events after 

Myocardial Infarction ............................................................................................................. 77 

Table 5: Summary of Studies on the Relation of Depression to Quality of Life after 

Myocardial Infarction ............................................................................................................. 80 

Table 6: Summary of Studies on the Relation of Depression to Biomarkers after Myocardial 

Infarction................................................................................................................................. 83 

Table 7: Summary of Studies on Treatment of Post-Myocardial Infarction Depression ............. 84 

Table 8: Summary of Studies on Methods of Screening for Depression in Myocardial 

Infarction Patients................................................................................................................... 90 

Table 9: Summary of Characteristics of Studies on the Relation of Depression to Use of 

Treatment after Hospitalization for Myocardial Infarction .................................................... 93 

Table 10: Summary of Results of Studies on the Relation of Depression to Use of Treatment 

after Hospitalization for Myocardial Infarction...................................................................... 94 

References for Summary Tables...........................................................................95 

Appendixes 

Appendix A: Technical Experts and Peer Reviewers 

Appendix B: Priority Journals for Hand Searching 

Appendix C: Literature Search Strategies 

Appendix D: Abstract Review Form for Primary Literature 

Appendix E: Abstraction Forms 

Appendix F: Grading the Strength of Evidence 

Appendix G: Evidence Tables 

Appendix H: List of Excluded Studies 

 

Note: Appendixes and Evidence Tables are provided electronically at: 

http://www.ahrq.gov/clinic/tp/mideprtp.htm
Introduction

Major depression is common among patients

recovering from a myocardial infarction (MI).1-5

Additionally, clinically significant depressive

symptoms are present in other patients whose

symptom severity or duration does not meet

established criteria for a diagnosis of major

depression.5 Over the last decade, increasing

evidence suggests that in addition to its effect on

quality of life, post-MI depression also deserves

attention because of a reported relation to

increased morbidity and mortality.5-8

This evidence report reviews the studies that

have examined depression or depressive

symptoms in patients after an MI and focuses on

the prevalence, clinical significance, treatment,

and methods of evaluating this condition. A

number of studies have evaluated various aspects

of post-MI depression including prevalence,1-4,9-27

its association with mortality, 5-10,20,28-36 and major

adverse events,25,26, 31,37-39 and treatment.10,40-47 This

report addresses the following key questions

regarding post-MI depression.

1. In patients diagnosed with and hospitalized

for acute MI, what is the prevalence of

depression during initial hospitalization for

MI? Depression was defined as symptoms of

depression meeting established threshold

criteria by psychiatric interview or validated

questionnaire.

1a. What is the prevalence of depression

during initial hospitalization for an acute

MI, with and without a history of

previous depression as reported by study

investigators?

2. What percentage of patients with post-MI

depression continue to have depression (or

depressive symptoms) one or more months

after initial hospital discharge?

3. What is the association of post-MI

depression with outcomes independent of

other predictors of post-MI outcomes? PostMI outcomes include:

• Clinical outcomes—total mortality,

cardiac mortality, MI, resuscitated arrest,

stroke, arrhythmias, and

revascularization.

• Quality of life.

• Utilization of health care services—

readmission, total hospital days, and cost

of care. Potential predictors include

demographic and clinical characteristics

of patients that have been reported to be

associated with the risk of post-MI

outcomes.

3a. What is the association of post-MI

depression with surrogate markers of

cardiac risk independent of other

predictors of post-MI outcomes?

Surrogate markers of disease severity

include: heart rate variability, platelet

reactivity, and markers of inflammation

such as C-reactive protein.

Evidence Report/Technology Assessment

Number 123

Post-Myocardial Infarction Depression

Summary

Authors: Bush DE, Ziegelstein RC, Patel UV, Thombs BD, Ford DE, Fauerbach JA, 

McCann UD, Stewart KJ, Tsilidis KK, Patel AL, Feuerstein CJ, Bass EB

Agency for Healthcare Research and Quality

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality Evidence-Based

Practice
2

4. Do post-MI patients with depression have better

outcomes with depression treatment compared to those

without depression treatment? Depression treatment

includes all interventions intended to have specific impact

on depression, such as antidepressants, cognitive

behavioral therapy, inter-personal therapy, psychosocial

support, and cardiac rehabilitation.

4a. Do outcomes differ with or without improvement in

depression for post-MI patients with depression that

do receive depression treatment?

4b. Do outcomes differ with or without improvement in

depression for post-MI patients with depression that

do not receive depression treatment?

5. What are the performance characteristics (e.g., sensitivity,

specificity, reliability, and predictive value) of instruments

or methods that are used to screen for depression (or

depressive symptoms) following an acute MI?

5a. What are the performance characteristics of

instruments or methods that are used to screen for

depression (or depressive symptoms) following an

acute MI, during hospitalization?

5b. What are the performance characteristics of

instruments or methods that are used to screen for

depression (or depressive symptoms) following an

acute MI, within three months after hospitalization?

6. Does the use of cardiac treatment for patients with acute

MI differ for those with and without depression? Cardiac

treatment includes: revascularization (angioplasty or

bypass surgery), angiotensin converting enzyme (ACE)

inhibitors, beta blockers, statins, antiplatelet agents, or

other treatments recommended by the American Heart

Association or the American College of Cardiology.

Methods

The Johns Hopkins University Evidence-based Practice

Center (EPC) assembled a team including clinicians and

researchers from diverse specialties including cardiology,

psychiatry, general internal medicine, and cardiac rehabilitation.

The EPC team then recruited eight technical experts to provide

input regarding the choice of key questions. The expert review

panel consisted of a representative from the EPC’s partner

organization, the American Academy of Family Physicians, as

well as investigators active in post-MI depression research

including those from cardiology, psychiatry and psychology,

nursing, cardiac rehabilitation, and representatives of private

and governmental payers.

Literature Search

The EPC team performed a comprehensive search that

included electronic and hand searching. In March 2004, we

searched the following electronic databases: MEDLINE®, the

Cochrane CENTRAL® Register of Controlled Trials (Issue 1,

2003), the Cochrane Database of Methodology Reviews

(CDMR®), the Cumulative Index of Nursing and Allied

Health Literature (CINAHL®), the Psychological Abstracts

(PsycINFO®), and EMBASE®. 

Hand searching for possibly relevant articles was performed

by three techniques. First, the EPC team identified 16 journals

that we thought were most likely to contain relevant studies

and scanned the table of contents of each of these journals for

relevant citations from October 2003 to April 2004. Second,

we reviewed references cited in recent review articles for

inclusion. Third we examined the reference lists of eligible

articles for additional articles that might be relevant 

Two members of the EPC team independently reviewed the

abstracts identified by the search to exclude those that did not

meet the eligibility criteria. Primary studies were eligible if they

addressed one of the key questions, included original human

data, were not case reports, and were written in the English

language. Individual key questions had additional exclusion

criteria. When two reviewers agreed that an abstract was not

eligible, it was excluded from further review.

To focus the evidence report on the studies that would be

most valuable in addressing the key questions, we used the

following additional eligibility criteria:

• For key question 4 we excluded studies that did not

include a concurrent comparison group.

• For key question 5, we excluded studies that did not use a

validated reference standard.

Review Process

Paired reviewers assessed the quality of each eligible article.

Differences between the paired reviewers were resolved by faceto-face discussion. The reviewers assigned points for the quality

of the studies based on information about the

representativeness of the patients included in the study, the

potential for bias and confounding, the description of the

intervention or evaluation, the adequacy of followup, and the

appropriateness of the statistical methods. The score for each

category of study quality was the percentage of the total points

available in each category for that study, and could range from

zero to 100 percent.
One reviewer in each pair was the primary reviewer who

abstracted data from the article. The second reviewer confirmed

the accuracy of the first reviewer’s work.

Results

Key Question 1

In patients diagnosed with and hospitalized for acute MI

what is the prevalence of depression during initial

hospitalization for MI?

• Twenty-five articles met criteria for inclusion in this

review.1-5,9-27,48

• Articles were published between 1986 and 2004.

• Eight studies used a structured clinical interview,1-3,5,10,16,17,49

and 17 used a validated questionnaire. 4,5,9,11-15,18-25,50

• Major depression was reported in about one of every five

patients hospitalized for an MI. The reported prevalence

of potentially significant symptoms of depression varied

widely (range 10 to 47 percent).

• In general, the reported prevalence of potentially

significant symptoms of depression was higher when it

was based on a Beck Depression Inventory (BDI)5, 9,18-23,50

than when based on a Hospital Anxiety and Depression

Scale (HADS)12-15; this may be because the BDI includes

somatic symptoms that may overlap with MI symptoms,

whereas the HADS does not.

Key Question 1a. What is the prevalence of depression

during initial hospitalization for an acute MI, with and without

a history of previous depression as reported by study

investigators?

There was insufficient data to address this question.

Key Question 2

What percentage of patients with post-MI depression

continues to have depression (or depressive symptoms) one or

more months after initial hospital discharge? 

• We found 22 articles that met criteria for inclusion in this

review.

2,12,14,18-20,22,23,25,26,38,51-61

• Nine of the 22 used a standardized clinical interview to

diagnose depression.10,26,51-57

• Only three studies reported the prevalence of depression

in patients during the MI hospitalization and then

specifically re-assessed and reported the prevalence in these

same patients at followup.2,18,23

• Based on these three studies, most patients with

depression during the initial MI hospitalization continue

to have depression 1 to 4 months later.

Key Question 3

What is the association of post-MI depression with

outcomes independent of other predictors of post-MI

outcomes?

• Sixteen studies addressed the relationship of post-MI

depression and mortality.5-10,20,28-36

• Mortality has been assessed as early as 4 months5 and as

late as 10 years after MI.7

• The evidence indicates that post-MI depression is

associated with a significantly increased risk of death.

• A single study indicated that post-MI depression is

associated with increased cardiac re-admission in the first

year after MI.39

• Six studies reported on cardiac events in relationship to

post-MI depression.25,26,31,37-39 The three studies reporting a

positive relationship between post-MI depression and

cardiac events31,37,39 were generally larger than the three

studies finding no relationship25,26,38 suggesting that the

latter may have had insufficient power to detect

differences if they, in fact, were present.

• Depression during the initial hospitalization was related to

poor quality of life in the first year after MI.13,30,59,62

Key Question 3a. What is the association of post-MI

depression with surrogate markers of cardiac risk independent

of other predictors of post-MI outcomes?

• Three studies examined the association of post-MI

depression with heart rate variability, platelet activity, and

inflammatory markers (one study for each surrogate

marker).57,63,64

• All three studies reported surrogate markers of increased

risk in patients with post-MI depression, even after

adjustment for covariates.

Key Question 4

Do post-MI patients with depression have better outcomes

with depression treatment compared to those without

depression treatment?

• Twelve studies, 11 of which were randomized controlled

trials, addressed this question.10,40-47,65-67 The studies were

published between 1991 and 2003. 

• In post-MI patients with depression, psychosocial

intervention improves depression but not other

outcomes.10,44

3
4

• In post-MI patients with depression, selective serotonin

reuptake inhibitors improve depression and some

surrogate markers of cardiac risk, but no studies of

sufficient power address the question of whether this

treatment improves survival.45,46,65,66

Key Question 4a. Do outcomes differ with or without

improvement in depression for post-MI patients with

depression that do receive depression treatment?

There was insufficient data to address this question.

Key question 4b. Do outcomes differ with or without

improvement in depression for post-MI patients with

depression that do not receive depression treatment?

There was insufficient data to address this question.

Key Question 5

What are the performance characteristics (e.g., sensitivity,

specificity, reliability, and predictive value) of instruments or

methods that are used to screen for depression (or depressive

symptoms) following an acute MI?

• We found six studies published between 1968 and 1988

meeting criteria to address this issue.14,18,56,68-70

• Of the six studies, four were from Europe,14,56,68,70 one from

Canada18 and one from the United States.69

• All included studies reported exclusively on post-MI

populations.

• None of the instruments reported had been normalized

specifically for post-MI patients.

• The BDI tended to be more sensitive to lower levels of

depressive symptoms but less sensitive to more severe

depression compared to the HADS and the Symptom

Checklist-90 Depression scale.

Key question 5a. What are the performance characteristics

of instruments or methods that are used to screen for

depression (or depressive symptoms) following an acute MI

during hospitalization?

There was insufficient data to address this question.

Key question 5b. What are the performance characteristics

of instruments or methods that are used to screen for

depression (or depressive symptoms) following an acute MI,

within three months after hospitalization?

There was insufficient data to address this question.

Key Question 6

Does the use of cardiac treatment for patients with acute MI

differ for those with and without depression?

• Nine studies published between 1982 and 2004 met

criteria for review on this question. 23,26,37,50,71-75

• Four studies compared prescribed discharge medications

and were inconsistent in their findings: United States and

United Kingdom50,71 studies suggested decreased

prescriptions of beta-blockers and aspirin, while

European26 and Canadian23 studies found no difference.

• Three studies compared adherence to prescribed

medications and lifestyle modifications and consistently

found decreased adherence among depressed patients.71-73

• Two studies compared use of cardiac procedures and

reached divergent conclusions about the use of procedures

in post-MI patients.23,37

• Two studies assessed completion of cardiac rehabilitation

but had insufficient numbers to reach conclusions about

the influence of depression on completion of

rehabilitation.74,76

Discussion

Key Question 1

Major depression is reported in about one of every five

patients hospitalized for MI. This proportion is fairly consistent

among the eight studies that used a structured clinical interview

to establish this diagnosis. The reported prevalence of

potentially significant symptoms of depression varies more

widely (range 10 to 47 percent). This wide range of reported

prevalence rates appears to be due almost exclusively to

differences in measurement instruments used, and even to

differences in threshold criteria applied from study to study

when the same instrument was used. In general, the reported

prevalence of potentially significant symptoms of depression is

higher when this diagnosis is based on a BDI score of 10 or

higher than when it is based on a HADS score of either 8 or

higher or 11 or higher. This difference may be attributed to the

BDI’s inclusion of somatic symptoms that may overlap with

MI symptoms, whereas the HADS does not include somatic

symptoms and is designed for use in hospitalized patients. 

Additional studies also are needed to define the most

clinically-relevant measure of depression during the initial MI

hospitalization. Studies are needed to determine the clinical or

demographic factors that are associated with post-MI

depression.

Key Question 2

Although 22 studies reported the prevalence of depression in

patients 1 month or longer after initial hospital discharge, only
three reported the prevalence of depression in patients during

the MI hospitalization and then specifically reassessed and

reported the prevalence of depression in these same patients at

followup. These studies suggest that most patients (60 to 70

percent) with depression during the initial MI hospitalization

continue to have depression (or depressive symptoms) 1 to 4

months later.

Additional studies are needed that assess depression (or

depressive symptoms) in groups of patients during the initial

hospitalization and at various time points after MI. Studies of

patients who are reassessed for depression at multiple time

points post-MI are also needed.

Key Question 3

Sixteen studies evaluated the relationship between

depression, measured shortly after an acute MI, and subsequent

mortality. Studies have assessed this relationship as early as 4

months post-MI and as late as 10 years post-MI. Despite the

facts that various measures of depression have been used, that

different subgroups of depressed patients have been evaluated,

and that different post-MI survival times have been assessed,

the weight of the evidence is strikingly consistent. Overall, the

evidence supports the notion that post-MI depression is

associated with a significantly increased risk for subsequent

death, whether by cardiac or other causes. Depression appears

to be associated with about a 3-fold increased risk of cardiac

mortality per se based on at least three studies that addressed

cardiac mortality in a total of almost 2,000 patients.39,77,78

Depression during the initial hospitalization is associated with

poor quality of life in the first year after an MI.

During the first year after MI, depression during the initial

MI hospitalization has been found to be inversely related to

physical quality of life, social quality of life of women, sexual

activity and satisfaction among men, return to work of

employed men, and to physical, psychological, and social health

and function. Limitations of the above mentioned studies

included the variety of diagnostic instruments used to assess

depression; the lack of agreement on what aspects of quality of

life are of greatest import or how to measure included studies;

the degree to which potential confounders were adequately

considered; and the absence of data in early post-MI time

points.

Additional studies are needed to determine the major

cause(s) of mortality among depressed post-MI patients.

Additional studies also are needed to determine whether

patients with depression are at higher risk for malignant

arrhythmias than comparable post-MI patients without

depression.

Key question 3a. A small amount of evidence suggests that

post-MI patients with depression have alterations in autonomic

function as reflected by decreased heart rate variability,

increased platelet activity, and increased levels of soluble

adhesion molecule 4. These studies suggest that the risk

associated with post-MI depression could be transmitted by

multiple biological pathways.

Additional studies are needed to elucidate the mechanism(s)

responsible for increased mortality in patients with post-MI

depression. Particular emphasis should be placed on surrogate

markers which have been previously associated with increased

risk without regard to depression, including markers for sudden

death including heart rate variability, T-wave alternans, etc, and

inflammatory markers including C-reactive protein,

interleukins, adhesion molecules and others. Studies are needed

that evaluate the hemostatic and platelet function of patients

with post-MI depression. Future studies also should address

whether responses to commonly used antiplatelet agents differ

among post-MI patients with versus without depression.

Key Question 4

No studies of sufficient power have yet been performed that

directly address the question as to whether treatment with

antidepressants improves survival in depressed patients after an

MI. Some evidence suggests that selective serotonin reuptake

inhibitor antidepressants have beneficial effects on surrogate

markers of post-MI risk (e.g., heart rate variability, aortic time

velocity integral). There is evidence that both psychosocial

intervention and selective serotonin reuptake inhibitor

antidepressants improve depression in post-MI patients.

However, the possibility of increases in rare adverse events

cannot be excluded. 

Studies are needed to determine whether patients with

depression who are treated for depression, especially with highly

effective drugs, differ in outcomes from patients who are not

treated. Future studies should also determine whether treatment

for depression per se or resolution of depression is associated

with different outcomes.

Key Question 5

There are insufficient data to allow an adequate assessment

of the performance characteristics of instruments or methods

used to screen for depression during the initial MI

hospitalization. The very low positive predictive values of these

screening instruments (generally in the 25 to 50 percent range)

may be acceptable clinically if followed by a more thorough

assessment of those who screen positive; however, the low

positive predictive values are particularly problematic if used to

detect relationships to outcome variables in the research setting.

When compared with the HADS and Symptom Checklist-90

5
Depression scale, the BDI tends to diagnose less significant

symptoms of depression at higher rates. It may be less effective

in accurately diagnosing major depression.

Additional studies are needed to determine the performance

characteristics of instruments or methods used to screen for

depression (or depressive symptoms) during the initial MI

hospitalization. Studies are needed in post-MI patients that

examine the ability for depression screening instruments or

methods to distinguish symptoms of depression from

symptoms attributable to the MI, to poor physical health, or to

the hospitalization itself.

Key Question 6

It remains unclear whether there are significant differences in

cardiac medications prescribed to post-MI patients based on

the presence or absence of depression. Three studies evaluated

adherence to prescribed medications and secondary prevention

measures in post-MI patients and consistently found lower

adherence in those with depression than those without

depression. Two good-quality studies, using different methods,

came to diverse conclusions about whether the frequency with

which cardiac procedures are used varies between post-MI

patients with depression and those without depression. 

Additional large studies are needed to examine whether the

use of diagnostic and therapeutic procedures differs between

depressed and non-depressed post-MI patients. Future studies

should also address whether potential differences in procedures

are due to differences in provider recommendation or to

differences in patient acceptance. Further studies are needed to

determine whether the treatment prescribed to post-MI

patients with depression differs from those without depression.

Future studies should address whether the non-pharmacologic

interventions (including diet, exercise and cardiac

rehabilitation) recommended to post-MI patients differ

between those patients with and without post-MI depression.

Future studies should examine the adherence behavior of postMI patients and evaluate measures that could improve

adherence to recommended treatment.

Availability of the Full Report

The full evidence report from which this summary was taken

was prepared for the Agency for Healthcare Research and

Quality (AHRQ) by The Johns Hopkins University Evidencebased Practice Center under Contract No. 290-02-0018. It is

expected to be available in spring 2005. At that time, printed

copies may be obtained free of charge from the AHRQ

Publications Clearinghouse by calling 800-358-9295.

Requesters should ask for Evidence Report/Technology

Assessment No. 123, Post-Myocardial Infarction Depression. In

addition, Internet users will be able to access the report and this

summary online through AHRQ’s Web site at www.ahrq.gov.

Suggested Citation

Bush DE, Ziegelstein RC, Patel UV, Thombs BD, Ford DE,

Fauerbach JA, McCann UD, Stewart KJ, Tsilidis KK, Patel AL,

Feuerstein CJ, Bass EB. Post-Myocardial Infarction Depression.

Summary, Evidence Report/Technology Assessment No. 123.

(Prepared by the Johns Hopkins University Evidence-based

Practice Center under Contract No. 290-02-0018.) AHRQ

Publication No. 05-E018-1. Rockville, MD: Agency for

Healthcare Research and Quality. May 2005.

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ISSN 1530-440X

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3

Chapter 1: Introduction

Overview of Post-Myocardial Infarction Depression 

Myocardial infarction (MI) is the leading cause of death in this country.1 The prognosis of 

patients with MI depends on the extent, location, and type of infarct.2

In an effort to improve outcomes of patients with MI, a number of treatments are typically 

recommended, including medications, revascularization procedures, behavior and lifestyle 

changes, and cardiac rehabilitation. Co-existent depression may influence the recovery of 

patients with MI in a number of important ways reviewed in this report. 

Depression is manifested by a number of symptoms including depressed mood, diminished 

interest or pleasure in all or almost all, activities, low self-esteem, sleep disturbance, changes in 

appetite, loss of energy, difficulty concentrating, psychomotor retardation or agitation, and 

suicidal ideation. Depression is common among patients recovering from am MI. 

Approximately one in six patients with an MI experience major depression and at least twice as 

many as that have significant symptoms of depression soon after the event.3, 4 Although minor 

mood disturbance is likely to resolve spontaneously after an MI, major depression is more 

persistent.5 Many studies have found that depression is an independent risk factor for increased 

mortality among patients recovering from an MI. This increased risk appears to be present even 

by 4 months or earlier after hospital discharge,6 and the relation between depression and risk has 

been reported to be graded and "dose-dependent", with more severe depression associated with 

greater mortality risk.6 Despite these findings, depression in patients recovering from an MI is 

often unrecognized, as it is in other medical populations.7 Of note, only recently have MI 

treatment guidelines begun to call for the screening for post-MI depression.8

 This practice is in 

sharp contrast to the manner in which many other risk factors for increased morbidity and 

mortality are handled; for example, screening for diabetes mellitus or for reduced left ventricular 

ejection fraction (LVEF) are routinely performed as part of the standard care of patients 

hospitalized for an MI. 

Conceptual Framework 

No mechanism has yet been defined that links depression after MI with the observed higher 

morbidity and mortality. However, a number of plausible mechanisms have been proposed. 

These putative mechanisms fall into two broad categories, “behavioral” (either patient or 

provider/health system) or “biological”. “Behavioral” mechanisms include: (1) a greater 

prevalence of noncompliance on the part of the patient, and (2) a failure of providers to offer 

important cardiac treatments as often as those patients without depression. “Biological” 

mechanisms include: (1) an increased risk of sudden cardiac death, possibly indicated by 

decreased heart rate variability (HRV) (2) increased platelet activation and thrombosis, and (3) 

increased activation of the systemic inflammatory response. These mechanisms are likely to act 

in some combination as indicated in the conceptual framework shown in Figure 1. 
4

Prevalence of Post-MI Depression 

Depression has been reported to occur in a significant percentage of patients suffering from 

acute MI.3,6,9,10 However, the prevalence of post-MI depression may vary considerably by patient 

population and the instruments used to make the assessment. This evidence report reviews in 

detail the studies reporting the prevalence of depression among patients who had an acute MI. 

Depression and Risk of Coronary Heart Disease 

The development of coronary artery disease (CAD) involves the interplay of many factors. 

Some of these risk factors are well established: hypercholesterolemia, hypertension, diabetes, 

smoking, age, and genetic factors including sex. Management of these classic risk factors now 

forms the basis of current management recommendations for individuals at risk for coronary 

heart disease (CHD) events.11 Epidemiologic studies also have found an association between 

clinical depression or depressive symptoms and increased risk of developing future symptomatic 

CAD, MI, and cardiac mortality.12-19 Recent prospective studies have confirmed this association. 

In a study of 1,190 male medical students followed for up to 40 years, there was a 12 percent 

cumulative incidence of depression.20 A history of depression carried a two-fold greater risk of 

developing symptomatic CAD or MI. In the Cardiovascular Health Study 4,493 Americans 

without evident coronary disease at baseline were followed for 6 years.21 Depressive symptoms 

had a significant association with mortality, and an independent association with developing 

CAD and mortality, even after adjustment for other established coronary risk factors. 

Possible Mechanisms Linking Post-MI Depression and 

Adverse Outcomes 

Many potential mechanisms have been proposed as plausible links between depression and 

higher rates of mortality after MI. Increased mortality has been detected as early as 4 months and 

as late as 10 years after MI among patients with depression at the time of hospitalization for MI. 

6,9-22 Although no mechanism for the observed higher mortality has been established, suicide 

does not appear to play a role. Thus, there has been a search for other mechanisms by which 

post-MI depression could have a large adverse impact on survival within the first few months 

and extending for at least a decade. It is notable that not all studies of depressed post-MI patients 

have found an increase in mortality.23 

Figure 1 illustrates pathways by which depression could produce an early and sustained 

increase in post-MI mortality. In particular, increased thrombosis or arrhythmogenesis could 

directly cause higher mortality. Although numerous studies have reported an increased risk of 

sudden death with post-MI depression,24 one study failed to find an increased rate of non-fatal 

MI over 5 years of follow-up.25 Increased rates of non-fatal as well as fatal MI might be expected 

if a thrombotic mechanism were the prime mediator of increased risk. Taken together, these 

observations tend to favor an arrhythmic mechanism. 
5

Arrhythmias 

In support of an arrhythmic mechanism are the observations that patients with coronary 

disease and depression have lower HRV than age- and sex-matched patients with coronary 

disease who are not depressed.26 The finding of low HRV indicates abnormally high sympathetic 

tone with or without abnormally low parasympathetic neurological input to the heart, and it may 

be the link between post-MI depression and an apparently increased risk of sudden death. 

Individuals with post-MI depression have higher rates of ventricular ectopy than do those 

without depression.27 An interaction between depressive symptoms and ventricular ectopy has 

also been reported, with an odds ratio of 29 for 18-month cardiac mortality in comparisons 

between post-MI patients with depression and premature ventricular contractions (PVCs) of at 

least 10 per hour and post-MI patients without either of these characteristics.9 

Hemostasis 

Alterations in hemostasis are also plausible links between depression and post-MI adverse 

events. Individuals with depression have evidence of increased platelet activation. The 

neurobiology of depression involves alteration in serotonin receptors and transport pathways.28,29

The platelets of individuals with depression have alterations in receptors, including the serotonin 

5 hydroxy-tryptamine (serotonin 5-HT2) receptor, that result in increased levels of 

activation.30,31,32 

Inflammation 

The onset and progression of atherosclerosis is strongly associated with vascular 

inflammation characterized by increased levels of inflammatory mediators such as interleukin 

1(IL-1) and interleukin 6 (IL-6), tumor necrosis factor, and C-reactive protein (CRP).33 In 

particular, the acute phase reactant CRP has emerged as a significant predictor of increased 

risk.34 In populations without evident coronary disease, elevated CRP levels predict higher risk 

for developing an acute coronary syndrome (ACS). In those who have experienced an acute MI, 

higher levels of CRP are associated with poorer prognosis.35,36 Major depression also has been 

associated with elevated CRP levels particularly in men.37 Thus, adverse cardiac outcomes and 

depression could be linked through pathways with CRP or other markers. 

Quality of Life 

Depression in medical illness is associated with a marked decrease in quality of life (QOL) 

and an increase in utilization of health care resources.38,39 Among post-MI patients the presence 

of depression may be a powerful predictor of QOL.40 
6

Other Possible Mechanisms 

 There are certainly other mechanisms not already mentioned that may link depression 

with increased morbidity and mortality post-MI. Depression has been associated with increased 

activity of the sympathetic nervous system.41 In addition to its relationship to increased 

myocardial ischemia and arrhythmia, sympathetic nervous system activity may also result in 

higher blood pressure, insulin resistance, and an increased susceptibility to infection.42

Depression has also been associated with deficiencies of omega-3 fatty acids and with elevated 

homocysteine levels which may increase the burden or cardiovascular disease,43 and thereby 

adversely affect post-MI outcome. 

Response to Treatment for Depression 

Several trials have now evaluated pharmacologic and non-pharmacologic treatment of 

depressive symptoms in post-MI patients.44-50 However, these trials have had inconsistent results 

or insufficient power to detect significant differences. Consequently, no consensus exists 

regarding the efficacy of various treatment options for patients with post-MI depression. 

Patient Adherence and Provider Bias 

Depression is a risk factor for non-adherence to treatment in many medical conditions.51

Thus, it is important to determine the extent to which depression is associated with non 

adherence to recommended cardiac treatment in patients who have had an acute MI. As indicated 

in Figure 1, depression may well contribute to post-MI patients' difficulty in adhering to 

prescribed medications, accepting recommended procedures, and completing cardiac 

rehabilitation. Figure 1 also indicates that provider bias may play a role in keeping patients from 

receiving treatments that otherwise might be recommended after an MI. It is possible that health 

care providers are less likely to recommend some types of treatment for post-MI patients with 

depression than for those without depression. Indeed, some studies have found that patients with 

depression received a different level of medical treatment than those without depression.52

Screening and Diagnostic Approaches 

In their recently released recommendation for depression screening,53,54 the U.S. Preventive 

Services Task Force (USPSTF) points out that depressive disorders are common, chronic, and 

costly. The prevalence of depression is high, with community-based surveys indicating 

prevalence rates of 1.8 to 3.3 percent for depression within the last month and lifetime 

prevalence rates of 4.9 to 17.1 percent.55 Depressive illness is projected to be the second leading 

cause of disability worldwide in 2020.56 More than a decade ago, the economic burden of 

depression in the United States was estimated at approximately $44 billion, with $24 billion of 

that attributable to excess absenteeism of depressed workers and reductions in their productive 

capacity while at work during episodes of illness.57 The USPSTF supports screening adults for 

depression in clinical practices that have systems in place to assure accurate diagnosis, effective 
7

treatment, and follow-up.53 Although several reports address the ideal screening and diagnostic 

instruments for the detection of depression in general medical patients, little is known about the 

ideal method for diagnosing depression in patients in the post-MI period. What are the sensitivity 

and specificity of methods that could be used to screen for depression in post-MI patients? Do 

the accuracy and reliability of screening methods depend on the time of the evaluation relative to 

the diagnosis of an acute MI? Since post-MI depression has been associated with adverse 

outcomes, it is particularly important to have answers to these types of questions.

Therapeutic Approaches 

A number of therapeutic approaches have been advocated for patients with post-MI 

depression, including cardiac rehabilitation, social support, cognitive behavior therapy, and 

antidepressants. Two recent large studies examined the safety and efficacy of treating depression 

in patients recovering from an MI. In the Enhancing Recovery in Coronary Heart Disease 

Patients (ENRICHD) study, the effects of a psychosocial intervention on cardiac outcomes was 

examined in post-MI patients who were either depressed or had low perceived social support, or 

both.58 The Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) examined the 

safety and efficacy of antidepressant therapy with a selective serotonin reuptake inhibitor (SSRI) 

in patients who recently experienced an acute MI.59 Although several types of antidepressant 

drugs might be considered in patients recovering from an MI, the tricyclic antidepressants 

usually are avoided because of their tendency to increase resting heart rate, produce orthostatic 

hypotension, and alter intracardiac conduction and the susceptibility to ventricular arrhythmias.60

The SSRI antidepressants do not appear to have important cardiac side effects when 

administered to patients soon after an acute MI.59
8
 9 

Chapter 2: Methods

 

 The American Academy of Family Physicians (AAFP) requested an evidence report to 

synthesize the available evidence on depression and post-MI depression, with an overall goal of 

using the report in supporting the development of evidence based clinical practice guidelines. 

The Johns Hopkins University Evidence-based Practice Center (EPC) was awarded this contract 

in December 2003. The EPC established a team and work plan to develop the evidence report. 

The project consisted of recruiting technical experts, formulating and refining the specific 

questions, performing a comprehensive literature search, summarizing the state of the literature, 

constructing evidence tables, and submitting the report for peer review. 

Recruitment of Experts and Peer Reviewers 

At the beginning of the project, we recruited a panel of eight external technical experts (see 

Appendix A*) from national and international communities to give us input on key steps 

including the selection and refinement of questions to be examined. This panel of experts 

included a representative from our partner organization (the AAFP), as well as other respected 

experts from the fields of psychiatry, psychology, rehabilitation, and cardiology. This panel of 

experts provided feedback on the key questions and was asked to review the draft report.

Target Population 

Our review focused on studies of adults (male and female), including members of any 

racial/ethnic population, who had suffered an acute MI. The main targeted users of the review 

are clinical leaders of health care quality improvement efforts and clinicians, including family 

physicians, internists, cardiologists, psychiatrists, and psychologists.

Identifying the Key Questions 

The AAFP provided the EPC its original list of questions. We revised the questions on the 

basis of preliminary literature searches. The panel of technical experts reviewed the draft 

questions and ranked each question according to importance, amount of available evidence, and 

clarity. We collected the responses from the experts and revised the questions as suggested. 

Key Questions 

 The EPC team sought evidence to address the following key questions: 

1. In patients diagnosed with and hospitalized for acute MI, what is the prevalence of depression 

during initial hospitalization for MI? 

 

* Note: Appendixes and Evidence Tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/mideprtp.htm. 
10

● We defined depression as symptoms meeting established clinical threshold criteria for 

depression as measured by validated questionnaires or standardized psychiatric 

interviews. 

1a. What is the prevalence of depression during initial hospitalization for an acute MI, with or 

without a history of previous depression, as reported by study investigators? 

2. What percentage of patients with post-MI depression continues to have depression (or 

depressive symptoms) 1 month or longer after initial hospital discharge? 

3. What is the association of post-MI depression with outcomes independent of other predictors 

of post-MI outcomes? 

● Post-MI outcomes include (1) clinical outcomes—total mortality, cardiac mortality, MI, 

resuscitated arrest, stroke, arrhythmias, and revascularization, (2) QOL, and (3) 

utilization of health care services—readmission, total hospital days, and cost of care. 

● Potential predictors include demographic and clinical characteristics of patients that have 

been reported to be associated with the risk of post-MI outcomes. 

3a. What is the association of post-MI depression with surrogate markers of cardiac risk 

independent of other predictors of post-MI outcomes? 

● Surrogate markers of disease severity include HRV, platelet reactivity, and markers of 

inflammation such as CRP. 

4. Do post-MI patients with depression have better outcomes with depression treatment than do 

those without such treatment? 

● We defined depression treatment as including all interventions intended to have specific 

impact on depression, such as antidepressants, cognitive behavioral therapy, interpersonal 

therapy, psychosocial support, and cardiac rehabilitation. 

4a. Do outcomes differ with or without improvement in depression for post-MI patients with 

depression who do receive depression treatment? 

4b. Do outcomes differ with or without improvement in depression for post-MI patients with 

depression who do not receive depression treatment? 

5. What are the performance characteristics (e.g., sensitivity, specificity, reliability, and 

predictive value) of instruments or methods that are used to screen for depression (or depressive 

symptoms) after an acute MI? 

5a. What are the performance characteristics of instruments or methods that are used to screen 

for depression (or depressive symptoms) after an acute MI, during hospitalization? 

5b. What are the performance characteristics of instruments or methods that are used to screen 

for depression (or depressive symptoms) after an acute MI, within 3 months after 

hospitalization? 
11

6. Does the use of cardiac treatment for patients with acute MI differ for those with and those 

without depression? 

● Cardiac treatment includes revascularization (angioplasty or bypass surgery), angiotensin 

converting enzyme (ACE) inhibitors, beta blockers, statins, antiplatelet agents, or other 

treatments recommended by the American Heart Association or the American College of 

Cardiology.

Analytic Framework 

 We used our conceptual framework (see Figure 1) to guide the analysis of our questions, 

based on the relationships between MI, depression, various risk factors, pertinent treatment 

options, and subsequent clinical events. 

Literature Search Methods 

 Searching the literature included the steps of identifying reference sources, formulating a 

search strategy for each source, and executing and documenting each search. 

Sources 

Our comprehensive search plan included electronic and hand searching. In March 2004, we 

searched the following electronic databases: MEDLINE®, the Cochrane CENTRAL Register of 

Controlled Trials (Issue 1, 2003), the Cochrane Database of Methodology Reviews (CDMR), the 

Cumulative Index of Nursing and Allied Health Literature (CINAHL®), the Psychological 

Abstracts (PsycINFO®), and EMBASE®. 

 Hand searching for possibly relevant citations took several forms. First, the EPC team 

identified 16 journals that we thought were most likely to contain relevant studies (see Appendix 

B). We scanned the tables of contents of these journals for relevant citations from October 2003 

to April 2004. 

 For the second form of hand searching, we used ProCite®, a reference management software, 

to create a database of reference material identified through an electronic search for relevant 

guidelines and reviews, through discussions with experts, and through the article review process. 

We also reviewed the references in pertinent recent review articles that were identified during the 

abstract review process. 

 Finally, we examined the reference lists of eligible articles to identify any other potentially 

relevant articles. This task was performed by the second reviewer as part of the article review 

process (see description of article review process below). 

Search Terms and Strategies 

 Search strategies, specific to each database, were designed to maximize sensitivity. Initially, 

we developed a core strategy for MEDLINE, accessed via PubMed®, based on an analysis of the 

Medical Subject Headings (MeSH) and text words of key articles identified a priori. The 
12

PubMed strategy formed the basis for the strategies developed for the other electronic databases 

(see Appendix C).

Organization and Tracking of the Literature 

We downloaded electronic search results into the citation management database ProCite. 

(ProCite, ISI Research Soft, Berkeley, CA) The software's duplication check was used to 

eliminate citations already retrieved. We used the ProCite software to store and track the 

searching strategies and sources used to retrieve each citation. This software was also useful 

during the abstract review process to track the reviewed abstracts.

Title Review 

After the search strategies were completed and the citations downloaded into ProCite, two 

reviewers independently scanned the titles. During this scan, reviewers looked for article titles 

that clearly were irrelevant to the study questions. If both reviewers agreed, on the basis of the 

title, that an article was irrelevant, it was excluded from further consideration. Once a citation 

was selected for deletion, a note was made in the ProCite database deleting the citation from 

further review. 

Abstract Review 

Specific inclusion and exclusion criteria were applied at each of the levels of review, with 

criteria becoming more stringent as the process moved from database searches, to the review of 

titles, to the review of abstracts, and to the review of articles. After identifying a title as 

potentially relevant, two team members independently reviewed the abstract of the citation, and 

articles were included or excluded from the article review on this basis. Also at this step, 

abstracts were flagged according to their relevance to a key question. To be excluded at this 

stage, both reviewers had to agree that an abstract was ineligible. Discrepancies were discussed 

during weekly face-to-face meetings.

Inclusion and Exclusion Criteria 

During the abstract review process, emphasis was placed on identifying all articles that could 

have original data pertinent to the questions. As previously described, a representative of the 

AAFP was consulted during the development of inclusion and exclusion criteria. In evaluating 

titles and abstracts, the following criteria were used to exclude articles from further 

consideration: (1) not in English, (2) no human data, (3) no original data, and (4) meeting 

abstract (no full article for review).

We also had two question-specific exclusion criteria. For key question 4, we excluded studies 

that did not have a concurrent comparison group. For key question 5, we excluded studies that 

did not have a validated reference standard for diagnosing depression.
13

Abstract Review Process 

The EPC team used an abstract review form for this stage of the process that was similar to 

abstract forms used in other EPC projects. The form was designed to address our specific 

questions and the eligibility criteria appropriate for this project (see Appendix D). Each abstract 

was circulated to two members of the EPC team who independently reviewed the abstract both 

for eligibility and applicability to specific key questions. For those articles deemed ineligible, the 

reviewers selected a reason for exclusion. When a citation contained no abstract, or when the 

reviewers could not determine from the abstract if the citation met eligibility criteria, a full copy 

of the article was obtained for review. Investigators met face-to-face to adjudicate disagreements 

about the eligibility of abstracts.

Article Review 

The purpose of the article review was to confirm the relevance of each article to the research 

questions, to determine methodological characteristics pertaining to study quality, and to collect 

evidence that addressed the research questions. The study team reviewed each article identified 

as being eligible during the abstract review process. The abstraction forms for the article review 

process were filled out in a serial manner. Two study team members worked on each article. The 

first reviewer had the task of filling out the quality and content abstraction forms. The secondary 

reviewer performed an independent assessment of the quality of each study, and then checked 

the information recorded by the primary reviewer on the content abstraction form. We used faceto-face meetings to adjudicate differences between the reviewers on the quality and content 

forms. We did not mask author and journal names because previous work has shown that 

masking does not make a significant difference during the data abstraction.61

Qualitative and Quantitative Data Abstraction 

The study team developed content review forms and a quality review form for use in this 

project. The forms were pilot tested and revised before use. Because of the different types of 

questions, the team had a general content review form (See Appendix E), and five separate 

question-specific content review forms (see Appendix E): one addressing key questions 1 and 2, 

and one each for key questions 3, 4, 5, and 6. To make sure that all articles met eligibility 

criteria, the general content review form began with a check of the eligibility criteria (see 

Abstract Review, above). For key question 4, the team limited the review to studies with a 

comparison group, and for key question 5, the studies were limited to studies using a validated 

reference standard.

The quality assessment form included items about study quality in the following categories: 

representativeness of study population, bias and confounding, description of therapy and 

management, description of assessment protocols, test or instrument interpretation, outcome and 

follow-up, statistical analysis, and conflict of interest (see Appendix E).
14

Evidence Tables 

For each key question, the EPC team created a set of evidence tables. Each set of tables 

contained basic information about study aims and eligibility criteria, selected characteristics of 

study participants, assessments of study quality, and results most pertinent to the key question. 

Grading of the Evidence 

 After all articles were reviewed, we graded the evidence supporting each question on the 

basis of its quantity, quality, and consistency. Our evidence-grading scheme followed the 

approach recommended by the International GRADE Working Group.62 In terms of quantity of 

evidence for each question, we determined the number of studies and the total number of patients 

studied. We assessed the quality and consistency of evidence on each key question based on the 

criteria recommended by the Grade Working Group that applies to the questions (see Appendix F 

for details). 

 

Peer Review 

 Throughout the project, feedback was sought from the technical experts through formal and 

ad hoc requests for guidance. A draft of the completed report was sent to the technical experts, as 

well as to the partner (AAFP), Agency for Healthcare Research and Quality (AHRQ) and other 

peer reviewers. Substantive comments were catalogued and entered into a database. Revisions 

were made to the evidence report as warranted, and a summary of the comments and their 

disposition was submitted to AHRQ with the final report.
Note: Appendixes and Evidence Tables cited in this report are provided electronically at 

http://www.ahrq.gov/clinic/tp/mideprtp.htm. 

. 

15 

Chapter 3: Results

Literature Search and Abstract Review 

 The literature search process identified 3,770 unique citations potentially relevant to key 

questions for which the EPC team evaluated primary literature (see Figure 2). Fifteen duplicate 

citations were found and excluded. During the title review process 2,597 citations were excluded 

because they did not appear to pertain to the subject. At abstract review 825 citations were found 

not to meet the criteria for inclusion. Abstracts were excluded for the following reasons: the 

article was not in English; did not include human data; did not have original data; or was a 

meeting abstract (hence no full article available for review). For articles related to only key 

question 4, the team excluded studies that did not have a concurrent comparison study; for key 

question 5, the team excluded articles without a validated reference model. 

Articles Eligible for Review 

 Following the abstract review process 318 articles were found to be eligible. Of these, 128 

were tagged for key question 1 and 2; 56 were tagged for question 3; 54 were tagged for question 

4; 12 for question 5; and 13 for question 6. Added together the total number of articles pertaining 

to key questions exceeded the actual number of articles reviewed because some articles were 

identified as relevant for more than one key question. 

Key Questions 1 and 2 

Question 1. In patients diagnosed with and hospitalized for acute MI, what is the prevalence of 

depression during initial hospitalization for MI? 

Question 1a. What is the prevalence of depression during initial hospitalization for MI in 

patients with or without a known history of depression as reported by study investigators? 

Question 2. What percentage of patients with post-MI depression continue to have depression (or 

depressive symptoms) 1 month or longer after initial hospital discharge? 

Introduction 

 Most studies that examined the prevalence of depression after MI examined patients at the 

time of the initial hospitalization and at various times after discharge. Because question 2 refers 

to the percentage of patients who continue to have depression after hospital discharge, these two 

questions are interrelated, and therefore questions 1 and 2 are combined for the purposes of this 

report. 

 Important technical and methodological issues should be clarified before examining this 

review. First, depression is defined and addressed differently from study to study. For the 
16

purposes of this review, we have defined depression as "symptoms meeting established clinical 

threshold criteria for depression as measured by validated questionnaires or standardized 

psychiatric interviews." It must be noted, however, that the manner in which "clinical threshold 

criteria" is interpreted varies considerably across studies. For example, one study used a score of 

8 or higher on the depression subscale of the Hospital Anxiety and Depression Scale (HADS) to 

report a prevalence of "clinically significant levels of depression",63 whereas another used a 

cutoff of 11 to denote "clinical levels of depression".64 Three other studies referred to a score in 

the 8 to 10 range as "possibly clinically significant" or "borderline" depression and a score of 11 

or higher as "probably clinically significant" depression.65-67 This review found similar 

variability in threshold criteria and designation when other screening instruments were used. 

Wherever possible, this has been specifically noted given that prevalence data may become 

confusing when "depression" is characterized according to different threshold criteria. In 

addition, although the definition of depression for the purposes of this review includes 

measurements by validated questionnaires and standardized interviews, the former typically 

measure symptoms of depression whereas the latter typically use a version of the Diagnostic and 

Statistical Manual (DSM) to establish a diagnosis of major or minor depression or dysthymia. 

Again, wherever possible, this is noted in the report. Finally, it should be noted that the 

screening instruments typically used for depression are referred to in this report as "validated 

questionnaires or rating scales." Some validation evidence is available for all of these, but the 

quality varies and no systematic validation has been carried out in patient populations with recent 

MI. Indeed, question 5 of this report addresses the performance characteristics of instruments or 

methods used to screen for depression after an acute MI. 

 Question 2 asks specifically about the percentage of patients with post-MI depression who 

continue to have depression (or depressive symptoms) 1 month or longer after initial hospital 

discharge. To address this question, a study must provide data on the prevalence of depression 

during the initial hospitalization and then reassess those patients with depression after hospital 

discharge and specifically indicate the prevalence of depression at follow-up in those patients 

initially depressed. Whereas data are provided in the tables (Appendix G Evidence Tables 2.1, 

2.2, 2.3, 2.4 ) from studies that report prevalence data only at follow-up (i.e., no data were 

available on the prevalence of depression during the hospitalization), these studies do not 

specifically address question 2 and therefore are handled separately in this report. To specifically 

address question 2, a study would have to report the prevalence of depression at follow-up in 

those patients depressed during the hospitalization. Several studies reported prevalence data at 

hospitalization and follow-up, but did not report the prevalence of depression after discharge 

among the group initially depressed; these studies also are handled separately in this report. 

Results of Literature Search 

 After the final article review, 51 articles were eligible pertaining to question 1. Of these, 22 

were studies reporting data that were also reported in at least one other study. For example, some 

investigators reported the prevalence of in-hospital depression and outcome at 6 months. In 

another study by the same investigators, the prevalence of in-hospital depression was again 

reported but with a 12-month outcome. In such instances, only one article was considered 

eligible for question 1. After these 22 articles were excluded, 5 others were excluded because the 
17

prevalence of depression was determined by using a non-standard screening instrument for 

which no validation was provided. This left 25 articles for question 1. 

 After article review, 30 articles were eligible pertaining to question 2. One of these was 

excluded as duplicative, and six others were excluded because the prevalence of depression was 

determined by using a non-standard screening instrument for which no validation was provided. 

One study was excluded because the follow-up data were collected 2 weeks after discharge 

rather than the minimum 1 month after discharge that was required for this question. This left 22 

articles for question 2. Of these 22 articles, seven reported prevalence data both at hospitalization 

and follow-up. However, only three of these separately reported prevalence data at follow-up for 

those depressed during hospitalization. The other four articles and the 15 that reported only 

follow-up data are reported separately because they did not directly address question 2. 

Characteristics of Studies 

 Tables are presented separately for questions 1 and 2 (see Tables 1 and 2, and Appendix G). 

In Evidence Table 1 and 2 (Appendix G) for each question we have summarized the study aims, 

number of subjects included, and study quality scores for the 24 studies for question 1 and the 22 

studies for question 2. The articles were published between 1986 and 2004. 

 Of the 25 articles for question 1, eight used a standardized clinical interview for the diagnosis 

of depression (e.g., Structured Clinical Interview or the Diagnostic Interview Schedule).58,68-74 

One of these72 interviewed patients within a month of their MI, but the exact timing of the 

assessment relative to the hospitalization is unclear, and so data from this study are not included 

in summary tabulations. Seventeen used one or more validated questionnaires or rating scales 

such as the Beck Depression Inventory (BDI),25,74-81 Hamilton Rating Scale for Depression 

(HAMD),78,82 HADS,63-67 Montgomery and Asberg Depression Rating Scale,83 or Symptom 

Check List-90 (SCL-90) Depression Subscale.84

 Of the 22 articles for question 2, nine used a standardized clinical interview for the diagnosis 

of depression.10,69,85-91 Seventeen used one or more validated questionnaires or rating scales such 

as the BDI,10,75,76,78,80,81,88,89,92 HAMD,10,78,93 Zung Depression Rating Scale (ZDS),94,95

HADS,10,64,66,88,89 or SCL-90 Depression Subscale.10,84,88,89,96

Quality of Studies 

 As shown in Appendix G Table 1.3, the number of eligible studies on question 1 with scores 

greater than 50 percent for given study quality categories were as follows: 18 for 

representativeness of the study population, none for description of therapy and management, 20 

for description of the assessment protocol, nine for reporting of outcomes and follow-up, and 

four for statistical analyses. Only 13 studies reported information about potential conflicts of 

interest. As indicated in Appendix G Table 2.3, the number of eligible studies on question 2 with 

scores greater than 50 percent for the following study quality categories were 18 for 

representativeness of the study population, only one for description of therapy and management, 

14 for description of the assessment protocol, 12 for reporting of outcomes and follow-up, and 

four for statistical analyses. Only nine of these studies reported information about potential 

conflicts of interest. 
18

Results of Studies 

Question 1. In patients diagnosed with and hospitalized for acute MI, what is the prevalence of 

depression during initial hospitalization for MI? (Table 1) 

 Table 1.1(Appendix G) describes the patient populations and prevalence of depression during 

the initial MI hospitalization. Table 1.2 (Appendix G) describes the patient populations and 

prevalence of depression 1 month or longer after hospital discharge. 

 Of the 25 articles for question 1, seven included fewer than 100 subjects,63,64,68,73,75,76,80 and 

17 studied more than 100 individuals.25,58,65-67,69-72,77-79,81-84,97 The range of subjects studied was 

37 to 2,481 patients. Thirteen studies were from the United States and/or Canada,25,58,68-72,74-

76,78,80,82 and 12 studies were from Europe.63-67,73,77,79,80,83,84,97 The mean age of study subjects 

ranged from 52 to 67 years. Sex was reported in all but two studies; men alone were studied in 

three reports and the remainder reported depression prevalence from a population mix of men 

and women. Only three of 25 studies reported race;58,70,78 in these three, non-whites made up 33 

to 38 percent of the sample. Nine studies reported the prevalence of individual cardiac risk 

factors25,58,67,68,71,74,77,80,84; whereas one study reported the aggregate number of cardiac risk 

factors in the population.76 Killip class and/or LVEF was reported in seven studies. 25,69-71,73,74,81

All studies reported depression prevalence data from MI survivors alone or from a study sample 

in which prevalence data from MI survivors were reported separately. 

 Although in question 1a the prevalence of depression in patients with a history of depression 

(as reported by study investigators) was to be addressed, only two studies reported history of 

depression,71,78 and none provided separate prevalence data for this segment of the sample. 

Therefore, there is insufficient evidence to answer this question. 

 The prevalence of depression ranged from 17 to 27 percent in the seven studies that used a 

Structured Clinical Interview for DSM IV (SCID) to establish the diagnosis. The largest of these 

studies, the ENRICHD study,58 which examined 2,481 patients, reported a prevalence of 20 

percent with major depression. 

 In the 17 studies that used a validated questionnaire or rating scale, 10 to 47 percent of 

patients had symptoms of depression considered above a clinical threshold criterion. Of the nine 

studies that used the original version of the BDI, five used a cutoff score of 10 or 

higher.25,74,77,78,80,81 The prevalence of at least mild to moderate symptoms of depression using a 

cutoff of 10 or higher on the BDI was 21 to 37 percent. In the four studies that used a HADS 

cutoff score of 8 or higher,63,65-67 the prevalence of possible clinical depression was 11 to 18 

percent. In the four studies that used a HADS cutoff score of 11 or higher,64-67 the prevalence of 

probable clinical depression was 6 to 13 percent. 

 In summary, the prevalence of major depression during the initial MI hospitalization is fairly 

consistent across studies. Based on these studies, about one of every five patients has major 

depression during the initial MI hospitalization. By contrast, the prevalence of different levels of 

depressive symptoms varies more widely across studies assessed by questionnaire or rating scale. 

Variation in screening instruments used, as well as variation in cutoff criteria within instruments, 

may account for the difference. It is impossible given current research on the assessment of 

depression in MI patients to compare "possible clinical depression" based on a HADS depression 

subscale with "at least mild-to-moderate symptoms of depression" based on a BDI. In general, 
19

the prevalence of symptoms of depression that meet standard threshold criteria on the BDI (10 or 

higher) is greater than that using the HADS (either 8 or higher or 11 or higher) in patients during 

the initial MI hospitalization. For example, the two studies in this report that included the most 

patients used the BDI for 870 patients, reporting a prevalence of 32 percent25 and the HADS for 

688 patients, reporting prevalences of 18 percent and 10 percent depending on the cutoff.64 This 

is consistent with the prevalence ranges for all studies using these two instruments as noted 

above. This discrepancy is not surprising in that the BDI includes somatic symptoms that may 

overlap with MI symptoms in hospitalized patients, whereas the HADS is designed for use in 

hospitalized patients and does not include somatic symptoms. 

 As summarized in Evidence Grade Table 1, we concluded that the overall body of evidence 

on question 1 merited a medium quantity of evidence and reasonable quality of evidence despite 

the presence of some inconsistencies in the evidence. 

Question 2. What percentage of patients with post-MI depression continue to have depression (or 

depressive symptoms) 1 month or longer after initial hospital discharge? (Table 2) 

 The three studies that specifically addressed question 2 were from North America and 

reported data on 52 patients (mean age 51 years; 90 percent male),75 335 patients (mean age 64 

years; 64 percent male),69 and 550 patients (mean age 60 years; 79 percent male).81 None of 

these studies reported race, only one reported on cardiac risk factors,81 and two reported Killip 

class and/or LVEF.69,81 

 Nineteen of the studies reported the prevalence of depression at least 1 month after hospital 

discharge, but they did not address question 2 specifically. Of these studies, eight included fewer 

than 100 subjects,64,76,80,84-86,93,94 and 11 studied more than 100 individuals.10,66,87-92,95,96,98 The 

range of study subjects was from 32 to 1,042 patients. Six studies were from the United States 

and/or Canada,76,87,88,91,93,96 12 studies were from Europe,10,64,66,80,84-86,89,90,92,94,98 and one was 

from Asia.95 The mean age of study subjects ranged from 50 to 67 years. Men alone were studied 

in four reports,84-86,94 and the remainder reported depression prevalence from a gender-mixed 

population. Only three of 19 studies reported race.90,92,93 Three studies reported information on 

only one cardiac risk factor,85,87,96 six studies reported information on multiple cardiac risk 

factors,84,89,91,92,95,98 and one study reported the average number of risk factors per study 

subject.76 Killip class and/or LVEF was reported in five studies.87,88,91,92,95 Two studies included 

patients without MI,85,91 but in both of these studies, more than 80 percent of the patients were 

MI survivors. The other 17 studies reported depression prevalence data from MI survivors alone 

or from a study sample in which prevalence data from MI survivors were reported separately. 

 Three studies reported prevalence data at follow-up for those depressed during the initial MI 

hospitalization and therefore specifically addressed question 2. These studies reported follow-up 

data at 30 days after MI,81 6 to 8 weeks after MI,75 and 3 to 4 months after MI.69 A study by 

Davis and Jensen75 used the BDI to assess 52 patients during the initial hospitalization and again 

at follow-up. Of the five patients who were assessed as "clinically depressed" during the 

hospitalization (BDI of 13 or higher), three (60 percent) were still depressed 6 to 8 weeks later 

when the same BDI cutoff was used. Schleifer et al.68 studied 335 patients during the initial MI 

hospitalization and reported both in-hospital and follow-up data in 190 patients. Of these 190 

patients, 30 had major depression (15.8 percent) and 51 had minor depression (26.8 percent) 

according to a SCID performed during the initial hospitalization. Of the 30 patients with major 

depression at baseline, 11 (36.7 percent) still had major depression 3 to 4 months later and 
20

another 11 (36.7 percent) had minor depression. The total number of patients with either major 

or minor depression at follow-up was therefore 73.3 percent of those with major depression at 

baseline. Of the 51 patients with minor depression during the initial MI hospitalization, eight 

(15.7 percent) had major depression at follow-up and another 11 (21.6 percent) had minor 

depression. The total number of patients with either major or minor depression at follow-up was 

37.3 percent of those with minor depression at baseline. Lauzon et al.81 used the BDI to evaluate 

550 patients during the initial MI hospitalization. They reported a prevalence of clinically 

significant depressive symptoms (BDI of 10 or higher) as 34.7 percent at baseline. Of these 550 

patients, 466 were re-evaluated using a BDI 30 days later. These authors reported that of 

patients depressed at baseline, 70 percent continued to be depressed at 30 days; the breakdown of 

patients with and without depression in those lost to follow-up was not reported. In these three 

studies, the majority of patients with clinically significant depression during the initial MI 

hospitalization remained depressed when assessed 1 to 4 months later. 

 As summarized in Evidence Grade Table 1, we concluded that the overall body of evidence 

on question 2 merited a medium quantity of evidence and reasonable quality of evidence despite 

the presence of some inconsistencies in the evidence (see Appendix F). 

Key Question 3 

Question 3. What is the association of various measures of depression with outcomes in patients 

with acute MI, independent of other known predictors of post-MI outcomes? 

Question 3a. What is the association of various measures of depression with surrogate markers 

of cardiac risk in patients with acute MI, independent of known predictors of post-MI outcomes? 

Introduction 

 A number of studies have reported that depression after an MI is associated with increased 

mortality and poorer outcomes on a variety of psychosocial and health-related variables. 

However, not all of these studies accounted for the potential role of confounding factors that 

might have influenced these observations, including cardiovascular disease severity, 

socioeconomic factors, psychological variables, and psychiatric conditions apart from 

depression. To better understand the role of depression per se in predicting negative outcomes 

after an acute MI, we reviewed the English language literature for articles that evaluated the 

relationship between depression in days to weeks following an acute MI and a variety of health 

and psychosocial outcome measures. 

 We also reviewed the literature for articles that examined the relation between post-MI 

depression and surrogate markers of cardiac risk that might be associated with adverse 

outcomes—e.g., increased ventricular arrhythmias, reduced HRV, higher levels of inflammatory 

markers, and abnormal platelet function. 

Results of Literature Search 

 

 After final article review, there were 33 articles that reported on 27 different patient cohorts 

addressing question 3 or 3a. Thirty articles were eligible for question 3. Of these, 16 articles 
21

reported data on survival.6,22-25,40,58,74,77,99-105 Four of these articles were by Frasure-Smith and 

colleagues reported on the same cohort of patients or a subset at different times or with 

somewhat different analyses.25,101 102,105 Similarly, Lane et al. reported on a single patient cohort 

at three different times.23,40,77 Also, one included article was from the ENRICHD study58 and 

reported cardiac events in depressed patients who received and did not receive a psychosocial 

intervention. Another study compared a subsample of patients from ENRICHD with depression 

to a population of patients who had neither depression nor low perceived social support.74 This 

study74 and the ENRICHD study58 were considered separate studies and reported as such in this 

review. Thus, we found 11 independent studies with data on survival. Six studies reported data 

on cardiac events.24,52,84,89,95,106 Data on sudden cardiac death from one study24 were included in 

both the survival and cardiac events categories. Twelve articles from 11 independent studies 

reported data on QOL.6,23,40,63,65,67,93,107-111 Two of these articles reported data from the same 

study on different outcomes related to QOL.107,109 Three of the studies that reported data on QOL 

also reported data on survival.6,23,40 Three studies, published between 2001 and 2004, reported 

data for question 3a.91,112,113 Articles meeting criteria for inclusion in the review of this key 

question are shown in Tables 3, 4, 5, 6 and Appendix G (Evidence Tables 3.1, 3.2, 3.3 and 3.4). 

Characteristics of Studies 

 

 Tables are presented separately for each type of outcome addressed in question 3 and for 

question 3a (see Tables 3, 4, 5, 6 and Appendix G). In the first Evidence Table (Appendix G) for 

each type of outcome, we have summarized the study aims, design, setting, geographical area, 

and time period of data collection for the studies. The articles related to question 3 were 

published between 1990 and 2004, which included studies published from 1990 to 2003 for 

survival, from 1999 to 2004 for cardiac events, and from 1994 to 2003 for QOL. The studies 

with data relevant to question 3a were published between 2001 and 2004. 

 Tables 3 and Appendix G (Evidence Tables 3.1A, 3.2A, 3.3A and 3.4A) describe subject 

populations included in the 17 studies that assessed the relation of post-MI depression to 

survival. All studies were prospective, and evaluated the potential relation of depression (or 

depressed mood), assessed at a single point in time shortly after MI, to survival at various time 

points thereafter (4 months,40,74 6 months,100,101 1 year, 11⁄2 years, 2 years, 3 years, 5 years, and 

10 years). Some studies only reported data on cardiac mortality6,40,100,102,105 or sudden cardiac 

death, whereas others reported death from all causes.23,25,40,58,74,77,101,103-105 Some of the studies114

did not distinguish between depressed and nondepressed groups, but instead reported the 

association between depressed mood, as a continuous variable, and death. One study58 evaluated 

the influence of psychosocial treatment for depression on cardiac death in patients with post-MI 

depression. 

 Among the six studies that reported data on cardiac events (Table 4), there were three 

prospective cohort studies, two retrospective cohort studies, and one randomized clinical trial. 

All 11 independent studies with QOL outcome data were prospective cohort studies (Table 5). 

All three studies related to surrogate markers of cardiac risk were prospective cohort studies 

(Table 6). 

 Of the 12 articles that addressed QOL, the number of subjects ranged from 62110 to 347.65

One study was from the United States,93 seven from Europe,23, 6, 40, 63, 65, 67, 111 three from the 

Middle East,107,109,110 and one from Asia.108 The patient’s sex was reported in all studies; men 
22

alone were studied in three reports, women alone in one report, and the remaining studies 

reported on QOL outcome in a gender-mixed population. 

 As shown in Table 3a-1, the three studies that evaluated a surrogate marker of cardiac risk in 

patients with or without post-MI depression each evaluated a different marker. One study 

evaluated HRV,112 another assessed levels of platelet-derived substances as a surrogate maker for 

platelet activity,113 and another evaluated inflammatory markers.91 

Quality of Studies on Depression and Survival 

 

 As summarized in Evidence Table 3.3A in Appendix G, the numbers of studies that had 

scores greater than 50 percent in the study quality categories were as follows: 12 for 

representativeness of the study population, zero for description of therapy and management, nine 

for description of the assessment protocol, 12 for reporting of outcomes and follow-up, and 13 

for statistical analyses. Only eight studies reported information on potential conflicts of interest. 

Quality of Studies on Depression and Cardiac Events 

 

 As summarized in Evidence Table 3.3B in Appendix G, the numbers of studies on cardiac 

events that had scores greater than 50 percent in the study quality categories were as follows: 

four for representativeness of the study population, one for description of therapy and 

management, one for description of the assessment protocol, three for reporting of outcomes and 

follow-up, and four for statistical analyses. Only three studies reported information on potential 

conflicts of interest. 

Quality of Studies on Depression and Quality of Life 

 As summarized in Evidence Table 3.3C in Appendix G, the numbers of studies on QOL that 

had scores greater than 50 percent in the study quality categories were as follows: eight for 

representativeness of the study population, zero for description of therapy and management, six 

for description of the assessment protocol, nine for reporting of outcomes and follow-up, and 

nine for statistical analyses. Only six studies reported information on potential conflicts of 

interest. 

Quality of Studies on Depression and Surrogate Markers of Cardiac 

Risk 

 

 As shown in Evidence Table 3a.3 in Appendix G of the three studies meeting eligibility 

criteria for question 3a, the following numbers of studies had scores of at least 50 percent for the 

given criteria: one for representativeness of the study population, one for description of therapy, 

two for reporting outcomes and follow-up, three for description of assessment protocol and 

statistical analysis, and one for conflict of interest disclosure. 

Results of Studies on Depression and Survival 

 
23

 Two studies assessed the relation between post-MI depression and mortality 4 months after 

MI40,101 and differed in their conclusions (See Table 3 and Evidence Table 3.4A in Appendix G). 

In particular, one article reported that baseline depression, as measured using the BDI, was 

unrelated to 4-month survival.40 In contrast, the other study101 found depression (BDI score 

greater than or equal to 10) to be an independent predictor of mortality 4 months later. Further, 

this study found that higher levels of depression were associated with an increased risk for death, 

and that even subthreshold levels of depression (BDI scores of 4 to 9) were associated with an 

increased risk for death in these patients. 

 Two studies evaluated the relationship between post-MI depression and death 6 months after 

an MI. One study101 found depression, as measured using the National Institute of Mental Health 

Diagnostic Interview Schedule (DIS), to be an independent predictor for mortality, while 

adjusting for a variety of relevant covariates (see Evidence Table 3-4). All deaths in this 

population were secondary to cardiac events. The second study100 used non-English-language 

standard diagnostic instruments for measuring depression, and divided patients into low, 

medium, and high levels of major depression symptoms. These authors found that high levels of 

post-MI depression were predictive of cardiac mortality, even when accounting for other 

potential covariates (see Evidence Table 3.4A in Appendix G). 

 Four studies assessed mortality rates in post-MI depressed patients 1 year after the index 

event. One of these studies102 involved patients that were included in two other studies covered 

in this evidence report.25,115 In addition to assessing the potential relation of depression to 

mortality, this study evaluated the potential influence of the person’s sex on mortality in these 

patients. The study's major conclusion was that depression, which was a predictor of death at 3 

months, remained a significant risk factor for death 1 year after MI. Gender did not appear to 

influence this risk, which was largely independent of other post-MI risks for death. A second 

study114 assessed depression on a continuous scale using the BDI and found that increased 

depression scores predicted mortality, after statistical adjustment for known cardiac risk factors. 

Another study,23 which appears at odds with this conclusion, found that depression, measured 

using the BDI, did not predict either cardiac or all-cause mortality after MI. 

 Four studies evaluated patients approximately 11⁄2-3 years after an MI.12,24,58,77 Two studies 

involved a subgroup of patients in the ENRICHD trial who have been described elsewhere in this 

evidence report. The ENRICHD study58 evaluated the influence of treatment with cognitive 

behavioral therapy (and, when indicated, an SSRI) on post-MI patients with depression or low 

perceived social support. Depression was assessed using the DIS. At 29 months of follow-up, 

there were no differences in survival in the treated versus the untreated patients, nor were there 

differences in survival between patients in the depressed and low perceived social support 

groups. A substudy of ENRICHD74 compared depressed and nondepressed patients and found 

that depression was an independent risk factor for death after an acute MI, but the effect did not 

appear until nearly a year after the index event. 

 Two other studies reported on the 3- to 4-year survival of post-MI patients who had been 

evaluated for depression at the time of their index event. One study24 evaluated the risk of 

sudden cardiac death 4 years after an MI and found that increased depressive symptoms (BDI 

score greater than or equal to 10) during the initial MI hospitalization were associated with a 

more than two-fold increase in mortality 4 years later. In contrast to these findings, another 

study77 found that a BDI score of at least 10 after an MI did not predict survival 3 years after. 

Although the patients in these two trials were similar in age (63 years) and gender (75-82 

percent) male the patient populations of the two studies differed significantly. The study of 
24

Irvine et al24 was performed in post-MI patients with frequent PVCs. Depression was assessed 2 

to 4 weeks after the index MI. In this study the overall two-year mortality was 9.4 percent 

(63/671) with a cardiac mortality of 7.5 percent 50/671 and among those with cardiac deaths 68 

percent (34/50) were sudden. In contrast, in the study of Lane et al77 depression was assessed 

during the index hospitalization. The overall mortality was 13 (38/288) with a cardiac mortality 

of 11 percent (33/288). However, of the cardiac deaths only 9 percent were sudden (3/33) and 

accordingly many more deaths were due to recurrent ischemic events 60 percent (20/33) or heart 

failure 30 percent (10/33). Authors of both of these studies24,77 hypothesized that somatic 

symptoms of depression and/or disease severity may be more predictive of death than is 

depression per se. 

 Three studies,6,25,105 compared mortality rates in depressed patients versus non depressed 

patients 5 years after an acute MI. In one study,6

 patients were considered depressed when they 

scored in the upper tertile on a measure of depression. Symptoms of depression were not 

associated with an increased mortality risk, 5 years later. A second study,25 conducted in a cohort 

of patients that had been previously evaluated 1 year post-MI,102 found that post-MI depression 

was more closely linked to mortality 5 years after MI than 1 year after MI. Another study by the 

same group of researchers105 assessed the relation of depression, anxiety, and general health in 

post-MI patients to mortality 5 years after the index event. They concluded that an unidentified, 

but unique, aspect of depression predicts long-term cardiac mortality post-MI. 

 A single study102 reported on mortality in depressed post-MI patients 10 years after the index 

event. As with most of the studies that assessed the relationship between depression and 

mortality at earlier time points, this study found that death following MI was positively and 

independently associated with depressed mood, as measured by the ZDS. 

 As summarized in Evidence Grade Table 2, we concluded that the overall body of evidence 

on question 3, looking at survival as an outcome, merited a medium quantity of evidence and 

high quality of evidence (see Appendix F). 

Results of Studies on Depression and Cardiac Events 

 Six studies reported data on cardiac events, as shown in Evidence Table 3.4B in Appendix G. 

Irvine and colleagues24 evaluated 671 patients within 6 to 45 days of acute MI who participated 

in the Canadian Amiodarone Myocardial Infarction Arrhythmia Trial. Subjects eligible for this 

trial had frequent ventricular ectopy (at least 10 PVCs per hour) and were administered multiple 

screening questionnaires, including the BDI and the SCL-90, as well as measures of hostility, 

social support, and social participation. The average age of study subjects was 63.8 years and 

most were married men. About one quarter of the sample had a history of heart failure and about 

one third had a history of prior MI. There were 34 sudden cardiac deaths after 2 years of followup. In the Cox proportional hazards model, biological predictors of sudden cardiac deaths were 

prior MI (relative risk, 2.86; 95 percent CI, 1.37 to 5.99) and prior congestive heart failure 

(relative risk, 3.86; 95 percent CI, 1.89 to 7.89). Scores of 10 or higher on the BDI were also 

associated with a significantly increased risk for sudden cardiac death, SCD (relative risk, 2.45; 

95 percent CI, 1.14 to 5.35). When symptoms of fatigue were considered in the multivariate 

model, the contribution of depression was no longer significant (relative risk, 1.73; 95 percent 

CI, .076 to 3.98). When cognitive affective symptoms were considered separately, the 

relationship between mood and SCD was of borderline significance (relative risk, 1.09; 95 

percent CI, 0.99 to 1.19). Thus, depressive symptoms were associated with an increased risk of 
25

sudden cardiac death, but this relation was no longer present when symptoms of fatigue were 

controlled for. 

 Shiotani et al.95 evaluated 1,042 consecutive patients for symptoms of depression with the 

ZDS within 3 months of acute MI. Patients with depression over age 65 had significantly higher 

cardiac event rates during the first year after MI than did patients over age 65 without 

depression. There was a trend toward an association of depression and cardiac events in younger 

patients, but this did not reach statistical significance (p = 0.11). 

 Druss et al.52 evaluated a group of over 100,000 Medicare patients who sustained an MI, 

approximately 5 percent of whom had mental illness. Of the group of patients with mental 

illness, some had an affective disorder (major depression, dysthymia, or bipolar disorder). The 

group of patients with a mental illness, as well as the subgroup of patients with an affective 

disorder, had a lower likelihood of receiving cardiac revascularization procedures (percutaneous 

transluminal coronary angioplasty, PTCA or coronary artery bypass graft surgery, CABG) 

during the initial MI hospitalization than did the group of patients without mental illness. In a 

study such as this one, cardiac revascularization procedures may be treated either as an MI 

treatment or as an outcome variable (i.e., a cardiac event), and therefore this study was included 

in this question. 

 Frasure-Smith et al.106 studied 848 MI survivors and reported cardiac readmissions and 

procedures during the first year of follow-up. These authors found that depression (BDI score of 

10 or higher) during the initial MI hospitalization was associated with a significantly increased 

number of cardiac readmissions and days of hospitalization. There was no relationship of 

depression during the initial MI hospitalization and cardiac procedures (cardiac catheterization, 

angioplasty, or coronary bypass surgery) in the first year post-MI. 

 Strik et al.84 studied 315 men who completed measures of emotional distress, including 

depression, within the first month after the initial MI hospitalization. These authors then 

measured major adverse cardiac events, defined as cardiac death or recurrent MI, over an 

average follow-up period of 3.4 years. Although depression alone was a significant predictor of 

cardiac events (including cardiac death), this relation disappeared when a measure of anxiety was 

included in the multivariate model. 

 In a subsequent study with similar methodology, Strik et al.89 found similar results with a 

sample of 206 men and women followed for 3 years after their first MI. 

 As summarized in Evidence Grade Table 2, we concluded that the overall body of evidence 

on question 3, looking at cardiac events as an outcome, merited a medium quantity of evidence 

and reasonable quality of evidence despite the presence of some inconsistencies in the evidence 

(see Appendix F). 

Results of Studies on Depression and Quality of Life 

 

 Studies that addressed QOL measures reported the relation of depression during the initial 

MI hospitalization to physical-behavioral function, 6,23,40,65,67,93,111 psychological wellbeing,6,63,65,67,109-111 social and work role performance,6,23,65,93,107,108,111 and personal perception of 

health6,23,65 (See Table and Evidence Table 3-4 in Appendix G). Several studies reported on 

multiple aspects of health-related QOL. Some studies reported the relation of depression at the 

time of the initial MI hospitalization to QOL measures within the first 12 months postMI,63,67,107,108,111 whereas others reported on the relation to QOL at least 12 months post-MI.6,110
26

Two articles reported on the same sample at 4-month follow-up40 and at 12-month follow-up.23 

Three studies reported on both near- and long- term outcome.65,93,109 

 One study reported that depression as assessed by the HADS during the initial MI 

hospitalization was prospectively associated with a reduced score on the mental component of 

the short-form health survey (SF-36 Mental Component Score) but not with the SF-36 Physical 

Component Score at 5 months post-MI.67 Another study found that in-hospital depression for 

females and 1-month post-MI depression for males were prospectively related to the physical 

domain of QOL at 6 months as assessed by the Quality of Life After MI measure.111 This study 

also reported that social aspects of QOL at 6 months were predicted by in-hospital and 1-month 

depression for women but not for men and that 6-month psychological QOL was not related to 

depression at either earlier time for either sex.111 In-hospital depression measured with the BDI 

was prospectively related to sexual activity and sexual satisfaction of men 3 to 6 months post-MI 

in a multivariate analysis controlling for demographic (e.g., age, education) and medical (e.g., 

Killip class, diabetes mellitus) variables.107 One study among Japanese men documented that inhospital symptoms of depression after an MI were prospectively related to dichotomously 

measured return to work in multivariate analysis, but not to time until work resumption or 

returning to work at a reduced capacity.108 Thus, during the 1-year rehabilitation period, post-MI 

depression has been found to be related to physical QOL, social QOL of women, sexual activity 

and satisfaction among men, return to work of employed men, and health care utilization. 

 Another study found that QOL 4 months after MI measured with Dartmouth Primary Care 

Cooperative Information Project (COOP) charts (combining physical, social, role functioning, 

general health, pain, change in health, social support, and perceived health) was related to inhospital depression (BDI), having a partner, MI severity and state anxiety, even after controlling 

for sociodemographic, activity, and illness variables.40 In a follow-up of this sample,23

depression, living alone, MI severity (Peel Index score), and state anxiety were found to be 

independent predictors of 12-month QOL, even when controlling for sociodemographic, activity, 

and illness variables. 

 The three repeated-measures studies in this section had remarkable consistency across shortterm and long-term follow-ups. Individuals with high in-hospital distress (i.e., above established 

cutoffs for either HADS-depression or HADS-anxiety scales) scored significantly lower on all 

eight subscales of the SF-36 (four physical and four psychosocial) at 3-month follow-up.65 The 

mean HADS-depression score for the distressed group was significantly higher than for the 

nondistressed group. Consistent with the 3-month follow-up data, individuals with high inhospital distress scored significantly lower on all eight subscales of the SF-36 at the 12-month 

follow-up.65 DSM-III depressive disorder diagnosed in-hospital with use of the Present State 

Exam was associated with poorer physical functioning and greater depression severity only at 

discharge, and with less social connectedness only at the 6-month follow-up, whereas social 

functioning was significantly worse at the 3-, 6-, 9- and 12-month follow-ups.93 The third 

repeated-measures study found that in-hospital depression measured with the BDI was 

significantly related to psychological distress among male survivors of MI as measured by using 

the Mental Health Inventory at the 3- to 6-month post-MI follow-up, with controlling for 

sociodemographic and medical variables.109 Furthermore, psychological distress at 3 to 6 months 

moderated the effect of in-hospital depression on psychological distress at the 5-year follow-up 

among male survivors of MI, also with controlling for sociodemographic and medical 

variables.109 Thus, at both early and late follow-up times, in-hospital depression has been shown 

to be related to physical, psychological, and social health and function. 
27

 The 5-year QOL outcomes of patients with acute MI were examined in two studies. Inhospital depression measured with the BDI was significantly related to psychological well-being 

of women at the 5-year post-MI follow-up, as measured using the Mental Health Inventory and 

controlling for sociodemographic and medical variables.110 Similarly, among female survivors 

of MI, in-hospital depression and self-reported concomitant medical problems were related to 

psychological distress 5 years later.110 One 5-year outcome study used cutoffs on the Health 

Complaint Scale's somatic complaints and disability subscales to define poor QOL. Multivariate 

analysis found a significant relation between symptoms of depression (ZDS) and poor QOL.6

 

Thus, even 5 years after MI, psychological distress and physical health and functioning were 

related to in-hospital depression independent of other important QOL determinants. 

 As summarized in Evidence Grade Table 2, we concluded that the overall body of evidence 

on question 3, looking at quality of life outcomes, merited a medium quantity of evidence and 

low quality of evidence despite the presence of some inconsistencies in the evidence (see 

Appendix F). 

Results of Studies on Depression and Surrogate Markers of Cardiac 

Risk 

 Three studies reported data on surrogate markers of cardiac risk. (See Table Evidence Table 

3-1, 3-2, 3-3, and 3-4 in Appendix G.) Carney et al. evaluated HRV in 673 patients with acute 

MI between October 1997 and January 2000 who were screened for participation in the 

ENRICHD trial.112 The depressed subjects were eligible if they had a DSM-IV diagnosis of 

major or minor depression and a BDI score of 10 or higher within 28 days of admission for acute 

MI. The control group consisted of patients who were otherwise eligible for ENRICHD but did 

not meet the depression or social isolation criteria. Major exclusions included atrial fibrillation or 

flutter, the presence of an implanted electronic cardiac pacemaker, severe medical or severe 

psychiatric comorbidity, cognitive impairment, or substance abuse. Spectral HRV analysis was 

performed from ambulatory electrocardiographic monitors for the following bands: ultra low 

frequency (ULF, 1.15 x 10-5 Hz), very low frequency (VLF, 0.033 to 0.04 Hz) , low frequency 

(LF, 0.04 to 0.15 Hz), and high frequency (HF, 0.15-0.40 Hz). 

 All log-transformed indices of HRV were significantly lower in the 307 patients with 

depression than in the 365 without depression. The depressed patients were significantly younger 

(mean of 57.1 years versus 60.9 years), more likely to be female (49.5 percent versus 32 

percent), more likely to have diabetes mellitus (34.5 percent versus 22.1 percent), and more 

likely to smoke cigarettes (40.7 percent versus 23.5 percent). After adjustment for the baseline 

demographic differences, depression remained significantly associated with lower indices of all 

parameters of HRV except HF power. This study is consistent with greater autonomic 

dysregulation among post-MI patients with depression as compared with post-MI patients 

without depression. 

 Kuijpers et al. studied platelet function after a first MI in 24 patients, 12 of whom met DSMIV criteria for major depression and 12 of whom did not.113 There were 10 men and two women 

in each group; the mean age was 48.0 years in the depressed group and 49.8 years in the group 

without depression (see Evidence Table 3a-2 in Appendix G). In the depressed group, five 

patients smoked and one was hypertensive; in the non-depressed group, three smoked and six 

were hypertensive. At the time of the study all patients in the depressed group were taking 

aspirin. In the group without depression, 11 were using aspirin and one was using warfarin. 
28

Nondepressed patients were more likely than depressed patients to use ACE inhibitors (nine 

nondepressed patients versus four depressed patients) and nitrates (four nondepressed patients 

versus one depressed patient). Platelet factor 4 was significantly higher in patients with 

depression than in those without depression (mean 17.75 IU/mL versus 9.25 IU/mL, p = 0.02). 

Depressed patients tended to have higher levels of platelet beta-thromboglobulin (mean rank 

15.04 IU/mL vs. 9.96 IU/mL, p = 0.08). Although the sample size of this study was small, the 

results suggest that despite the use of aspirin, patients with post-MI depression have higher levels 

of platelet activity. 

 Lesperance and colleagues reported on the relationship between inflammatory markers and 

depression in patients with ACS.91 These authors studied patients 23 to 120 days after discharge 

from the hospital with a diagnosis of ACS between August 1999 and August 2002 (see Evidence 

Table 3a-2 in Appendix G). Altogether, 481 patients participated in this study, of whom 35 met 

DSM-IV criteria for the diagnosis of major depression according to the SCID. Of the 446 

patients without depression, 367 (82 percent) had an MI and 74 percent of the depressed patients 

had an MI. The investigators measured levels of IL-6, soluble intercellular adhesion molecule-1 

(sICAM-1), and CRP. Of these inflammatory markers only sICAM-1 was found to differ 

between depressed and nondepressed patients (mean 5.34 mg/mL versus 5.20 mg/mL). A 

number of characteristics were associated with higher levels of sICAM-1: older age, female sex, 

smoking, prior MI or coronary revascularization, metabolic syndrome, body mass index, use of 

antidepressants or adenosine diphosphate inhibitors, and not taking statins. After adjustment for 

sex, current smoking, and the presence of metabolic syndrome, depression remained a significant 

factor associated with higher sICAM-1 levels (p = 0.04). When the current use of antidepressants 

was included in the model, the effect of major depression was somewhat attenuated (p = 0.06). A 

significant interaction between depression and the use of statins was found with respect to CRP 

levels. Among those patients not taking a statin, those with current depression had significantly 

higher levels of CRP than those without depression. The results of this study demonstrate that 

patients with depression after ACS have higher levels of some inflammatory mediators that 

previously have been associated with an increased of coronary disease. However, this particular 

study, because of its cross-sectional design, could not establish whether these inflammatory 

markers were increased before the index event. 

 As summarized in Evidence Grade Table 3, we concluded that the overall body of evidence 

on question 3, looking at surrogate markers of disease severity as an outcome, merited a low 

quantity of evidence and high quality of evidence for some surrogate markers and low quality of 

evidence for others (see Appendix F). 

Key Question 4 

Question 4. Do post-MI patients with depression who received depression treatment have better 

outcomes than post-MI depression patients who did not receive such treatment? 

Introduction 

 

 The preceding sections of this evidence review have focused on the risks associated with 

having depression after an MI. Most of this evidence is based on observational studies and 

statistical approaches to determine whether any association between depression and these 

outcomes is independent of other factors. Studies of treatment for depression can provide 
29

important information on causal inferences for depression and poor outcomes. Treatment studies 

also address the issue of greatest concern to patients and clinicians: Can treatment reduce any of 

the increased risks that may be associated with having depression? Question 4 addresses whether 

post-MI patients with depression have better outcomes with depression treatment than do those 

without such treatment. An important aspect of this question relates to determining whether it is 

the resolution of the depression, or the treatment itself, that reduces the risk. For example, if 

SSRIs improve outcomes, is it because the SSRIs have beneficial platelet effects, or is it because 

the SSRIs increase the rate of depression resolution? These issues are the motivation for question 

4. 

Results of Literature Search 

 Our comprehensive literature search identified 12 articles addressing this question. 

Eleven studies were randomized clinical trials, and one used a less rigorous method for 

developing comparison groups. A common reason for eliminating studies was that patients 

entered into the studies did not all have clinical depression, and the results for the depression 

subgroup were not presented separately. Such studies do not provide direct evidence regarding 

question 4. One meta-analysis116 addressed the question of whether the addition of psychosocial 

interventions improves the outcome of a standard rehabilitation regimen for patients with CAD. 

The authors used a broad definition of psychosocial interventions and identified 23 randomized 

clinical trials. They concluded that the addition of psychosocial treatments to standardized 

cardiac rehabilitation regimens reduces mortality and morbidity, psychological distress, and 

some biological risk factors. 

Characteristics and Results of Studies 

 Table and Evidence Table 4.1 , 4.2, 4.3, and 4.4 in Appendix G, highlight characteristics and 

results of the studies eligible for our question 4. All were based in North America or England, 

although one study recruited some patients from Australia and Europe.59 The dates of publication 

for these studies ranged from 1991 to 2003. There was an excellent balance in the studies with 

seven addressing psychosocial interventions and five focusing primarily on antidepressant 

medications. The majority of the subjects had had a recent MI, but some studies included 

patients with CAD and no MI in the previous 6 months. All of the studies included women and 

men, but men accounted for about 75 percent of the total participants. Some studies excluded 

individuals over age 70. Apart from the ENRICHD trial, the ethnic diversity of the study samples 

was limited. 

 The largest studies with the highest quality data that most directly address the question are 

the SADHART or SADHART59 and the ENRICHD study.58 SADHART was conducted in 40 

outpatient cardiology centers in seven countries. Participants were randomized to 24 weeks of 

double-blind treatment with either sertraline or placebo. Participants were recruited in the 

hospital by either chart review or physician referral. Inclusion criteria included being 

hospitalized for either an MI or unstable angina in the past 30 days. Diagnosis of MI was made 

according to standard criteria. Unstable angina was defined as having (1) typical ischemic 

symptoms lasting longer than 10 minutes, (2) being hospitalized, and (3) having changes on an 

electrocardiogram (ECG) within the previous 12 hours. Alternatively, one could meet criteria for 

unstable angina by being hospitalized with unstable angina and having known CAD. Depression 
30

was identified with the DIS completed by a trained interviewer and with the self-rated BDI. The 

DIS was completed within 30 days of the hospitalization. For the DIS the 2-week duration 

criteria and impairment criteria were eliminated for the diagnosis of major depression because of 

the complicating cardiac event. Exclusions included (1) uncontrolled hypertension, (2) cardiac 

surgery anticipated in the next 6 months, (3) MI or cardiac surgery in the previous 3 months, (4) 

congestive heart failure, (5) bradycardia, and (6) MI or unstable angina of a nonatherosclerotic 

etiology. Psychiatric exclusions included alcohol or substance abuse, psychotic illness, cognitive 

impairment, current use of an antidepressant, or initiation of psychotherapy in the past 3 months. 

 After meeting the initial eligibility criteria for the study, all participants received placebo for 

14 days. During this time they completed their cardiovascular tests and a psychiatrist confirmed 

that their depressive symptoms were present for 2 weeks. Because many of the participants had 

mild depression, they were stratified by severity of depression, and it was hypothesized that 

those with more severe depression would have a greater benefit from treatment with sertraline. 

Participants were started on sertraline 50 mg daily and could be systematically increased to 200 

mg daily. The only other psychotropic medications allowed were chloral hydrate and zopiclone. 

The primary goal for the study was to evaluate the cardiac safety of sertraline. Therefore, the 

primary outcome was cardiac function, specifically LVEF. Depression outcomes included the 

BDI and 17-item HAMD (assessed up to 16 weeks) and Clinical Global Severity (assessed up to 

24 weeks). Cardiac events were adjudicated by a committee. Revascularization was not 

considered an endpoint for this study. 

 Of the 556 individuals who were initially eligible, 369 individuals remained eligible after the 

2-week run-in phase and were randomized. Because of the run-in phase, the mean time to start 

the intervention was 24 days after MI. There were no significant baseline differences between 

the groups. Most patients were aged between 50 and 70 years and had least two cardiac risk 

factors. While most had mild to moderate levels of depression, 25 percent met criteria for more 

severe depression. Most participants completed treatment (mean of 149 days) and achieved a low 

dose of sertraline at the end (mean of 68 mg daily). Those on sertraline did report more nausea 

and diarrhea, common side effects of sertraline. 

 The investigators presented data on 260 participants with baseline and final data (70 percent 

completion rate). As shown in Table 4.2, there were no differences in cardiac function at followup between those on sertraline and those receiving placebo. For important cardiac event 

outcomes, there was a trend toward lower numbers of events for those on sertraline. For the 

composite end point of death or cardiovascular events, the relative risk was 0.77 for those on 

sertraline compared with those on placebo, but the 95 percent confidence interval was 

moderately wide (0.51 to 1.16). 

 For depression outcomes, the results generally indicated that the sertraline group had better 

outcomes. The study groups did not differ on the HAMD ratings but these ratings stopped at 16 

weeks. Clinical Global Inventory outcomes were assessed through 24 weeks and did differ 

between the study groups. For those with a history of recurrent depression, outcomes for those 

randomized to sertraline were better than for those receiving placebo for both the Clinical Global 

Severity and HAMD ratings. 

 About 20 percent of the participants in the study had not experienced a recent MI. Results 

were not presented separately for those with an MI. No Kaplan-Meier data were presented to 

determine when the sertraline began to affect cardiac outcomes. It also was not clear how drop 

outs were handled in the analysis. 
31

 A second paper from the SADHART study was also included in our review. This study 

focused on QOL outcomes.117 For this analysis more than 90 percent of all randomized patients 

provided data. Overall, both the sertraline and placebo groups showed improvement in QOL. 

According to results from the Medical Outcomes Study Short Form 36 (SF-36), the study groups 

did not differ in Physical Component or Mental Component change scores. However, for the 

recurrent depression group, there was a significantly positive change on the Mental Component 

score for those on sertraline compared with those receiving placebo, and there was a trend 

toward more improvement on the Physical Component score as well. Similar results were found 

using the Quality of Life Enjoyment and Satisfaction scale (Q-LES-Q). 

 A second major study addressed the efficacy of treatment for depression in individuals who 

have depression after an MI—the ENRICHD study.118 This multicenter trial was designed to 

measure the effect of a psychosocial and cognitive behavior therapy intervention. A total of 

2,481 patients were recruited from eight clinical centers for the study. Eligibility requirements 

included meeting criteria for either depression (39 percent) or social isolation (26 percent), or 

both (34 percent). The depression measure was based on the Depression Interview and 

Structured Hamilton (DISH) instrument. The major modification with this instrument is that 

patients were eligible if they had depressive symptoms for 1 week, provided they had previously 

had an episode of major depression. DISH and BDI scores indicated most patients had moderate 

to minor levels of depression. The participants all had to be enrolled within 28 days of their MI. 

Initially the participants could not be taking antidepressants, but halfway through the study 

patients who remained depressed even after taking antidepressants for at least 14 days were 

included in the study. The criteria used to establish an MI were standard. 

 Patients were assigned randomly either to the intervention or routine care. Patients in both 

groups received written materials about cardiac risk factors based on the American Heart 

Association Active Partnership Program, and those in usual care had physician notification of 

their depression. The intervention included cognitive behavioral therapy provided first with three 

individual sessions and then within a group setting. Therapy could last up to 6 months. 

Intervention patients were referred to study psychiatrists for initiation of pharmacotherapy if they 

had scores higher than 24 on the HAMD or if they had less than 50 percent reduction in BDI 

scores after 5 weeks. Pharmacotherapy was usually sertraline and could be continued for up to 12 

months. 

 As shown in Evidence Table 2, study participants had a mean age of 61 years, 44 percent 

were female, 33 percent were nonwhite, and 47 percent had a high school education or higher. 

Cardiovascular risk factors were as expected, with 64 percent having a smoking history and 33 

percent having diabetes mellitus. Seven percent had a Killip class of III or IV; 83 percent had a 

cardiac catheterization; and 17 percent had a subsequent CABG surgery. Use of cardiac 

medications was common. 

 Between 1996 and 1999, 2,481 patients were randomized. Vital status was ascertained for 93 

percent of patients at 6 months and all patients were followed for at least 18 months. Ninety-two 

percent of those randomized to the intervention received the intervention as assigned. Median 

time to enrollment was 6 days post-MI, and the intervention started a median of 17 days after 

MI. Patients attended a median of 14 sessions. At baseline the intervention group was more 

likely to be on an antidepressant (9.1 percent versus 4.8 percent), and these differences were still 

apparent at the end of data collection (21 percent versus 14.6 percent). 

 Depression scores improved for both groups, but the intervention produced significant but 

modest differences in depression at 6 months as measured by the BDI and HAMD. At 30 months 
32

there were no differences between the intervention and usual care groups in terms of all-cause 

mortality, cardiovascular mortality, or nonfatal cardiac events. There was a statistically 

significant interaction between gender, intervention, and risk of death or recurrent nonfatal MI. 

Men in the intervention group had better outcomes than men in the usual care group, and women 

in the intervention group had worse outcomes than women in the usual care group. 

 Although not part of the randomized component of the study, the investigators presented an 

analysis of whether those on antidepressants had better cardiac outcomes. In both crude analyses 

and analyses adjusting for baseline variables including age, BDI score, Killip class, ejection 

fraction, serum creatinine, previous MI and prior diagnosis of congestive heart failure, stroke or 

transient ischemic attack, pulmonary disease or diabetes, the hazard rate for death or nonfatal MI 

was 0.63 (95 percent CI, 0.46 to 0.87) for those taking antidepressants compared with those not 

taking antidepressants. Antidepressant use was modeled as a time-dependent variable. 

 Overall, this study provided a high-quality counseling intervention that was initiated soon 

after an MI. It had a modest effect on depression but did not have any effect on cardiac outcomes 

early or up to 42 months of follow-up. Despite including individuals with only low social 

support, it did not seem to complicate conclusions related to depression care and outcomes. Any 

conclusions concerning the effects of antidepressants on cardiac outcomes are less certain. In 

light of the study protocol, which was to refer those only among the experimental group with 

high or persistent depression scores to be evaluated for antidepressants, it seems likely that those 

on antidepressants would have higher depression scores. This non-randomized component of the 

study could potentially produce selection bias, as antidepressants are related to both the exposure 

(psychosocial intervention) and the outcomes; thus it makes the experimental group look better 

than the control group, even if no true association exists. In their analysis the investigators 

adjusted for baseline BDI scores but not for subsequent BDI scores. It would appear that the 

analysis presented in the manuscript might underestimate the effect of antidepressants because it 

did not fully adjust for depression severity. It also would be reassuring to report if the effect of 

antidepressant therapy was detectable for both those in the usual care group and those in the 

intervention group. The analysis regarding antidepressants excluded all those who had entered 

the trial only for low social support. However, it was not clear who the comparison group was in 

this antidepressant analysis. Also, the study did not adjust for willingness to accept a 

recommendation to start an antidepressant, which may be a marker for overall adherence to 

multiple care recommendations. 

Other psychosocial intervention studies. With numerous studies demonstrating that depression 

is a risk for poor outcomes after an MI, several investigations were conducted to determine 

whether psychosocial interventions might reduce the elevated risk. The minimal risks associated 

with psychosocial interventions make such interventions attractive for patients who usually 

require multiple medical interventions for their cardiac care. 

 Frasure-Smith and colleagues48 completed a randomized clinical trial involving 1,376 postMI patients in which they compared a supportive and educational home nursing intervention and 

usual care. Most of the participants did not have significant problems with anxiety and 

depression. The mean BDI score was only 8.3 at baseline with 33 percent above the usual cutoff 

for clinical depression. The intervention was designed to address psychological distress, not 

specifically depression. The investigators met their target for intervention frequency in 87 to 94 

percent of the participants. Contact for most patients receiving the intervention was spread out 

over 6 to 7 months. Despite meeting their intervention target goals, the investigators found that 
33

mean BDI scores at 1 year had no greater reduction for those in the intervention group than for 

those in the usual care group. It is unlikely there would be large intervention effects for the 

subgroup with high levels of depression at baseline if there were no differences in mean change 

in BDI scores, but data on the subgroup of participants having a score above 10 on the baseline 

BDI would have been informative. The authors did not provide information on the percentage of 

patients receiving antidepressant medication or formal psychotherapy. In terms of cardiac death, 

noncardiac death, nonfatal reinfarctions, or hospital readmission, there were no statistical 

differences by intervention status. Women in the intervention group tended to do worse than 

those in the usual care group. For men, there were no significant differences between the 

intervention and usual care groups. The authors speculated that the intervention nurses did not 

receive specific training in psychiatric-disorder screening and psychotherapeutic techniques, and 

this deficiency might account for the lack of effect of the intervention. In addition, the low need 

for depression treatment at baseline effectively limited power to detect differences in outcome. 

 Taylor and colleagues119 tested the effect of a home-based, case-managed, multifactorial risk 

reduction program with 585 men and women aged 70 years or younger who were hospitalized 

for an acute MI in one of five San Francisco Bay Area hospitals. The intervention began in the 

hospital and included screening for psychological distress, monitoring with follow-up phone 

calls, and referring for mental health treatment when necessary. Patients were assessed at 6 

months and 12 months. Of note is the unusual manner in which depressive symptoms were 

assessed. Depression was assessed with a single question about mood. With depression assessed 

by a single question, it is nearly impossible to detect any change. During follow-up, depression 

scores dropped significantly for both groups. There were no differences between the intervention 

and usual care groups. The intervention was not effective even for those with moderate-to-severe 

depression scores at baseline. 

 Johnston et al.49 randomized by ward and recruited 100 patients from a Scottish hospital 

within 72 hours of admission for acute MI. Despite randomization at a group level, the study 

groups were balanced on important baseline characteristics. Randomization was to usual care, 

inpatient cardiac rehabilitation, or extended rehabilitation. The extended rehabilitation group was 

followed for up to 6 weeks after discharge and received a mean total of 9.5 sessions with 8.4 

hours of contact. Patients and their spouses picked topics and received "nonjudgmental" 

counseling with a focus on helping patients achieve their objectives. Possible topics included 

explanation of heart attacks, risk factor modification, or emotional effects after a heart attack. 

Depression scores, which were measured at baseline, discharge, 2 months, 6 months, and 12 

months after discharge with use of the HADS, indicated significantly lower levels of depression 

for both intervention groups. Unlike most studies the depression scores worsened for the usual 

care group after leaving the hospital. The authors suggested that their intervention had better 

results than others because the approach was one-to-one and not group, nurses worked from a 

treatment manual, and partners were included. 

 The study by Dracup et al.47 compared 41 patients who participated in a structured outpatient 

cardiac rehabilitation program to 100 patients who did not complete cardiac rehabilitation. There 

was no randomization. All patients were living with a partner. Patient characteristics at baseline 

were similar for the two groups. Depression was measured with the Multiple Affect Adjective 

Checklist. Between baseline and 6 months, the cardiac rehabilitation patients had a reduction in 

their depression score, whereas the group without cardiac rehabilitation had no reduction. These 

differences were statistically significant, but the statistical adjustment for covariates was not 

clear. 
34

 Brown and colleagues45 recruited patients from the cardiac rehabilitation centers of five 

major medical centers. All participants were required to have (1) MI or CABG within the past 4 

and 4 to 24 months, (2) prognosis no worse than 3.3 (New York Heart Association Criteria), 

which indicates a moderately compromised cardiac status, (3) stable cardiac disease and no 

contraindications to physical activity, (4) onset of depression/anxiety associated with MI/CABG 

as assessed by the Schedule of Affective Disorders and Schizophrenia, (5) scores greater than 13 

on the BDI or above 70 on the SCL-90 - Revised, and (6) spouses, friends, or relatives willing to 

participate in the treatment intervention. As compared with other study samples, this sample 

included individuals having higher levels of depression. Participants were randomized to either 

active treatment or attention control. Active treatment focused on principles of behavior therapy 

with relaxation training and some cognitive restructuring self-instruction. Treatment, which 

included 12 weekly sessions, was provided by three different therapists. Clinician ratings were 

completed by raters blinded to the intervention status of the participants. Both groups improved 

on depression ratings (self-report and clinician ratings), but at 12 and 15 months the behavior 

therapy group continued to improve whereas the attention control group began to relapse. No 

information on cardiovascular outcomes was collected. 

 The manuscript by Crowe and colleagues46 describes an observational study with a 

randomized component in which patients did or did not receive cardiac rehabilitation 

intervention. It is very difficult to determine the actual study design from the article. Evidence 

Table 4.4 suggests that both the rehabilitation and usual care group demonstrated major 

improvement in depression during the follow-up, but there were no differences between the 

groups. 

Other antidepressant intervention studies. Most of the pharmacological studies have used 

SSRI antidepressant medications. A 1998 study compared nortriptyline (tricyclic antidepressant) 

with paroxetine (SSRI).120 As part of this study, 81 individuals younger than 65 years who had 

ischemic heart disease and moderately severe major depression (16 or higher on the 17-item 

HAMD) were randomized to either paroxetine or nortriptyline. Each patient completed a 2-week 

placebo lead-in phase to establish the stability of the depression diagnosis and to complete their 

cardiovascular tests. About two thirds of the patients had a history of MI, but the MI was not 

recent. The primary aim of the study was to determine the effect of the two types of 

antidepressant medication on cardiovascular outcomes. Patients received the study medication in 

a double-blind fashion for 6 weeks. Both medications were equally effective in reducing 

depression (60 percent achieved a 50 percent reduction in depressive symptoms). However, 

more participants withdrew from the nortriptyline than the paroxetine group (10 versus 2). 

Paroxetine did not have a significant effect on heart rate, blood pressure, conduction intervals, or 

ventricular arrhythmias. Nortriptyline was associated with an 11 percent increase in heart rate, a 

significant decline in standing systolic blood pressure, and a decrease in HRV. There was no 

effect on cardiac conduction. For equally effective treatments, the SSRI had less cardiovascular 

effects than did the tricyclic antidepressant. This study was funded by Smith-Kline Beecham, 

the manufacturer of paroxetine. 

 Another small study looked at the safety and efficacy of fluoxetine in the treatment of 

patients with major depression after a MI.50 For this study, depression was confirmed by a 

clinician-administered HAMD between month 3 and month 12 after an MI, and patients younger 

than 75 years were eligible. In this double-blind study, 54 patients were randomized to either 

fluoxetine or placebo for 9 weeks. Despite the small sample size there was nearly a statistically 
35

significant greater reduction in depression for the fluoxetine group than for the placebo group. 

For the majority of cardiovascular measures there were no differences between those randomized 

to fluoxetine or placebo. The investigators measured cardiac output using the aortic time velocity 

integral and found it increased in the placebo group and decreased in the fluoxetine group. The 

QRS interval was lower in those on fluoxetine than in the placebo group (p=.03). This study was 

funded by Eli Lilly, manufacturer of fluoxetine. 

 In 2000 McFarlane and colleagues121 reported the results of a double-blind, randomized, 

placebo-controlled study of sertraline in 38 post-MI patients. The total sample was small with 12 

randomized to sertraline, 15 to placebo, and 11 non-depressed age-matched controls. Depression 

was diagnosed with a validated self-report instrument called the Inventory to Diagnose 

Depression (IDD). The IDD was administered before hospital discharge and again within 2 

weeks of the acute infarct. Ejection fractions averaged over 50 percent in each group. Depression 

scores tended to decrease faster in the sertraline group than the placebo group. Standard 

deviation of normal R-R interval (SDNN), a measure of HRV, increased by 5 percent in the 

sertraline group and decreased 9 percent in the placebo group. Lower levels of SDNN have been 

reported to be a marker for increased cardiac mortality. Differences by study group were not 

evident in several other markers of HRV. This study was not supported by a pharmaceutical 

company but by the Heart and Stroke Foundation of Ontario, Canada. 

 As summarized in Evidence Grade Table 4, we concluded that the overall body of evidence 

on question 4 merited a medium quantity of evidence and medium to low quality of evidence 

(see Appendix F). 

Quality of Studies 

 There was a wide variation in the quality of the eligible studies with the larger and more 

recent studies generally having higher levels of quality. Median quality scores across the various 

domains of study quality ranged from a low of 50 percent on statistical analysis and 

measurement of depression to 100 percent on reporting potential conflicts of interest. (See 

Evidence Table 4.3 in Appendix G) 

Key Question 5 

Q5. What are the performance characteristics (e.g., sensitivity, specificity, reliability, and 

predictive value) of instruments that are used to screen for depression (or depressive symptoms) 

after an acute MI? 

Q5a. What are the performance characteristics of instruments that are used to screen for 

depression (or depressive symptoms) after an acute MI, during hospitalization? 

Q5b. What are the performance characteristics of instruments that are used to screen for 

depression (or depressive symptoms) after an acute MI, within 3 months after hospitalization? 

Introduction
36

 Clinicians and investigators need accurate and reliable methods to screen for depression in 

post-MI patients. The screening assessment methods should have adequate validity, reliability, 

and diagnostic utility within post-MI populations. Population-specific evaluation of the 

performance characteristics of assessment tools is particularly important with MI survivors 

because somatic symptoms of depression are easily mistaken for, and often overlap with, the 

physical sequelae of MI. Moreover, the timing of the depression assessment may influence its 

reliability and accuracy given that the hospitalization itself (question 5a) may adversely affect 

sleep habits, appetite, and other aspects of the usual depression assessment. Adequate validity of 

an assessment instrument is achieved if the instrument can successfully measure depression and 

differentiate it from similar, but distinct constructs. Reliability refers to the degree of consistency 

of a measure. Diagnostic utility refers to the extent to which a measure correctly identifies 

individuals who meet or do not meet certain diagnostic criteria as determined by a "gold 

standard," which for depression would typically be a structured interview process. Validity, 

reliability, and diagnostic utility are multidimensional concepts that gain strength with 

convergence of evidence. They cannot be established globally for a particular instrument, but 

rather defined in terms of specific groups or populations and the purpose for which they are used 

(i.e., screening versus research diagnosis). 

 As reviewed in the section of the report on questions 1 and 2, numerous measurement 

instruments have been used to assess depression in post-MI patient populations. Perhaps the two 

most frequently used instruments are the BDI and the HADS. Evidence was presented in the 

section of the report on questions 1 and 2 indicating that the BDI tends to produce higher 

prevalence estimates across studies than the HADS. This finding raises questions about the 

performance characteristics of these and other measures used with post-MI patients. This section 

will review evidence related to the validity, reliability, and diagnostic utility of assessment 

techniques that have been used to evaluate depression in survivors of MI. 

Results of Literature Search 

 After article review, seven articles were eligible for review on question 5. One study was 

excluded at this point because it did not report specific cutoff criteria used for diagnosing 

depression. Of the six remaining studies, two also were deemed eligible for question 5a.119,122 In 

one of these two studies, the majority of participants (78 percent) were interviewed during 

hospitalization and the balance post-discharge, but within 28 days of the index MI.122 Three 

studies were eligible for question 5b as well as for question 5.75,90,123 One study reported data 

relevant to both questions 5a and 5b.66

Characteristics of Studies 

 A summary of key aspects of the six eligible studies is presented in Appendix G Tables 5. 

Included studies were published between 1988 and 2003. All of the studies were composed 

entirely of post-MI patients. Two studies reported data on diagnostic utility,75,90 two on 

factor/construct validity,66,119 one on convergent validity,122 one on discriminant validity,123 and 

two on internal consistency reliability.66,119 Four studies were conducted in Europe,66,90,119,123 

one in Canada,75 and one in the United States.122 Only one - which included over 2,000 

participants, but provided limited data for this question - was a multicenter study.122 The other 

studies included between 52 and 335 participants. The mean age of participants ranged from 51 
37

to 67 years. The ENRICHD study,122 which was designed to maximize diversity of participants, 

enrolled 44 percent women and 34 percent non-white participants. The other studies enrolled 

between 73 and 90 percent men. Only one other study provided data on race; it enrolled only 

white participants.90 The ENRICHD study122 was the only eligible study to report cardiac risk 

factors, and none of the studies reported MI characteristics such as Killip class or LVEF. 

Quality of Studies 

 As shown in Table 5.2, the number of studies that had a study quality score higher than 50 

percent were as follows: five for representativeness of the study population, three for potential 

bias and confounding, two for description of therapy and management, four for description of 

assessment protocol, two for test interpretation, two for reporting of outcomes and follow-up, 

and five for statistical analyses. Only two studies reported information on potential conflicts of 

interest. 

Results of Studies 

 Table 5.1 presents evidence on performance characteristics of measures of depression with 

post-MI samples, as reported by the six reviewed articles. The three studies that reported 

performance data from hospitalized post-MI populations included data on the BDI, the HADS, 

and the HAMD. The BDI is a 21-item self-report rating scale measuring characteristic attitudes 

and symptoms of depression. The HAMD is a 17-item observer rated scale to assess the presence 

and severity of depressive symptoms. The HADS is a 14-item (seven depression items) selfreport questionnaire designed to detect symptoms of anxiety and depression in a non-psychiatric 

hospitalized population. 

 Internal consistency reliability for the HADS and the HADS Depression subscale (HADS-D) 

as measured by Cronbach's alpha was found to be 0.82 and 0.72, respectively, in a sample of 194 

male and female patients.119 Another study by the same authors, which included 335 male and 

female patients, reported internal consistency reliability for the HADS as 0.87, 0.88, and 0.90 at 

1 week in-hospital, 6 weeks, and 6 months post-MI and for the HADS-D as 0.76, 0.80, and 0.81 

for the same follow-up times.66 Nunnally has suggested a widely referenced guideline of 0.70 as 

a lower bound for acceptability of internal consistency reliability. These two studies also 

reported data from an exploratory factor analysis119 and confirmatory factor analyses across 

time66 that supported the construct validity of the HADS-D as measuring depression distinct 

from anxiety. 

 The ENRICHD investigators122 reported evidence on the convergent validity of the selfreport BDI and the HAMD, the items of which were embedded in an SCID. A Pearson 

correlation coefficient between the BDI and the HAMD was 0.64, close to the low end of the 

range of similar correlations that have been reported in other clinical settings (0.61 to 0.87).124

The ENRICHD sample, however, included only individuals with symptoms of depression. This 

stipulation would be expected to restrict the range of scores on the BDI and HAMD and to lower 

the correlation coefficient compared to what might be found in a screening sample of both 

depressed and nondepressed individuals. 

 Three additional studies reported psychometric data within 3 months after hospitalization for 

the BDI, the HADS, the HAMD, the Symptom Checklist-90 Depression subscale (SCL-90-Dep), 

and the ZDS. The SCL-90 is a brief, multidimensional self-report inventory designed to screen 
38

for a wide range of symptoms of psychopathology that includes an index of depression.125 The 

ZDS is a 20-item self-rating scale to screen for symptoms of depression.126 

 Two studies assessed the diagnostic utility of measurement instruments as compared with a 

SCID for DSM diagnosis.75,90 One of these studies75 counted any subject with a total BDI score 

of 1 to 12 as symptomatic, resulting in difficult to interpret concordance data. This study was 

also limited by its very small sample size. In the other study,90 data on diagnostic utility 

(sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) 

were reported on both major depression and combined major and minor depression for the BDI, 

HADS and HADS-D, HAMD, and SCL-90-Dep as compared with a physician-administered 

SCID-IV. SCID-IV prevalence for major depression was 11.2 percent and 7.8 percent for minor 

depression with a combined prevalence of 18.9 percent. Cutoff points were derived by using 

receiver operating characteristic (ROC) analysis, which attempts to determine optimal sensitivity 

and specificity. The number of patients included in each comparison ranged from 179 to 206, 

depending on the measure. For combined major and minor depression, sensitivities ranged from 

0.75 for the HADS-D to 0.84 for the BDI. Specificities ranged from 0.72 for the BDI to 0.86 for 

the HAMD. PPVs ranged from 0.25 for the BDI to 0.41 for the HAMD. NPVs ranged from 0.93 

for the SCL-90-Dep to 0.99 for the HAMD. For major depression alone, sensitivities ranged 

from 0.82 for the BDI to 0.96 for the SCL-90-Dep. Specificities ranged from 0.74 for the SCL90-Dep to 0.92 for the HAMD. PPVs ranged from 0.32 for the HADS-D to 0.59 for the HAMD. 

NPVs ranged from 0.96 for the SCL-90-Dep to 0.98 for the HAMD, HADS-D, and BDI. Figures 

3 and 4, show sensitivity and specificity data for all measures for major/minor and major 

depression. 

 One study123 reported evidence on the convergent validity of the SCL-90-Dep and the ZDS 

for 143 patients with a Pearson correlation coefficient ranging from 0.70 to 0.77 across four time 

periods (1, 3, 6, and 12 months). Evidence related to discriminant validity was also reported for 

both the SCL-90-Dep and the ZDS as compared with a measure of "vital exhaustion" developed 

in the Netherlands. That these correlations ranged from 0.75 to 0.83 for the two measures across 

the four time periods suggests these measures do not discriminate well between depression and 

post-MI symptoms of fatigue. The construct validity of vital exhaustion, however, is unclear and 

the measurement instrument used included numerous symptoms of depression. Additionally, in 

this study patients with a diagnosis of clinical depression, as determined by the HAMD, at 

baseline were offered antidepressants and withdrawn from the study. The lack of patients with 

significant symptoms of depression in the study population may have contributed to the lack of 

differentiation reported between symptoms of depression and vital exhaustion. 

 As summarized in Evidence Grade Table 5, we concluded that the overall body of evidence 

on question 5 merited a low quantity of evidence and low quality of evidence (see Appendix F). 

Summary of Studies 

 The measures reviewed here seem to be measuring depression based on adequate sensitivities 

and specificities across studies as compared with the SCID-IV90 and evidence from confirmatory 

and exploratory factor analyses.66,119 Evidence also exists for convergent validity122,123 and 

adequate internal consistency127 of the measures. 

 Given the limited number of studies and analyses performed, it is difficult to draw 

conclusions about performance characteristics at each time period. This is particularly true 

during the initial MI hospitalization. Overall, however, evidence is relatively scant regarding the 
39

adequacy of the assessment of depression in post-MI populations. None of the measures 

reviewed here has been normalized explicitly on post-MI populations. In this context, two 

interrelated concerns predominate. The first relates to construct validity and how well these 

measures accurately distinguish between symptoms of depression and somatic symptoms related 

to poor physical health. The study samples covered in this review tended to be small for these 

purposes. Furthermore, the psychometric methods that were used are relatively weak ones and 

provide limited information. Existing psychometric methods that are able to establish the 

equivalence of key measurement characteristics across post-MI and nonhospitalized depressed 

subjects would be useful in refining assessment practices for depression in MI survivors. 

 A second concern relates to the intended use of the instruments reviewed and the very low 

PPVs reported.90 If these instruments are to be used for general screening that will be followed 

by a more thorough assessment of those who screen positive, then low PPVs and high NPVs are 

acceptable, and cutoff points to achieve this objective have been reported.90 A research setting, 

however, in which relatively few of those diagnosed with major depression are actually 

depressed (as compared with diagnosis by SCID-IV) is problematic and reduces the power to 

detect relationships between depression and outcome variables. Strik and colleagues90 reported 

utility statistics for prominent measures of depression that were based on cutoff scores generated 

by an ROC paradigm intended to maximize combined sensitivity and specificity. This resulted in 

cutoff points well below those used in normal settings where cutoff points are set pragmatically 

according to specific clinical or research objectives. A stronger analysis might have included 

data for commonly used cutoff points. Despite this flaw, the study pointed out a potential 

problem in research on the relationship between depression and post-MI outcomes. The slightly 

higher cutoffs normally employed would be expected to lessen but not completely alleviate this 

problem. 

 Furthermore, Strik's study provides data relevant to the discrepancy in prevalence rates 

generated by studies using the BDI as compared with studies using the HADS. For combined 

major and minor depression, the BDI tends to be highly sensitive relative to the other measures, 

but with lower specificity. When only major depression is considered, the BDI is the least 

sensitive measure and is in the middle to lower range of specificities. This suggests that 

compared with the HADS, SCL-90-Dep, and HAMD, the BDI tends to diagnose patients with 

less significant depressive symptoms at much higher rates than do the other measures, but it may 

be less effective in accurately diagnosing major depression. Given the expected distribution of 

symptoms of depression, the BDI would be expected to identify more patients as having 

significant symptoms of depression, but it would do a poorer job of consistently identifying those 

who are most depressed. 

 In summary, the quality of evidence varies for performance characteristics of instruments 

that measure symptoms of depression in post-MI populations, both in terms of numbers of 

patients studied and in terms of types of evidence that have been reported. 

Key Question 6 

Question 6. Does use of cardiac treatment for patients with acute myocardial infarction differ for 

those with and those without depression? 

Introduction 
40

 Patients who are depressed after MI may receive different treatment than patients without 

depressive symptoms. Several factors could explain this difference in practice. Patients with 

depression may have a diminished capacity to make important decisions about their health. As a 

result, depressed patients may be less willing to undergo cardiovascular procedures such as 

catheterization, percutaneous coronary intervention (PCI), or CABG. Depression may also result 

in decreased adherence with prescribed medications, refusal to participate in cardiac 

rehabilitation, and reluctance to make lifestyle changes such as smoking cessation. In addition, 

physicians and other health care providers may not refer patients with depression for 

cardiovascular procedures or other therapies like cardiac rehabilitation even when medically 

appropriate. This practice, in turn, might reflect a bias against depressed patients on the part of 

health care providers. Alternatively, the depressed patient's perception and communication of 

cardiovascular symptoms may differ from those of a patient without depression in a manner that 

makes it less likely for certain treatments to be considered necessary. To evaluate this question 

we reviewed the English language literature that addressed the relation of depressed mood to use 

of cardiac treatment after an acute MI. 

Results of Literature Search 

 Our search found nine studies, published between 1982 and 2004, that met criteria for 

inclusion in this review (see Table 6). 

Characteristics of Studies 

 As shown in Table 9, seven of the nine eligible studies on key question 6 used prospective 

cohort designs with the other using a retrospective cohort design.52 Four studies reported whether 

patients with and without depression differed with regard to prescribed cardiac medications after 

MI.79,81,89,128 Three studies evaluated adherence to secondary prevention medications and 

lifestyle recommendations in depressed and nondepressed patients.128-130 Two studies evaluated 

whether patients with post-MI depression received invasive cardiac procedures at a different 

frequency compared to MI patients without depression. Two studies131,132 examined factors 

associated with noncompletion of cardiac exercise rehabilitation. 

Quality of Studies 

 As shown in Table 6.3, the number of eligible studies with scores greater than 50 percent for 

the following criteria, were as follows: six for representativeness of the study population, one for 

description of therapy and management, eight for description of the assessment protocol, seven 

for reporting of outcomes and follow-up, and seven for the statistical analyses. Only three studies 

provided information about potential conflicts of interest. 

Results of Studies 

 Four studies have evaluated whether depressed and nondepressed post-MI patients are just as 

likely to be prescribed medications recommended to reduce post-MI risk (see Table 6.4). 

Ziegelstein et al.128 in a U.S.-based study found that on hospital discharge depressed post-MI 

patients were less likely than patients without depression to be prescribed beta-blockers. They 
41

found no difference in discharge prescriptions for aspirin, lipid-lowering therapy and ACE 

inhibitors between depressed and nondepressed patients. Steeds et al.79 in a United Kingdom - 

based study also found that MI patients with depression when compared with those without 

depression had lower rates of use of beta-blockers (32 percent versus 55 percent, p = 0.02) and 

higher rates of use of calcium channel blockers (37 percent versus 12 percent, p = 0.02). Strik et 

al.89 monitored 206 Dutch patients with a first MI for up to 3 years. Patients with major or minor 

depression were prescribed platelet inhibitors at significantly lower rates than those without 

depression (81 percent versus 95 percent, p = 0.001). However, no significant differences were 

observed between depressed and nondepressed patients in the use of beta-blockers or in the rates 

of use of PTCA. Lauzon and colleagues81 studied 550 Canadian post-MI patients and found no 

difference between depressed and nondepressed patients in prescribed levels of use of aspirin, 

beta-blockers, lipid-lowering drugs, ACE inhibitors, nitrates, or calcium-channel blockers. They 

did find that depressed patients had a significantly higher rate of rehospitalization for cardiac 

complications than nondepressed patients. Overall, these studies were not consistent with each 

other. The U.S. - and U.K.-based studies both found that depression was associated with 

decreased use of beta-blockers in post-MI patients, whereas the Dutch and Canadian studies both 

found that depression was not associated with decreased use of beta-blockers in post-MI patients. 

 Three studies examined the effect of depression on adherence behaviors after MI (see Table 

6-4). In the study performed by Ziegelstein et al.128 276 patients were followed for 4 months after 

an acute MI, and those with major depression and/or dysthymia were less likely to follow 

dietary, exercise, and stress-reduction recommendations or to take prescribed medications than 

were patients without depression. Conn et al.129 assessed multiple self-care behaviors in 94 postMI patients aged 65 years or older who were deemed capable of self-care. Depression, but not 

anxiety, was significantly associated with decreased adherence at 1 to 2 years of follow-up for all 

self-care behaviors assessed: exercise, diet, medications, smoking cessation, and stress 

management.128 More recently, Romanelli et al. also studied adherence behaviors in post-MI 

patients aged 65 years or older.130 They found that post-MI patients had significantly lower rates 

of adherence than nondepressed MI patients for use of prescribed medications as well as 

recommendations for following a low fat diet, increasing exercise, and reducing stress.52,81 These 

three studies thus were consistent in showing that depression was associated with decreased 

adherence to prescribed medications and other risk reduction behaviors in post-MI patients. 

 Two studies examined the use of invasive procedures after MI (see Table 6-4). Druss et 

al.52 reviewed Medicare claims in a national cohort of 113,653 patients coded as having MI and 

compared the 5,365 coded with a secondary diagnosis of mental disorder to the other 108,288. 

The patients with the following mental disorders were considered: schizophrenia, affective 

disorders, substance abuse, and others (excluding dementia and delirium). Those with mental 

disorders were significantly less likely than those without mental disorders to undergo cardiac 

catheterization, PTCA, and CABG. This decreased tendency for undergoing invasive 

cardiovascular procedures among post-MI patients, extended to the subgroup of 315 patients 

with a mental disorder characterized as an affective disorder, among whom the rates of 

catheterization, PTCA, and CABG were 33.4 percent, 9.2 percent, and 7.9 percent, respectively. 

Those rates were significantly lower than the rates observed in the patients without mental 

illness, which were 43.7 percent, 16.8 percent, and 12.6 percent, respectively. In contrast, 

Lauzon et al73 studied 550 post-MI patients in Quebec hospitalized between 1996 and 1998 and 

found that 23 the rates of undergoing cardiac catheterization, PTCA, and CABG were not lower 

among those with BDI scores of 10 or higher than among those with BDI scores lower than 10. 
42

Thus, these two studies reported conflicting results about the relation of depression to 

undergoing invasive procedures in post-MI patients. 

 One study by Blumenthal et al.132 evaluated 35 post-MI patients referred for cardiac 

rehabilitation for factors associated with completion of the prescribed program (see Table 6.2). 

They found that patients with higher depression scores on the Minnesota Multiphase Personality 

Inventory (MMPI) were more likely to drop out of the program (p < 0.03). However, in 

multivariate analysis, only ejection fraction, ego strength, and social introversion were associated 

with continued adherence to the cardiac rehabilitation program. Another study,133 performed in 

the United Kingdom examined psychological determinants of attendance in cardiac rehabilitation 

among 93 patients after an acute MI (see Table 6.2). These investigators found that the best 

predictors of poor or no attendance were lower perceptions of symptoms and controllability or 

curability of illness, and less frequent use of problem-focused coping strategies and more 

frequent use of maladaptive coping strategies. Although depression scores on the HADS were 

lower among those with poor or no attendance, depression score was not an independent 

determinant of attendance in cardiac rehabilitation. The higher depression score among attendees 

suggests that those who are experiencing a greater degree of distress after MI are more likely to 

attend, but this explanation is not conclusive. Because neither of these studies enrolled a 

sufficient number of patients with a clinical diagnosis of depression, a definitive conclusion 

about an independent relationship between depression and completion of recommended cardiac 

rehabilitation is not possible. 

As summarized in Evidence Grade Table 6, we concluded that the overall body of 

evidence on question 6 merited a low quantity of evidence and medium to low quality of 

evidence (see Appendix F).
43

Chapter 4. Discussion

Conclusions and Limitations 

Question 1. In patients hospitalized for acute MI what is the prevalence of depression during the 

initial hospitalization for MI? 

 Important technical and methodological issues affect the interpretation of studies that address 

this question. These issues include variations from study to study in (1) the definition of 

"depression" (modified major depression versus potentially significant symptoms of depression 

versus definition not specified), (2) the screening instrument or method of diagnosis employed, 

and (3) the clinical threshold criteria (i.e., cutoffs) used even with the identical screening 

instrument. 

 Major depression is reported in about one of every five patients hospitalized for MI. This 

proportion is fairly consistent among the seven studies that used a SCID to establish this 

diagnosis. 

 The reported prevalence of potentially significant symptoms of depression varies more 

widely (range 10 to 47 percent). This wide range of reported prevalence rates appears to be due 

almost exclusively to differences in measurement instruments used, and even to differences in 

threshold criteria applied from study to study when the same instrument was used. Although it is 

difficult to draw conclusions from small numbers of studies and different assessment methods, 

the variability in reported prevalence does not appear to be explained by differences in 

demographic characteristics such as age and sex. 

 

 Of note, although the reported prevalence of potentially significant symptoms of depression 

varies fairly widely from 10 to 47 percent, closer inspection suggests less variability in actual 

prevalence rates. The study that reported a prevalence rate of 47 percent was the only study that 

used the revised version of the BDI-II79 This study was reported in brief format (i.e., as a 

“Scientific letter”) and without key demographic information. Of the five studies that used a 

cutoff score of 10 or higher on the BDI,25, 77, 78, 80, 81 four reported prevalence rates between 32 

and 37 percent. The sample size of the study that reported a prevalence rate of 21 percent80 was 

relatively small (85 patients). 

 In general, the reported prevalence of potentially significant symptoms of depression is 

higher when this diagnosis is based on a BDI score of 10 or higher than when it is based on a 

HADS score of either 8 or higher or 11 or higher. This difference may be attributed to the BDI’s 

inclusion of somatic symptoms that may overlap with MI symptoms, whereas the HADS does 

not include somatic symptoms and is designed for use in hospitalized patients. 
44

Question 1a. What is the prevalence of depression during initial hospitalization for MI in 

patients with or without a known history of depression as reported by study investigators? 

 Study investigators reported information about a history of depression in only two studies, 

and neither provided separate prevalence data for these patients. There is therefore insufficient 

evidence to address this question. 

Question 2. What percentage of patients with post-MI depression continue to have depression (or 

depressive symptoms) 1 month or longer after initial hospital discharge?

 Although 22 studies reported the prevalence of depression in patients 1 month or longer after 

initial hospital discharge, only three reported the prevalence of depression in patients during the 

MI hospitalization and then specifically reassessed and reported the prevalence of depression in 

these same patients at follow-up. 

 These studies suggest that most patients (60-70 percent) with depression during the initial 

MI hospitalization continue to have depression (or depressive symptoms) 1 to 4 months later. 

Question 3. What is the association of various measures of depression with outcomes in patients 

with acute MI, independent of known predictors of post-MI outcomes? 

 Seventeen studies evaluated the relationship between depression, measured shortly after an 

acute MI, and subsequent mortality. Studies have assessed this relationship as early as 4 months 

post-MI and as late as 10 years post-MI. Despite the facts that various measures of depression 

have been used, that different subgroups of depressed patients have been evaluated, and that 

different post-MI survival times have been assessed, the weight of the evidence is strikingly 

consistent. Overall, the evidence supports the notion that post-MI depression is associated with a 

significantly increased risk for subsequent death, whether by cardiac or other causes. Depression 

appears to be associated with about a 3-fold increased risk of cardiac mortality per se based on at 

least four studies that addressed cardiac mortality in a total of almost 2,000 patients.22, 23, 100

 Six studies evaluated the relationship between depression and cardiac events. The study that 

examined the relation between depression during the initial MI hospitalization and cardiac 

readmission106 suggests depression is associated with increased cardiac readmission during the 

first year, even after controlling for important cardiac variables. That there may be a relation 

between post-MI depression and cardiac events is indicated by three studies that evaluated this 

association.84, 89, 95 Strik et al. found a relation between depression and cardiac events in one 

study.84 However, this relation was not significant after anxiety was added to the model. 

Shiotani et al.95 evaluated a much larger sample and found a trend toward a multivariate 

relationship between post-MI depression and cardiac events for patients younger than 65 years 

and a significant multivariate relationship in those older than 65. None of these three studies 

presented data on the statistical power to detect differences in cardiac events given the sample 

sizes. Given the relatively low cardiac event rates, the sample sizes of the studies that did not 

find a significant independent relation between depression and cardiac events84, 89 were relatively 
45

small compared with the larger sample size of the studies of Shiotani et al.95 and Frasure-Smith 

et al.106

 

 During the first year after MI, depression during the initial MI hospitalization has been found 

to be inversely related to physical QOL, social QOL of women, sexual activity and satisfaction 

among men, return to work of employed men, and to physical, psychological, and social health 

and function. Studies show that even as long as 5 years after an MI, in-hospital depression can 

have a prolonged negative impact on psychological distress and physical health and functioning. 

 Limitations of the above-mentioned studies included the variety of diagnostic instruments 

used to assess depression (some of which were not categorical or diagnostic, but continuous in 

nature); the lack of agreement on what aspects of QOL are of greatest import or how to measure 

them; limits in the power to draw firm conclusions, based on the small number of subjects 

included in studies; the degree to which potential confounders were adequately considered; the 

question of whether it is appropriate to adjust for symptoms of fatigue when analyzing the 

association between depression and clinical outcomes after an MI; and the absence of data in 

early post-MI time points (e.g., 30 days). 

Question 3a. What is the association of various measures of depression with surrogate markers 

of cardiac risk in patients with acute MI, independent of known predictors of post-MI outcomes? 

 Three studies have been performed in post-MI patients to compare HRV, platelet-derived 

substances, and inflammatory markers in those with and those without depression. All three 

studies reported differences in at least one surrogate marker between patients with a major 

depressive syndrome post-MI compared with post-MI groups without depression. All three 

studies found surrogate markers of increased risk in the patients with post-MI depression. The 

higher risk profile in all surrogate markers persisted after adjustment for covariates. Thus, a 

small amount of evidence suggests that post-MI patients with depression have alterations in 

autonomic function as reflected by decreased HRV, increased platelet activity, and increased 

levels of soluble adhesion molecule 4. These studies suggest that the risk associated with postMI depression could be transmitted by multiple biological pathways. 

 Few studies have evaluated these surrogate markers in post-MI patients with depression and 

compared them to post–MI patients without depression. All studies have compared only patients 

with major depressive syndrome to those without major depression. It is unknown whether other 

forms of depression are also associated with similar changes in these biomarkers. 

 

Question 4. Do post-MI patients with depression have better outcomes with depression treatment 

than do those without such treatment? 

 No studies of sufficient power have yet been performed that directly address the question as 

to whether treatment with antidepressants improves survival in depressed patients after an MI. 

However, there is evidence that SSRI antidepressants do not have common adverse cardiac 

effects when administered to early post-MI patients. Increases in rare adverse effects cannot be 
46

excluded. Some evidence suggests that SSRI antidepressants have beneficial effects on surrogate 

markers of post-MI risk (e.g., HRV, aortic time velocity integral). 

 

 There is evidence that both psychosocial intervention and SSRI antidepressants improve 

depression in post-MI patients. However, the possibility of increases in rare adverse events 

cannot be excluded. Current clinical trial evidence suggests psychosocial interventions do not 

improve post-MI cardiac outcomes. 

Question 5. What are the performance characteristics (e.g., sensitivity, specificity, and predictive 

value) of instruments or methods that are used to screen for depression (or depressive symptoms) 

after MI? 

 There are insufficient data to allow an adequate assessment of the performance 

characteristics of instruments or methods used to screen for depression during the initial MI 

hospitalization.

 HAMD has adequate sensitivities and specificities for identifying depression within 3 months 

after hospitalization for an MI, as compared to a diagnosis of depression based on a SCID. There 

is also evidence for convergent validity and adequate internal consistency. 

 None of these measures has been normalized specifically in post-MI populations. It is 

unclear how well these instruments distinguish symptoms of depression from somatic symptoms 

related to the MI, to poor physical health, or to the hospitalization itself. 

 The very low PPVs of these screening instruments (generally in the 25 to 50 percent range) 

may be acceptable clinically if followed by a more thorough assessment of those who screen 

positive; however, the low PPVs are particularly problematic if used to detect relationships to 

outcome variables in the research setting. The study that generated diagnostic utility figures 

used cutoffs that were slightly lower than those commonly employed in research studies. If the 

more commonly-used cutoffs had been employed, PPVs would have been slightly higher. 

 When compared with the HADS, SCL-90-Dep, and HAMD, the BDI tends to diagnose less 

significant symptoms of depression at higher rates,. It may be less effective in accurately 

diagnosing major depression. 

 Important questions remain and further research is needed to improve performance. This 

research should include more sophisticated analyses of existing measures as well as the potential 

development of new measurement techniques specifically validated for use with MI survivors. 

Question 6. Does the use of cardiac treatment for patients with acute MI differ for those with and 

those without depression? 

 Four studies included in this review evaluated whether the use of medications for the 

secondary prevention of adverse cardiac events post-MI differs between depressed and 
47

nondepressed patients. The findings of these studies were inconsistent. Two studies found that 

beta-blockers were prescribed less frequently among post-MI patients with depression than 

among post-MI patients without depression. One study found that aspirin or antiplatelet agents 

were used less frequently in depressed than nondepressed post-MI patients. Finally, one study 

found no difference in the use of any recommended medication between depressed and 

nondepressed post-MI patients. Thus, it remains unclear whether there are significant differences 

in cardiac medications prescribed to post-MI patients based on the presence or absence of 

depression. 

 Three studies evaluated adherence to prescribed medications and secondary prevention 

measures in post-MI patients and consistently found lower adherence in those with depression 

than those without depression. 

 Two good-quality studies, using different methods, came to diverse conclusions about 

whether the frequency with which cardiac procedures are used varies between post-MI patients 

with depression and those without depression. 

 Two small studies examined participation in post-MI cardiac rehabilitation programs and 

reported discordant results. No conclusion can be reached about the likelihood of patients 

completing cardiac rehabilitation programs based on the presence or absence of post-MI 

depression. 

Future Research 

Question 1. In patients hospitalized for acute MI, what is the prevalence of depression during the 

initial hospitalization for MI?

 Additional studies are needed to define the most clinically relevant measure of "depression" 

during the initial MI hospitalization. The definition of depression varies considerably from study 

to study; to determine the most appropriate definition in this setting, clinical relevance should be 

determined for each definition. 

 Studies are needed to determine the clinical or demographic factors that are associated with 

post-MI depression. Given the episodic nature of depression, future studies on this topic should 

carefully document which patients have had depression diagnosed and/or treated in the past and 

which patients report significant depressive symptoms in the past that might not have been 

formally diagnosed or treated. 

Question 2. What percentage of patients with post-MI depression continue to have depression (or 

depressive symptoms) 1 month or longer after initial hospital discharge?

 Additional studies are needed that assess depression (or depressive symptoms) in groups of 

patients during the initial hospitalization and at various times after MI. In particular, the group 

of patients with depression (or depressive symptoms) during the initial MI hospitalization should 

be reassessed at certain time points after discharge. 
48

Question 3. What is the association with various measures of depression with outcomes in 

patients with acute MI, independent of known predictors of post-MI outcomes?

 Additional studies are needed to determine the major cause(s) of mortality among depressed 

post-MI patients and whether these causes differ in distribution from nondepressed post-MI 

patients. Additional studies also are needed to determine whether patients with depression are at 

higher risk for malignant arrhythmias than are comparable post-MI patients without depression. 

Question 3a. What is the association of various measures of depression with surrogate markers 

of cardiac risk in patients with acute MI, independent of known predictors of post-MI outcomes? 

 

 Additional studies are needed to elucidate the mechanism(s) responsible for increased 

mortality in patients with post-MI depression. Additionally, studies which establish the time after 

an MI at which the adverse effects of depression on post-MI outcomes first become evident may 

yield important indirect insights into potential mechanisms involved. 

 Studies that evaluate the hemostatic and platelet function of patients with post-MI depression 

are needed. Studies also should address whether responses to commonly used antiplatelet agents 

differ between post-MI patients and those without depression. 

Question 4. Do post-MI patients with depression have better outcomes with depression treatment 

than those without such treatment?

 Additional studies are needed which evaluate this question. There are actually three questions 

within this larger question. The first is whether cardiac outcomes are better if depression is 

successfully treated. The second question is whether cardiac outcomes are better with 

antidepressant treatment regardless of whether depression improves. The third question is 

whether cardiac outcomes are better if depression resolves with antidepressant treatment 

compared to spontaneous resolution. None of these questions has been adequately addressed by 

the existing literature. 

Question 5. What are the performance characteristics of instruments or methods that are used to 

screen for depression (or depressive symptoms) after MI? 

 Additional studies are needed to determine the performance characteristics of instruments or 

methods used to screen for depression (or depressive symptoms) during the initial MI 

hospitalization. Studies are needed in post-MI patients that examine the ability for depression 

screening instruments or methods to distinguish symptoms of depression from symptoms 

attributable to the MI, to poor physical health, or to the hospitalization itself. 
49

Question 6. Does the use of cardiac treatment for patients with acute MI differ for those with and 

those without depression? 

 Additional large studies are needed to examine whether the use of diagnostic and therapeutic 

procedures differs between depressed and non depressed post-MI patients. Studies should also 

address whether potential differences in procedures are due to differences in providers’ 

recommendations or to differences in patients’ acceptance. Further studies also are needed to 

determine whether the treatment prescribed for post-MI patients differs between those with and 

those without depression. Future studies should examine the adherence behavior of post-MI 

patients and evaluate measures that could improve adherence to recommended treatment. 

51

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61

Figure 1. Conceptual ModelCHF - Congestive heart failureCOPD - Chronic obstructive pulmonary diseaseCRF - Cardiac risk factorsCRP - C-reactive proteinDM - Diabetes mellitus

HTN - HypertensionICAM-1 - Intercellular adhesion molecule-1 IL-6 - Interleukin-6MI - Myocardial infarctionRx - Treatment
62

Electronic Databases1

MEDLINE® – 2989

CENTRAL – 327

EMBASE – 739

CINAHL® – 265

PsycINFO – 343

Hand Searching 

9

Abstract Review

1158

Duplicates 

15

Article Review 

318

Articles Eligible 

86

Excluded – 825

Unable to Review – 15

Excluded 

232

Retrieved

3770

1 CENTRAL - the Cochrane CENTRAL Register of Controlled Trials; CINAHL® - Cumulative Index of Nursing and 

Alliance Health Literature.

Excluded -

2597

Title Review

3755

Figure 2. Literature Search
63

M ajor and M inor De pre s s ion

0.7

0.75

0.8

0.85

0.9

0.95

1

BDI SCL-90-Dep HA DS HA DS-D HA MD

Sens itiv ity

Spec if ic ity

Figure 3. Sensitivity and Specificity of Instruments used to Screen for Major and Minor Depression Following

an Acute Myocardial Infarction

BDI - Beck Depression Inventory

SCL -90 Dep - Symptom Checklist 90 for Depression

HADS - Hospital Anxiety and Depression Scale

HADS-D - Hospital Anxiety and Depression Scale (Depression)

HAMD - Hamilton Rating Scale for Depression
64

M ajor De pre s s ion

0.7

0.75

0.8

0.85

0.9

0.95

1

BDI SCL-90-Dep HA DS HA DS-D HA MD

Sens itiv ity

Spec if ic ity

Figure 4. Sensitivity and Specificity of Instruments used to Screen for Major Depression Following an Acute

Myocardial Infarction

BDI - Beck Depression Inventory

SCL -90 Dep - Symptom Checklist 90 for Depression

HADS - Hospital Anxiety and Depression Scale

HADS-D - Hospital Anxiety and Depression Scale

HAMD - Hamilton Rating Scale for Depression
67

Table 1. Summary of Studies on the Prevalence of Depression During Hospitalization for Acute Myocardial Infarction (Ques

Study

Author, 

Year

Study

Design Location No. of Subjects Mean Age Male (%) White (%) HTN a (%) DM b (%) Smoking (%) Lipid c (%) Metho

Asse

Dep

Taylor, 1986

RCT d USA 173 52 100 NR e NR NR NR NR HAMD f

3 wk g p

Bennett, 1988

Procohort i Europe 37 62 73 NR NR NR NR NR HADS j; In hosp

Davis, 1988

Procohort

Canada 52 51 90 NR NR NR NR NR SCID l, 

BDI m;In hosp

Carney, 1990

Casecontrol

USA 70 53 76 NR 43 16 48 NR DIS n;

In hosp

Silverstone1990

Procohort 

Europe 100 NR NR NR NR NR NR NR Montgo

Asberg;In hosp

Gilutz,1991

Procohort 

Europe;MiddleEast

Europe:98; MiddleEast: 87

NR o NR NR NR NR Europe: 32; 

MiddleEast: 35

NR Holland 

Anxiety Scale;In hosp10-15 d 

Schleifer,1991

Procohort 

USA 335 63 64 NR NR NR NR NR Nurse In

8-10 d p

Forrester, 1992

Crosssectional USA 129 59 74 62 NR NR NR NR PSE q; In hosp

10 d po

Legault, 1992

Procohort 

Canada 52 55 78 NR NR NR NR NR BDI;

In hosp

Kaufmann, 1999

Procohort 

USA 331 NR r 66 NR 50 27 28 38 DIS;

In hosppost-MI

O'Rourke, 1999

Procohort 

Europe 70 58 74 NR NR NR NR NR HADS;

3 - 5 d p

Mayou, 2000

Procohort 

Europe 344 63 73 NR NR 34 58 NR HADS;

In hospwithin 3 
Table 1. Summary of Studies on the Prevalence of Depression During Hospitalization for Acute Myocardial Infarction (Questi

Study

Author, 

Year

Study

Design Location No. of Subjects Mean Age Male (%) White (%) HTN a (%) DM b (%) Smoking (%) Lipid c (%) Metho

Asse

Dep

68

Bush, 2001

Procohort

USA 267 65 58 82 43 33 27 59 SCID, a

BDI;In hosp2-5 d po

Brink,2002

Procohort 

Europe 114 68 68 NR 35 15 31 NR HADS;

In hospwithin 1 

Lane,2002

Procohort 

Europe 288 63 75 93 39 13 43 72 BDI;

In hosp15 d po

Lesperance,2002

Procohort 

Canada 896 59 68 NR 35 16 47 NR BDI;

In hosp

Luutonen, 2002

Procohort 

Europe 85 61 77 NR NR NR NR NR BDI;

In hosp

Watkins, 2002

Crosssectional USA 204 59 58 65 NR Non- depressed

31, Depressed49

Nondepressed53, Depressed81

NR DIS;

In hosppost-MI

Barefoot,2003

Procohort 

USA 196 61 63 67 NR NR NR NR HAMD, 

BDI;within 2 

Berkman,2003

RCT USA 9279 s 63 61 26 60 t 33 t 64 t 57 t SCID;

2-4 wk p

Lauzon, 2003

Procohort 

Canada 550 60 80 96 35 16 40 38 BDI;

Within 2 hospital

Martin, 2003

Procohort 

Europe 335 67 67 NR NR NR NR NR HADS;

In hospwithin 1 
Table 1. Summary of Studies on the Prevalence of Depression During Hospitalization for Acute Myocardial Infarction (Questi

Study

Author, 

Year

Study

Design Location No. of Subjects Mean Age Male (%) White (%) HTN a (%) DM b (%) Smoking (%) Lipid c (%) Metho

Asse

Dep

69

Rafanelli, 2003

Procohort 

Europe 61 61 85 NR NR NR NR NR SCID;

Within 1 

post-MI

Strik,2003

Procohort

Europe 318 52 1 NR 28 9 54 20 SCL-90

1 mo po

Steeds,2004

Procohort 

Europe 131 NR NR NR NR NR NR NR BDI-II;

In hosp

a Hypertensionb Diabetes mellitusc Hyperlipidemiad Randomized controlled triale Not reportedf Hamilton Rating Scale for Depressiong Weekh Myocardial infarctioni Prospective cohort studyj Hospital Anxiety and Depression Scalek Also assessed at a later point. See Question 2l Structured Clinical Interview for Diagnostic & Statistical Manual of Mental

Disorders - IV

m Beck Depression Inventoryn Diagnostic Interview Scheduleo In the European population 21% were less than 45 

years old and 25% were 56 - 60 years old. population 30% were less than 45 years ol

and 24% were 56 - 60 years old p Day

q Psychological Stress Evaluator r 45% were less than 65 years old and 56% were greas Medically eligible and screened for depressiont Of those with depression or low social supportu Month
70

Table 2. Summary of Studies on the Prevalence of Depression After Hospitalization for Acute Myocardial Infarction (Question 2

Study

Author,

Year

Study 

Design Location No. of Subjects Mean Age Male (%) White (%) HTN a (%) DM b (%) Smoking (%) Lipid c (%) Method & Time 

Assessment 

Depression 

Trelawny, 1987

NR d Europe 32 NR 100 NR NR NR 71 NR Goldberg's CIS e;

In hospital, 10 d f post d/c g, 2 mo h post d/c,6 mo post d/c

Davis, 1988

Retrocohort i

Canada 52 51 90 NR NR NR NR NR BDI j;

6 - 8 wk k post-MI l 

Follick,1988

RCT m USA 238 55 72 NR NR NR 53 NR SCL-90 n;

Baseline,1 mo,3 mo,9 mo 

Schleifer, 1991

Retrocohort

USA 335 64 64 NR NR NR NR NR RDC o (Nurse Inter

8-10 d,3-4 mo

Legault,1992

Procohort r

Canada 52 55 78 NR NR NR NR NR BDI;

In hospital, 3 mo post-MI, 12 mo post-MI

Garcia, 1994

Crosssectional Europe 97 50 100 NR NR NR NR NR RDC; In hospital, 

1 mo post-MI

Travella,1994

Procohort 

USA 70 s 58 74 NR NR NR NR NR HAMD t, 

PSE;3 mo post-MI, 6 mo post-MI, 9 mo post-MI, 12 mo post-MI
Table 2. Summary of Studies on the Prevalence of Depression After Hospitalization for Acute Myocardial Infarction (Question 2

Study

Author,

Year

Study 

Design Location No. of Subjects Mean Age Male (%) White (%) HTN a (%) DM b (%) Smoking (%) Lipid c (%) Method & Time 

Assessment 

Depression 

71

Clarke, 1996

Procohort 

Canada 52 NR 100 NR NR NR NR NR ZDS u

;

3 mo post-MI 

Lesperance, 1996

Procohort 

Canada 222 60 78 NR NR NR NR NR DIS v

;

6 mo post-MI,12 mo post-MI

Bennett, 1998

Procohort 

Europe 37 62 73 NR NR NR NR NR HADS 

w

;

In hospital,3 mo post-MI 

Lehto, 2000

Retrocohort 

Europe 101 62 69 NR 28 15 12 63 DEPS x

;

20.5 mo (median) p

Strik,2001

Procohort 

 Europe 206 60 76 NR NR NR NR NR SCID z, 

HAMD, SCL-90, BDI, HADS;1 mo post-MI 

Lane,2002

Procohort 

Europe 288 q 63 75 93 NR NR NR NR BDI;

In hospital,4 mo post-MI, 12 mo post-MI

Luutonen, 2002

Procohort

Europe 85 61 77 NR NR NR NR NR BDI;

6 mos,18 mos

Shiotani,2002

Procohort 

Asia 1042 64 80 NR 48 32 66 37 ZDS;

within 3 mo post-M
Table 2. Summary of Studies on the Prevalence of Depression After Hospitalization for Acute Myocardial Infarction (Question 2

Study

Author,

Year

Study 

Design Location No. of Subjects Mean Age Male (%) White (%) HTN a (%) DM b (%) Smoking (%) Lipid c (%) Method & Time 

Assessment 

Depression 

72

Strik,2002

Retrocohort 

Europe 140 58 76 NR NR NR NR NR BDI, HADS, SCL-9

one positive assesswith SCID;3 mo post-MI 

Aben,2003

Procohort 

Europe 200 60 77 NR NR NR NR NR BDI, HADS, SCL-9

one positive assesswith SCID and HAM1 mo after MI, 3 mo after MI, 6 mo after MI, 9 mo after MI, 12 mo after MI

Barefoot,2003

NR USA 196 61 63 67 NR NR NR NR HAMD, 

BDI;In hospital, 2 wk after firstassessmenthospitalization

Lauzon,2003

Procohort 

Canada 550 60 80 96 35 16 40 38 BDI;

In hospital,1 mo post-MI, 6 mo post-MI, 12 mo post-MI

Martin, 2003

Crosssectional Europe 335 67 67 NR NR NR NR NR HADS; 6 wk post-MI, 

6 mo post-MI

Strik,2003

Procohort

Europe 318 52 1 NR 28 9 54 20 SCL-90;

1 mo post-MI 

Lesperance, 2004

Procohort

Canada 481 60 81 NR 66 NR 15 NR SCID;

Approx. 2 mo post-
Table 2. Summary of Studies on the Prevalence of Depression After Hospitalization for Acute Myocardial Infarction (Question 2

73

a Hypertensionb Diabetes mellitusc Hyperlipidemiad Sample of suspected myocardial infarction patients 28 of 32 confirmed e Clinical Interview Schedulef Dayg Dischargeh Monthi Retrospective cohort studyj Beck Depression Inventoryk Weekl Myocardial Infarctionm Randomized controlled trialn Symptom Check List 90

o Research Diagnostic Criteriap Major depressionq Minor depressionr Prospective cohort studys With variable numbers at different time points t Hamilton Rating Scale for Depressionu Zung Depression Scalev Diagnostic Interview Schedule w Hospital Anxiety and Depression Scalex Depression scalez Structured Clinical Interview for Diagnostic & Statisti

Disorders - IV

aa Year
74

Table 3. Summary of Studies on Relation of Depression to Survival after Myocardial Infarction (Question 3)

Study 

Author, Year

No. 

Enrolled

Depression

Instrument

Outcome Reported

Stata

Dep 

vs.

Non Depb

Cardiac 

Mortality

Total

Mortality Other 

Ahern, 1990

265 BDI c profile

of moodstates

NA d NA TM e or cardiac

arrest at baseline

RR f NR g 

Ladwig, 1991

560 NR Low: 0.9;

Medium: 2.4;High: 7.5

NA Sustained VT i

admission

OR j Mantel-Haenszel

p<0.001

FrasureSmith, 1993

222 MIMH DIS k NA At 6 mos l NA HR m 5.74 

(CI 4.61 - 6.87)

FrasureSmith, 1999

904 BDI NA NA Arrhythmia; 

MI recurrence;RevascularizationAny hard event

OR CV n death 3.23 

(CI 1.65 - 6.33);Arrhythmia 3.11 (CI 1.32 - 7.37);MI recurrence 1.62 (CI 0.93 - 2.8);Revascularization0.82 (CI 0.53 - 1.26);Any hard events 1.97 (CI 1.25 - 3.13)

Irvine, 1999

703 BDI Sudden

cardiac death

NA NA HR AMIo 0.52 

(CI 0.15 - 1.76)

Denollet,2000

319 ZDSp Cardiac

events

NA QOLq poor

perceived healthat 5 yrs r, 

Depressive effect

OR NR 

Lane, 2000

288 BDI Dep 9%, 

NonDep0.7%

Dep 10.1%, NonDep 8%

Dartmouth chart OR NR 

Welin, 2000

275 ZDS 17% 24% Non-fatal

recurrent MI;Stroke;Cancer

HR TM: 2.45 

(CI 1.49 - 4.02), CM s: 3.54 

(CI 1.85 - 6.79)
Table 3. Summary of Studies on Relation of Depression to Survival after Myocardial Infarction (Question 3) (continued)

Study 

Author, Year

No. 

Enrolled

Depression

Instrument

Outcome Reported

Stata

Dep 

vs.

Non Depb

Cardiac 

Mortality

Total

Mortality Other 

75

Bush, 2001

285 SCID t

BDI

NA Dep: 13%, 

NonDep:3.8%

NA RR 3.8 p=0.008 

Druss, 2001

88241 NR NA NA NA HR Mental 1.19 

(CI 1.04 - 1.36),Affective 1.11 (CI 1.03 - 1.18)

Lane, 2001

288 BDI 10% 10% QOL OR CM 1.15 

(CI 0.49 - 2.69)

Lane, 2002

288 BDI Dep: 10% NA NA OR TM 1.04

(CI 0.5 - 2.16), CM 0.84 (CI 0.37 - 1.90)

Lesperance,2002

896 BDI < 5 yrs:

7.2%;5 - 9 yr:13.7%;10-18 yr:18.5%;> 19 yr:26.6%

< 5 yr:10.7%;5 - 9 yr:16.2%;10-18 yr:23.2%;> 19 yr:32.9%

NA HR BDI 5 - 9: 1.94 

(CI 1.16 - 3.25);BDI 10 - 18: 2.8 (CI 1.68 - 4.66);BDI > 19: 1.32 (CI 2.4 - 7.75) 

Carney, 2003

NR Depression

interview:structuredHAMDu, BDI

NA Non-fatal AMI NA HR TM 2.4 

(CI 1.2 - 4.7)Non-fatal AMI 1.2 (CI 0.7 - 2.0)

FrasureSmith, 2003

NR NR At 5 yr NA NA HR NR 

a Comparison statistic b Depressed versus non-depressedc Beck Depression Inventory

d Not applicablee Total mortality f Relative risk
Table 3. Summary of Studies on Relation of Depression to Survival after Myocardial Infarction (Question 3) (continued)

76

g Not reported h Confidence Intervali Ventricular tachycardiaj Odds Ratio k National Institute of Mental Health Diagnostic Interview Schedule l Monthm Hazard ration Cardiovascular

o Acute myocardial infarctionp Zung Depression Scaleq Quality of lifer Years Cardiac Mortalityt Structured Clinical Interview for DSM-IVu Hamilton Rating Scale for Depression
77

Table 4. Summary of Studies on the Relation of Depression to Cardiac Events after Myocardial Infarction (Question 3)

Study

Author,

Year

No

Enrolled

Depression

Instrument

Outcome

Stat

a

Dep 

vs.

Non-Dep b

Cardiac Events Cardiac Mortality Other 

Irvine, 1999

703 Psychological

questionnaire

NR c Sudden cardiac

death 34,Other cardiacdeath 16

Vasculardeath 1, Non-cardiacdeath 12

RR d NR e Amio

BDI 

(CI 0BDI 0.73 (CI 0PlacBDI (CI 0BDI 1.09 (CI 0

FrasureSmith, 2000

222 Structured

baselineinterview

Recurrentcardiac eventsg

NA h NA OR i Any cardiac event:

3.32 (CI 1.69,6.53);ACS j:

 2.75 (CI 1.32,5.72);Arrhythmic event:3.65 (CI 0.99,10.47)

Rec1.99 (CI 0

Druss, 2000

NR ICD-9CM NA TM at 1 mo k Likelihood of

PTCA l or

CABG m

during indexhospitalization

OR TM n:

Affective disorders7.3%;No mental disorders10.8%

TM 0with Use patiedisoPTCCAB
Table 4. Summary of Studies on the Relation of Depression to Cardiac Events after Myocardial Infarction (Question 3) (continue

Study

Author,

Year

No

Enrolled

Depression

Instrument

Outcome

Stat a Dep vs.

Non-Dep b

Cardiac Events Cardiac Mortality Other 

78

Shiotani, 2002

1086 ZDS o Annual cardiac

event rate: Dep 31%, Non-dep 24%;Cardiac events: Dep 138, Non-dep 145; MI: Dep 19, Non-dep 15;Arrhythmias: Dep 2, Non-dep 1; RePTCA: Dep 94, Non-dep 110 ; Heart Failure: Dep 7, Non-dep 5; Angina: Dep 6, Non-dep 5

CM p:

Dep 4 ,Non-dep 1

Readmission:Dep: 34,Non-dep: 26

OR Cardiac events:

1.46 (CI q 1.11 -

1.92)

Card(CI 1

Strik,2003

318 SCL-90 r Non-fatal MI at

3-4 yrs s 

Fatal MI at 3 - 4yrs

Consumptionat 3-4yrs t

HR u

OR v

Consumptionx: 1.61 

(CI 1.00 - 2.57) w

MI:CCon(CI 0
Table 4. Summary of Studies on the Relation of Depression to Cardiac Events after Myocardial Infarction (Question 3) (continue

Study

Author,

Year

No

Enrolled

Depression

Instrument

Outcome

Stat a Dep vs.

Non-Dep b

Cardiac Events Cardiac Mortality Other 

79

Strik,2004

422 Baseline:

SCID;Follow-up: 3psychiatric selfrating scalesBDI, SCL-90,HADS aa

Major cardiacevents 1 mo - 3yrs y; 

Increased consumption 

NR Consumption

1 mo - 3 yrs

HRab

OR

ac

Cardiac events:1.1(0.36,3.42);Consumption: 1.66(CI 0.90 - 3.07)

Card(CI 0Con(CI 1

a Comparison statisticb Depressed versus non depressedc Not reportedd Risk ratioe Depression reported not to be significant predictor of sudden cardiac death in

univariate analysis f Beck Depression Inventory

g Survived and nonsurvived reinfarctions, admission for unstable angina, arrhythmic

deaths, survived cardiac arrests h Not applicable

i Odds ratioj Acute coronary syndromek Monthl Percutaneous transluminal coronary angioplastym Coronary artery bypass graftn Total mortality

o Zung Depression Scalep Cardiac mortalityq Confidence intervalr Symptom Checklist - 90s Yearst Cardiac rehospitalization and/or frequent visitsu Cardiac eventsv Health care consumptionw Confidence intervals not reported as single variablesx Heath care consumption y Death or recurrent myocardial infarctionz > 6 visits at cardiac outpatient clinic during follow-upaa Hospital Anxiety and Depression Scale ab Depression as predictor of major cardiac eventac Depression as predictor of health care 
80

Table 5. Summary of Studies on the Relation of Depression to Quality of Life after Myocardial Infarction (Question 3)

Study

Author,

Year

No.

Enrolled

Depression

Instrument

Outcome

 Stat b Dep vs.

Non Dep c

M

QOL a Other

Travella,1994

129 Present

stateexamination- modified,HAMD d

Johns Hopkins functioninginventory,Social functioning exam

NA e Multivariate

Rank

NR f Soc

with bas3 m6 m9 m12 

Drory, 1998

276 BDI h Frequency of sexual

activity after MI i at 3 - 6

mos, Satisfaction with sexualactivity after MI

Depression Pearson

Correlation

Frequency of sexualactivity 0.16 (p<0.01); Satisfaction with sexualactivity 0.14 (p<0.01)

FreactSatact

Irvine, 1999

703 BDI

symptomchecklist

Social perception and help, daily living

Suddencardiacdeath

Cox j OR k NR

Ladwig,1999

552 D-S NA Perception

of anginapectoris

OR NR 2.9

O'Rourke,1999

70 HADS m Illness perception

questionaire

NA Regression

ANOVA

NR NR

Soejima,1999

134 Depression

Index

RTW m NA Logistic

regressionOR

NR RT

3.7De

0.1

Bogg,2000

220 HADS (II)

GlobalMood Scale

QOL after MI measure NA Regression NR Phy

PhyR2=

Bas
Table 5. Summary of Studies on the Relation of Depression and Quality of Life after Myocardial Infarction (Question 3) (continu

Study

Author,

Year

No.

Enrolled

Depression

Instrument

Outcome

 Stat b Dep vs.

Non Dep c

M

QOL a Other

81

Denollet,2000

322 ZDS p Global Mood Scale, 

Health complaint scale

NA Regression

OR

NR Fai

2.3 De3.3 Typ2.2 EFq 

Hyp2.0 

Lane, 2000

288 BDI Dartmouth COOP r Charts, 

BDI

NA Correlation

score

Gender r=0.31,Partner status r=0.24,Living alone r=0.20,Employment statusr=0.18,Frequency of exercise r= -0.21,Duration of exercise r= -0.17BDI r=0.37,State anxiety r=0.28,Treat anxiety r=0.32,Peel Index r=0.27,LOSs r=0.15

BD

Parp=0PeeSta

Mayou,2000

344 HADS SF-36 Score t NA HR At baseline: 

51.2 (distressed),67.5 (non-distressed) p < 0.05;At 3 mos: 38.7 (distressed),62.3 (non-distressed)p < 0.05;At 12 mos : 47.2 (distressed),64.0 (non-distressed)p < 0.05

NR
Table 5. Summary of Studies on the Relation of Depression and Quality of Life after Myocardial Infarction (Question 3) (continu

Study

Author,

Year

No.

Enrolled

Depression

Instrument

Outcome

 Stat b Dep vs.

Non Dep c

M

QOL a Other

82

Lane, 2001

288 BDI NR NA Regression

Correlation

Gender r=0.2,Partner status r=0.22,Living alone r=0.3,Employment statusr=0.18,Frequency of exercise r=-0.18,BDI r=0.32,State anxiety r=0.28,Treat anxiety r=0.24,Peel Index r=0.29,Killip class r=0.15,LOS r=0.25

BDLivPeeSta

Brink, 2002

134 HADS Physical Component SF36, 

Mental Component SF-36

NA Zero order

correlation

NR Phy

0.4Me

Drory,2002

NR BDI Perceived health status NA Hierarchical

regression

NR Psy

Drory, 2003

NR BDI Perceived health status NA Regression NR NR

a Quality of lifeb Comparison statisticc Depressed versus non-depressedd Hamilton Rating Scale for Depressione Not applicablef Not reportedg Monthh Beck Depression Inventoryi Myocardial infarctionj Cox regressionk Odds ratiol Hospital Anxiety and Depression Scalem Confidence interval

n Return to worko Symptomsp Zung Depression Scaleq Ejection fractionr Charts for Primary Care Practicess Length of stayt Medical Outcomes Study Short Form 36 Health Surve
83

Table 6. Summary of Studies on the Relation of Depression to Biomarkers after Myocardial Infarction (Question 3a)

Study

Author, 

Year

No. 

Enrolled

Depression

Instrument

Outcome

Stat a

Depressed 

vs

Non-Depressed

Biomarkers

Carney, 2001

Dep b 380

NonDep c

424

Screening:ENRICHD dmodified DSM-IVeDISH f present

depressiveepisodeBDI g severity of

depression

In univariate analysis all 4 indices of24 hour HRVh were significantlylower in patients with depression.In multivariate analysis all 3 indicesexcept 24 hour HRV weresignificantly lower in patients withdepression.

Linearregression

NR i 

Kuijpers, 2002

NR DSM-IV PF4 j was significantly higher in Dep

post-MI patients compared toNonDep post-MI patients, p=0.021. There was a trend toward asignificantly increased B-TG k level

with p=0.08, inspite of use of aspirin

MannWhitney U PF4 mean rank 15.75 IU/ml vs. 9.25

IU/ml B-TG mean rank 15.04 IU/ml vs. 9.96IU/ml

Lesperance, 2004

965 SCID l Dep patients had significantly higher

sICAM-1 levels even after adjustmentfor confounders.These results wereonly slightly attenuated byadjustment for antidepressanttreatment.No significant association betweendepression and IL6 n.Uncertain about the relationship ofCRP o on depression as patients

were on statins.

Linearregression

NR 

a Comparison statistic b Depressedc Non-depressed d Enhancing Recovery in Coronary Heart Disease Triale Diagnostic & Statistical Manual of Mental Disorders f Depression Interview and Structured Hamiltong Beck Depression Inventory h Heart rate variabilityi Not reported

j Platelet factor 4k ß-thromboglobulin l Structured Clinical Interview for Diagnostic & Statisti

Disorders-IV

m Soluble intracellular adhesion molecule 1n Interleukin 6o C-reactive protein
84

Table 7. Summary of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4)

Study

Author,

Year

Study

Design

Intervention

Description

Duration of

Intervention;

Duration of

Follow-Up

Depression Scores Cumulative Cardiac Events 

Dracup, 1991

Procohort a

Group A: Cardiacrehabilitation program; Group B: Noparticipation in aformal program

12 wks b;

8 mos c

Multiple Affective AdjectiveChecklist @ 6 mos Group A: 8 , Group B: 13

NA Multiple A

Checklist Group A: Group B: PsychosoScoreGroup A: Group B: Marital AGroup A: Group B: 

Brown, 1993

RCT d Group C: Cognitive

behavioral therapy; Group D: Control

12 weekly1-hoursessions;3, 9, 15 mos

SCL 90-R eGroup C: pre 65.1, 3 mos 62.1,15 mos 56.1;Group D: pre 71.2, 3 mos 62.3,15 mos 63.3;BDI f 

Group C: pre 12.1, 3 mos 6.9, 15mos 5.6;Group D: pre 17.3, 3 mos 9.4, 15mos 10.5; MMPI-168 g

Group C: pre 74.1, 3 mos 68.1,15 mos 67.5;Group D: pre 79.2, 3 mos 72.8,15 mos 77.4

NA NA
Table 7. Summary of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

Study

Design

Intervention

Description

Duration of

Intervention;

Duration of

Follow-Up

Depression Scores Cumulative Cardiac Events 

85

Crowe, 1996

RCT NR NR;

1 yr h

BDIGroup E: 3 d 4.1, 3 mos 3.3, 6mos 2.6, 14 mos 3.2Group F: 3 d 3.9, 3 mos 3.7; 6mos 3.3, 14 mos 2.9

NA NA

FrasureSmith, 1997 

RCT Group G: Intervention

involved combinationof emotional support,reassurance,education, practicaladvice, and referralhealth resources;Group H: Usual care

1 yr; 12 mos

BDIGroup G: baseline 8.1, 12 mos6.9;Group H: baseline 8.4, 12 mos7.6

Cardiac mortality Group G: 4.8%; Group H:3.4%;Myocardial infarctionGroup G: 4.8%; Group H:5%; Revascularization Group G: 13.4%; Group H:14%

Total moGroup G

Taylor, 1997

RCT Group I: 

Nurse-managed,home-based systemfor coronary risk factormodification andstress management;Group J: Usualmedical care

1 yr;Upto 1 yr

Low levels depressed moodGroup I: baseline 1.7, 12 mos 1.3; Group J: baseline 1.8, 12 mos1.2;Moderate-high levels depressedmoodGroup I: baseline 6.1, 12 mos 1.4;Group J: baseline 5.7, 12 mos 1.5

Mortality Group I: 4%; Group J: 3%

Low leveGroup I: Group J: ModeratemoodGroup I: Group J: Low leveGroup I: Group J: ModerateGroup I: Group J: 
Table 7.Summary of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

Study

Design

Intervention

Description

Duration of

Intervention;

Duration of

Follow-Up

Depression Scores Cumulative Cardiac Events 

86

Taylor, 1997

Low angeGroup I: Group J: ModerateGroup I: Group J: 

Roose, 1998

RCT Group K: Paroxetine

10-20 mg/day;Group L: Nortriptyline25 mg/day

2 wks;6 wks

NA Heart rate 

Group K: baseline 10%, 6wks 6%;Group L: baseline 11%, 6wks 7%; Standing pulse ratestandingGroup K: baseline 11%, 6wks 11%; Group L: baseline 14%, 6wks 16%;Supine pulse rate supineGroup K: baseline 10%, 6wks 10%;Group L: baseline 12%, 6wks 14%;HRV SDNN i

Group K: baseline 37%, 6wks 27;Group L: baseline 19%, 6wks 16%; HRV pNN50 jGroup K: baseline 10%, 6wks 4%;Group L: baseline 9%, 6wks 7%

NA
Table 7.Summary of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

Study

Design

Intervention

Description

Duration of

Intervention;

Duration of

Follow-Up

Depression Scores Cumulative Cardiac Events 

87

Johnston, 1999

RCT Group M: Extended

program involvingadditional sessions inthe 2 mos afterdischarge; Group N:Inpatient cardiacrehabilitation program; Group O: Control

6 wks;Up to 1 yr

HADS k

Group M: baseline 4.1, 12 mos 3;Group N: baseline 4.4, 12 mos3.6;Group O: baseline 4.6, 12 mos5.8 

NA HADS An

Group MGroup NGroup O

Strik, 2000

RCT Group P: Fluoxetine

20 mg/day; Group Q: Placebo

Up to 25 wks;1, 3, 6, 9 wksthen monthlyuntill 1 yr

HAMD l change @ 25 wks

Group P: -9.65(7.2), Group Q:-6.9(6.9)

Chest pain Group P: 5; Group Q: 4

GI m com

Group PAgitation Group POther Group PRehospitGroup PDecrease 

Group PQRS o in

Group PQRS inteGroup Q
Table 7.Summary of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

Study

Design

Intervention

Description

Duration of

Intervention;

Duration of

Follow-Up

Depression Scores Cumulative Cardiac Events 

88

McFarlane, 2001

RCT Group R:

Sertraline 50 mg/day;Group S: Placebo

6 mos;6 mos

NR NA SDNN (S

Group Rmos 121 Group Smos 86 (RMSSD(Group Rmos 30 (Group Smos 23.7 LF/HF r r

Group R1.62 (0.2

Glassman, 2002

RCT Group T: 

Sertraline 50 mg/daydaily; Group U: Placebo daily

Group T:149.5 d; 24 wks;Group U:153.8 d;24 wks

CGI - 1 s mean score

Group T: 2.57, Group U: 2.75; HAMD mean change in score @6 mos Group T: -8.4, Group U: -7.6 

MI Group T: 5, Group U: 7;Congestive heart failure Group T: 5, Group U:7;Angina Group T: 26, Group U:30 

Total moGroup T: ComposiGroup T: 

Berkman,2003ENRICHD

RCT Group V: Cognitive

behavioral therapy,Social problemsolving, plus SSRI t

certain conditions(Sertraline 50 mg/day)Group W: Usual care

180 d;18 mos

BDI change (baseline- 6 mos)Group V -8.6(9.2), Group W:-5.8(8.9);HAMD change (baseline- 6 mos)Group V -10.1(7.8), Group W:-8.4(7.7)

Cardiac Mortality Group V: 7.8%, Group W:9.3%; MIGroup V: 13.6%, Group W:13.7%;Revascularization Group V: 17.4%, Group W:18.5%

Total moGroup VCardiovaGroup V
Table 7.Summary of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

Study

Design

Intervention

Description

Duration of

Intervention;

Duration of

Follow-Up

Depression Scores Cumulative Cardiac Events 

89

Swenson, 2003

RCT Group X: 

Sertraline 50 mg/day; Group Y: Placebo 

24 wks;18 mos

HAMD score change @ 16 wks Group X: -8.4(0.4), GroupY:-7.6(0.4) BDI score change @ 16 wksGroup X:-8.0(0.6), GroupY:-7.3(0.6)

NA SF-36 u

Mental CGroup XPhysical Group A

a Prospective cohort studyb Weeksc Monthsd Randomized controlled triale Symptom Checklist - 90f Beck Depression Inventoryg Minnesota Multiphase Personality Inventoryh Yeari Heart rate variability - Standard deviation of normal R-R intervalj Heart rate variability - the proportion of pairs of adjacent intervals differing by

more than 50 ms k Hospital Anxiety and Depression Scale

l Hamilton Rating Scale for Depressionm Gastrointestinaln Aortic time velocity integralo QRS Intervalp Standard deviation of normal R-R interval (Standard eq Root mean square of successive differences (Standard r Low frequency/high frequencys Clinical Global Inventoryt Selective serotonin re-uptake inhibitorsu Medical Outcomes Study Short form 36 health survey
90

Table 8. Summary of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Question 5)

Study Author,

Year

Study

Design Location No. of Subjects Mean Age Male (%) Test Sensitivity Specificity 

Davis, 1988 

Procohort a

Canada 52 51 90 #1 SCID b nurse &

therapist interview

Co

#2 SCID nurse and BDI c Co

#3 Therapist interview and

BDI

Co

Martin, 2000

Crosssectional Europe 194 63.4 73 #1 HADS d all items In

#2 HADS Depression

subscale

InExre

Wojciechowski, 2000

Procohort 

Europe 143 57.8 81 #1 Zung SDS e/ 

SCL-90-Dep f

Pe0.1, 

#2 Zung SDS / Maastricht

Quest (vital exhaustion)

Pe0.1, 

#3 SCL-90-Dep /

Maastricht Quest (vitalexhaustion)

Pe0.1, 
Table 8. Summary of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Question 5) (continued

Study Author,

Year

Study

Design Location No. of Subjects Mean Age Male (%) Test Sensitivity Specificity 

91

Strik, 2001 

Crosssectional Europe 206 59.9 76 #1 SCL - 90 81% major/ minor h, 96% major i only 84% major/minor, 74% major only PP

4036N

9396

#2 BDI 84% major/minor, 

82% major only

72% major/minor, 79% major only

PP2533N9898

#3 HADS/ HADSDepression subscale HADS: 78% major/minor, 

90% major only; HADS-D:75% major/minor, 85% major only

HADS:85% major/minor, 84% major only; HADS-D:78% major/minor, 75% major only

HA4545HA9999HA3232HA9898

#4 17-item HAMD m 76% major/minor, 

86% major only

86% major/minor, 92% major only

PP41N9998
Table 8. Summary of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Question 5) (continued

Study Author,

Year

Study

Design Location No. of Subjects Mean Age Male (%) Test Sensitivity Specificity 

92

Freedland, 2002

Procohort 

USA 2404 61 56 BDI / HAMD Pe

Martin,2003

Procohort 

Europe 335 67.4 67 #1 HADS all items In

0.wk

#2 HADS depression

subscale

In0.0.Coan

a Prospective cohort studyb Structured Clinical Interview for Diagnostic & Statistical Manual of Mental

Disorders - IV

c Beck Depression Inventory d Hospital Anxiety and Depression Scalee Zung Self-Rating Depression Scale f Symptom Check List 90g Monthsh Major and minor depression

i Major depression j Positive predictive value k Negative predictive value l There appears to be a misprint in original article tables 

value and negative predictive value as equal major/minor depression,which does not reconpresented. 

m Hamilton Rating Scale for Depression
93

Table 9. Summary of Characteristics of Studies on the Relation of Depression to Use of Treatment after Hospitalization for 

(Question 6)

Study

Author,

Year

Study

Design Location Study Group No. of Subjects Mean Age Male (%) HTN a (%) DM b (%) 

Bennet, 2003 Pro cohort d Europe NA e 37 62 73 NR f NR 

Blumenthal, 1982 Pro cohort USA NA 35 54 94 NR NR Druss, 2000

Retro cohort g USA Mental disorders 5365 76 52 42 22 

No mental disorders 108288 76 46 40 26 

Ziegelstein, 2000 Pro cohort USA

BDI h >10 35 46 46 71 31 

BDI <10 169 55 59 62 30 Major Depression/Dysthymia 31 42 52 71 36 

No MajorDepression/Dysthymia

173 54 58 63 31 

Romanelli, 2002 Pro cohort USA Depressed 35 75 57 71 49 

Not depressed 118 73 55 70 33 

Bennet, 2003 Pro cohort Europe NA 37 62 73 NR NR Lauzon, 2003 Pro cohort Canada Depressed 191 60 75 34 16 

Not depressed 359 60 81 36 16 

Whitmarsh, 2003 Pro cohort Europe NA 93 64 76 NR NR Steeds, 2004 Pro cohort Europe BDI f $12 62 NR NR NR NR 

BDI < 12 69 NR NR NR NR 

Strik, 2004 Pro cohort Europe Depressed 63 NR 67 NR NR 

Not depressed 143 NR 80 NR NR 

a Hypertension b Diabetes mellitusc Hyperlipidemia d Prospective cohort studye Not applicable

f Not reportedg Retrospective cohort studyh Beck Depression Inventory
94

Table 10. Summary of Results of Studies on the Relation of Depression to Use of Treatment after Hospitalization for Myoca

(Question 6)

Study

Author,

Year

Study Group Diagnosis of MI

Method of

Assessing of

Depression 

used for

Analysis

No. of

Subjects Follow-Up

Cardiac

Cath a

(% )

PTCA b

(%)

CABG c

(%)

Druss, 2000

Major depression/affective ICD-9 d ICD-9 315 16 mos e 33 f 9 8 

No mental disorders 108288 16 mos 44 f 17 13 

Ziegelstein, 2000

Major depression/dysthmia Pain, EKG g,

CPK-MB h

SCID i

BDI j > 10

31 4 mos NR NR NR 

Not depressed 173 4 mos NR NR NR 

Romanelli, 2002

Depressed(BDI $10) Pain, EKG,

CPK-MB

SCID

35 4 mos NR NR NR 

Not depressed 118 4 mos NR NR NR 

Lauzon, 2003

Depressed NR

BDI-10

191 30 d k 57 32 7 

Not depressed NR 359 30 d 47 25 8 Depressed NR

BDI-10

191 1 yr l 67 39 19 

Not depressed NR 359 1 yr 55 30 16 

Steeds,2004

Depressed Pain, 

EKG, CPK-MB

BDI-12

62 32 mos NR NR NR 

Not depressed 69 32 mos NR NR NR 

Strik, 2004

Depressed/Minor depression Pain, EKG, 

ASAT m

SCID

63 1 yr NR 36 NR 

Not depressed 143 1 yr NR 36 NR 

a Cardiac catheterizationb Percutaneous transluminal coronary angioplastyc Coronary artery bypass graft d The International Statistical Classification of Diseases and Related Health

Problems

e Monthsf p < 0.001g Electrocardiogram

h Creatine phosphokinase - muscle brain i Structured Clinical Interview for DSM IV j Beck Depression Inventory k Day l Yearm Aspartate aminotransferase 
95 

References for Summary Tables 

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the one year cumulative incidence of depression after 

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Ahern DK, Gorkin L, Anderson JL, et al. Biobehavioral 

variables and mortality or cardiac arrest in the Cardiac 

Arrhythmia Pilot Study (CAPS). Am J Cardiol 1990; 

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Barefoot JC, Burg MM, Carney RM, et al. Aspects of 

social support associated with depression at 

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404-12. 

Bennett P, Mayfield T. Mood and behaviour change 

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289(23): 3106-16. 

Blumenthal JA, Williams RS, and Wallace AG. 

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Bogg J, Thornton E, and Bundred P. Gender variability in 

mood, quality of life and coping following primary 

myocardial infarction. Cor Health Care 2000; 4(4): 

163-168. 

Brink E, Karlson BW, and Hallberg LR. Health 

experiences of first-time myocardial infarction: factors 

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of life after five months. Psychology Health & 

Medicine 2002; 7(1): 5-16 . 

Brown MA, Munford AM, and Munford PR. Behavior 

therapy of psychological distress in patients after 

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Cardiopulm Rehabil 1993; 13(3): 201-210. 

Bush DE, Ziegelstein RC, Tayback M, et al. Even minimal 

symptoms of depression increase mortality risk after 

acute myocardial infarction. Am J Cardiol 2001; 

88(4): 337-41. 

Carney RM, Blumenthal JA, Catellier D, et al. Depression 

as a risk factor for mortality after acute myocardial 

infarction. Am J Cardiol 2003; 92(11): 1277-81. 

Carney RM, Blumenthal JA, Stein PK, et al. Depression, 

heart rate variability, and acute myocardial infarction. 

Circulation 2001; 104(17): 2024-8. 

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Appendix A: Technical Experts and Peer Reviewers

Technical Experts

Expert Area and Organization Name Location

Partner Organization

American Academy of Family

Physicians (AAFP)

Lee Green MD, MPH University of Michigan

Ann Arbor, MI

Government

Center for Medicaid and Medicare

Services (CMS)

Carlos Cano MD Woodlawn, MD

Payer

IPRO Charles Stimler MD,

MPH

Lake Success, NY

University

Washington University School of

Medicine

Robert M. Carney PhD St. Louis, MO

University of Birmingham Douglas Carroll PhD Edgbaston, Birmingham,

United Kingdom

Tilburg University Johan Denollet, PhD Tilburg, The Netherlands

McGill University Nancy Frasure-Smith

PhD

Montreal, QC

Canada

Columbia University Alexander Glassman

MD

New York, NY

Professional Organizations

American College of Physicians

(ACP)

Vincenza Snow MD Philadelphia, PA
2

Peer Reviewer

Expert Area and Organization Name Location

Partner Organization

American Academy of Family

Physicians (AAFP)

Lee Green MD, MPH University of Michigan

Ann Arbor, MI

American Academy of Family

Physicians (AAFP)

Belinda Ireland MD,

MS

Leawood, KS

Government

Center for Medicaid and Medicare

Services (CMS)

Carlos Cano MD Woodlawn, MD

Payer

IPRO Charles Stimler MD,

MPH

Lake Success, NY

University

Columbia University Alexander Glassman

MD

New York, NY

Professional Organizations

American College of Physicians

(ACP)

Vincenza Snow MD Philadelphia, PA

American Association of

Cardiovascular and Pulmonary

Rehabilitation (AACVPR)

Douglas R. Southard

PhD, MPH, PA-C

Roanoke, VA
1

Appendix B. Priority Journals for Hand Searching

Priority Journal Titles

American Heart Journal 

American Journal of Cardiology

American Journal of Medicine

American Journal of Psychiatry

Annals of Behavioral Medicine

Archives of General Psychiatry

Archives of Internal Medicine

Biological Psychiatry

Circulation

Health Psychology

JAMA 

Journal of Behavioral Medicine

Journal of Cardiopulmonary Rehabilitation

Journal of the American College of Cardiology

Psychosomatic Medicine

Psychosomatics

* Tables of Contents reviewed from 1 October 2003 to 30 March 2004.
1

Appendix C. Literature Search Strategies

Medline

(myocardial infarction[mh] OR myocardial infarct*[tiab]) AND (depression[mh] OR mental

disorder[mh] OR mood disorder[mh] OR depression[tiab] OR depressive symptom*[tiab] OR

mood disorder[tiab] OR mental disorder[tiab] OR psychiatric disorder[tiab]) AND eng[la] NOT

(animal[mh] NOT human[mh])

Cochrane

(myocardial next infarction) and (depression)

EMBASE

'acute heart infarction'/exp OR 'heart infarct'/exp OR 'heart infarction'/exp OR (myocardial AND

('infarct'/exp OR 'infarction'/exp)) AND ('depression'/exp OR 'mood disorder'/exp OR ((mental

OR 'mood'/exp OR psychiatric) AND (disorder))) AND [english]/lim AND [humans]/lim AND

[embase]/lim

CINAHL

(((myocardial or myocardiac) and (infarct*)) and ((depression) or (mental disorder) or (mood

disorder) or (psychiatric disorder) or (depressive symptom))) and (ZL "ENGLISH")

PsychInfo

((myocardial infarct*) and ((depression) or (mental disorder) or (psychiatric disorder) or

(depressive symptom))) and (ZL "ENGLISH")
1

Appendix D. Abstract Review Form for Primary Literature

Date: EPC Depression Post-MI Reviewer: _________

Abstract Review Form

Data Entry: ________

Record ID:

Title:

Abstract:

Step 1: General Exclusion Criteria

Delete article because (check one):

9 not in English

9 does not include human data

9 no original data

9 meeting abstract (no full article for review)

9 other: (specify) ________________________

9 Unclear: get article to decide

_______________________________________________

Step 3: Question-Specific Exclusion Criteria 

Question 4:

 " Not a concurrent comparison study

 

Questions 5:

 " Does not have a validated reference standard

Do not go on if any item above is checked.

Step 2: Article may address following questions (check

all that apply):

9 depression during hospitalization (Q1)

9 depression during hospitalization w/ & w/out a known history (Q1a)

9 depression after initial hospitalization (Q2)

9 depression measures and outcomes (Q3)

9 depression measures and surrogate markers (Q3a)

9 outcomes w/ & w/out depression treatment (Q4)

9 outcomes w/ depression resolution (Q4a)

9 outcomes w/out depression resolution (Q4b)

9 screening performance characteristics (Q5)

9 screening performance characteristics during hospitalization (Q5a)

9 screening performance characteristics after hospitalization (Q5b)

9 cardiac treatment differences with depression (Q6) 

9 This article does not apply to any of the questions

9 Get article for reference regarding:

_________________________________________
1

Appendix E. Abstraction Forms 

General Content Review Form 

JOHNS HOPKINS EVIDENCE-BASED PRACTICE CENTER 

 POST MYOCARDIAL INFARCTION DEPRESSION 

GENERAL FORM

Article ID: _________________________ First Author: _______________________ 

Reviewer 1: ________________________ Reviewer 2: ________________________ 

1. Exclude article from review because (Check one): 

does not include human data 

no original data 

not in English 

meeting abstract (no full article for review) 

case report or case series (no denominator) 

letter 

published before 1980 

no data reported on when MI occurred relative to when depression assessed 

study population is mixed (i.e. cardiac and non-cardiac) 

AND 

patients with MI not reported separately 

patients with MI not reported separately in study (e.g., CAD, MI and unstable angina) 

 AND 

patients with MI represent < 50% of the sample 

does not apply to any of the questions 

other: (specify) ___________________________________________________________ 

IF ANY OF THE ABOVE IS CHECKED, STOP! DO NOT CONTINUE 

Return article and form. 
2

2. Key Questions: (Check all that apply) 

Q1. What is the prevalence of depression in patients diagnosed with and hospitalized for acute 

myocardial infarction (MI)? [depression assessed during initial hospitalization for MI] 

Q1a. What is the prevalence of depression in patients diagnosed with and hospitalized for acute 

MI, with and without a history of previous depression as reported by study investigators? 

Q2. What percentage of patients with post-MI depression continue to have depression (or 

depressive symptoms) one or more months after initial hospital discharge? [depression assessed 

one or more months after initial hospitalization and not during the initial hospitalization] 

Q3. What is the association of post-MI depression with outcomes independent of other predictors 

of post-MI outcomes? [must include at least one of the following outcomes: death, MI, 

rehospitalization, revascularization, arrhythmias, utilization, quality of life, disability and 

adherence] 

Q3a.What is the association of post-MI depression with surrogate markers of cardiac risk 

independent of other predictors of post-MI outcomes? [must include at least one of the following 

surrogate markers: heart rate variability, platelet reactivity, C-reactive protein or other markers 

of inflammation] 

Q4. Do post-MI patients with depression have better outcomes with depression treatment 

compared to those without depression treatment? 

If the study does not involve a concurrent comparison, check this box as not eligible for Q4. 

Q4a. Do outcomes differ with or without improvement in depression for post-MI patients with 

depression that do receive depression treatment? 

Q4b. Do outcomes differ with or without improvement in depression for post-MI patients with 

depression that do not receive depression treatment? 

Q5. What are the performance characteristics (e.g., sensitivity, specificity, reliability, and 

predictive value) of instruments or methods that are used to screen for depression (or depressive 

symptoms) following an acute MI? 

If the study does not use a validated reference standard, check this box as not eligible for Q5. 

If the study does not use quantitative methods to assess depression, check this box as not 

eligible for Q5. 

Q5a. During hospitalization? 

Q5b.Within 3 months after hospitalization? 

Q6. Does the use of cardiac treatment for patients with acute MI differ for those with and without 

depression? 

None of the above. If this is checked, STOP HERE. Return article and forms
3

ASSESSMENT OF STUDY DESIGN AND QUALITY

3. Study design 

case control study retrospective cohort study

nested case control study prospective cohort study

cross-sectional study randomized clinical trial

other (specify): ___________________________________________________________

CHARACTERISTICS OF STUDY

4. Provide a brief statement of the main aims beginning with “To ...” 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

5. Source of funding (check all that apply): 

University Private 

Pharmaceutical company No funding 

Government Not reported 

Other (specify): __________________________________________________________ 

6. In what geographical area was the study mainly performed (check all that apply)? 

North America (USA) 

North America (Canada) 

South or Central America 

Europe 

Asia 

Africa 

Australia 

7. Was this a multicenter study? 

Yes. Number of centers, if known____________________________________________ 

No 

Unclear 

8. Data comes from patients diagnosed with MI between which years (mo/yr) 

Start: ______/_________ End: ______/__________ 

 Mo. Yr. Mo. Yr. 

Not applicable 
4

9. Does this study include patients with acute coronary syndromes other than acute MI? 

Yes 

No 

If yes: 

a. How many patients had an acute coronary syndrome?____________________ 

b. What percentage of these patients had an acute MI? _____________________ 

c. Was the data for acute MI reported separately? 

Yes 

No 

This item DOES NOT apply to Q1, Q2 & Q5 

10. Does this study include patients with mental disorders other than depression? 

Yes 

No 

If yes: 

a. How many patients were diagnosed with mental disorders? _______________ 

b. What percentage of these patients had depression or affective disorder? _____ 

c. Was the data for depression or affective disorder reported separately? 

Yes 

No 
5

11. Study inclusion and exclusion criteria 

NOTE: Record in terms of exclusions if possible 

Not 

Applicable Inclusion Exclusion Range 

Age _________________________ 

Gender _________________________ 

Race _________________________ 

Education _________________________ 

Marital status _________________________ 

Occupation _________________________ 

Cardiac surgery anticipated _________________________ 

Index ACS developed after 

CABG _________________________ 

Significant bradycardia _________________________ 

MI of non-atherosclerotic 

etiology _________________________ 

Killip class _________________________ 

Uncontrolled hypertension _________________________ 

Persistent clinically 

significant abnormalities _________________________ 

Renal dysfunction _________________________ 

Hepatic dysfunction _________________________ 

Other significant nonreactive 

disease _________________________ 

Women of childbearing 

potential not using 

adequate contraception _________________________ 

Alcohol or substance abuse _________________________ 

Psychotic symptoms _________________________ 

History of psychosis, bipolar 

disorder, organic brain 

syndrome or dementia _________________________ 

Significant suicide risk _________________________ 

Terminally ill _________________________ 

Serious comorbidities _________________________ 

Cognitive impairment _________________________ 

Non-English speaking _________________________ 

Other:__________________ _________________________ 

_______________________ _________________________ 

_______________________ _________________________ 

_______________________ _________________________ 

_______________________ _________________________ 
6

12. Criteria for diagnosis of myocardial infarction: (Check all that apply) 

In hospital assessment: 

Chest pain 

Electrocardiogram 

Creatine kinase 

Troponin 

Other cardiac enzymes 

Other (specify): _______________________________________________________ 

Physician report (e.g., as documented in medical record) 

Patient self report 

Radionuclide (e.g. thallium) study 

Other (specify): ___________________________________________________________ 

Depression measurement: 

13. Was a validated questionnaire used to assess depression? (Check at least one) 

Beck Depression Inventory (BDI) 

Hamilton Rated Scale for Depression (HAM – D) 

Zung Self-Assessment Depression Scale 

General Health Questionnaire (GHQ) 

Center for Epidemiologic Study Depression Scale (CES-D) 

Hospital Anxiety and Depression Scale (HADS) 

Geriatric Depression Scale 

Symptom Check List 90 (SCL-90) 

Clinical Global Impression (CGI-1) 

Other (specify): ______________________________________________________ 

No validated questionnaire 

14. Was a standardized psychiatric interview used to assess depression? (Check at least one) 

Diagnostic Interview Schedule (DIS) 

Depression Interview and Structured Hamilton (DISH) 

Structured Clinical Interview for DSM-IV (SCID) 

Semi-structured Clinical Interview for DSM-IV (SCID) 

Other (specify): _______________________________________________________ 

No standardized psychiatric interview 
7

15. Was a clinical interview by a mental health professional (DSM III, III-R, IV criteria) used to 

assess depression? (Check at least one) 

Yes 

No 

16. Was another method used to assess depression? (Check at least one) 

Review of medical records 

Other (specify): _______________________________________________________ 

Not stated 

None 

17. Provide a description for each group in reference to acute MI, depression and other key 

characteristics (e.g. A: Acute MI depression, B: Acute MI without depression).

Description 

Group Acute MI Depression Other 

yes yes

A 

no:_____________________ no:_____________________

yes yes

B 

no:_____________________ no:_____________________

yes yes

C 

no:_____________________ no:_____________________

yes yes

D 

no:_____________________ no:_____________________

Comments: 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________
8

18. Description of subjects [use % except for total number and age] 

 Group A Group B Group C Group D 

Total number (N) 

Age 

(mean +/- SD) 

(Median and range) 

Gender, male % 

Race/ethnicity: 

 Caucasian, % 

 Non-Caucasian, % 

 African American, % 

 Asian American, % 

 Hispanic American, % 

 Other, ____________% 

Marital status, married, % 

Discharged home, % 

Education high school 

 or higher, % 

Employed full/part time, % 

Cardiac risk factors: 

Hypertension 

Diabetes mellitus 

Smoking 

Hyperlipidemia 

Obesity 

Prior cardiac disease 

( ______________________ ) 

Previous angina 

Previous MI 

Previous heart failure 

Peripheral vascular disease 

Sedentary lifestyle 
9

Description of subjects [use % except for total number and age] 

 Group A Group B Group C Group D 

Features of MI: 

Killip Class 

Class I, % 

Class II, % 

Class III, % 

Class IV, % 

Other ________________ 

Ejection fraction, 

mean +/- SD 

Other_________________ 

Maximum creatine kinase 

mean +/- SD 

Other_________________ 

Pre-discharge exercise test 

result in METS, mean 

Received revascularization, % 

History of depression 

Family history of depression 

Received thrombolytics, % 

Other:____________________ 

_________________________ 

_________________________ 

_________________________ 
10
11

Quality Assessment Form 

JOHNS HOPKINS EVIDENCE-BASED PRACTICE CENTER 

 POST MYOCARDIAL INFARCTION DEPRESSION 

QUALITY ASSESSMENT FORM

Article ID: _________________________ First Author: _______________________ 

Reviewer 1: ________________________ Reviewer 2: ________________________ 

REPRESENTATIVENESS OF STUDY POPULATION

1. Did the study describe the setting and population from which the study sample was drawn, and 

the dates of the study? 

a. Adequate (setting AND population described AND start and end date specified) 2 

b. Fair (setting AND population described but NOT start and end date) 1 

c. Inadequate (not specified) 0 

2. Were detailed inclusion/exclusion criteria provided? 

a. Adequate (detailed description of specific inclusion and exclusion criteria OR 

statement that all eligible patients enrolled) 

2 

b. Fair (some description, but would be difficult to replicate based on information 

provided) 

1 

c. Inadequate (minimal description or not at all) 0 

3. Was information provided on excluded or non-participating patients? 

a. Adequate (all reasons for exclusion AND number excluded OR no exclusion) 2 

b. Fair (only one of above criteria specified or information not sufficient to allow 

replication) 

1 

c. Inadequate (none of the above criteria specified) 0 
12

4. Does the study describe key patient characteristics at enrollment? 

Demographics: age, gender, race/ethnicity, education, marital status, occupation 

Medical characteristics: current smoking, Body Mass Index (BMI), diabetes, hypertension, 

hypercholesterolemia, cerebrovascular disease, peripheral vascular disease, renal insufficiency, cardiac 

medications, antidepressants 

Depression Features: depression measured by validated questionnaire, standardized psychiatric 

interview, clinical interview by mental health professional, and review of medical records; first episode of 

depression; recurrent depression; prior episodes of major depression; prior psychotropic treatment 

Cardiac Features: cardiac event leading to current hospitalization, left ventricular ejection fraction 

(LVEF in %), previous MI, previous CABG surgery, previous PTCA, history of congestive heart failure, 

Killip class, peak CPK 

a. Good: 4 of 4 categories described well (i.e., most items in each category described) 2 

b. Fair: 2 or 3 categories described well 1 

c. Poor: 0 or 1 categories described 0 

5. Did the study include a consecutive series of individuals presenting with the relevant symptoms 

or a randomly selected sample? 

a. Consecutive series 2 

b. Random sample 2 

c. Other 1 

d. Unclear 0 

6. What was recruitment based on? 

[THIS ITEM APPLIES TO Q5 ONLY] 

a. Predetermined diagnostic criteria 2 

b. Previous testing with the index test/instrument or the reference standard used in the 

study 1 

c. Unclear 0 

d. Not applicable N/A 
13

BIAS AND CONFOUNDING

7. Was assignment of patients to study group randomized? 

 [THIS ITEM APPLIES TO Q4 ONLY] 

a. Adequate (investigators could not predict assignment) 2 

b. Partial (date of birth, admission date, hospital record number, or other nonrandom 

scheme for assignment OR did not state) 1 

c. Not randomized 0 

d. Unclear 0 

e. Not applicable N/A 

8. Did the patient groups have any important differences in key patient characteristics? 

[THIS ITEM APPLIES TO Q4 ONLY] 

Demographics: age, gender, race/ethnicity, education, marital status, occupation, days from index MI to 

first day of therapy 

Medical characteristics: current smoking, Body Mass Index (BMI) kg/m2, diabetes, hypertension, 

hypercholesterolemia, cerebrovascular disease, peripheral vascular disease, renal insufficiency, cardiac 

medications, antidepressants 

Depression Features: depression measured by instruments such as HAM –D, CGI-1or Beck Depression 

Inventory; first episode of depression; recurrent depression; prior episodes of major depression; prior 

psychotropic treatment 

Cardiac Features: cardiac event leading to current hospitalization, left ventricular ejection fraction 

(LVEF in %), previous MI, previous CABG surgery, previous PTCA, history of congestive heart failure, 

Killip class, peak CPK 

a. Groups equivalent in all factors examined 2 

b. Groups have minor difference in 1 or 2 factors 1.5 

c. Groups have an important difference in one or more factors OR minor difference in 

more than two factors 1 

d. Analysis not done 0 

e. Not applicable N/A 
14

9. Was the decision to obtain the reference test affected in any way by the results of the study 

test/instrument, or vice versa? 

[THIS ITEM APPLIES TO Q5 ONLY] 

[Note: we want to understand the extent to which testing decisions were independent of each other. There 

are two ways for testing not to be independent: 

(1) The decision to perform the 2nd test can be dependent on the results of the 1st test 

(2) The decision to include a patient in the study can be based on a referral for testing] 

a. Decision to test was NOT affected by either (1) above OR (2) above 2 

b. Decision to test was affected by either (1) above OR (2) above 0 

c. Unclear 0 

d. Not applicable N/A 

10. Was there blinding of study test interpretation, reference test interpretation, and clinical data? 

[THIS ITEM APPLIES TO Q5 ONLY] 

[Note: This question concerns blinding: not independence of interpretations] 

a. Excellent (ALL 3 blinded, including both test interpretations with each other) 2 

b. Good (test interpretations blinded to each other but not to clinical data) 1 

c. Fair (test interpretations blinded to clinical data but not to each other) 0.5 

d. Poor (no blinding OR not stated) 0 

e. Not applicable N/A 

11. Was interpretation of the study test performed by two or more independent observers? 

 [THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (multiple observers AND independent) 2 

b. Fair (multiple observers but NOT independent) 1 

c. Inadequate (Neither OR not stated) 0 

d. Not applicable (e.g., if using self rating or test doesn’t require interpretation) N/A 
15

12. Was interpretation of the reference test performed by two or more independent observers? 

[THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (multiple observers AND independent) 2 

b. Fair (multiple observers but NOT independent) 1 

c. Inadequate (Neither OR not stated) 0 

d. Not applicable (e.g., if using self rating or test doesn’t require interpretation) N/A 

13. Were the reference standard and the index test measured before any interventions were started 

with knowledge of test results? 

[THIS ITEM APPLIES TO Q5 ONLY] 

a. Yes 2 

b. No 0 

c. Unclear 0 

d. Not applicable N/A 

14. If the study was a controlled clinical trial, was there blinding of clinicians, patients, and 

outcome assessors? 

 [THIS ITEM APPLIES TO Q4 ONLY] 

a. Excellent (All three blinded, including all treatment arms) 2 

b. Good (Only 2 of the 3 blinded, or some but not all of the arms) 1.5 

c. Fair (Only 1 of the 3 blinded) 1 

d. Poor (No blinding or not stated) 0 

e. Not applicable N/A 
16

DESCRIPTION OF THERAPY/MANAGEMENT

15. How well did the study describe details of the cardiac therapy regimen given for the MI? 

(e.g., types of procedures, types of medications, dose intensity, duration of therapy) 

a. Adequate – detailed enough that it could be replicated 2 

b. Fair – one or two key features not described 1 

c. Inadequate – not described 0 

d. Not applicable N/A 

16. Did the study describe details of the psychiatric treatment given for post-MI depression? 

a. Adequate (treatment fully described) 2 

b. Fair (some description, but information not sufficient to allow replication) 1 

c. Inadequate (not described) 0 

d. Not applicable N/A 

17. How was the description of other medical or psychiatric treatments given study subjects while 

they were in the study? (e.g., other medications or procedures, psychiatric medications other than 

study drug, psychiatric therapy other than therapy being studied)

a. Adequate (other treatment fully described) 2 

b. Fair (some description, but information not sufficient to allow replication) 1 

c. Inadequate (not described) 0 

d. Not applicable N/A 

18. How did the study describe details of the flow of participants through each stage? For each 

group the number of participants randomly assigned, receiving intended treatment, completing 

the study protocol and analyzed for the primary outcome. 

 [THIS ITEM APPLIES TO Q4 ONLY] 

a. Adequate 2 

b. Fair (one of the above NOT described) 1 

c. Inadequate (more than one of above NOT described) 0 
17

19. How was the assessment of adherence to the therapy of interest? 

[THIS ITEM APPLIES TO Q4 ONLY] 

a. Adequate (strong methods AND results of assessment reported in detail) 2 

b. Fair (weak methods such as self-report OR results of assessment not reported in 

detail but NOT both) 1 

c. Inadequate (neither reported) 0 

d. Not appliacable N/A 

DESCRIPTION OF THE ASSESSMENT PROTOCOLS

20. Was data collection planned before the index test/instrument and reference standard were 

performed (prospective study)? 

[THIS ITEM APPLIES TO Q5 ONLY] 

a. Yes 2 

b. No 1 

c. Unclear 0 

21. Did the study describe details of the methods used for the initial diagnosis of depression? 

 [THIS ITEM DOES NOT APPLY TO Q5] 

a. Adequate (used a validated questionnaire or standardized interview process OR 

enough description to replicate)

2 

b. Fair (not a validated questionnaire or standardized interview process OR enough 

description to replicate)

1 

c. Inadequate (no description) 0 

22. Was the interpretation criteria for a positive diagnosis of depression described? 

 [THIS ITEM DOES NOT APPLY TO Q5] 

a. Adequate (enough description to replicate) 2 

b. Fair (some description, but not enough to replicate) 1 

c. Inadequate (no description) 0 
18

23 Did the study describe details of the reference standard used to assess the study test/instrument 

protocol? 

[THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (enough description to replicate) 2 

b. Fair (some description, but not enough to replicate) 1 

c. Inadequate (no description) 0 

d. Not applicable N/A 

 

24. Did the study report the time interval between performance of the index test/instrument and 

the reference standard? 

[THIS ITEM APPLIES TO Q5 ONLY] 

a. Yes AND it was within 1 day 2 

b. Yes AND it was more than 1 day but less than 1 week 1 

c. Yes AND it was 1 week or more 0 

d. Unclear 0 

e. Not applicable N/A 
19

TEST/INSTRUMENT INTERPRETATION

25. Were the interpretation criteria of a positive depression test/instrument described for the study 

test? 

 [THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (enough description to replicate) 2 

b. Fair (some description, but not enough to replicate) 1 

c. Inadequate (no description) 0 

d. Not applicable N/A 

26. Did all individuals receiving the study test/instrument also receive the reference test? 

 [THIS ITEM APPLIES TO Q5 ONLY] 

a. All (all received BOTH tests) 2 

b. Some (some received both tests) 1 

c. None (no one received both tests) 0 

d. Unclear 0 

e. Not applicable N/A 

27. Were the interpretation criteria of a positive depression test/instrument described for the 

reference test? 

 [THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (enough description to replicate) 2 

b. Fair (some description, but not enough to replicate) 1 

c. Inadequate (no description) 0 

d. Not applicable N/A 
20

28. Was a summary index of test performance (e.g., sensitivity/specificity, area under ROC curve)

reported for the study test AND an indicator of variability (standard error, confidence interval)? 

[THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (both reported) 2 

b. Fair (test performance but no index of variability) 1 

c. Inadequate (no information given) 0 

d. Not applicable N/A 

29. Were methods for calculating test reproducibility described? 

 [THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (enough description to replicate) 2 

b. Fair (some description, but not enough to replicate) 1 

c. Inadequate (no description) 0 

d. Not applicable N/A 

30. Did the authors describe how indeterminate results, missing responses and outliers of the index 

test/instrument and the reference test were handled? 

 [THIS ITEM APPLIES TO Q5 ONLY] 

a. Adequate (enough description to replicate) 2 

b. Fair (some description, but not enough to replicate) 1 

c. Inadequate (no description) 0 

d. Not applicable N/A 
21

OUTCOMES AND FOLLOW-UP

31. Did the study report the numbers or reasons for withdrawals from the study protocol or 

patients otherwise lost to follow-up? 

a. Adequate (both numbers AND reasons reported, OR no withdrawals) 2 

b. Fair (only numbers OR reasons reported) 1 

c. Inadequate (neither given) 0 

d. Not applicable (no longitudinal follow-up was performed) N/A 

32. What was the percentage of patients that withdrew from the study protocol or were lost to 

follow-up? 

 [THIS ITEM APPLIES TO Q2, Q3, Q4 AND Q6 ONLY] 

a. None 2 

b. < 10% 1.5 

c. 10 - 20% 1 

d. > 20% 0 

e. Not stated 0 

f. Not applicable (no follow-up) N/A 

33. How did the investigators determine whether the patients received cardiac treatment? 

 [THIS ITEM APPLIES TO Q6 ONLY] 

a. Adequate (clear definitions of type of treatment AND exact techniques to assess 

whether treatments received) 2 

b. Fair (some description, but information not sufficient to allow replication) 1 

c. Inadequate (no information provided) 0 

d. Not applicable N/A 
22

34. How were cardiac heart disease outcome measures defined? (e.g., left ventricular ejection fraction 

(%), heart rate variability, blood pressure, standard ECG, runs of ventricular premature contractions, 

occurrence of cardiovascular events – myocardial infarction, stroke, severe angina, congestive heart 

failure, death) 

[THIS ITEM APPLIES TO Q3 & Q4 ONLY] 

a. Adequate (clear definitions of each outcome AND exact techniques to assess the 

outcome) 2 

b. Fair (some description, but information not sufficient to allow replication) 1 

c. Inadequate (no information provided) 0 

d. Not applicable (cardiac outcomes not measured OR no intervention) N/A 

35. How were depression outcome measures defined? (e.g., instruments such as Hamilton Rated Scale 

for Depression (HAM –D) and Beck Depression Inventory (BDI) scores, validated questionnaires, 

standardized psychiatric interview, clinical interview by mental health professional (DSM III or IV) ) 

[THIS ITEM APPLIES TO Q3 & Q4 ONLY] 

a. Adequate (clear definitions of each outcome measure AND exact techniques to 

assess the outcome) 2 

b. Fair (some description, but information not sufficient to allow replication) 1 

c. Inadequate (no information provided) 0 

d. Not applicable (no intervention) NA 

36. Were the same tools for diagnosing depression and the mode of administration used for baseline 

and follow up? 

a. Adequate (tool AND method of administration are same) 2 

b. Fair (same tool but different mode of administration) 1 

c. Inadequate (different tool) 0 

d. Not applicable (e.g., no follow-up assessment of depression) N/A 
23

37. Did the study assess and report adverse effects experienced by patients? 

 [THIS ITEM APPLIES TO Q4 ONLY] 

a. Adequate (cardiovascular adverse events AND at least one non-cardiovascular 

adverse effect assessed and reported) 2 

b. Fair (only cardiovascular events mentioned OR non-cardiovascular adverse effects 

mentioned, but NOT fully assessed and reported) 1 

c. Inadequate (cardiovascular adverse events NOT mentioned) 0 

d. Not applicable (no intervention) N/A 

38. What was the planned length of follow-up since initiation of treatment? 

[THIS ITEM APPLIES TO Q3, Q4 AND Q6 ONLY] 

a. >= 1 year 2 

b. 6 - 11 months 1.5 

c. 3 - 5 months 1 

d. < 3 months 0 

e. Not stated 0 

f. Not applicable (no follow-up) N/A 

STATISTICAL ANALYSIS

39. Was the statistical test of all analyses clearly identified? 

a. Adequate (identified for all analyses) 2 

b. Fair (identified for some of the analyses) 1 

c. Inadequate (not identified) 0 

d. Not applicable (no statistical tests needed) N/A 
24

40. Was loss to follow-up handled appropriately in the analysis? 

 [THIS ITEM APPLIES TO Q2, Q3, Q4 &Q6 ONLY] 

a. No loss to follow-up 2 

b. By intention to treat (or by original group assignment) 2 

c. Sensitivity analysis 1 

d. None of the above 0 

e. Not applicable (no follow-up) N/A 

41. For primary endpoints of the evaluation, does the study report the magnitude of difference 

between groups OR magnitude of the association between outcomes and patient characteristics 

AND an index of variability – including pre-post testing (e.g., test statistic, p value, standard error, 

confidence interval) ? 

 [THIS ITEM APPLIES TO Q3, Q4 & Q6] 

a. Adequate (BOTH reported with index of variability using standard error or 

confidence intervals) 2 

b. Fair (BOTH reported with index of variability using only test statistic or 

 p value) 

1 

c. Inadequate (one OR both not reported) 0 

d. No comparisons (descriptive analysis only) 0 

e. Qualitative analysis only N/A 

f. Not applicable (e.g., no comparison group) N/A 

42. Was adequate adjustment made for confounding in the analysis from which the main findings 

were drawn?

a. Adequate (adjusted for all potential confounding factors that differed between groups) 2 

b. Fair (adjusted for some but not all potential confounding factors) 1 

c. Inadequate (did not adjust for confounding factors or unclear whether potential 

confounding factors differed between groups) 0 

d. Not applicable (e.g., groups did not differ in important patient characteristics) N/A 
25

43. Was the prevalence of depression reported using a 95% confidence interval? 

 [THIS ITEM APPLIES TO Q1 & Q2 ONLY] 

a. Yes 2 

b. No 0 

c. Not applicable N/A 

CONFLICTS OF INTEREST

44. Did the study report identify the sources of funding and the type and degree of involvement of 

the funding agency? 

a. Adequate (source AND type or degree of involvement OR no funding) 2 

b. Fair (source only) 1 

c. Inadequate (neither) 0 
26
27

Question 1 and 2 Form 

JOHNS HOPKINS EVIDENCE-BASED PRACTICE CENTER 

 POST MYOCARDIAL INFARCTION DEPRESSION 

QUESTION 1 & 2 FORM

Article ID: _________________________ First Author: _______________________ 

Reviewer 1: ________________________ Reviewer 2: ________________________ 

CHARACTERISTICS OF STUDY 

1. Criteria used for diagnosis of depression: 

For baseline assessment (during hospitalization for MI) 

standard 

modified (e.g., duration or impairment) 

not applicable 

For follow-up/ assessment (after hospitalization for MI) 

standard 

modified (e.g., duration or impairment) 

not applicable 

2. Timing of the depression measurement (check all that apply): 

during hospitalization, NOS 

within first two days 

3 - 13 days after MI 

2 - 4 weeks after MI 

1 - 5 months after MI 

6 - 11 months after MI 

1 - 2 years after MI 

> 2 years after MI 

other: specify __________________________________________________________ 

unclear 
28

3. Minimum duration of symptoms to meet criteria: 

At baseline 

<2 weeks 

=2 weeks 

>2 weeks 

not specified 

At follow-up 

<2 weeks 

=2 weeks 

>2 weeks 

not specified 

not applicable (no follow-up) 

4. Symptoms of depression in relation to MI hospitalization: 

symptoms appeared after hospitalization 

symptoms appeared before hospitalization 

both populations included 

not specified 

not applicable 

5. Depression treatment given between initial hospitalization and the next period of assessment. 

depression treatment given 

If yes, assignment of treatment: 

random 

non-random 

not stated 

depression treatment not given 

no information available 

not applicable 
29

6. Severity of depression (Check all that apply): 

depression reported as continuous variable 

depression reported as categorical variable 

depression reported as dichotomous variable 

not specified 

severity not measured 

RESULTS OF STUDY 

7. What number and percentage of patients had depression during hospitalization? 

Depression n % 95% CI 

primary instrument____________> __________ 

major depression 

minor depression 

major/minor depression 

other affective disorders 

other: __________________________________ 

other: __________________________________ 

Not applicable 

8. What number and percentage of patients had depression at the first follow-up visit after the cardiac 

event? 

Depression n % 95% CI 

primary instrument____________> __________ 

major depression 

minor depression 

major/minor depression 

other affective disorders 

other: ___________________________________ 

other: ___________________________________ 

Not applicable 

9. When was the first follow-up visit? ____________weeks or ____________months 

Not applicable 
30

10. What number and percentage of patients had depression at the last follow-up visit after the cardiac 

event? 

Depression n % 95% CI 

primary instrument____________> __________ 

major depression 

minor depression 

major/minor depression 

other affective disorders 

other: _________________________________ 

other: _________________________________ 

Not applicable 

11. When was the last follow-up visit? _______weeks or _______months or _______years 

Not applicable 

12. Other comments about the study not already reported: 

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________ 
31
32

Question 3 Form 

JOHNS HOPKINS EVIDENCE-BASED PRACTICE CENTER 

POST MYOCARDIAL INFARCTION DEPRESSION 

QUESTION 3 FORM

Article ID: _________________________ First Author: _______________________ Reviewer 1: ________________________ Reviewer 2: ________________________ 

RESULTS OF STUDY 

Outcome events NOTE: Report number AND/OR % population. ***Include DENOMINATOR IF different from total*** 

Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Outcome Depression 

n ( % ) 

No Depression 

n ( % ) 

1. Total no. in group at 

enrollment (N) 

2. Total no. in group available for 

analysis at last follow-up 

3. Mean/median follow-up 

mean median 
33

Compa

( + 95% Co

Relative RisOdds RatioHazard Rati

Outcome Depression 

n ( % ) 

No Depression 

n ( % ) 

P-value 

Univariate 

4. Total Mortality at 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

5. Cardiac Mortality at 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

6. Myocardial Infarction(recurrent)

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
34

Com

( + 95% 

Relative Odds RaHazard 

Outcome Depression 

n ( % ) 

No Depression 

n ( % ) 

P-value 

Univariat

7. Arrhythmias 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

8. Revascularization procedure 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
35

Depression No Depression 

Comp

( + 95% C

Relative ROdds RatiHazard Ra

Outcome 

Mean SD CI Mean SD CI 

P-value 

Univariate 

9. Utilization of healthcare services

(specify) ____________________ 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

10. Cost of care (specify how defined) 

____________________________ 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

11. Quality of life (specify instrument) 

____________________________

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
36

Depression No Depression 

Comp

( + 95% C

Relative ROdds RatiHazard Ra

Outcome 

Mean SD CI Mean SD CI 

P-value 

Univariate 

12. Depression Score (specify 

instrument) __________________ 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

13. Patients with depression (specify 

how defined) ____________________________ 

n ( % ) n ( % )

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
37

Com

( + 95% 

Relative ROdds RatHazard R

Outcome Depression 

n ( % ) 

No Depression 

n ( % ) 

P-value 

Univariate 

14. Disability (specify how measured) 

____________________________

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

Mean SD CI Mean SD CI 15. Heart rate variability (specify 

how measured) ____________________________ 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
38

Com

( + 95% 

Relative ROdds RatHazard R

Outcome Depression 

n ( % ) 

No Depression 

n ( % ) 

P-value 

Univariate 

16. Heart rate variability (specify 

how measured) ____________________________

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

Mean SD CI Mean SD CI 17. Heart rate variability (specify 

how measured) ____________________________ 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
39

Com

( + 95% 

Relative ROdds RatHazard R

Outcome Depression 

n ( % ) 

No Depression 

n ( % ) 

P-value 

Univariate 

18. Heart rate variability (specify 

how measured) ____________________________

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

Mean SD CI Mean SD CI 19. Platelet reactivity (specify how 

defined) ____________________________ 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
40

Depression No Depression 

Comp

( + 95% C

Relative ROdds RatiHazard Ra

Outcome 

Mean SD CI Mean SD CI 

P-value 

Univariate 

20. Platelet reactivity (specify how 

defined) ____________________________ 

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

21. C-reactive protein

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
41

Depression No Depression 

Comp

( + 95% C

Relative ROdds RatiHazard Ra

Outcome 

Mean SD CI Mean SD CI 

P-value 

Univariate 

22. Other markers of inflammation 

(specify) ____________________________

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

23. Other markers of inflammation 

(specify) ____________________________

n ( % ) n ( % )

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 
42

Depression No Depression 

Comp

( + 95% C

Relative ROdds RatiHazard Ra

Outcome 

Mean SD CI Mean SD CI 

P-value 

Univariate 

24. Other outcomes (specify) 

____________________________

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

25. Other outcomes (specify) 

____________________________

n ( % ) n ( % )

a. 1 month b. 2 months c. 3 months d. 6 months e. 12 months f. last follow-up 

_________ record mean/median follow-up 

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________
43

26. Which one of the following outcomes was the dependent variable in the main multivariate 

analyses? 

None 

Total mortality 

Cardiac mortality 

Myocardial Infarction (recurrent) 

Arrhythmias 

Revascularization procedure 

Utilization (of health care facility) 

Cost of care 

Quality of life 

Depression 

Disability and adherence 

Heart rate variability 

Platelet reactivity 

C-reactive protein 

Other markers of inflammation (specify): ______________________________________ 

Other outcomes (specify): __________________________________________________ 

 
 

44

27. What were the independent variables in the main multivariate analysis? 

(Check one box in each row) 

Factor p <= 0.05 p > 0.05 Not Considered 

Age 

Gender 

Race/Ethnicity 

Hypertension 

Diabetes Mellitus 

Serum Cholesterol 

Smoking 

Previous MI 

Left ventricular ejection fraction (LVEF) 

Killip Class 

History of depression 

Social Support 

Other cardiac factor: (specify) 

_________________________________ 

 

Other cardiac factor: (specify) 

_________________________________ 

 

Other depression measure: (specify) 

_________________________________ 

 

Other depression measure: (specify) 

_________________________________ 

 

Other: (specify) 

_________________________________ 

 

Other: (specify) 

_________________________________ 

 
45

28. Which one of the following outcomes was the dependent variable in the other multivariate 

analysis? 

None 

Total mortality 

Cardiac mortality 

Myocardial Infarction (recurrent) 

Arrhythmias 

Revascularization procedure 

Utilization (of health care facility) 

Cost of care 

Quality of life 

Depression 

Disability and adherence 

Heart rate variability 

Platelet reactivity 

C-reactive protein 

Other markers of inflammation (specify): ______________________________________ 

Other outcomes (specify): __________________________________________________ 

 

 
 

46

29. What were the independent variables in the other multivariate analysis? (Check one box in 

each row) 

Factor p <= 0.05 p > 0.05 Not Considered 

Age 

Gender 

Race/Ethnicity 

Hypertension 

Diabetes Mellitus 

Serum Cholesterol 

Smoking 

Previous MI 

Left ventricular ejection fraction (LVEF) 

Killip Class 

History of depression 

Social Support 

Other cardiac factor: (specify) 

_________________________________ 

 

Other cardiac factor: (specify) 

_________________________________ 

 

Other depression measure: (specify) 

_________________________________ 

 

Other depression measure: (specify) 

_________________________________ 

 

Other: (specify) 

_________________________________ 

 

Other: (specify) 

_________________________________ 

 
47
 

48

Question 4 Form 

JOHNS HOPKINS EVIDENCE-BASED PRACTICE CENTER 

 POST MYOCARDIAL INFARCTION DEPRESSION 

QUESTION 4 FORM

Article ID: _________________________ First Author: _______________________ 

Reviewer 1: ________________________ Reviewer 2: ________________________ 

CHARACTERISTICS OF STUDY

1. For each group, provide a brief description of the intervention (less than 10 words) 

Group A: _______________________________________________________________ 

_________________________________________________________________ 

Group B: _______________________________________________________________ 

 _________________________________________________________________ 

Group C: _______________________________________________________________ 

 _________________________________________________________________ 

Group D: _______________________________________________________________ 

 _________________________________________________________________ 

2. Treatment 

Group A Group B Group C Group D 

Antidepressant drug 

Starting dose (mg or units/kg) 

Frequency of administration 

(e.g., QD, BID) 

Duration of intervention in days 

Cognitive behavioral therapy 

Interpersonal therapy 

Psychosocial therapy 

Cardiac rehabilitation 

Others___________________ 
49

3. Protocol adherence achieved 

NOTE: Report mean of value OR median if only median reported 

Group A Group B Group C Group D 

Days from MI to 

starting 

antidepressant 

mean 

median 

Target no. of psychotherapy sessions 

No. of 

psychotherapy 

sessions achieved 

mean 

median 

No. of weeks on 

study drug 

mean 

median 

Daily dose achieved 

in mg per day 

mean 

median 
50

4. Outcome events NOTE: Report number AND/OR % of population. ***Include DENOMINATOR IF different from total*** 

Outcome Group A 

n / % 

Group B 

n / % 

Group C 

n / % 

Group D 

n / % 

Pvalue

Com

sta

Risk OddHaz

Total no. in group at enrollment (N) Total no. in group available for analysis at last follow-up Mean/median follow-up 

mean median 

Total mortality at 

1 month, n (%) 2 months, n (%) 3 months, n (%) 6 months, n (%) 12 months, n (%) last follow-up at 

_______ months, n (%) (if >12 months) 

Cardiac mortality at 

1 month, n (%) 2 months, n (%) 3 months, n (%) 6 months, n (%) 12 months, n (%) last follow-up at 

_______ months, n (%) (if >12 months) 
51

Outcome Group A 

n / % 

Group B 

n / % 

Group C 

n / % 

Group D 

n / % 

Pvalue

Com

sta

Risk OddHaz

Myocardial infarction at 

1 month, n (%) 2 months, n (%) 3 months, n (%) 6 months, n (%) 12 months, n (%) last follow-up at 

_______ months, n (%) (if >12 months) 

Revascularization procedures at 

1 month, n (%) 2 months, n (%) 3 months, n (%) 6 months, n (%) 12 months, n (%) last follow-up at 

_______ months, n (%) (if >12 months) 
52

Group A 

n / % 

Group B 

n / % 

Group C 

n / % 

Group D 

n / % 

Outcome

Mean SD+ CI++ Mean SD+ CI++ Mean SD+ CI++ Mean SD+ CI++

P 

Value 

Quality of life: Instrument_______________________________ Score at 

1 month, n (%) 2 months, n (%) 3 months, n (%) 6 months, n (%) 12 months, n (%) last follow-up at 

_______ months, n (%) (if >12 months) 

Cost of care: definition____________ mean costs at 

1 month, n (%) 2 months, n (%) 3 months, n (%) 6 months, n (%) 12 months, n (%) last follow-up at 

_______ months, n (%) (if >12 months) 

 + CI - Confidence Interval  ++ SD – Standard Deviation 
53

Group A 

n / % 

Group B 

n / % 

Group C 

n / % 

Group D 

n / % 

Outcome

Mean SD+ CI++ Mean SD+ CI++ Mean SD+ CI++ Mean SD+ CI++

P 

Value 

Depression: Instrument_______________________________ Score at 

1 month, n (%) 2 months, n (%) 3 months, n (%) 6 months, n (%) 12 months, n (%) last follow-up at 

_______ months, n (%) (if >12 months) 

Other outcome: (specify) ____________________ at 

_____month(s), n (%) _____months, n (%) 

Other outcome: (specify) ____________________ at 

_____month(s), n (%) 

 _____months, n (%)  + CI - Confidence Interval  ++ SD – Standard Deviation Comments:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
54

5. Subgroup analyses 

Subgroup 

characteristics 

Main outcome(s) 

reported Results in subgroups P–value 

 

 

 

 

 

 

6. Summary of main conclusions: 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________
 

55
56

Question 5 Form 

JOHNS HOPKINS EVIDENCE-BASED PRACTICE CENTER 

 POST MYOCARDIAL INFARCTION DEPRESSION 

QUESTION 5 FORM

Article ID: _________________________ First Author: ________________________ 

Reviewer 1: ________________________ Reviewer 2: ________________________ 

1. Results of test utility (specify study test _______________________________________) 

Statistic Confidence Interval (P) 

Sensitivity 

Specificity 

Intra-rater Reproducibility Inter-rater 

Percent agreement/correlation with 

validated questionnaire 

Percent agreement/correlation with 

psychiatric interview 

Percent agreement/correlation with 

mental health professional 

Other :________________________ 

Other :________________________ 

2. Results of test utility (specify study test _______________________________________) 

Statistic Confidence Interval (P) 

Sensitivity 

Specificity 

Intra-rater Reproducibility Inter-rater 

Percent agreement/correlation with 

validated questionnaire 

Percent agreement/correlation with 

psychiatric interview 

Percent agreement/correlation with 

mental health professional 

Other :________________________ 

Other :________________________ 

 
 

57

3. Results of test utility (specify study test _______________________________________) 

Statistic Confidence Interval (P) 

Sensitivity 

Specificity 

Intra-rater Reproducibility 

Inter-rater 

Percent agreement/correlation with 

validated questionnaire 

Percent agreement/correlation with 

psychiatric interview 

Percent agreement/correlation with 

mental health professional 

Other :________________________ 

Other :________________________ 

4. Other comments: 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ 
58
59

Question 6 Form 

JOHNS HOPKINS EVIDENCE-BASED PRACTICE CENTER 

POST MYOCARDIAL INFARCTION DEPRESSION 

QUESTION 6

Article ID: _________________________ First Author: _______________________ Reviewer 1: ________________________ Reviewer 2: ________________________ 

RESULTS OF STUDY 

1. What number and percentage of subjects received the following procedures? 

Cardiac Procedure Group A 

n (%) 

Group B 

n (%) 

Group C 

n (%) 

Group D 

n (%) 

Comparison statistic 

( + 95% CI ) 

Risk Ratio Odds RatioHazard Ratio

Catheterization Revascularization (CABG or percutaneous intervention) Percutaneous intervention (angioplasty, stenting) CABG Thrombolytic therapy Other:_______________ 

Not applicable (N/A) 
60

2. What number and percentage of subjects received and/or were recommended the following lifestyle interventions

Lifestyle Interventions Group A n (%) Group B n (%) Group C n (%) Group D n (%) 

Comparison statistic 

( + 95% CI ) 

Risk Ratio Odds RatioHazard Ratio

Smoking cessation Physical exercise Weight management Dietary lipid management Other:_______________ 

Not applicable (N/A) 

3. What number and percentage of subjects received and/or were recommended the following medications? 

Medications Group A 

n (%) 

Group B 

n (%) 

Group C 

n (%) 

Group D 

n (%) 

Comparison statistic 

( + 95% CI ) 

Risk Ratio Odds RatioHazard Ratio

ACE inhibitors Beta-blockers Statins Aspirin Other antiplatelet therapy Anticoagulants Other:_______________ 

Not applicable (N/A)
61

4. What number and percentage of subjects received a referral for a cardiac rehabilitation program, and what num

subjects participated in a cardiac rehabilitation program? 

Group A 

n (%) 

Group B 

n (%) 

Group C 

n (%) 

Group D 

n (%) 

Comparison statistic 

( + 95% CI ) 

Risk Ratio Odds RatioHazard Ratio

Type of Program: ____________________________ ____________________________ Referral Participation 

Not applicable (N/A) 
62

5. Among studies that evaluated depression as a potential barrier to cardiac treatment, what were the 

other factors influencing cardiac treatment for patients with acute MI? 

Statistically

Significant 

Not 

Statistically 

Significant 

Reported as 

Qualitatively 

Important 

Reported as 

Qualitatively 

Not 

Important 

Not 

Assessed

Lack of referral □ □ □ □ □

Medical illness □ □ □ □ □

Other psychiatric illness □ □ □ □ □

Don’t need treatment / exercise 

alone □ □ □ □ □

Too busy □ □ □ □ □

Transportation □ □ □ □ □

Cost of treatment □ □ □ □ □

Low socioeconomic status □ □ □ □ □

Unemployment □ □ □ □ □

Lack of insurance / inadequate 

insurance □ □ □ □ □

Lack of availability of tertiary 

medical centers □ □ □ □ □

Communication barrier □ □ □ □ □

Lack of effective aftercare □ □ □ □ □

Other:_______________________ □ □ □ □ □

Other:_______________________ □ □ □ □ □

Other:_______________________ □ □ □ □ □

Not applicable (N/A) 
 

63

6. Was depression found to be a significant barrier to cardiac treatment (p < 0.05)? 

Yes 

No 

Not applicable (N/A) 

7. Subgroup Analyses

Subgroup 

Characteristics 

Main Outcome(s) 

Reported 

Results in 

Subgroups p-value 

 

Comments not captured by previous questions: 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ 
Appendix F. Grading the Strength of Evidence 
1

Evidence Grade Table 1. Grading of the Quality of Evidence on the Prevalence of Depression After Myocardial Infarction (Ques

During Initial Hospitalization One or More Mon

Quantity of Evidence:

Number of studies 23 

Total number of patients studied 14,017 Quality and Consistency of Evidence:

Were study designs appropriate for determining prevalence? (yes = high quality; no = low quality) 

No 

Did the studies have serious (-1) or very serious (-2) limitations in quality? (Enter 0 if none) 0 Did the studies have important inconsistency? (-1) -1 Was there some (-1) or major (-2) uncertainty about the directness or extent to which the people, measures and outcomes are similar to those of interest? 

0 

Were data imprecise or sparse? (-1) 0 Did the studies have high probability of reporting bias? (-1) 0 Did the studies show strong evidence of association between depression and myocardial infarction? (“strong” if significant relative risk or odds ratio > 2 based on consistent evidence from 2 or more studies with no plausible confounders (+1); “very strong” if significant relative risk or odds ratio > 5 based on direct evidence with no major threats to validity (+2)) 

Not Applicable Not 

Did the studies have unmeasured plausible confounders that most likely reduced the magnitude of the observed association? (+1) Not Applicable Not What was median (and range) of estimated prevalence? 

~26% 

Range 2- 47% 

Rang

Overall quality grade (high, medium, low, very low) Medium M

*NOTE – Numbers based on data at 1-3 months (N=17) Evidence grading scheme as described in: Grade Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 149
2

Evidence Grade Table 2. Grading of the Quality of Evidence on the Independent Association of Measures of Depression with C

Patients with Acute Myocardial Infarction (Question 3)

Survival Cardiac Events 

Quantity of Evidence:

Number of studies 14 6 

Total number of patients studied 92958 116,697 Quality and Consistency of Evidence:

Were study designs appropriate for determining the association between depression and outcomes? (yes = high quality; no = low quality) 

Yes Yes 

Did the studies have serious (-1) or very serious (-2) limitations in quality? (Enter 0 if none) 0 0 Did the studies have important inconsistency? (-1) -1 0 Was there some (-1) or major (-2) uncertainty about the directness or extent to which the people, measures and outcomes are similar to those of interest? 

0 -1 

Were data imprecise or sparse? (-1) 0 0 Did the studies have high probability of reporting bias? (-1) 0 0 Did the studies show strong evidence of association between depression and outcomes? (“strong” if significant relative risk or odds ratio > 2 based on consistent evidence from 2 or more studies with no plausible confounders (+1); “very strong” if significant relative risk or odds ratio > 5 based on direct evidence with no major threats to validity (+2)) 

+1 0 

Did the studies have evidence of a dose-response gradient? (+1) +1 0 Did the studies have unmeasured plausible confounders that most likely reduced the magnitude of the observed association? (+1) 

0 0 
Evidence Grade Table 2. Grading of the Quality of Evidence on the Independent Association of Measures of Depression with C

Patients with Acute Myocardial Infarction (Question 3) (Continued)

3

Survival Cardiac Events 

What was median (and range) of estimated association? Not Applicable Not Applicable Overall quality grade (high, medium, low, very low) High Medium Importance of outcome (critical, important, or not important) Critical Important 

Evidence grading scheme as described in: Grade Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 149
4 

Evidence Grade Table 3. Grading of the Quality of Evidence on the Independent Association of Measures of Depression with S

Disease Severity in Patients with Acute Myocardial Infarction (Question 3a) 

Heart Rate 

Variability

BetaThromboglobulin Platelet Factor 4 

Soluble 

Intercellular 

Adhesion 

Molecule-1 

Interleukin-6 

Quantity of Evidence:

Number of studies 1 1 1 1 1 

Total number of patients studied 804 24 24 481 481 Quality and Consistency of Evidence: 

Were study designs appropriate for determining the association between depression and the surrogate measures? (yes = high quality; no = low quality) 

Yes Yes Yes Yes Yes 

Did the studies have serious (-1) or very serious (-2) limitations in quality? (Enter 0 if none) 

0 -1 -1 -1 -1 

Did the studies have important inconsistency? (-1) 0 0 0 0 0 Was there some (-1) or major (-2) uncertainty about the directness or extent to which the people, measures and outcomes are similar to those of interest? 

0 0 0 0 0 

Were data imprecise or sparse? (-1) 0 -1 -1 0 0 Did the studies have high probability of reporting bias? (-1) 

0 0 0 0 0 
Evidence Grade Table 3. Grading of the Quality of Evidence on the Independent Association of Measures of Depression with S

Disease Severity in Patients with Acute Myocardial Infarction (Question 3a) (Continued) 

5

Heart Rate 

Variability

BetaThromboglobulin Platelet Factor 4 

Soluble 

Intercellular 

Adhesion 

Molecule-1 

Interleukin-6 

Did the studies show strong evidence of association between depression and the surrogate measures? (“strong” if significant relative risk or odds ratio > 2 based on consistent evidence from 2 or more studies with no plausible confounders (+1); “very strong” if significant relative risk or odds ratio > 5 based on direct evidence with no major threats to validity (+2)) 

0 0 0 0 0 

Did the studies have evidence of a dose-response gradient? (+1) 

0 0 0 0 0 

Did the studies have unmeasured plausible confounders that most likely reduced the magnitude of the observed association? (+1) 

0 0 0 0 0 

What was median (and range) of estimated association? 

Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 

Overall quality grade (high, medium, low, very low) High Low Low High High Importance of outcome (critical, important, or not important) 

Important Important Important Important Important 
Evidence Grade Table 3. Grading of the Quality of Evidence on the Independent Association of Measures of Depression with S

Disease Severity in Patients with Acute Myocardial Infarction (Question 3a) (Continued) 

6

Evidence grading scheme as described in: Grade Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 149
7 

Evidence Grade Table 4. Grading of the Quality of Evidence on the Efficacy of Depression Treatment for Myocardial Infarction Depression (Question 4)

Medications Psychosoc

Quantity of Evidence:

Number of studies 5 

Total number of patients studied Active group: 490 Control group: 408 Active 

Contro

Quality and Consistency of Evidence:

Were study designs randomized trials (high quality), nonrandomized controlled trials (medium quality), or observational studies (low quality)? 

5 randomized controlled trials 

6 randomize

1 prosp

Did the studies have serious (-1) or very serious (-2) limitations in quality? (Enter 0 if none) 0 Did the studies have important inconsistency? (-1) No Was there some (-1) or major (-2) uncertainty about the directness or extent to which the people, interventions and outcomes are similar to those of interest? 

No 

Were data imprecise or sparse? (-1) -1 Did the studies have high probability of reporting bias? (-1) No Did the studies show strong evidence of association between treatment and outcomes? (“strong” if significant relative risk or odds ratio > 2 based on consistent evidence from 2 or more studies with no plausible confounders (+1); “very strong” if significant relative risk or odds ratio > 5 based on direct evidence with no major threats to validity (+2)) 

No 

Did the studies have evidence of a dose-response gradient? (+1) No Did the studies have unmeasured plausible confounders that most likely reduced the magnitude of the observed association? (+1) No 
Evidence Grade Table 4. Grading of the Quality of Evidence on the Efficacy of Depression Treatment for Myocardial Infarction 

Depression (Question 4) (Continued)

8

Medications Psychosoc

What was median (and range) of estimated treatment effect? 

Depression: unable to assess due to the 

different methods of assessing depression 

used, the different follow-up times and the 

different antidepressants evaluated. 

Total mortality: unable to assess, as only 

one study reported results for total mortality 

(Relative Risk for death was 0.39 with 95% 

confidence intervals between 0.08 and 1.39 

comparing sertraline to placebo). 

Depression: diffic

different methods 

used and the di

Total Mortality (ran

m

Interventio

Control 

Overall quality grade (high, medium, low, very low) Medium Importance of outcome (critical, important, or not important) Important Im

Evidence grading scheme as described in: Grade Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 149
9 

Evidence Grade Table 5. Grading of the Quality of Evidence on the Performance Characteristics of Methods Used to Screen foMyocardial Infarction (Question 5)

BDI HADS SCL-90 Dep. Zung 

Quantity of Evidence:

Number of studies 3 3 2 1 

Total number of patients studied 2,739 735 349 143 Quality and Consistency of Evidence:

Were study designs appropriate for determining the performance characteristics of the screening methods? (yes = high quality; no = low quality) 

Yes Yes Yes No 

Did the studies have serious (-1) or very serious (-2) limitations in quality? (Enter 0 if none) 

-1 0 -1 -2 

Did the studies have important inconsistency? (-1) 0 0 0 0 Was there some (-1) or major (-2) uncertainty about the directness or extent to which the people, measures and outcomes are similar to those of interest? 

0 0 0 0 

Were data imprecise or sparse? (-1) -1 0 -1 -1 Did the studies have high probability of reporting bias? (-1) 0 0 0 

0 

Did the studies have unmeasured plausible confounders that most likely reduced the magnitude of the estimated validity and reliability? (+1) 

+1 0 0 0 
Evidence Grade Table 5. Grading of the Quality of Evidence on the Performance Characteristics of Methods Used to Screen fo

Myocardial Infarction (Question 5) (Continued)

10

BDI HADS SCL-90 Dep. Zung 

What was median (and range) of estimated sensitivity, specificity and reliability? 

Sensitivity: 

MDD* .82 (1 study) 

Specificity: 

 MDD .79 (1 study) 

Reliability: 

No data 

Sensitivity: 

MDD .90 (1 study) 

Specificity: 

 MDD .84 (1 study) 

Reliability: 

.88 (.82, .90) 

Sensitivity: 

MDD .96 (1 study) 

Specificity: 

 MDD .74 (1 study) 

Reliability: 

No Data 

Sensitivit

No data 

Specificit

 No data 

Reliabilit

No data 

Overall quality grade (high, medium, low, very low) Low Medium Low Very Low 

* Major depressive disorder Evidence grading scheme as described in: Grade Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 149
11 

Evidence Grade Table 6. Grading of the Quality of Evidence on Whether Use of Recommended Treatment for Patients with AcuDiffers For Those With and Without Depression (Question 6)

Cardiac Procedures Lifestyle Interventions Medications C

Quantity of Evidence:

Number of studies 3 1 4 

Total number of patients studied 109359 108 1244 Quality and Consistency of Evidence:

Were study designs appropriate for determining the association between depression and use of treatment? (yes = high quality; no = low quality) 

Yes Yes Yes 

Did the studies have serious (-1) or very serious (-2) limitations in quality? (Enter 0 if none) 

0 0 0 

Did the studies have important inconsistency? (-1) -1 0 -1 Was there some (-1) or major (-2) uncertainty about the directness or extent to which the people, measures and outcomes are similar to those of interest? 

-1 -1 -1 

Were data imprecise or sparse? (-1) 0 -1 0 Did the studies have high probability of reporting bias? (-1) 0 0 0 Did the studies show strong evidence of association between depression and use of treatment? (“strong” if significant relative risk or odds ratio > 2 based on consistent evidence from 2 or more studies with no plausible confounders (+1); “very strong” if significant relative risk or odds ratio > 5 based on direct evidence with no major threats to validity (+2)) 

0 0 0 
Evidence Grade Table 6. Grading of the Quality of Evidence on Whether Use of Recommended Treatment for Patients with Acu

Differs For Those With and Without Depression (Question 6) (Continued)

12

Cardiac Procedures Lifestyle Interventions Medications C

Did the studies have evidence of a dose-response gradient? (+1) 0 0 0 Did the studies have unmeasured plausible confounders that most likely reduced the magnitude of the observed association? (+1) 

0 0 0 

What was median (and range) of estimated association? Not Applicable Not Applicable Not Applicable Overall quality grade (high, medium, low, very low) Low Very low Low 

Evidence grading scheme as described in: Grade Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 149
1

Evidence Table 1.1. Characteristics of Studies on Prevalence of Depression During Hospitalization For Acute Myocardial Infarc

Study

Author,

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period St

Taylor, 1986

RCT a Only MI b

patients

Ac > 70; Fd; medically unable to

undergo treadmill exercise testing 3wke post-MI

Multicenter, 2 USA NR f To document t

uncomplicated week treadmill determine the training on psycompared to a no exercise trathe relationship factors and mepatients.

Bennett, 1988

Pro cohort g Only MI

patients

A > 75; anticipating cardiac surgery;previous MI; presence of othermajor physical conditions

Single center Europe NR To investigate 

in coronary risk months followin

Davis, 1988

Pro cohort Only MI

patients

A > 65; psychiatric Rx h Single center Canada NR To identify opti

depression in m

Carney, 1990

Casecontrol

Only MIpatients

A $ 70; serious co-morbidconditions; unable to completeinterview and psychological testing;previous MI; h/oi angioplasty/CABGjsurgery; CHFk; valvular heart

disease; "severe" DMl; chronicmedical illness; severe mentalimpairment

Single center USA NR To determine w

degressive disinsomnia two w

Silverstone,1990

Pro cohort Only MI

patients

NR NR Europe NR To investigate 

depressive symmedical illness importance of sparticular.
Evidence Table 1.1. Characteristics of Studies on Prevalence of Depression During Hospitalization For Acute Myocardial Infarc

(Question 1) (continued)

Study

Author,

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period St

2

Gilutz,1991

Pro cohort Only MI

patients

A < 34 or > 70; previous MI; DM;HTN m; any other chronic disease

Multicenter, 2 Europe;

Middle East

Europe: 1979 - 1980;Middle East:1983 - 1986

To evaluate caand whether threhabilitation o

Schleifer, 1991

Pro cohort Only MI

patients

Terminal noncardiac conditions;cognitively impaired; too ill toparticipate; non-English speaking;undergoing CABG; died prior to day8 post-MI

Multicenter, 2 USA Aug 1983 -

May 1985

To evaluate the cardioactive mfollow-up contrdepression.

Forrester, 1992

Crosssectional Only MI patients A $ 80; too ill to be interviewed; delirium/dementia; h/o coarse brain

injury; scheduled for CABG;angioplasty; residence outside ofmetro Baltimore

Multicenter, 3 USA NR 1. To find prev

among post-M2. To investiga(eg cardiac hisfactors, cognitidepression.

Legault, 1992

Pro cohort Only MI

patients

A < 18 or > 70; language/literacyproblems; medical status precludingpsychiatric assessment; previousadmission to CCU n 

Single center Canada Dec 1986 - 

Jan 1988

To assess prevmorbidity durinfollow up. To ebetween psychcardiac diagno

Kaufmann, 1999

Pro cohort Only MI

patients

Another medical condition likely toinfluence 1-yr o survival; insufficient

English; cognitive problemsinterfering with interview; clinicallyunable to complete interview

Single center USA Jan 1995 - 

Dec 1995

To examine the major depressimortality rate a discharge from myocardial infa
Evidence Table 1.1. Characteristics of Studies on Prevalence of Depression During Hospitalization For Acute Myocardial Infarc

(Question 1) (continued)

Study

Author,

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period St

3

O'Rourke, 1999

Pro cohort Only MI

patients

A $ 76; non-English speaking;recurrent MI; emergencyangioplasty; emergency cardiacbypass

Multicenter, 2 Europe NR To examine pr

psychosocial vbeliefs, locus operception, socdepression) on 6 months follow

Mayou, 2000

Pro cohort Only MI

patients

A $ 80; no other criteria specified;event occurred within 28 d p of

preceding event

Multicenter Europe Nov 1994 -

Nov 1995

To investigate emotional distrmyocardial infaphysical, psychoutcome and r

Brink,2002

Pro cohort Only MI

patients

Serious co-morbid conditions;dementia; non-Swedish; recurrentMI

Single center Europe Oct 1998 - 

Sep 1999

To explore heafirst time myocfive months aft

Lane,2002

Pro cohort Only MI

patients

MI resulted from CABG/angioplasty;co-morbidity likely to cause deathwithin 12 mos; non-Englishspeaking; cognitively impaired;medically unable to completeassessment within 15 d post-MI

Multicenter, 2 Europe Jun 1997 - 

Aug 1998

To examine the symptoms of d3 year survival 

Lesperance,2002

Pro cohort Only MI

patients

Other life-threatening conditions;non-French/non-English speaking;cognitively impaired/physicallyunstable to complete interview; livedtoo far from hospital for f/u q

Multicenter Canada Jan 1991 - 

Nov 1994

To evaluate a ddepression symcardiac mortaliimpact of depresignificant aftecardiac diseasimpact of depreduring hospitalevaluate the prchanges in depthe first post M
Evidence Table 1.1. Characteristics of Studies on Prevalence of Depression During Hospitalization For Acute Myocardial Infarc

(Question 1) (continued)

Study

Author,

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period St

4

Luutonen, 2002

Pro cohort Only MI

patients

A > 75 Multicenter, 2 Europe Mar 1998 -

Aug 1998

To investigate depressive symreported psych

Watkins, 2002

Crosssectional Only MI patients Not in sinus rhythm; cross spectral analysis of SBPr power and RR s

interval; showed no patients ofcoherence of 0.5 or greater; unableto complete interview due to severephysical disability or altered mentalstatus

Single center USA NR To evaluate wh

associated with sensitivity in pa

Barefoot,2003

Pro cohort Only MI

patients

Index ACS u developed after

CABG/PTCA v; cognitively impaired;

likely to die in 1 yr; limited physicalcapacity; participation in conflictingresearch protocol

Multicenter, 8 USA Jun 1996 - 

Aug 1996

To assess the support and depatients at the 

2 weeks afterw

Berkman,2003

RCT Only MI

patients

Index ACS after surgery; h/o ofactive substance abuse; h/opsychosis; h/o suicide risk; severedementia; non cardiac conditionlikely to be fatal within 1y; too ill/refused to participate; participatingin other research protocol;inaccessible for intervention/f/u;receiving psychotherapy; before Apr1998 patients on antidepressantafter Apr 1998 patients onantidepressant but who remaineddepressed were included

Multicenter, 8 USA, Oct 1996 - 

Oct 1999

To determine wrecurrent infarctreatment of de

cognitive behasupplemented 

indicated in padays after MI.

Lauzon, 2003

Pro cohort Only MI

patients

Non-English/non-French speaking;physically incapable of respondingto a questionaire; unable to giveinformed consent

Multicenter, 10 Canada Dec 1996 -

Nov 1998

To measure thprognostic impsymptoms afteinfarction.
Evidence Table 1.1. Characteristics of Studies on Prevalence of Depression During Hospitalization For Acute Myocardial Infarc

(Question 1) (continued)

Study

Author,

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period St

5

Martin, 2003

Pro cohort Only MI

patients

Medically unsuitable for cardiacrehab y; died before/shortly after

starting rehab program; refusedcardiac rehab

Multicenter, 3 Europe NR To determine t

HADS z in a cli

MI and to estabcharacteristics reliability of the group.

Rafanelli, 2003

Pro cohort Only MI

patients

Not referred to cardiac rehabprogram

Single center Europe NR To study the p

distress in the rehabilitation.

Steeds,2004

Pro cohort Only MI

patients

A > 75; incapable of providinginformed written consent; other ACSexcept MI

Single center Europe 1999 - 2000 To determine t

elevated BDI arelation betweeprognosis in U

MI.

a Randomized controlled trialb Myocardial infarctionc Age d Femalee Weekf Not reportedg Prospective cohort study h Treatmenti History ofj Coronary artery bypass graft k Congestive heart failure l Diabetes mellitusm Hypertensionn Coronary care unito Yearp Dayq Follow-up
Evidence Table 1.1. Characteristics of Studies on Prevalence of Depression During Hospitalization For Acute Myocardial Infarc

(Question 1) (continued)

6

r Systolic blood pressures Respiratory ratet Acute myocardial infarctionu Acute coronary syndromev Percutaneous transluminal coronary angioplasty w Low perceived social supportx Selective serotonin reuptake inhibitory Rehabilitationz Hospital Anxiety and Depression Scaleaa Beck Depression Inventory ab United Kingdom
7

Evidence Table 1.2. Characteristics of Patients in the Studies on Prevalence of Depression During Hospitalization for Acute My(Question 1)

Study

Author,

Year

No. of 

Subjects

 Mean 

Age 

 Male

(%)

White

(%)

 Married

(%)

HTN a

(%)

DM b

(%)

 Smoking

(%)

Lipid c

(%)

Taylor, 1986

173 52 100 NR 86 NR d NR NR NR 

Bennett, 1998

37 62 73 NR NR NR NR NR NR 

Davis, 1988

52 51 90 NR 48 NR NR NR NR 

Carney, 1990

70 53 76 NR NR 43 16 48 NR 

Silverstone,1990

100 NR NR NR NR NR NR NR NR 

Gilutz;1991

Europe:98; MiddleEast: 87

NR e NR NR Europe:

85;MiddleEast: 96

NR NR Europe:

32; MiddleEast: 35

NR 

Schleifer, 1991

335 63 64 NR NR NR NR NR NR 

Forrester, 1992

129 59 74 62 55 NR NR NR NR 

Legault, 1992

52 55 78 NR NR NR NR NR NR 

Kaufmann, 1999

331 NR f 66 NR 70 49 27 28 38 

O'Rourke, 1999

70 58 74 NR 73 NR NR NR NR 
Evidence Table 1.2. Characteristics of Patients in the Studies on Prevalence of Depression During Hospitalization for Acute My

(Question 1) (continued)

Study

Author,

Year

No. of 

Subjects

 Mean 

Age 

 Male

(%)

White

(%)

 Married

(%)

HTN a

(%)

DM b

(%)

 Smoking

(%)

Lipid c

(%)

8

Mayou, 2000

344 63 73 NR NR NR 34 58 NR 

Brink,2002

114 68 68 NR 72 35 15 31 NR 

Lane, 2002

288 63 75 93 70 39 13 43 72 

Lesperance,2002

896 59 68 NR 72 35 16 47 NR 

Luutonen, 2002

85 61 77 NR NR NR NR NR NR 

Watkins, 2002

204 59 58 65 NR NR NonDep h

31, Dep i 49

NonDep53, Dep 81

NR 

Barefoot, 2003

196 61 63 67 NR NR NR NR NR 

Berkman,2003,

9279 j 63 62 26 52 60 33 64 57 

Lauzon, 2003

550 60 80 96 70 35 16 40 38 

Martin, 2003

335 67 67 NR NR NR NR NR NR 

Rafanelli, 2003

61 61 85 NR NR NR NR NR NR 

Steeds,2004

131 NR NR NR NR NR NR NR NR 

a Hypertension b Diabetesc Hyperlipidemia
Evidence Table 1.2. Characteristics of Patients in the Studies on Prevalence of Depression During Hospitalization for Acute My

(Question 1) (continued)

9

d Not reportede In the European population 21% were less than 45 years old, 54% were 46 - 55 years old and 25% were 56 - 60 years old. In the Middle Eastern pop

45 years old, 46% were 46 - 55 years old and 24% were 56 - 60 years old f 45% were less than 65 years old and 56% were greater than 65 years old

g Ejection Fraction h Non depressed i Depressed j Medically eligible and screened for depression
10

Evidence Table 1.3. Assessment of Study Quality in Studies on the Prevalence of Depression During Hospitalization for Acute (Question 1)

Study Author,

Year Representativeness Description Therapy & Management Description Assessment Protocol Outcomes & Follow-Up Statistical Ana

Taylor,1986 50% 0% 100% 100% 50% Bennett, 1988 10% 0% 100% 50% 0% Davis,1988 30% 0% 100% 67% 42% Carney,1990 45% 0% 88% N/A 33% Silverstone,1990 10% 0% 100% 75% 33% Gilutz,1991 45% 0% 75% N/A 0% Schleifer,1991 80% 0% 100% 67% 29% Forrester,1992 70% 0% 88% N/A 33% Legault,1992 80% 0% 100% 50% 75% Kaufmann, 1999 90% 0% 100% 75% 38% O'Rourke, 1999 50% 0% 100% 50% 19% Mayou, 2000 65% 0% 100% 67% 19% Brink,2002 65% 0% 100% 63% 50% Lane,2002 50% N/A 100% 0% 50% Lesperance,2002 85% 0% 100% 79% 50% Luutonen, 2002 80% N/A N/A 83% 50% Watkins, 2002 30% 0% 50% N/A 42% 
Evidence Table 1.3. Assessment of Study Quality in Studies on the Prevalence of Depression During Hospitalization for Acute 

(Question 1) (continued)

Study Author,

Year Representativeness Description Therapy & Management Description Assessment Protocol Outcomes & Follow-Up Statistical Ana

11

Barefoot, 2003 45% 0% 100% 50% 25% Berkman,2003 90% 0% 100% 92% 94% Lauzon, 2003 65% 0% 100% 71% 25% Martin, 2003 60% 0% 100% 50% 33% Rafanelli, 2003 50% 0% 100% 0% 50% Steeds,2004 30% 0% 100% 50% 50% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the 

(2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether thseries or randomly selected sample (2 patients).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other 

Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Outcomes and Follow-up: Percentage score was based on a total maximum score of 6 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), and whether the same tools for dused for baseline and follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether adjustment was made for confounding (2 points), and whether confidence int

patients).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency
12

Evidence Table 1.4. Results of Prevalence of Depression During Hospitalization for Acute Myocardial Infarction (Question 1)

Study

Author,

Year

 Diagnosis of MI a Diagnosis of Depression Depression Assessment Method b Criteria Prevalence (%) Depression Severity Measure c 

Taylor, 1986

NR d Modified baseline

assessment

HAMD e HAMD $ 10 3 wk f post-MI 13 Dichotomous

variable

NA g

Bennett, 1988

NR Standard baseline

assessment

HADS h HADS $ 11 In hospital i 13 Dichotomous

variable

NA

Davis, 1988

NR Standard baseline

assessment 

BDI j BDI $ 13 In hospital 10 Dichotomous

variable

NA

Carney, 1990

Chest pain compatible withischemia, ECG k, 

Creatine kinase (MB l

fraction)

Modified baselineassessment 

DIS m DSM-III n criteria

for MajorDepressiveEpisode

In hospital 23 Dichotomous

variable

DIS trainseniorevieusing 100% both 

Silverstone,1990

NR Standard baseline

assessment

MontgomeryAsberg M-A o $ 21 In hospital 19 Dichotomous variable Stud

medhospsepa

Gilutz,1991

NR Standard baseline

assessment 

Holland SgroiAnxietyDepressionScale

Mild, Moderate/SevereDepression

In hospital 31, 10-15 d p post-MI 

35

Categoricalvariable

Specfor ddepr

Schleifer, 1991

Compatible history, cardiacenzyme elevation, Qwaves, or 24 hrs q ST-T

wave abnormalities

Modified baselineassessment

NurseInterview 

RDC r criteria for

major, minordepression

8-10 d i

Maj dep 17;Min dep 30

Categoricalvariable

MajoasseAND MinoasseAND men
Evidence Table 1.4. Results of Prevalence of Depression During Hospitalization for Acute Myocardial Imfarction (Question 1) (c

Study

Author,

Year

 Diagnosis of MI a Diagnosis of Depression Depression Assessment Method b Criteria Prevalence (%) Depression Severity Measure c 

13

Forrester, 1992

Creatine kinase Modified baseline

assessment: 

PSE s DSM - III

criterion forMajorDepression

In hospital:within 10 d post-MI19

Dichotomousvariable

NA

Legault,1992

"Conventional clinicalcriteria" confirmed by ECGand elevation of MB-Ck t

Standard baselineassessment 

BDI BDI $ 16 In hospital i 18 Dichotomous

variable

Authdemangipainfor M

Kaufmann, 1999

In hospital assessment:chest pain, ECG, Ck

Standard baselineassessment 

DIS DIS score $ 5 In hospital:

3-15 d post-MI 27

Dichotomousvariable

NA

O'Rourke, 1999

WHO u criteria Standard baseline

assessment

HADS HADS $ 8 3 - 5 d post-MI 17 Dichotomous

variable

NA

Mayou, 2000

In hospital assessment:ECG, other cardiacenzymes

Standard baselineassessment 

HADS HADS $ 8,

HADS $ 11

In hospital 18, within 3 d post-MI 8

Categoricalvariable 

NA

Brink,2002

NR Standard baseline

assessment

HADS HADS $ 8,

HADS $ 11

In hospital 11, within 1 wk post-MI8

Categoricalvariable

NA

Lane,2002

In hospital assessment:chest pain, ECG, Ck

Standardbaselineassessment

BDI BDI $ 10 In hospital: 

within 15 d post-MI i

31

Dichotomousvariable

NA

Lesperance,2002

Symptom enzyme andECG criteria

Standard baselineassessment 

BDI BDI $ 10 In hospital i 32 Dichotomous

variable

NA

Luutonen, 2002

In hospital assessment:chest pain, ECG, Ck

Standard baselineassessment

BDI BDI $ 10 In hospital i 21 Dichotomous

variable

NA
Evidence Table 1.4. Results of Prevalence of Depression During Hospitalization for Acute Myocardial Imfarction (Question 1) (c

Study

Author,

Year

 Diagnosis of MI a Diagnosis of Depression Depression Assessment Method b Criteria Prevalence (%) Depression Severity Measure c 

14

Watkins, 2002

In hospital assessment:cardiac enzymes, ECG

Modified baselineassessment, 

DIS DSM - IV criteria

for MajorDepression

In hospital: 3 - 9 d post-MI 18

Dichotomousvariable

NA

Barefoot, 2003

Characteristic enzymes, MIcompatible symptoms

Standard baselineassessment

HAMD, BDI

"Signs ofDepression",BDI $ 10

Within 2 wk post-MI i

28, 37

Categorical,dichotomousvariable

NA

Berkman,2003

Characteristic enzymes, MIcompatible symptoms

Modified baselineassessment 

StructuredInterview forDSM-IV

DSM - IV criteriafor MajorDepression

2-4 wk post-MI 27 Dichotomous

variable 

The 

treatmon

Lauzon, 2003

In hospital assessment:ECG

Standard baselineassessment

BDI BDI $ 10 Within 2 - 3 d of

hospitalization i 35

Dichotomousvariable

NA

Martin, 2003

In hospital assessment:ECG, Troponin, ST waveelevation, patient history

Standard baselineassessment

HADS HADS $ 8,

HADS $ 11

In hospital 15,within 1 wk post-MI i

6

Categoricalvariable

NA

Rafanelli, 2003

In hospital assessment:chest pain, shortness ofbreath, ECG, Ck

Modified baselineassessment 

SCID x DSM-IV criterion

for Major, MinorDepression

Within 1 mo y postMI 2, 10 Dichotomous variable NA

Steeds,2004

NR Standard baseline

assessment 

BDI-II BDI-II $ 12 In hospital 47 Dichotomous

variable

NA

a Myocardial infarctionb Method of assessing of depression used for analysisc How severity of depression was measuredd Not reportede Hamilton Rating Scale for Depressionf Weekg Not applicableh Hospital Anxiety and Depression Scale
Evidence Table 1.4. Results of Prevalence of Depression During Hospitalization for Acute Myocardial Imfarction (Question 1) (c

15

i Also assessed at later point. See Table 2 j Beck Depression Inventory k Electrocardiogram l Muscle brainm Diagnostic Interview Schedulen Diagnostic & Statistical Manual of Mental Disorderso Montgomery-Asbergp Dayq Hoursr Research Diagnostic Criterias Psychological Stress Evaluatort Creatine kinaseu World Health Organizationv Randomized controlled trialw Cognitive behavioral therapyx Structured Clinical Interview for Diagnostic & Statistical Manual of Mental Disorders - IV y Month
16

Evidence Table 2.1. Characteristics of Studies on Prevalence of Depression After Hospitalization For Acute Myocardial Infarctio

Study

Author,

Year

Study Design Exclusion Criteria Number of Study Sites Study Site Recruitment Period Stud

Trelawny, 1987

Sample of suspectedMI a patients 28 of 32

confirmed

A b > 65; F c; unmarried NR d Europe NR To describe respo

admission for possrelationships of 4 aexercise, leisure, a

Davis, 1988

Retro cohort e A > 65; receiving psychiatric Rx f NR Canada NR To identify optima

depression in med

Follick,1988

RCT g of

transtelephonic system

A > 70 Multicenter, 2 USA NR To examine the ef

management systand social functionpatients.

Schleifer, 1991

Retro cohort Terminal noncardiac illness;

undergoing CABG h; died prior to

day 8 post-MI; discharged;transferred to another facility; tooill to participate in interview;cognitively impaired; non-Englishspeaking

Multicenter, 2 USA Aug 1983 -

May 1985

To evaluate the comedications to deprecovering from an 

Legault,1992

Pro cohort A < 18 or > 70; literacy problems;

medical status precludingpsychiatric assessment

Single center Canada Dec 1986 -

Jan 1988

To assess prevalemorbidity during hup. To evaluate assocmorbidity with cardmorbidity.

Garcia, 1994

Cross-sectional A > 65; F; illiteracy; concomitant

diseases; previous MI

Single center Europe NR To determine influ

personality variablin early phase of Mpsychopathology d
Evidence Table 2.1. Characteristics of Studies on Prevalence of Depression After Hospitalization For Acute Myocardial Infarctio

(continued)

Study

Author,

Year

Study Design Exclusion Criteria Number of Study Sites Study Site Recruitment Period Stud

17

Travella,1994

Pro cohort Anticipating cardiac surgery;

serious comorbidity; cognitivelyimpaired; treated depression;brain injury

Multicenter, 3 USA NR To examine the co

correlates of depreafter MI.

Clarke, 1996

Pro cohort A > 70; F; CABG pending;

previous MI; unmarried/not livingin stable relationship

Multicenter, 4 Canada NR To test the hypoth

protectiveness of pspouse has a neg

Lesperance, 1996

Pro cohort MI after surgery; nonEnglish/non-French speaking;

comorbidity likely to influencesurvival; not medically stable 

Single center Canada Aug 1991 -

July 1992

To study how comprior to MI; are thepsychological corrdepression and dopatient's medical aevolution during th

 Bennett, 1998

Pro cohort A > 75; anticipating cardiac

surgery; non-atherosclerotic MI;previous MI; other physicalconditions

Single center Europe NR To investigate the 

coronary risk behafollowing first MI.

Lehto, 2000

Retro cohort A > 70; DEPS i score not

available; outside catchment area

Single center Europe NR To study the preva

least 6 months aftdisease events anbetween depressio

Strik,2001

Pro cohort Recurrent MI; unable to fill out

questionnaires

NR Europe May 1997 -

Sep 1999

To assess sensitivself-report questiorating scale as scrdepression followi
Evidence Table 2.1. Characteristics of Studies on Prevalence of Depression After Hospitalization For Acute Myocardial Infarctio

(continued)

Study

Author,

Year

Study Design Exclusion Criteria Number of Study Sites Study Site Recruitment Period Stud

18

Lane,2002

Pro cohort Serious comorbidity; cognitively

impaired; non-English speaking;MI from CABG/angiography;medically unstable within 15 d j

post-MI; other conditions that would lead to death within 12 mok

Multicenter, 2 Europe Jan 1997 -

Aug 1998

To assess prevaleanxiety in post-MI hospitalization and association of posanxiety with mortamonth follow-up.

Luutonen, 2002

Pro cohort NR NR Europe Mar 1998 -

Aug 1998

To investigate the symptoms and seltreatment after MI

Shiotani,2002

Pro cohort Died in hospital; unable to

verbally communicate; majorpsychiatric disease; refusedregistry

Multicenter, 25 Asia Apr 1998 -

Apr 2000

To investigate the symptoms on progwith acute MI.

Strik,2002

Retro cohort Data not available for serum lipid

at 1 mo; AMI l diagnosis not

explicit

NR Europe May 1997 -

Sep 1999

To study relation olipoproteins to dep

Aben,2003

Pro cohort Psychotic symptoms; cognitive

impairment; depressive episodeweek before MI; major psychiatricdisorder; intracerebral disease

Single center Europe NR To compare the cu

of depression aftetaking into considesex, and the level 

Barefoot,2003

NR Index ACS

m after surgery/PTCAn

;

cognitively impaired; h/o postprocedure MI; likely to die in 1yro; limited physical capacity;

participating in conflictingresearch protocol

Multicenter, 8 USA, Jun 1996 -

Aug 1996

To assess the relasupport and depreat the time of hospafterwards.
Evidence Table 2.1. Characteristics of Studies on Prevalence of Depression After Hospitalization For Acute Myocardial Infarctio

(continued)

Study

Author,

Year

Study Design Exclusion Criteria Number of Study Sites Study Site Recruitment Period Stud

19

Lauzon,2003

Pro cohort Transfer from other hospital;

incapable of responding toquestionnaire; unable to giveconsent

NR Canada Dec 1996 -

Nov 1998

To measure the pimpact of depressMI.

Martin, 2003

Cross-sectional Medically unsuitable for cardiac

rehab; died before/shortly afterstarting program

Multicenter, 3 Europe NR To determine the f

HADS p in a popu

establish change-sand psychometric this patient group.

Strik,2003

Pro cohort F; h/o q psychosis; cognitively

impaired; non-Dutch speaking;comorbid life-threateningcondition; h/o MI

Single center Europe, May 1994 -

Sep 1999

To examine whethpredictor of incomthan anxiety, and temotional distress cardiac events but and health care co

Lesperance, 2004

Pro cohort Life expectancy < 2 yr due to

medical illness; cognitivelyimpaired; non-English/nonFrench speaking; ACS due tomedical illness

Multicenter, 2 Canada Aug 1999 -

Aug 2001

To determine wheassociated with hiinflammatory markfrom ACS.

a Myocardial infarctionb Agec Femaled Not reportede Retrospective cohort studyf Treatmentg Randomized controlled trialh Coronary artery bypass graft i Depressionj Dayk Month
Evidence Table 2.1. Characteristics of Studies on Prevalence of Depression After Hospitalization For Acute Myocardial Infarctio

(continued)

20

l Acute myocardial infarctionm Acute coronary syndromen Percutaneous transluminal coronary angioplastyo Yearp Hospital Anxiety and Depression Scaleq History of
21

Evidence Table 2.2. Characteristics of Patients in the Studies on Prevalence of Depression After Hospitalization for Acute Myoc(Question 2)

Study Author,

Year

No. of 

Subjects

Mean 

Age 

 Male

(%)

White

(%)

 Married

(%)

HTN a

(%)

DM b

(%) Smoking (%) Lipid c (%) Killip Class (I-IV) (%) 

Trelawny, 1987

32 NR d 100 NR 100 NR NR 71 NR NR 

Follick,1988

238 55 72 NR NR NR NR 53 NR NR 

Davis, 1988

52 51 90 NR 48 NR NR NR NR NR 

Schleifer, 1991

335 64 64 NR NR NR NR NR NR NR 

Legault,1992

52 e 55 78 NR NR NR NR NR NR NR 

Garcia, 1994

97 f 50 100 NR 69 NR NR NR NR NR 

Travella,1994

70 g 58 74 NR NR NR NR NR NR NR 

Lesperance, 1996

222 60 78 NR NR NR NR NR NR Class I - IV:

depressed: 20, non depressed: 

Clarke, 1996

52 NR 100 NR NR NR NR NR NR NR 

Lehto,2000

101 62 69 NR NR 28 15 12 63 NR 

Luutonen, 2002

85 61 77 NR NR NR NR NR NR NR 

Shiotani,2002

1042 64 80 NR NR 48 32 66 37 Class II-IV: 12.5 

Strik,2002

140 58 76 NR NR NR NR NR NR NR 

Aben, 2003

200 60 77 NR NR NR NR NR NR NR 

Martin, 2003

335 67 67 NR NR NR NR NR NR NR 
Evidence Table 2.2. Characteristics of Patients in the Studies on Prevalence of Depression After Hospitalization for Acute Myoc

(Question 2) (continued)

Study Author,

Year

No. of 

Subjects

Mean 

Age 

 Male

(%)

White

(%)

 Married

(%)

HTN a

(%)

DM b

(%) Smoking (%) Lipid c (%) Killip Class (I-IV) (%) 

22

Barefoot, 2003

196 61 63 67 NR NR NR NR NR NR 

Strik,2003

318 52 1 NR NR 28 NR 54 20 NR 

Strik,2004

206 59 76 NR NR NR NR 13 30 NR 

Lane,2002

288 h 63 75 93 NR NR NR NR NR NR 

Bennett, 1998

37 62 73 NR NR NR NR NR NR NR 

Strik2001

206 60 76 NR NR NR NR NR NR NR 

Luutonen, 2002

85 61 77 NR NR NR NR NR NR NR 

Lauzon, 2003

550 60 80 96 70 35 16 40 38 Class II - IV: 18 

Lesperance, 2004

481 60 81 NR NR 66 NR 15 NR NR 

a Hypertension b Diabetesc Hyperlipidemia d Not reportede Patients with myocardial infarction of 92 total f 67 were assessed at 1 monthg With variable numbers at different time points h 199 available at 4 months; 188 at 12 month
23

Evidence Table 2.3. Assessment of Study Quality in Studies on Prevalence of Depression After Hospitalization for Acute Myoca(Question 2)

Study Author,

Year Representativeness Description Therapy & Management Description Assessment Protocol Outcomes & Follow-Up Statistical Analyse

Trelawny, 1987

15% 8% 38% 0% 44% 

Davis, 1988

35% 0% 100% 0% 42% 

Follick,1988

25% 50% 50% 0% 17% 

Schleifer, 1991

90% 17% 100% 17% 0% 

Legault,1992

90% 25% 100% 0% 75% 

Garcia, 1994

55% 0% 100% 0% 0% 

Travella,1994

70% 38% 88% 17% 33% 

Clarke, 1996

50% 0% 100% 0% 0% 

Lesperance,1996

60% 17% 88% 8% 25% 

Bennett, 1998

10% 0% 100% 8% 0% 

Lehto, 2000

45% 0% 88% N/A 0% 

Strik,2001

80% 0% 100% N/A 50% 

Lane,2002

90% 0% 100% 0% 50% 

Shiotani,2002

80% N/A N/A 0% 50% 

Strik,2002

75% 8% 100% 0% 50% 

Barefoot,2003

50% 0% 100% 0% 25% 
Evidence Table 2.3. Assessment of Study Quality in Studies on Prevalence of Depression After Hospitalization for Acute Myoca

(Question 2) (continued)

Study Author,

Year Representativeness Description Therapy & Management Description Assessment Protocol Outcomes & Follow-Up Statistical Analyse

24

Aben,2003

80% 0% 100% 0% 33% 

Lauzon,2003

65% 33% 100% 8% 13% 

Martin, 2003

65% 8% 100% 8% 33% 

Strik,2003

65% 25% 100% 0% 50% 

Lesperance, 2004

90% 33% 100% 0% 19% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the 

(2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether thseries or randomly selected sample (2 patients).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other 

Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Outcomes and Follow-up: Percentage score was based on a total maximum score of 6 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), and whether the same tools for dused for baseline and follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether adjustment was made for confounding (2 points), and whether confidence int

patients).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
25

Evidence Table 2.4. Results of Studies on Prevalence of Depression After Hospitalization for Myocardial Infarction (Question 2)

Study Diagnosis of MI

Depression

Assessment

Method a

Criteria

Depression

Severity

Measure b

Prevalence

(%) Co

Trelawny, 1987

Confirmed by cardiologist Goldberg's

clinicalinterviewschedule

Depression notspecified

NR c 10 d d 20;

2 mos e 26;

6 mos 26

Group consisted oan ER f with suspe

Davis, 1988

MI patients admitted to CCU h

BDI i $ 13 Categorical

variable 

6-8 wks j 10 Prevalence of dep

methods 17 BDI rating 27 SCID k rating

Follick,1988

In-hospital assessment,chest pain, ECG l, creatinekinase 

SCL-90 m No standard

definition ofdepression 

Dichotomousvariable 

Baseline 16;9 mos 10

NA n

Schleifer, 1991

In-hospital assessment,chest pain, creatine kinase,ECG

RDC o (NurseInterview)

Major/Minordepression

Categoricalvariable 

8-10 d: Major p 17,

 Minor q 30;3-4 mos: Major 14, Minor= 19

Major depression mood and 4 sympMinor depression mood and 2 symp

Legault,1992

In-hospital assessment,ECG, creatine kinase. 

BDI $ 16 Dichotomous

variable 

3 mos 7;12 mos 9

Authors reported dunstable angina, apain. Only the data on MFollow up at 3 moinitial.

Garcia, 1994

In-hospital assessment RDC Major/Minor

depression

Continousvariable, Categoricalvariable 

1 mo: Major 11, Minor 27

All patients with firdepression - no coData reported at h(diagnosis standaronly means & CIs and mood measur
Evidence Table 2.4. Results of Studies on Prevalence of Depression After Hospitalization for Myocardial Infarction (Question 2) 

Study Diagnosis of MI

Depression

Assessment

Method a

Criteria

Depression

Severity

Measure b

Prevalence

(%) Co

26

Travella,1994

ECG, CPK s HAMD t

PSE u

Major/Minordysthymia

Categoricalvariable 

In hospital: MDD v 26,

 Dys 

w 3;

3 mos: MDD 15, Dys 4;6 mos: MDD 21, Dys 3;9 mos: MDD 28, Dys 3;12 mos MDD 16, Dys 13

NA

Clarke, 1996

In-hospital assessment ZDS x NR Dichotomous

variable 

3 mos 24 NA

Lesperance, 1996

In-hospital assessment,chest pain, creatine kinase,new Q waves

DIS y Depression NR 6 mos 21;

12 mos 9

NA

Bennett, 1998

In-hospital assessment HADS z $ 11 Dichotomous

variable 

3 mos 3 NA

Lehto, 2000

Interviews and clinicalexaminations at least 6months after the cardiacevents,physician report 

DEPS aa $ 9 Continuous

variable,Dichotomousvariable 

At least 6 mospost-MI d 16

NA

Strik,2001

In-hospital assessment,ECG, AST, clinical picture

SCID, HAMD, SCL-90, BDI, HADS

Major/Minordepression

Dichotomousvariable 

1 moMajor 11,Minor 8

NA
Evidence Table 2.4. Results of Studies on Prevalence of Depression After Hospitalization for Myocardial Infarction (Question 2) 

Study Diagnosis of MI

Depression

Assessment

Method a

Criteria

Depression

Severity

Measure b

Prevalence

(%) Co

27

Lane,2002

In-hospital assessment, chest pain, ECG, creatinekinase

BDI $ 10 Continuous

variable,Dichotomousvariable 

4 mos 38;12 mos 37

NA

Luutonen, 2002

In-hospital assessment,chest pain, ECG, creatinekinase 

BDI $ 10 Continuous

variable, Categoricalvariable 

6 mos 30;18 mos 34

NA

Shiotani,2002

In-hospital assessment,chest pain, ECG, creatinekinase, 

ZDS $ 40% Dichotomous

variable 

Within first 3 mos 42

Depression not ashospitalization.SDS ab mailed with

Strik,2002

In-hospital assessment,chest pain, ECG, AST

BDI, HADS,SCL-90 if anyone positiveassessmentwith SCID

Major or minordepression

Dichotomousvariable 

3 mos: Major 11, Minor 2

NA

Aben, 2003

In-hospital assessment,chest pain, ECG, AST ac 

BDI, HADS,SCL-90 if anyone positiveassessmentwith SCID andHAMD

Depression Dichotomous

variable 

1 mo 14 The study reports 

depression at 1, 3Cumulative incide2.

Barefoot,2003

In-hospital assessment,ECG, cardiac enzyme

NR HAMD d/x ad,

BDI $10

Continuousvariable,categoricalvariable 

2 wks: HAMD 17, BDI 27

NA

Lauzon,2003

In-hospital assessment,ECG

BDI $ 10 Dichotomous

variable 

1 mo 39;6 mos 39;1 yr 30

NA
Evidence Table 2.4. Results of Studies on Prevalence of Depression After Hospitalization for Myocardial Infarction (Question 2) 

Study Diagnosis of MI

Depression

Assessment

Method a

Criteria

Depression

Severity

Measure b

Prevalence

(%) Co

28

Martin, 2003

In-hospital assessment,ECG, troponin, patienthistory

HADS $ 11 (probable

depression)$ 8 (possibledepression)

Continuousvariable,Dichotomousvariable 

1 wk:

$ 8: 15,$ 11: 6;

6 wk:

$ 8: 13,$ 11: 5;

6 mos:

$ 8: 10,$ 11: 5

NA

Lesperance, 2004

In-hospital assessment,chest pain, ECG,creatinekinase 

SCID Major depression Dichotomous

variable 

Approx 2 mos: 7 NA

a Method of assessing of depression used for analysisb How severity of depression was measuredc Not reportedd Daye Monthf Emergency roomg Myocardial infarctionh Coronary care uniti Beck Depression Inventoryj Weeksk Structural Clinical Interview for Diagnostic & Statistical Manual of Mental Disorders IV l Electrocardiogramm Symptoms Checklist 90n Not applicableo Research Diagnostic Criteriap Major depressionq Minor depressionr Confidence intervalss Creatine phosphokinaset Hamilton Rating Scale for Depressionu Present State Examinationv Major Depressive Disorder
Evidence Table 2.4. Results of Studies on Prevalence of Depression After Hospitalization for Myocardial Infarction (Question 2) 

29

w Dysthymiax Zung Depression Scaley Diagnostic Interview Schedulez Hospital Anxiety and Depression Scaleaa Depression Scale ab Self-Rating Depression Scaleac Aspartate amino transferase ad Diagnosis
30

Evidence Table 3.1A. Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial Infarctio

Study

Author, Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period S

Ahern, 1990

Procohort a

Only MI bpatients 

Age > 70, index ACS c after symtoms,

non-atherosclerotic MI, pulmonaryhypertension, symptomatic urinarytract infection, chronic active hepatitis,nonischemic MI, women of childbearing age, < 10 PVCs/hr d, non

English speaking

Multicenter, 10 USA,

Canada

NR e To test the p

between biomortality or c

Ladwig, 1991 Pro

cohort

Only MIpatients 

Age > 66, female Multicenter Europe Jan 1983 - Dec

1985

To assess inbehaviour andepression iafter MI.

FrasureSmith, 1993 

Procohort

Only MIpatients 

Cognitively impaired, medicalcondition likely to impact 6 mossurvival, non English or non Frenchspeaking, too unstable to completeinterview

Single center Canada Jul 1991 - Jun

1992

To determine depression ifollowing MI independent mortality ovedischarge.

FrasureSmith, 1999

Procohort

Only MIpatients

Life threatening conditions, cognitivelyimpaired, non French, lived too far toreturn to follow up, administrativereasons, physician refusal,participation in other research earlydischarge

Multicenter, 10 Canada Jul 1991 -

1994

To assess gimpact of decardiac morthospitalized 

Irvine, 1999

RCT g Only MI

patients 

Age > 65,more than 1 MI, nonGottenberg residents

Multicenter Canada Jun 1996 - Nov

1995

To examine symptoms ayear sudden controlling fo

Denollet,2000

Procohort

Patients withACS 

Serious co-morbidity Single center Europe Jan 1989 - Dec

1992

To test the hcardiac disodistress confcardiac even

despite appr
Evidence Table 3.1A. Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial Infarctio

(continued)

Study

Author, Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period S

31

Lane, 2000

Procohort

Only MIpatients 

Index ACS after symptoms:, anothercondition likely to lead to death within12 mos, non English speaking,medically unstable, MI, CABG i, PCI j

Multicenter Europe Jan 1997 - Aug

1988

To determine and anxiety life in patientacute MI.

Welin, 2000

Procohort

Only MIpatients 

NR Multicenter Europe Oct 1985 - Oct

1987 

To test whetafter MI is restress, lack oand/or depre

Bush, 2001

Procohort

Only MIpatients 

Serious co-morbidity likely to die in 6mos of medical condition, not admittedto the cardiology service, died ortransferred, other facility within 48 hrsof hospitalization

Single center USA Jul 1995 - Dec

1996

To determine symptoms of than those csignificant arincreased m

Druss, 2001

Procohort

Only MIpatients 

Age < 65, terminally ill, cognitivelyimpaired, died during currentadmission, DNR k order, dementia

Multicenter USA Feb 1994 - Jul

1995

To investigaquality of meportion of the associated wthe year afte

Lane, 2001

Procohort

Only MIpatients 

Index ACS after surgery, serious comorbidities, cognitively impaired, nonEnglish, medically unstable

Multicenter Europe Jan 1997 - Aug

1998

To determine of depressioand quality ohospitalized 

Lane, 2002

Procohort

Only MIpatients 

NR Multicenter Europe Jun 1997 - Aug

1998

To examine symptoms of & 3 year surv
Evidence Table 3.1A. Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial Infarctio

(continued)

Study

Author, Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period S

32

Lesperance,2002

Procohort

Only MIpatients 

NR Multicenter Canada Jan 1991 - Nov

1994

To evaluate between deplong-term cathat any impsymptoms recontrol for mdisease seveof depressiohospitalizatioevaluate the changes in dthe first post

Carney, 2003 Pro

cohort

Only MIpatients 

H/o 

m psychosis, cognitively impaired,

life threatening medical illness, to ill toparticipate, TCA n or MAOI o or otheranti-depressant that may affect heartrate variability, refused logistically,unable to participate

Multicenter USA Oct 1997 - Jan

2000

To determine associated wmortality and subsample o

depressed pgroup of nonrecruited for 

FrasureSmith, 2003

Procohort

Only MIpatients 

Index ACS after surgry, cognitivelyimpaired:, non English or non French,life threatening illness, physicalinability to complete hospital interview,living to far to return to hospital for f/u q, physician refusal, participation in

other research

Multicenter Canada Jan 1991 - Sep

1994

To examine depression, support in prrelated mortaassess the underlying d

a Prospective cohort studyb Myocardial infarctionc Acute coronary syndromed Premature ventricular contractions per hourf Not reportedg Randomized controlled trialh Quality of life
Evidence Table 3.1A. Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial Infarctio

(continued)

33

i Coronary artery bypass graftj Percutaneous coronary interventionk Do not resuscitatel Acute myocardial infarctionm History ofn Tetracyclic antidepressanto Monoamine oxidase inhibitorp Enhancing Recovery in Coronary Heart Diseaseq Follow-up
47

Evidence Table 3.1B. Characteristics of Studies on the Relation of Depression to Cardiac Events in Patients After Myocardial In

Study

Author,

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period Stu

Irvine, 1999

RCT a Only MI b

patients

non English or non French speaking,not well enough to completequestionaire

Multicenter Canada NR c To examine the i

symptoms and sosudden cardiac dfatigue symptoms

Druss, 2000

Retrocohortd Only MI patients Age < 65 yrs e, terminally ill, transfer from another hospital, do not

resuscitale order, not fee for service

Multicenter USA Feb 1994 -

Jul 1994

To assess whethmental disorder ilikelihood of cardvascularization a

FrasureSmith, 2000

Retro cohort Only MI

patients

Non-English or non-French speaking,life threating condition, cognitivelyimpaired, physically unstable, live farfrom hospital, administrative reason

Multicenter Canada M-HART g:

1991 - 1995EPPI h: NR

To examine the rMI depression anincluding both oureadmissions.

Shiotani, 2002

Pro cohort i Only MI

patients

Died in hospital, unable to verballycommunicate, major psychologicaldisease, refused registry

Multicenter Asia Apr 1998 -

Apr 2000

To investigate the symptoms on propatients with AM

Strik, 2003

Pro cohort First MI H/o j psychosis, cognitively impaired,

non Dutch speaking

Single center Europe May 1994 -

Sep 1999

1) To examine wbetter predictor oafter MI than anx2) To examine thdistress not only but also on re-hoincreased health 

Strik, 2004

Pro cohort First MI H/o psychosis,cognitively impaired, cant

express themselves, non Dutchspeaking, lived more than 50 kms k, comorbid life threatening illness

Single center Europe NR 1)To evaluate wh

incidence of majoa consecutive coMI in first MI patie2)To evaluate whpopulation major symptoms, predicmorbidity upto 3 y

a Randomized controlled trialb Myocardial infarctionc Not reported d Retrospective cohort study
Evidence Table 3.1B. Characteristics of Studies on the Relation of Depression to Cardiac Events in Patients After Myocardial In

(continued)

48

e Yearsf Acute myocardial infarctiong Montreal Heart Attack Readjustment Trial h Emotions and Prognosis Post-Infarct Studyi Prospective cohort studyj History ofk Kilometers
56

Evidence Table 3.1C. Characteristics of Studies on the Relation of Depression to Quality of Life in Patients After Myocardial Inf

Study Author, 

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruit- ment Period S

Travella, 1994

Pro cohort a Only MIb patients Attempted cardiac surgery,serious

co-morbidities,cognitively impaired,h/o c depression

Multicenter USA NR d To examine 

correlates of year after M

Drory,1998

Pro cohort Only MI patients Females, previous AMI e, not sexually

active prior to MI

Multicenter Asia NR To examine 

sociodemogpsychologicapredicton of satisfaction ia first AMI.

O'Rourke,1999

Pro cohort included patients

with ACS f other

than MI. Data for MI notreportedseparately

Age>76, non-English, recurrent MI, emergency angioplasty,emergency cardiac by pass

Multicenter Europe NR To examine 

psychosociabeliefs, locus perception, sdepression) utilization 6 m

Soejima, 1999

Pro cohort Only MI patients NR Multicenter Asia Apr 1992 -

Jan 1996

To investigaclinical factoresumption, and level of myocardial inmale patient

Bogg,2000

Pro cohort Only MI patients CVA g Single Center Europe, NR To assess th

quality of life with depress

Denollet,2000

Pro cohort 322 patients with

ACS,50.31% patientswith MI No data for MIreportedseparately

Serious co-morbidities Single center Europe, Jan 1989 -

Dec 1992

To test the hcardiac disodistress confcardiac even

despite appr
Evidence Table 3.1C. Characteristics of Studies on the Relation of Depression to Quality of Life in Patients After Myocardial Inf

(continued)

Study Author, 

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruit- ment Period S

57

Lane,2000

Pro cohort Only MI patients Index ACS after surgery, serious comorbidities, another medical

condition likely to lead to death withinthe next 12 months, non-English,medically unstable, too unstable tocomplete the baseline assessmentwithin 15 days of their infarction

Multicenter Europe, Jan 1997 -

Aug 1998

To determine and anxiety in patients hmyocardial in

Mayou, 2000

Pro cohort Only MI patients Age > 80 years Multicenter Europe Nov 1994-

Nov 1995

To investigaemotional dimyocardial inphysical, psyoutcome and 

Lane, 2001

Pro cohort Only MI patients Index ACS after surgery, serious comorbidities, cognitively impaired, nonEnglish, medically unstable Multicenter Europe, Jan 1997- Aug 1998 To determine 

of depressioand quality ohospitalized 

Brink, 2002

Pro cohort Only MI patients Serious co-morbidities, dementia, 

non- Swedish

Single Center Europe, Oct 1998 -

Sep 1999

To explore hin first time mpatients, five attack.

Drory, 2002

Pro cohort Only MI patients Previous MI Multicenter Asia, NR To evaluate 

independent demographic variables assdischarge on term mental 
Evidence Table 3.1C. Characteristics of Studies on the Relation of Depression to Quality of Life in Patients After Myocardial Inf

(continued)

Study Author, 

Year

Study

Design

Target

Population Exclusion Criteria Number of Study Sites Study Site Recruit- ment Period S

58

Drory,2003

Pro cohort Only MI patients Men, previous MI Multicenter Asia, NR To compare 

well being anafter a first aof women wiof a normativwomen and socio-demogpsychologic psychologic psychologic 

a Prospective cohort study b Myocardial infarctionc History of d Not reportede Acute myocardial infarctionf Acute coronary syndromeg Cardiovascular angioplastyh Quality of life
34

Evidence Table 3.2A. Patient Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial In

Study

Author,

Year

No. of

Subjects

 Mean 

Age 

Male

(%)

White

(%)

Married a

(%)

Education b

(%)

Employed

c

(%)

HTN d

(%)

DM e

(%)

Smoking

(%)

Lipid f

(%)

Killi

Clas

(I-IV

(%

Ahern, 1990

265 NR h NR NR NR NR NR NR NR NR NR NR 

Ladwig,1991

560 NR 100 NR NR NR NR Group A:

109, Group B:36, Group C:33

NR Group A:

222, Group B:79, Group C:45

NR NR 

FrasureSmith, 1993 

222 NR 78 NR NR > 8 yrs j:

69

NR 30 12 40 NR 21 

FrasureSmith, 1999

Female:283, Male: 613

Female: 63, Male: 58

68 NR Female:

51, Male: 18

< 7yrs:Female:38Male: 23

NR Female:

52, Male: 28 (n=612)

Female:23, Male: 13

Female:45, Male: 49

NR Class I

Female57, Male: 7Class IFemale15, Male: 1Class IFemale25, Male: 1Class IFemaleMale: 2

Irvine, 1999

634 64 83 NR 74 14 NR NR 15 NR NR NR 
Evidence Table 3.2A. Patient Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial In

(continued)

Study

Author,

Year

No. of

Subjects

 Mean 

Age 

Male

(%)

White

(%)

Married a

(%)

Education b

(%)

Employed c

(%)

HTN d

(%)

DM e

(%)

Smoking

(%)

Lipid f

(%)

Killi

Clas

(I-IV

(%

35

Denollet,2000

EventFree: 270, CVl Event:

22, TotalEvents: 49

Event Free:38, CV Event:59, TotalEvents: 53

EventFree: 92, CVEvent:95, TotalEvents:94

NR NR NR NR Event

Free: 32, CV Event:27, TotalEvents: 29

NR Total

Events:20

EventFree:36 , CVEvent:36 , TotalEvents:37 

NR 

Lane, 2000

BDI 

m

 >

10: 89, BDI < 10:199

BDI > 10:63, BDI < 10:63

BDI > 10:62,BDI < 10:80

BDI > 10:91,BDI < 10:94

BDI > 10:67,BDI < 10:71

BDI > 10: 10, BDI < 10: 10

BDI > 10:24, BDI < 10:36

BDI > 10:42, BDI < 10:37

BDI >10: 19, BDI <10: 10

BDI > 10:44, BDI < 10:43

BDI >10: 74, BDI <10: 79

Class IIV:BDI > 58, BDI < 49

Welin, 2000

275 NR 84 NR NR NR NR 21 9 19 NR NR 

Bush, 2001

271 64.8 58 86 79 NR NR 66 35 29 62% Class I

IV: 41

Druss, 2001

Mental n

:

4664, No Mental: 83577

Mental: 76, No Mental :76

Mental :53 NoMental :47

NR NR Mental: 6, 

No Mental:0

NR Mental :

42, No Mental: 40

Mental :22, NoMental :26

Mental :22, NoMental :15

NR NR 
Evidence Table 3.2A. Patient Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial In

(continued)

Study

Author,

Year

No. of

Subjects

 Mean 

Age 

Male

(%)

White

(%)

Married a

(%)

Education b

(%)

Employed c

(%)

HTN d

(%)

DM e

(%)

Smoking

(%)

Lipid f

(%)

Killi

Clas

(I-IV

(%

36

Lane, 2001

Group A:89, Group B:199

Group A:63, Group B:63 

Group A:62, Group B:80

Group A:91, Group B:94

Group A:91, Group B:94

Group A:10, Group B:10

Group A:24, Group B:36

Group A:42, Group B:37

GroupA: 19, GroupB: 10

Group A:44, Group B:43

GroupA: 74, GroupB: 79

Class IIV:Group 58, Group 49

Lane, 2002 Dep o: 89, 

NonDep p

:

199

Dep: 63, NonDep: 63

75 93 Dep: 71, 

NonDep:67

Dep: 10, NonDep:10

Dep: 24, NonDep:36

Dep: 42, NonDep:37

Dep: 19, NonDep: 10

Dep: 44, NonDep:43

NR Class I

IV:Dep: 5NonDe49

Lesperance,2002

870 59 68 NR 36 NR NR 35 16 47 NR Class I 

IV: 31

Carney,2003

Group A:358, Group B:408

Group A:57, GroupB: 61

Group A:53, Group B:62

Group A:28, Group B:21

NR NR NR NR Group

A: 33, GroupB: 22

NR NR Class I

Group 6, Group 

FrasureSmith, 2003

887 59 69 NR NR NR NR NR NR 62 NR NR 

a Married or partneredb High School or higher educationc Employed full-time or part-timed Hypertensione Diabetesf Hyperlipidemiag History ofh Not reportedi Ejection fraction
Evidence Table 3.2A. Patient Characteristics of Studies on the Relation of Depression to Survival in Patients After Myocardial In

(continued)

37

j Yearsk Confidence intervall Cardiovascularm Beck Depression Inventoryn Mental disorder/no mental disordero Depressedp Non-depressed
49

Evidence Table 3.2B. Patient Characteristics of Studies on the Relation of Depression to Cardiac Events in Patients After Myoc(Question 3) 

Study

Author, 

Year

No. of 

Subjects

 Mean 

Age 

Male

(%)

HTN a

(%)

DM b

(%)

 Smoking

(%)

Lipid c

(%)

Mean 

Ejection

Fraction

Irvine, 1999

634 64 83 NR d 15 NR NR NR 

Druss, 2000

Mental e: 5365 

No Mental f:

108288

Mental: 50 No Mental: 49

Mental: 52No Mental: 46

Mental: 42 No Mental: 40

Mental: 22 No Mental: 26

Mental:22 No Mental: 151

NR EF g $ 55%

Mental: 14 No Mental: 1

FrasureSmith, 2000

848 NR 69 34 16 48 NR EF # 35%: 1

Shiotani, 2002

Dep h: 438 

NonDep i: 604 Dep: 63 NonDep: 64 Dep: 81 NonDep: 80 Dep: 49 NonDep: 46 Dep: 36 NonDep: 29 Dep: 70 NonDep: 62 Dep: 35 NonDep: 39 NR 

Strik, 2003

318 58 100 28 9 54 20 EF # 50%: 4

Strik, 2004

Dep: 63 NonDep: 143

NR Dep: 84

NonDep: 74

NR NR Dep: 10 

NonDep: 13

Dep: 35 NonDep: 29

EF < 50%Dep: 77,NonDep: 31EF > 50%Dep: 56,NonDep: 69

a Hypertension b Diabetesc Hyperlipidemia d Not reportede Any mental disorder f No mental disorderg Ejection fraction h Depressed i Non-depressed
59

Evidence Table 3.2C. Patient Characteristics of Studies on the Relation of Depression to Quality of Life in Patients After Myoca

(Question 3) 

Study

Author, 

Year

No. 

of

Subjects

Mean

Age 

Male

(%)

NonWhite

(%)

Married

(%)

Educationa

(%)

Employed b

(%)

HTN c

(%)

DM d

(%)

Smoking

(%)

Lipid e

(%)

 Killi

Class

(I-IV)

(%)

Travella, 1994

Dep f:

18, NonDep g: 52

Dep: 63, NonDep:57 

Dep: 54, NonDep:82

Dep: 44, NonDep:36

NR Dep: 12, 

NonDep: 12 

NR NR NR NR NR NR 

Drory,1998

276 51 100 33 rest of

group fromEurope/American/Israel

99 13 NR NR 9 NR NR Class I

83, Class I16, ClassIII: 1, ClassIV: 1

O'Rourke1999

EHM h:

45, NoEHM i:

25

EHM: 58, No EHM:60

EHM: 73, No EHM:76

NR EHM: 73, 

No EHM:72

NR EHM: 31, 

No EHM:44

NR NR NR NR NR 

Soejima, 1999

134 54 100 NR NR NR 100 34 22.5 (14.8,

30.3)

 74.8 31.5

(22.9,40.2)

Class I847(780-91.4)ClassII:15.3(8.6-22.6)

Bogg,2000

220 NR 77 NR NR NR NR NR NR NR NR NR 

Denollet,2000

Free j:

270, Cardiac k: 22, 

Total l:

49

Free: 38, Cardiac:59, Total: 53

Free: 92,Cardiac:95,Total: 94

NR NR NR NR Free: 32

(85), Cardiac:27 (6), Total: 29(14)

NR Free: 17

(45), Cardiac: 18(4), Total: 20(10)

Free: 36(103), Cardiac:36 (8), Total: 37(18)

NR 
Evidence Table 3.2C. Patient Characteristics of Studies on the Relation of Depression to Quality of Life in Patients After Myoca

(Question 3) (continued)

Study

Author, 

Year

No. 

of

Subjects

Mean

Age 

Male

(%)

NonWhite

(%)

Married

(%)

Educationa

(%)

Employed b

(%)

HTN c

(%)

DM d

(%)

Smoking

(%)

Lipid e

(%)

 Killi

Class

(I-IV)

(%)

60

Lane,2000

Dep:89, NonDep: 199

Dep: 63,NonDep:63

Dep: 62, NonDep:80

Dep: 9, NonDep: 7

NR Dep: 10, 

NonDep: 10

Dep: 24, NonDep:36

Dep: 42, NonDep:37

Dep: 19, NonDep: 9

Dep: 44, NonDep: 43

Dep: 35, NonDep:39

Class IDep: 4NonDe: 51, Class IDep: 5NonDe: 49

Mayou, 2000

Total:344, Distress m: 51, 

NonDistress n

:

293

Total: 63, Distress:58, NonDistress: 64

Total: 73Distress:69, NonDistress: 74

NR NR NR NR NR NR NR NR NR 

Lane, 2001

Dep:89, LowDepo: 199

Dep: 63, LowDep:63

Dep: 62, LowDep:80

Dep: 9, LowDep: 7

NR Dep: 10, 

LowDep: 

Dep: 24, LowDep:36

NR NR NR NR NR 

Brink, 2002

Women: 37, Men:77

Women:72, Men: 65

68 NR Women:

60, Men: 78

Women:78, Men: 71

NR Women:

51, Men: 28

Women:16, Men: 15

Women:24, Men: 34

NR NR 
Evidence Table 3.2C. Patient Characteristics of Studies on the Relation of Depression to Quality of Life in Patients After Myoca

(Question 3) (continued)

Study

Author, 

Year

No. 

of

Subjects

Mean

Age 

Male

(%)

NonWhite

(%)

Married

(%)

Educationa

(%)

Employed b

(%)

HTN c

(%)

DM d

(%)

Smoking

(%)

Lipid e

(%)

 Killi

Class

(I-IV)

(%)

61

Drory, 2002

209 52 100 NR NR 12 NR NR NR NR NR Class 

81ClassII: 17ClassIII: 1ClassIV: 1

Drory,2003

62 56 0 20 NR 12 NR NR NR NR NR Class 

- IV: 1

a High School or higherb Employed full-time or part-timec Hypertensiond Diabetese Hyperlipidemiaf Depressedg Not depressedh Received Edinburgh Heart Manuali Did not received Edinburgh Heart Manualj Event freek Fatal and non fatal cardiac events at 5 yearsl Cardiac events and revascularization at 5 yearsm Distressed cases at baselinen Not distressed cases at baselineo Low levels of depression as indicated by Beck Depression Inventory score less than 10
38

Evidence Table 3.3A. Assessment of Study Quality in Studies on the Relation of Depression to Survival in Patients After Myoca(Question 3)

Study Author,

Year Representativeness

Description of

Therapy &

Management

Description of

Assessment

Protocol

Outcomes and 

Follow-Up Statistical Analy

Ahern, 1990

75% 25% 100% 69% 63% 

Ladwig, 1991

30% 0% 38% 69% 38% 

Frasure-Smith, 1993

75% 17% 100% 88% 63% 

Frasure-Smith,1999

100% 0% 100% 30% 63% 

Irvine, 1999

70% 58% 100% 63% 63% 

Denollet, 2000

60% 8% 100% 85% 81% 

Lane, 2000

95% 8% 100% 88% 88% 

Welin, 2000

70% 0% 100% 80% 63% 

Bush, 2001

75% 0% 100% 78% 56% 

Druss, 2001

90% 0% 100% 94% 75% 

Lane, 2001

95% 25% 100% 42% 69% 

Lane, 2002

50% N/A 100% 60% 75% 

Lesperance, 2002

95% 42% 100% 90% 75% 

Carney, 2003

85% 42% 100% 60% 81% 

Frasure-Smith,2003

70% 0% 100% 88% 88% 
Evidence Table 3.3A. Assessment of Study Quality of Studies on the Relation of Depression to Survival in Patients After Myoca

(Question 3) (continued)

39

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the (2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether thseries or randomly selected sample (2 patients).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other 

Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Outcomes and Follow-up: Percentage score was based on a total maximum score of 12 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), whether the cardiac outcome me

points), whether the depression outcome measures were defined (2 points), whether the same tools for diagnosing depression were used for baseline a

the planned length of follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether the magnitude of the difference for primary endpoints or magnitude of associ

index variability is reported (2 points) and whether adjustment was made for confounding (2 points).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
50

Evidence Table 3.3B. Assessment of Study Quality in Studies on the Relation of Depression to Cardiac Events in Patients After 

(Question 3)

Study Author,

Year Representativeness

Description of

Therapy &

Management

Description of

Assessment Protocol

Outcomes and FollowUp Statistical Analyses 

Irvine, 1999

70% 58% 100% 63% 63% 

Druss, 2000

85% 8% 50% 50% 100% 

Shiotani, 2002

80% 17% 100% 92% 75% 

Strik, 2003

65% 25% 100% 56% 106% 

Strik, 2004

75% 8% 100% 83% 75% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the (2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether thseries or randomly selected sample (2 patients).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other 

Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Outcomes and Follow-up: Percentage score was based on a total maximum score of 12 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), whether the cardiac outcome me

points), whether the depression outcome measures were defined (2 points), whether the same tools for diagnosing depression were used for baseline a

the planned length of follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether the magnitude of the difference for primary endpoints or magnitude of associ

index variability is reported (2 points) and whether adjustment was made for confounding (2 points).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
62

Evidence Table 3.3C. Assessment of Study Quality in Studies on the Relation of Depression to Quality of Life in Patients After M

(Question 3)

Study Author,

Year Representativeness

Description of

Therapy &

Management

Description of

Assessment Protocol

Outcomes and 

Follow-Up Statistical Ana

Travella,1994

70% 38% 88% 80% 50% 

Drory, 1998

60% 0% 100% 58% 50% 

Irvine, 1999

70% 58% 100% 63% 63% 

Ladwig, 1999

30% 0% 38% 69% 38% 

O'Rourke, 1999

60% 0% 100% 63% 19% 

Soejima, 1999

75% 0% 63% 63% 69% 

Bogg,2000

35% 0% 50% 97% 50% 

Denollet,2000

60% 8% 100% 85% 81% 

Lane 2000

95% 8% 100% 88% 88% 

Mayou, 2000

75% 17% 100% 58% 50% 

Lane, 2001

75% 0% 100% 63% 63% 

Brink,2002

75% 0% 100% 78% 56% 

Drory,2002

45% 0% 100% 58% 44% 

Drory, 2003

20% 0% 50% 40% 50% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the 
Evidence Table 3.3C. Assessment of Study Quality in Studies on the Relation of Depression to Quality of Life in Patients After M

(Question 3) (continued)

63

(2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether th

series or randomly selected sample (2 patients).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other 

Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Outcomes and Follow-up: Percentage score was based on a total maximum score of 12 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), whether the cardiac outcome me

points), whether the depression outcome measures were defined (2 points), whether the same tools for diagnosing depression were used for baseline a

the planned length of follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether the magnitude of the difference for primary endpoints or magnitude of associ

index variability is reported (2 points) and whether adjustment was made for confounding (2 points).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
40

Evidence Table 3.4A. Assessment of Depression in Studies on the Relation of Depression to Survival in Patients after Myocard(Question 3)

Study

Author, Year

No 

Screened

No 

Enrolled

Depression

Instrument

Time of Baseline

Assessment

Mean 

Follow -up

 Total Number at Enro

Depressed Non-De

Ahern, 1990

502 265 BDI a profile of

mood states

6 - 60 d b 1 yr c NR d 

Ladwig, 1991

779 560 NR 3 wks e post MI 6 mos f "Extreme

depression": 80

4

FrasureSmith, 1993

332 222 MIMH DIS g 5 - 15 d 6 mos 35 1

FrasureSmith, 1999

2512 904 BDI After transfer from

CCU h to ward 1 yr 290 6

Irvine, 1999

969 703 BDI 20 - 59 d 2 yrs NR 

Denollet,2000

322 319 ZDS i Within 2 mos

post-MI

5 yrs Event free: 32%;

CV j Events: 50%;

Total Events: 57%

Event frCV EvenTotal Ev

Lane, 2000

437 288 BDI Within 15 d postMI 4 mos 89 1

Welin, 2000

333 275 ZDS 3 - 6 d post-MI 10 yr ZDS > 40: 37% ZDS < 4

Bush, 2001

696 285 SCID k

BDI

2.5 d post-MI 4 mos 73 1

Druss, 2001

NR 88241 NR NR NR NR 

Lane, 2001

437 288 BDI Within 15 d postMI 12 mos 89 1

Lane, 2002

437 288 BDI Within 15 d postMI 3 yrs 89 1

Lesperance,2002

NR 896 BDI Transfer from

CCU to ward

5 yrs 290 6

Carney, 2003 NR NR Depression

interview: structuredHAMD l and BDI

Within 28 d postMI Upto 30 mos 358 4
Evidence Table 3.4A. Assessment of Depression in Studies on the Relation of Depression to Survival in Patients after Myocard

(Question 3) (continued)

Study

Author, Year

No 

Screened

No 

Enrolled

Depression

Instrument

Time of Baseline

Assessment

Mean 

Follow -up

 Total Number at Enro

Depressed Non-De

41

FrasureSmith, 2003

NR NR NR NR 12 mos NR 

a Beck Depression Inventoryb Dayc Yeard Not reportede Weeksf Monthsg National Institute of Mental Health Diagnostic Interview Schedule h Coronary care uniti Zung Depression Scalej Cardiovasculark Structured Clinical Interview for DSM-IVl Hamilton Rating Scale for Depression
51

Evidence Table 3.4B. Assessment of Depression in Studies on the Relation of Depression to Cardiac Events in Patients after M

(Question 3)

Study

Author,

Year

No.

Screened No. Enrolled Depression Instrument Time of Baseline Assessment Mean Follow-Up Total Number at Enrollment No. at Follow-Up To

Depressed Non Depressed De

Irvine, 1999

969 703 Psychological

questionnaire

After 2 wks a

during postrandomization 

2 yrs b 634 NR c NR NR 

FrasureSmith, 2000

337 222 Structured

baseline interview

1 wk followingadmission

1 yr 260 588 NR NR 

Druss, 2000

All patientdischargedfrom acutecarehospitalwithdiagnosisof AMI d

NR ICD-9CM e During index

admission

30 d f NR NR NR NR 

Shiotani, 2002

1828 1086 Zung g Zung mailed

within 3 mos hafter the onsetof AMI.

12 mos 438 604 1042 NR 

Strik, 2003

407 318 SCL-90 i 1 mo post-MI j 3-4 yrs

post-MI

NR NR NR NR 

Strik, 2004

NR 422 Baseline: SCID k

Follow-up: 3psychiatric selfrating scales BDIl,

SCL-90,HADS m

1 mo post-MI NR 63 143 NR 59 

a Weeksb Yearsc Not reported d Acute myocardial infarctione The International Statistical Classification of Diseases and Related Health Problemsf Day
Evidence Table 3.4B. Assessment of Depression in Studies on the Relation of Depression to Cardiac Events in Patients after M

(Question 3) (continued)

52

g Montreal Heart Attack Readjustment Trial h Zung Self-Rating Depression Scalei Monthsj Symptom Checklist - 90k Structured Clinical Interview for Diagnostic & Statistical Manual of Mental Disorders IV l Beck Depression Inventorym Hamilton Anxiety and Depression Scale
64

Evidence Table 3.4C. Depression Assessment of Studies on the Relation of Depression to Quality of Life in Patients after Myoc(Question 3)

Study

Author, Year No. Screened No. Enrolled Depression Instrument Time of Baseline Assessment Mean Follow-Up Total Number at Enrollmen

Depressed NonDepresse

Travella,1994

NR a 129 Present state

examination -modified,HAM-D b

Duringhospitalization

12 months 18 52 

Drory, 1998

NR 276 BDI c 7 days 3 - 6 months NR NR 

Irvine, 1999

969 703 BDI symptom

checklist

2 weeks 2 years NR NR 

Ladwig,1999

NR 552 DepressivitatsSkaln 17-21 days 6 months 74 466 

O'Rourke,1999

85 70 HADS d 3-5 days 6 months 12 58 

Soejima,1999

136 134 Depression Index "soon after MI e" NR NR NR 

Bogg,2000

231 220 HADS (II) Global

mood scale

3-4days 6 months NR NR 

Denollet,2000

NR 322 Zung e Within 2 months 5 years NR NR 

Lane 2000

437 288 BDI Within 15 days 4 months 89 199 

Mayou, 2000

546 344 HADS 3 days 3 months, 

12 months

51 293 

Lane, 2001

437 288 BDI Within 15 days 12 months 89 199 
Evidence Table 3.4C. Depression Assessment of Studies on the Relation of Depression to Quality of Life in Patients after Myoc

(Question 3) (continued)

Study

Author, Year No. Screened No. Enrolled Depression Instrument Time of Baseline Assessment Mean Follow-Up Total Number at Enrollmen

Depressed NonDepresse

65

Brink, 2002

144 134 HADS Within 1week 5 months NR NR 

Drory,2002

NR NR BDI 1 week 3 months, 

6 months & 5 years

NR NR 

Drory, 2003

NR NR BDI 1 week 5 years NR NR 

 a Not reported b Hamilton Rating Scale for Depression c Beck Depression Inventory d Hospital Anxiety and Depression Scale e Zung Self-Rating Depression Scale
42

Evidence Table 3.5A. Results of Studies on the Relation of Depression to Survival in Patients after Myocardial Infarction (Quest

Study

Author, Year

Outcome Reported

 Stat a

Depressed 

vs.b

Non Depressed

Multivariate 

Comparison

Cardiac Mortality Total Mortality Other 

Ahern, 1990

NA c NA TM d or cardiac

arrest at baseline

RR e NR f 1.38 

(CI g 0.99 - 1.93) p < 

Ladwig, 1991

Low: 0.9;Medium: 2.4;High: 7.5

NA Sustained VT k

admission

OR l Mantel-Haenszel

p<0.001

2.8 low/med depressi4.9 low/high depressip=0.07

Frasure-Smith,1993

At 6 mos m NA HR n 5.74 

(CI 4.61 - 6.87)p = 0.0006

4.29 (CI 3.14 - 5.44)p = 0.013

Frasure-Smith,1999

NA NA Arrhythmia; 

MI recurrence;Revascularization;Any hard event

OR CV death: 3.23 

(CI 1.65 - 6.33);Arrhythmia 3.11 (CI 1.32 - 7.37);MI recurrence: 1.62 (CI 0.93 - 2.8);Any hard events: 1.97 (CI 1.25 - 3.13);Revascularization: 0.82(CI 0.53 - 1.26)

3.66 (CI 1.68 - 7.99)**

Irvine, 1999

Sudden cardiacdeath

NA NA HR AMI q: 0.52 

(CI 0.15 - 1.76)

NR 
Evidence Table 3.5A. Results of Studies on the Relation of Depression to Survival in Patients after Myocardial Infarction (Quest

Study

Author, Year

Outcome Reported

 Stat a

Depressed 

vs.b

Non Depressed

Multivariate 

Comparison

Cardiac Mortality Total Mortality Other 

43

Denollet, 2000

Cardiac events NA QOL s: Poor

perceived health at5 yrs t, Depressive effect

OR NR 1.31 

(CI 0.53 - 3.24)p=0.56

Lane, 2000

Dep u: 9%, 

NonDep v: 1%

Dep: 10.1%, NonDep: 8%

Dart Dartmouthchart

OR NR NR 

Welin, 2000

17% 24% Non fatal recurrent

MI;Stroke;Cancer

HR TM: 2.45 

(CI 1.49 - 4.02) ***, CM 

w: 3.54 

(CI 1.85 - 6.79)***

TM 1.75 (CI 1.02 - 2.99)*, CM 3.16 (CI 1.38 - 7.25)***

Bush, 2001

NA Dep: 13%, 

NonDep: 4%

NA RR 3.8 p=0.008 3.5 p=0.001 

Druss, 2001

NA NA NA HR Mental: 1.19 

(CI 1.04 - 1.36),Affective 1.11 (CI 1.03 - 1.18)

NR 

Lane, 2001

10% 10% QOL OR CM 1.15 

(CI 0.49 - 2.69)

NR 
Evidence Table 3.5A. Results of Studies on the Relation of Depression to Survival in Patients after Myocardial Infarction (Quest

Study

Author, Year

Outcome Reported

 Stat a

Depressed 

vs.b

Non Depressed

Multivariate 

Comparison

Cardiac Mortality Total Mortality Other 

44

Lane, 2002

Dep: 10% NA NA OR TM: 1.04

(CI 0.5 - 2.16), CM: 0.84 (CI 0.37 - 1.90)

NR 

Lesperance,2002

< 5 yr: 7%;5 - 9 yr: 14%;10-18 yr: 19%;> 19 yr: 27%

 44***;< 5 yr: 11%;5 - 9 yr: 16%;10-18 yr: 23%;> 19 yr: 33%

NA HR BDI 5 - 9: 1.94 

(CI 1.16 - 3.25) p=0.01;BDI 10 - 18: 2.8 (CI 1.68 - 4.66) p<0.001;BDI > 19: 1.32 (CI 2.4 - 7.75) p<0.001

TM: BDI 10 - 18: 2.35 (CI 1.53 - 3.61)***BDI $ 19 (CI 2.16 - 5.92)***TM:BDI 10 - 18: 3.17 (CI 1.79 - 5.6)***BDI $ 19: 3.13 (CI 1.56 - 6.27)***

Carney, 2003

NA NA Non Fatal AMI HR NR TM 2.4 

(CI 1.2 - 4.7)**Non-Fatal AMI 1.2 (CI 0.7 - 2.0)*
Evidence Table 3.5A. Results of Studies on the Relation of Depression to Survival in Patients after Myocardial Infarction (Quest

Study

Author, Year

Outcome Reported

 Stat a

Depressed 

vs.b

Non Depressed

Multivariate 

Comparison

Cardiac Mortality Total Mortality Other 

45

Frasure-Smith,2003

At 5 yr NA NA HR NR 1.44 

(CI 91.17-1.78)***

a Comparison statistic

b Versusc Not applicabled Total mortalitye Risk ratiof Not reportedg Confidence intervalh Significant at p<0.05i Premature ventricular contractions per minutej Myocardial infarction
Evidence Table 3.5A. Results of Studies on the Relation of Depression to Survival in Patients after Myocardial Infarction (Quest

46

k Ventricular tachycardial Odds ratiom Monthsn Hazard ratioo Left ventricular ejection fractionp Beck Depression Inventoryq Acute myocardial infarctionr Congestive heart failures Quality of lifet Yearsu Depressedv Non Depressedw Cardiac mortalityx Ejection fractiony Coronary artery diseasez Acetylsalicyclic Acidaa Acute coronary event ab History of hypertension treatment
53

Evidence Table 3.5B. Results of Studies on the Relation of Depression to Cardiac Events after Myocardial Infarction (Question 

Study

Author,

Year

Outcome

 Stats a Univariate Comparison Multivariate Compariso

Cardiac Events Cardiac Mortality Other 

Irvine, 1999

NR b Sudden cardiac

death 34Other cardiacdeath16

Vascular death1, non-cardiacdeath 12

RR c Depression not reported to

be significant predictor ofSCD d in univariate analysis

Amiodarone Group:BDI e somatic score1.10(0.93,1.29)BDI cognitive-affectivescore 0.73 (0.52,1.01)Placebo Group:BDI somatic score1.00(0.88,1.13)BDI cognitive-affectivescore 1.09(0.99,1.89)

FrasureSmith, 2000

Recurrent cardiacevents (survivedand nonsurvivedreinfarctions),admission forunstable angina,arrhythmicdeaths, survivedcardiac arrests.

NA h NA OR i Any cardiac event: 3.32

(1.69,6.53)Acute coronary syndrome2.75 (1.32,5.72)Arrhythmic event: 3.65(0.99,10.47)

Recurrent cardiac events1.99(0.92,4.31)

Druss, 2000

NA Total mortality at 1

month

Likelihood ofPTCA k or

CABG l during

indexhospitalization

OR Total Mortality 7.3% in

patients with affectivedisorders compared to10.8% in patients with nomental disorders. 

Total Mortality 0.63 (p=0.2) in patients withaffective disordersRR for use of PTCA andCABG in patients with affective disorders: PTCA: 0.51CABG : 0.63
Evidence Table 3.5B. Results of Studies on the Relation of Depression to Cardiac Events after Myocardial Infarction (Question 

Study

Author,

Year

Outcome

 Stats a Univariate Comparison Multivariate Compariso

Cardiac Events Cardiac Mortality Other 

54

Shiotani, 2002

Annual cardiacevent rate 31.2%in Dep r patientand 23.9% inNonDep s patient.

Cardiac events: Dep 138, NonDep145; MI: Dep 19, NonDep15;Arrhythmias: Dep 2, NonDep 1; RePTCA: Dep 94 ,NonDep110 ; Heart Failure: Dep 7, NonDep 5; Angina: Dep 6, NonDep 5

Cardiac Mortality:Dep 4 NonDep 1 

Readmission Dep: 34 NonDep: 26 

OR Cardiac Events: 1.46 (CI t

1.11 - 1.92)

Cardiac Events: 1.41(CI1.04 - 1.92)

Strik,2003

Non Fatal MI at 3-4 yrs u

Fatal MI at 3 - 4 yrs Healthcare

consumption at3-4 yrs v

HR- cardiaceventsOR- Healthcareconsumption

CI- Not reported as single variables.Healthcare Consumption:1.61 (CI 1.00 - 2.57)

MI:CI 2.32 (1.04 - 5.18) ;Healthcare Consumption:1.55 (CI 0.96 - 2.52)
Evidence Table 3.5B Results of Studies on the Relation of Depression to Cardiac Events after Myocardial Infarction (Question 3

Study

Author,

Year

Outcome

 Stats a Univariate Comparison Multivariate Compariso

Cardiac Events Cardiac Mortality Other 

55

Strik,2004

Major cardiacevents 1 mo - 3yrs (includeddeath/recurrentMI; increasedhealth careconsumption, > 6visits at thecardiac outpatientclinic during followup)

NA Healthcare

consumption1m - 3 yrs

Depressionas predictorof majorcardiacevent-HR;depressionas predictorof healthcareconsumption- OR

Cardiac events:1.1(0.36,3.42)HealthcareConsumption1.66 (CI 0.90 -3.07)

Cardiac Events:0.88(0.26,2.93)Healthcare Consumption1.98 (CI 1.0 - 3.93)

a Comparison statisticb Not reportedc Risk ratiod Sudden cardiac deathe Beck Depression Inventoryf Myocardial infarctiong Congestive heart failureh Not applicable i Odds ratioj Angiotensin I converting enzymek Percutaneous coronary angioplastyl Coronary artery bypass graftm Hypertensionn Diabeteso Left ventricular ejection fractionp Systolic blood pressureq Treatmentr Depresseds Non-depressedt Confidence intervalu Yearsv Cardiac rehospitalization and/or frequent visits
66

Evidence Table 3.5C. Results of Studies on the Relation of Depression to Quality of Life in Patients after Myocardial Infarction 

Study

Author,

Year

Outcome Comparison

Statistic

Univariate

Comparison Multivariate Comparison Indepen

QOL a Other for in 

Travella,1994

Johns Hopkinsfunctioning inventory,Social functioningexam

NA b Multivariate

Rank

NR c Social functioning exam with

depression after baseline: f=1.85 (p=0.167); 3mos d: f=7.73 (p=0.1),

6mos f=4.38 (p=0.45) ,9mos: f=13.45 (p=0.001), 12mos f=7.94 (p=009)

NR

Drory,1998

Frequency of sexualactivity after MI at 3 -6mos, Satisfaction withsexual activity afterMI e

Depression Pearson

Correlation

Frequency of sexualactivity -0.16 (p<0.01); Satisfaction withsexual activity -0.14(p<0.01);

Frequency of sexual activity: -0.14(p<0.01); Satisfaction with sexual activity:-0.15(p<0.01))

Age, Race/ethnDiabetes, Previous hOther medDepressioPerceived Frequency 

Education

Irvine,1999

Social perception andhelp, daily living

Sudden cardiacdeath

Cox OR g NR Prev MI, 

Prev CHF 

Dyspnea/FSocial parSocial net

Ladwig,1999

NA Perception of

angina pectoris

OR NR 2.98 (CI i 1.50 - 5.90) Age > 50y

SBP j > 16Pre-infarcRecurrent SES l, 

Stroke, Non-fatal Re-infarctCardiac suHospitalizEpisode o
Evidence Table 3.5C. Results of Studies on the Relation of Depression to Quality of Life in Patients after Myocardial Infarction 

Study

Author,

Year

Outcome Comparison

Statistic

Univariate

Comparison Multivariate Comparison Indepen

QOL a Other for in 

67

O'Rourke,1999

Illness perceptionquestionnaire

NA Regression

ANOVA

NR NR Anxiety,

Control,Conseque

Soejima,1999

RTW m NA Logistic

regressionOR

OR RTW Extroversion 3.72 (CI

1.33 - 10.4)Despressive Sx n in hospital

0.15 (CI 0.02 - 0.87)

Age, Gender (mExtraversiDepressiv

EducationOccupatio

Bogg,2000

QOL after MI NA Regression NR Physical QOL male R2=46,

Physical QOL female R2=27,

Baseline anxiety R2=54

NR

Denollet,2000

Global mood scale, Health complaintscale

NA Regression

or OR

NR Failure to quit smoking 2.3 (1.2

- 4.5);Depressive sx 3.3 (1.9 - 5.8);Type D personality 2.2 (1.2 -3.8);EF o < 50% 2.0 (1.0 - 3.9);Hyperlipidemia 2.0 (1.1 - 3.4)

NR

Lane 2000

Dartmouth COOP p

Charts, BDI q

NA Correlation

score

Gender R=0.31,Partner status R=0.24,Living alone R=0.20,Employment statusR=0.18,Frequency of exerciseR= -0.21,Duration of exerciseR= -0.17BDI R=0.37,State anxiety R=0.28,Treat anxiety R=0.32,Peel Index R =0.27,LOSr R=0.15

BDI R2= 0.11 (p=0.0001),

Partner status 0.05 (p=0.002),Peel Index 0.05 (p=0.001),State anxiety 0.02 

BDI,Peel IndexPartner stState anxi
Evidence Table 3.5C. Results of studies on the Relation of Depression to Quality of Life in Patients after Myocardial Infarction (

Study

Author,

Year

Outcome Comparison

Statistic

Univariate

Comparison Multivariate Comparison Indepen

QOL a Other for in 

68

Mayou,2000

SF-36 Score s NA HR t Total mortality: NR;

At baseline:51.2(distressed),At baseline: 67.5(nondistressed) p<0.05;At 3 mos:38.7(distressed),At 3m: 62.3(nondistressed) p<0.05;At 12 mos:47.2(distressed),At 12 mos: 64.0(nondistressed) p<0.05

Total mortality: NR NR

Lane, 2001

NR NA Regression

Correlation

Gender R=0.2,Partner status R=0.22,Living alone R=0.3,Employment statusR=0.18,Frequency of exerciseR= -0.18,BDI R=0.32,State anxiety R=0.28,Treat anxiety R=0.24,Peel Index R=0.29,Killip class R=0.15,LOS R=0.25

BDI 0.11,Living alone 0.07,Peel Index 0.07,State anxiety 0.03

BDI,Peel IndexPartner stState anxi

Brink, 2002

Physical ComponentSF-36, Mental ComponentSF-36

NA Zero order

Correlation

NR Physical Component:-0.47;

Mental Component: -0.66

HADS u-a

Coping, Health com

Drory,2002

Perceived healthstatus

NA Hierarchical

Regression

NR Psychological well being Sense of c

DepressioEducationSocial sup
Evidence Table 3.5C. Results of studies on the Relation of Depression to Quality of Life in Patients after Myocardial Infarction (

Study

Author,

Year

Outcome Comparison

Statistic

Univariate

Comparison Multivariate Comparison Indepen

QOL a Other for in 

69

Drory, 2003

Perceived healthstatus

NA Regression NR NR Health st

ConcomiPerceive

 a Quality of life b Not applicable c Not reported d Months e Myocardial infarction f Acute myocardial infarctiong Odds ratioh Congestive heart failure i Confidence intervalj Systolic blood pressurek Millimeters of mercuryl Socio-economic statusm Return to workn Symptomso Ejection fractionp Dartmouth Primary Care Cooperative Information Project charts q Beck Depression Inventoryr Length of stays Medical Outcomes Study 36-item short form questionnaire t Hazard ratiou Hospital Anxiety and Depression Scale
70

Evidence Table 3a.1. Characteristics of Studies on the Relation of Depression to Biomarkers in Patients After Myocardial Infarc

Study

Author,

Year

Study

Design Target Population Exclusion Criteria Number of Study Sites Study Site Recruitment Period 

Carney,2001 

Pro cohort a Only MI b patients Active suicidal ideation, h/o c of

alcoholism/substance, cognitivelyimpaired, life threatening medicalillness, severe psychiatricdisorder, physically unable tocomplete the interview, lived toofar away, atrial fibrillation orflutter, implanted pacemaker

Multicenter,4 USA Oct 1997 -

Jan 2000

To detassocirate varecent 

Kuijpers, 2002

Pro cohort Only MI patients Previous MI NR d Europe NR To inve

functiodepresusing P

markeof nonpatientand siz

Lesperance, 2004

Pro cohort 481 patients with ACS g

81.7% with MIData for MI not reportedseperately. 

Terminally ill < 2 years,cognitively impaired, non Frenchspeaking, ACS secondary tomedical illness, too far fromintervention site, using antibiotics

Multicenter,2 Canada Aug 1999 -

Aug 2001

To detdepreshigher markefrom a

a Prospective cohort study b Myocardial infarctionc History of d Not reportede Platelet factor 4f Beta-thromboglobuling Acute coronary syndrome
71

Evidence Table 3a.2. Patient Characteristics of Studies on the Relation of Depression to Biomarkers in Patients After Myocardi

(Question 3a) 

Study

Author,

Year

No. of

Subjects

 Mean 

Age Male (%) Married (%) HTN a (%) DM b (%) Smoking (%) Lipid c (%) Killip Class (I-IV)

(%)

Me

Carney,2001 

Dep: 307, NonDep: 366

Dep: 57, NonDep: 4

Dep: 50, NonDep: 68

Dep: 57, NonDep: 77

Dep: 22, NonDep: 20

Dep: 35, NonDep: 22

Dep: 41, NonDep: 23

NR e NR Dep

Non

Kuijpers, 2002

Dep: 12, NonDep: 12

Dep: 48,NonDep: 50

Dep: 95, NonDep: 95

NR Dep: 8, 

NonDep: 50

NR Dep: 42, 

NonDep: 25

NR NR NR 

Lesperance, 2004

NonDep: 446, Dep: 35

NonDep: 60,Dep: 57

NonDep: 82, Dep: 66

NR NonDep: 66, 

Dep: 66

NonDep: 32, Dep: 43

NonDep: 14, Dep: 43

NonDep: 48, Dep: 74

NR EFf 

Non

Dep

a Hypertension b Diabetesc Hyperlipidemia d History ofe Depressed f Non-depressedg Not reportedh Ejection fractioni N=434
72

Evidence Table 3a.3. Assessment of Study Quality in Studies on the Relation of Depression to Biomarkers in Patients After Myo

(Question 3a)

Study Author, Year Representativeness Description of Therapy & Management Description of Assessment Protocol Outcomes and Follow-Up Statistical Analyses 

Carney, 2001

80% 17% 100% 58% 75% 

Kuijpers, 2002

40% 50% 100% 50% 75% 

Lesperance, 2004

90% 33% 100% 50% 0% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the 

(2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether thseries or randomly selected sample (2 patients).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other 

Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Outcomes and Follow-up: Percentage score was based on a total maximum score of 12 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), whether the cardiac outcome me

points), whether the depression outcome measures were defined (2 points), whether the same tools for diagnosing depression were used for baseline a

the planned length of follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether the magnitude of the difference for primary endpoints or magnitude of associ

index variability is reported (2 points) and whether adjustment was made for confounding (2 points).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
73

Evidence Table 3a.4. Depression Characteristics of Studies on the Relation of Depression to Biomarkers in Patients after Myoc(Question 3a)

Study

Author, 

Year

No. 

Screened

No. 

Enrolled Depression Instrument Time of Baseline Assessment Mean Follow-Up

Total Number at

Enrollment

Total N

Last F

Dep a NonDep b Dep 

Carney, 2001

NR c Dep 380

NonDep 424

Screening: ENRICHD dmodified DSM-IV eDISH f: present

depressive episodeBDI g: severity of

depression

Recent acute MI h

(#28 di)

NA j 307 366 NA 

Kuijpers, 2002

NR NR DSM-IV 3-6 mos k after first

MI

NA 12 12 NR 

Lesperance, 2004

2716 965 SCID l 2 mos after hospital

discharge

NA 35 446 NR 

a Depressed b Non-depressedc Not reported d Enhancing Recovery in Coronary Heart Diseasee Diagnostic & Statistical Manual of Mental Disorders f Depression Interview and Structured Hamiltong Beck Depression Inventory h Myocardial infarction i Day j Not applicable k Monthsl Structured Clinical Interview for Diagnostic & Statistical Manual of Mental Disorders-IV
74

Evidence Table 3a.5. Results of Studies on the Relation of Depression to Biomarkers in Patients after Myocardial Infarction (Qu

Study

Author, 

Year

Outcome

Comparison

Statistic

Depressed 

vs a

Non-Depressed

Multivariate

Comparison

Independent

Predictor

Variables

Adjusted for

in the

Multivariate

Analyses

Biomarkers

Carney, 2001

In univariate analysis all 4indicies of 24 hour HRV b were

significantly lower in patientswith depression.In multi-variate analysis all 3indices except 24 hour HRVwere significantly lower inpatients with depression.

Linearregression

NR c NR Age, 

Gender, Diabetessmokingstatus.

Patients after exscore $concentThe EN

DSM-IV

eligible present provided one prio

Kuijpers, 2002

PF4 f was significantly higher in

depressed post MI patientscompared to non-depressedpost MI patients, p=0.021. There was a trend toward asignificantly increased B-TG g

level with p=0.08, inspite ofuse of aspirin

MannWhitney U PF4 mean rank 15.75 IU/ml vs 9.25

IU/ml B-TG mean rank 15.04 IU/ml vs 9.96IU/ml

NR Age, 

Gender, Size of MI

No patieor hepaSmall sDepressany antAll patiehyperte

Lesperance,2004

Depressed patients hadsignificantly higher sICAM-1 hlevels even after adjustment forconfounders. These resultswere only slightly attenuated byadjustment of antidepressanttreatment.No significant associationbetween depression and IL6 i.

Uncertain about therelationship of CRP j on

depression as patients were onstatins.

Linearregression

NR sICAM

0.095+/-0.044 (withdepression)0.086+/-0.045 (withantidepressant addedto the model) 

Gender k,

Smoking k,

Metabolicsyndrome k

Results sample the time markers eventHigher n
Evidence Table 3a.5. Results of Studies on the Relation of Depression to Biomarkers in Patients after Myocardial Infarction (Qu

75

a Versusb Heart rate variabilityc Not reportedd Enhancing Recovery in Coronary Heart Disease Triale Diagnostic & Statistical Manual of Mental Disordersf Platelet factor 4g Beta thromboglobulinh Serum levels of soluble anti-intercellular adhesion molecule-1i Interleukin 6j C-reactive proteink Significant at p< 0.05
76

Evidence Table 4.1. Characteristics of Studies of Treatment of Post-Myocardial Infarction Depression (Question 4)

Study

Author,

Year

Study

Design Target Population Exclusion criteria Number of Study Sites Study Site Recruitment Period St

Dracup, 1991

Procohort

a

141 patients withCABG b69% with MI cNo separate data forMI patients provided

A d < 25 or $ 80; h/o e psychosis;bipolar disorder; non-English speaking;MI/CABG > 12 mos

Multicenter, 6 USA May 1985 -

Apr 1989

To compare tadaptation of in a multidimerehabilitation patients who 

Brown, 1993

RCT g 81 patients with ACSh

included62.5% with MINo separate data forMI patients provided

A < 43 or > 75; unstable medicalcondition; severe depression statusbefore cardiac event; suicidal ideation;changes in county residence;unwilling/unable to include partner

Multicenter, 5 USA May 1994 -

Dec 1997

To evaluate etherapy for trediagnosed witanxiety after a

Crowe, 1996

RCT Only MI patients A > 73; non-English speaking; unable to

complete questionnaire; unable toexercise with cycle ergometer/treadmillat low levels/limited by musculoskeletal;neurological/other medical conditions

Multicenter, 6 Canada Mar 1985 -

Apr 1988

To assess paanxiety and dhospitalized fodescribe the oof anxiety and group of patieafter the acute 

FrasureSmith, 1997 

RCT Only MI patients Life-threatening conditions; cognitively

impaired; residence from study hospital> 20 miles; deafness; refusal by patientphysician; participation in other trials;no telephone; non-English/non-Frenchspeaking

Multicenter,10

Canada Jan 1991 -

Sep 1994

To find out whmonthly screedistress combeducational hfor distressed year cardiac mwomen.
Evidence Table 4.1. Characteristics of Studies of Treatment of Post-Myocardial Infarction Depression (Question 4) (continued

Study

Author,

Year

Study

Design Target Population Exclusion criteria Number of Study Sites Study Site Recruitment Period St

77

Taylor, 1997

RCT Only MI patients A > 70; serious comorbid conditions;

non-English speaking; substanceabuse/other psychological problems

Multicenter, 5 USA 1988 - 1991 To assess eff

managed, muprogram on pamong post-M

Roose, 1998

RCT 81 patients with ACS

included62.5% with MINo separate data forMI patient provided

MI within 3 mos; QTc i > 460 ms; takingclass I antiarrhythmic; taking warfarin;unstable angina/cressendo 

Multicenter, 4 USA Not specified To compare t

cardiovasculaSSRI j(paroxe

antidepressanhydrochloridewith ischemic 

Johnston, 1999

RCT Only MI patients A > 70; non-English speaking; unable to

give informed consent 

Single center Europe Jan 1992 -

Feb 1983

To see after a who receive arehabilitation greater benefnormal care o

Strik, 2000

RCT Only MI patients A < 18 or > 75; hepatic dysfunction;

other significant non-reactive disease;psychosis; bipolar disorder; organicbrain syndrome; dementia; seriouscomorbidity; pregnant or lactating; useof psychotropic drugs; right ventricularfilling pressure > 30 mmHg; ATVI k< 20

cm; hypersensitivity to fluoxetine

Multicenter, 2 Europe May 1994 -

Dec 1997

To investigate the anti-deprepatients with dMI.

McFarlane, 2001

RCT Only MI patients CHF l; life threatening illness; inability to

complete questionnaire; already onantidepressants; 24 hour pre-dischargeholter monitoring with AF m/ventricular

ectopic beat > 100/hour

Single center Canada Sep 1996 -

Mar 1999

To determine SSRI, facilitatcardiac autonacute MI in pa
Evidence Table 4.1. Characteristics of Studies of Treatment of Post-Myocardial Infarction Depression (Question 4) (continued

Study

Author,

Year

Study

Design Target Population Exclusion criteria Number of Study Sites Study Site Recruitment Period St

78

Glassman, 2002

RCT 369 patients with ACS 

79.67%,with MI No separate data forMI provided

Anticipating cardiac surgery within 6m;index ACS < 3 mos after surgery;resting HR n < 40/min; Killip Class > III;

uncontrolled HTN o; persistent clinically

significant abnormalities; renaldysfunction; hepatic dysfunction; othersignificant noncardiac illness; anemia;cocaine use; alcohol or substanceabuse; women of childbearing potentialnot using adequate contraception;psychosis; bipolar disorder; organicbrain syndrome; dementia; significantsuicide risk; terminally ill; MMSE p < 23;concomitant Rx q with class I antiarrhythmic

Multicenter,40

USACanadaEuropeAustralia

Apr 1997 -Apr 2001

To evaluate ssertraline trea

hospitalized foand free of ot

Berkman,2003

RCT Only MI patients Noncardiac conditions fatal within 1y;

too ill to participate; participating inanother protocol; major psychiatriccomorbidity; imminent risk for suicide;physician disallowed participation;receiving psychotherapy for depression;MI following PCI s or CABG

Multicenter, 8 USA Oct 1996 -

Oct 1999

To determine recurrent infatreatments of 

with cognitive supplemented indicated, in pdays after MI.
Evidence Table 4.1. Characteristics of Studies of Treatment of Post-Myocardial Infarction Depression (Question 4) (continued

Study

Author,

Year

Study

Design Target Population Exclusion criteria Number of Study Sites Study Site Recruitment Period St

80

Swenson, 2003

RCT Included cases of MI

and unstable angina. Patients of unstableangina not recruitedtill 1998No separate data forMI provided

Anticipating cardiac surgery; index ACS< 3 mos after surgery; nonatherosclerotic MI; Killip Class > III;uncontrolled HTN; persistent clinicallysignificant abnormalities; renaldysfunction; hepatic dysfunction; othersignificant cardiac disease; women ofchildbearing A not using adequatecontraception; alcohol or substanceabuse; psychosis; bipolar disorder;organic brain syndrome; dementia;resting HR < 40/min; Rx with class Iantiarrhythmic; reserpine; guanethidine;clonidine; methyldopa; anticonvulsants;neuroleptics; antidepressant; regularbenzodiazepine; initiation ofpsychotherapy in 3m prior to studyentry

Multicenter, 7countries40 outpatientcardiologycenters andpsychiatryclinics

USA, Canada, Europe, Australia 

Apr 1997 -Apr 2001

To examine thtreatment on functioning in major depressrecently hospunstable angi

a Prospective cohort study b Coronary artery bypass graftc Myocardial infarction d Agee History of f Monthsg Randomized controlled trialh Acute coronary syndrome i QT Interval corrected for heart ratej Selective serotonin reuptake inhibitor k Aortic time velocity integral l Congestive heart failurem Atrial fibrillationn Heart rateo Hypertension
Evidence Table 4.1. Characteristics of Studies of Treatment of Post-Myocardial Infarction Depression (Question 4) (continued

81

p Mini Mental State Evaluationq Treatmentr Major depressive disorders Percutaneous Coronary Interventiont Low perceived social support
81

Evidence Table 4.2. Characteristics of Patients in Studies of Treatment of Post-Myocardial Infarction Depression (Question 4)

Study

Author,

Year

No. of 

Subjects

 Mean 

Age Male

(%)

White

(%)

 Married

a

(%)

Education b

(%)

Employed c

(%)

HTN d

(%)

DM e

(%)

Smoking

(%)

Lipid f

(%)

Killip C

(%

Dracup, 1991

41h; 

100i

63h; 

63i

93h; 

88i

NR 95h; 

97i

34h; 

15i

39h;

46ii

NR NR NR NR NR 

Brown, 1993

20 i; 

20 j

63i; 58j

55i; 90j

100i; 100j

90i; 

85j

100i; 

100j

NR NR NR NR NR NR 

Crowe, 1996

99j; 

102i

55 NR NR NR NR NR NR NR NR NR NR 

FrasureSmith, 1997 

692k; 

684l

59k; 

59l 66k; 65l NR NR NR NR Report ed

HTNRxm:

37k; 

34l

NR 49k; 

50l

NR Class I: 

63k, 66l

Class II16k; 14l

Class II21k; 20l

Taylor, 1997

199s; 

179l

57s; 

57l

80s; 

75l

76s; 

80l

78s; 82l

NR Full time:

74s; 69l

NR NR 41s; 

39l

NR NR 

Roose, 1998

41r; 

40t

58r; 

58t

88r; 78t

NR NR NR NR NR NR NR NR NR 

Johnston, 1999

29k; 38l; 

33l

57k; 

54l; 57l

67k; 

71l; 59l

NR NR 100k; 

100l; 

100l

NR NR NR 48k; 

74l; 61l

NR NR 

Strik,2000

27v; 

27p

54v; 

59p

77v; 

62p

NR NR NR NR NR NR NR NR NR 

McFarlane, 2001

12r; 

15t

56r;

 56t

67r; 

53t

NR NR NR NR 50r; 

38t

30r; 

23t

58r; 67t

NR NR 

Glassman, 2002

186w; 

183u

57w; 58u

63w; 64u

74w; 

79u

NR NR NR 61w; 

69u

31w; 

30u

27w; 

28u

70w; 

67u

Class II-7.1w; 7.

Berkman,2003

1238s;

1243l

61s; 

61l

57s; 

56l

67s; 

66l

53s; 

51l

48s; 

46l

NR 60s; 

61l

32s; 

33l

64s; 65l

58s; 

56l

Class II7s; 7l

Swenson, 2003

184r; 

183u

57r; 

58u

63r; 64u

74r; 

79u

55r; 

72u

73r; 69u

38r;38u

61r; 69u

30r; 31u

78r; 74u

69r; 67u

Class II 7.0r; 7.1

a Married or living with a partner b Education high school or higher
Evidence Table 4.2. Characteristics of Patients in Studies of Treatment of Post-Myocardial Infarction Depression (Question 4) (

82

c Employment full-time or part-time d Hypertensione Diabetes mellitusf Hyperlipidemiag History of h Cardiac rehabilitationi Usual carej Rehabilitationk Psychosocial intervention l Behavioral interventionm Treatmentn Ejection fractiono Usual care, no supportive therapyp Extended cardiac counselingq Inpatient cardiac counselingr Interventions Paroxetinet Nortriptylineu Placebov Fluoxetinew Sertraline
83

Evidence Table 4.3. Assessment of Study Quality in Studies of Treatment of Post-Myocardial Infarction Depression (Question 4

Article ID Representativeness Bias and Conflict Description Therapy and Management Description Protocol Outcomes and Follow-Up Statistical Anal

Dracup, 1991

35% 33% 34% 34% 34% 34% 

Crowe, 1996

80% 38% 59% 48% 53% 51% 

FrasureSmith, 1997

85% 88% 86% 87% 87% 87% 

Roose,1998

70% 58% 64% 61% 63% 62% 

Johnston,1999

60% 88% 74% 81% 77% 79% 

McFarlane,2001

75% 88% 81% 84% 83% 84% 

Berkman,2003

100% 63% 81% 72% 77% 74% 

Swenson,2003

90% 100% 95% 98% 96% 97% 

Brown, 1993

70% 75% 73% 74% 73% 73% 

Taylor,1997

70% 50% 60% 55% 58% 56% 

Strik, 2000

85% 83% 84% 84% 84% 84% 

Glassman,2002

95% 88% 91% 89% 90% 90% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the (2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether th

series or randomly selected sample (2 patients).Bias and Confounding: Percentage score was based on a total maximum score of 6 points. This included assessment of whether patients were random

(2 points), wether patient groups had important differences in patient characteristics (2 points), and whether there was blinding of test interpretation (2 Description of Therapy: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described therapy given (2 points), whether the study described details of the psychiatric treatment given (2 points), whether there was adequate description of o
Evidence Table 4.3. Assessment of Study Quality in Studies of Treatment of Post-Myocardial Infarction Depression (Question 4

84

points), whether description of the flow of participants was adequate (2 points), and whether assessment of adherence to therapy was given.

Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Outcomes and Follow-up: Percentage score was based on a total maximum score of 12 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), whether cardiac outcome measu

whether depression outcome measures were defined (2 points), whether the same tools for diagnosing depression were used for baseline and follow-up length of follow-up was planned (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether adjustment was made for confounding (2 points), and whether confidence int

patients).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
85

Evidence Table 4.4. Results of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4)

Study

Author,

Year

 Random

a

Meds

SSRI b Psycho- therapy Cardiac Rehabilitation

Duration

of

Intervention

Duration of

FU c

Drop-Out

Rate

Depression

Scores

Cumulative Cardia

Events 

Dracup, 1991

NA d NA NA A: Cardiac

RehabilitationProgram B: Noparticipation toa formalprogram

12 wks e 6 mos f NR g Multiple Affective

AdjectiveChecklist @ 6mos A: 8 , B: 13

NA 

Brown, 1993

4 to 24mos

NA C:

CognitiveBehavioralTherapy; D: Control

NA C: 12 wkly

1-hrsessions; D: 12 wkly1-hrsessions

C: 3, 9, 15mos; D: 3, 9, 15 mos

NR SCL 90-R

C: pre 65.1, 3 mos62.1, 15 mos 56.1;D: pre 71.2, 3 mos62.3, 15 mos 63.3;BDIC: pre 12.1, 3 mos6.9, 15 mos 5.6;D: pre 17.3, 3 mos9.4, 15 mos 10.5; MMPI-168C: pre 74.1, 3 mos68.1, 15 mos 67.5;D: pre 79.2, 3 mos72.8, 15 mos 77.4

NA 
Evidence Table 4.4. Results of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

 Random

a

Meds

SSRI b Psycho- therapy Cardiac Rehabilitation

Duration

of

Intervention

Duration of

FU c

Drop-Out

Rate

Depression

Scores

Cumulative Cardia

Events 

86

Crowe, 1996

6 wks NA NA NA NR 1 yr k 18% BDI

E: 3 d 4.1, 3 mos3.3, 6 mos 2.6, 14mos 3.2;F: 3 d 3.9, 3 mos3.7; 6 mos 3.3, 14mos 2.9;

NA 

FrasureSmith, 1997

NR NA NA G: Intervention

that involved acombination ofemotionalsupport,reassurance,education,practicaladvice & healthresources. H: usual care

1 yr 12 mos 6.5% BDI

G: baseline 8.1,12 mos 6.9;H: baseline 8.4,12 mos 7.6

Cardiac Mortality G: 4.8%; H: 3.4%;MI l

G: 4.8%; H: 5%; Revascularization G: 13.4%; H: 14%
Evidence Table 4.4. Results of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

 Random

a

Meds

SSRI b Psycho- therapy Cardiac Rehabilitation

Duration

of

Intervention

Duration of

FU c

Drop-Out

Rate

Depression

Scores

Cumulative Cardia

Events 

87

Taylor,1997

Day 3 oras soonas theirmedicalconditionstabilized

NA NA I: Nursemanaged,

home-basedsystem forcoronary riskfactormodificationand stressmanagement. J: Usualmedical care

1 yr Upto 1 yr I: 29%; 

J: 37%

Low levelsdepressed moodI: baseline 1.7, 12mos 1.3; J: baseline 1.8, 12mos 1.2;Moderate-highlevels depressedmoodI: baseline 6.1, 12mos 1.4;J: baseline 5.7, 12mos 1.5

Mortality I: 4%; J: 3%
Evidence Table 4.4. Results of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

 Random

a

Meds

SSRI b Psycho- therapy Cardiac Rehabilitation

Duration

of

Intervention

Duration of

FU c

Drop-Out

Rate

Depression

Scores

Cumulative Cardia

Events 

88

Roose,1998

NS K:

Paroxetine 10-20mg/day, L:Nortriptyline25mg/day

NA NA 2 wks 6 wks NR Heart rate 

K: baseline 10%,6 wks 6%;L: baseline 11%, 6wks 7%; Standing pulserate standingK: baseline 11%,6 wks 11%; L: baseline 14%, 6wks 16%;Supine pulse ratesupineK: baseline 10%,6 wks 10%;L: baseline 12%, 6wks 14%;HRV SDNNK: baseline 37%,6 wks 27;L: baseline 19%, 6wks 16%; HRV pNN50K: baseline 10%,6 wks 4%;L: baseline 9%, 6wks 7%

NA 
Evidence Table 4.4. Results of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

 Random

a

Meds

SSRI b Psycho- therapy Cardiac Rehabilitation

Duration

of

Intervention

Duration of

FU c

Drop-Out

Rate

Depression

Scores

Cumulative Cardia

Events 

89

Johnston,1999

Within 72hrs

NA NA M: Extended

programinvolvingadditionalsessions in the2m afterdischarge. N: InpatientcardiacrehabilitationprogramO: Control

6 wks Up to 1 yr NR HADS

M: baseline 4.1,12 mos 3;N: baseline 4.4,12 mos 3.6;O: baseline 4.6,12 mos 5.8 

NA 

Strik, 2000

3 - 12mos

A:Fluoxetine20mg/day; B:Placebo

NA NA Maximum

25 wks

Up to 1 yr A: 33%;

B: 19%

HAMD change @25 wksGroup P:-9.65(7.2), GroupQ: -6.9(6.9)

NA 
Evidence Table 4.4. Results of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

 Random

a

Meds

SSRI b Psycho- therapy Cardiac Rehabilitation

Duration

of

Intervention

Duration of

FU c

Drop-Out

Rate

Depression

Scores

Cumulative Cardia

Events 

90

McFarlane,2001

Atdischargefrom MI

Sertraline50mgdaily,Placebo daily

NA NA 6 mos 6 mos 29% NR NA 

Glassman,2002

33.7 (9.9)days

A:Sertraline50mg/ddaily; B:Placebodaily

N/A N/A 149.5 for

sertralineand 153.8days forplacebogroup

24 wks A: 18%;

B: 12%

CGI - 1 meanscoreA: 2.57, B: 2.75; HAM-D meanchange in score at6 mos A: -8.4, B: -7.6 

MI A: 5, B: 7;Congestive heartfailure A:5, B:7 Angina A:26, B:30 
Evidence Table 4.4. Results of Studies on Treatment of Post-Myocardial Infarction Depression (Question 4) (continued)

Study

Author,

Year

 Random

a

Meds

SSRI b Psycho- therapy Cardiac Rehabilitation

Duration

of

Intervention

Duration of

FU c

Drop-Out

Rate

Depression

Scores

Cumulative Cardia

Events 

91

Berkman,2003

Within28 days

Sertraline50mg/d

A: Usualcare B:Cognitivebehavioraltherapy,Socialproblemsolving,plus SSRIcertainconditions

NA 180 days A: 18 mos; 

B: 18 mos

NR BDI change

(baseline- at 6mos)A: -5.8(8.9), B -8.6(9.2) HRSD change(baseline- at 6mos)A: -8.4(7.7) B -10.1(7.8)

Cardiac Mortality A: 115 (9.3%); B: 96 (7.8%); MI (recurrent nonfatal)A: 170 (13.7%); B: 168 (13.6%), Revascularization A: 230 (18.5%); B: 216 (17.4%)

Swenson,2003

A: 34 B: 34

A:Sertraline50mg/daily; B:Placebo daily

NA NA 24 wks A: 18 mos; 

B: 18 mos

NR HAMD score

change at 16wks A: -8.4(0.4)B:-7.6(0.4) BDIscore change at16 wks A:-8.0(0.6) B:-7.3(0.6)

NR 

a Time to randomization after myocardial infarction b Medications selective serotonin reuptake inhibitorc Follow-up d Not applicablee Weeksf Monthsg Not reported h Symptom Checklist 90 i Beck Depression Inventory j Minnesota Multiphase Personality Inventory k Yearl Myocardial infarction
92

Evidence Table 5.1. Characteristics of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Que

Study Author,

Year Study Design Exclusion Criteria

Study

Site

Recruitment

Period Study Objective 

Numbe

Subjec

Davis, 1988 

Pro cohort a,

single center

Age > 65; psychiatrictreatment

Canada NR b To identify optimal methods of

detecting depression in medically illsubjects.

52 

Martin, 2000

Cross-sectional,single center

Non-English speaking Europe NR To determine the utility of HADS c in

acute MI d patients by examination of

the instrument's underlying factorstructure.

194 

Wojciechowski, 2000

Pro cohort,single center

Age < 18 or > 75;previous MI

Europe May 1994 -

Jan 1996

To investigate whether or notdepression and vital exhaustion areseparate entities.

143 

Strik, 2001 

Cross-sectional,single center

Recurrent MI Europe May 1997 -

Sep 1999

To assess sensitivity and specificity of3 self-report questionnaires and oneobserver rating scale as screeninginstruments for major and minordepression following first MI.

206 

Freedland, 2002

Pro cohort AMI e post CABG f/invasive procedure;

significant othermedica/majorpsychiatriccomorbidity;psychiatricmedications/psychotherapy

USA Oct 1996 - Oct

1999

To evaluate the effects of apsychosocial intervention oncardiovascular morbidity and mortalityin post-MI patients exhibitingdepression and/or social isolation. 2404 

Martin, 2003

Pro cohort, multi-center

NR Europe NR To determine the factor structure of

the HADS in a clinical populationfollowing MI and to determine changesensitivity characteristics andpsychometric reliability of the HADS inthis patient group.

335 

a Prospective cohort
Evidence Table 5.1. Characteristics of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Ques

93

b Not reportedc Hospital Anxiety and Depression Scale d Myocardial infarctione Acute myocardial infarction f Coronary artery bypass graft
94

Table 5.2. Assessment of Study Quality in Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Q

Study Author,

Year Representativeness Bias and Confounding Assessment of Therapy and Management Description of Assessment Protocol Test/ Interpretation Outcomes and Follow-Up St

A

Davis, 1988 46% 50% 0% 58% 33% 50% Wojciechowski, 2000 75% 67% 42% 58% 71% 100% Martin, 2003 71% 0% 8% 100% 33% 75% Martin, 2000 75% 40% 0% 17% 42% 0% Strik, 2001 83% 40% 0% 67% 50% N/A Freedland, 2002 100% 60% 0% 50% 17% 100% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the 

(2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether thseries or randomly selected sample (2 patients).Bias and Confounding: Percentage score was based on a total maximum score of 10 points. This included assessment of whether the decision to obtain 

affected by results of the study instrument (2 points), whether there was blinding of test interpretation (2 patients), whether interpretation of the study 

or more independent observers (2 patients), whether interpretation of the reference test was performed by two or more independent observers (2 pointstandard and study test were measured before interventions were started with knowledge of test results (2 points).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).Test Interpretation: Percentage score was based on a total maximum score of 12 points. This included assessment of the description of interpretation c

depression (2 points) and of the reference test (2 points), whether individuals receiving the study test also received the reference test (2 points), whethperformance and index of variability was reported for the study test (2 points), whether methods for calculating test reproducibility were described (2 authors described how indeterminate results were handled (2 patients).
Table 5.2. Assessment of Study Quality in Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Q

95

Outcomes and Follow-up: Percentage score was based on a total maximum score of 6 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), and whether the same tools for dused for baseline and follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether adjustment was made for confounding (2 points), and whether confidence int

patients).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
96

Evidence Table 5.3. Results of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Question 5)

Study Test Sensitivity Specificity 

Davis, 1988 

#1 SCID a nurse & therapist

interview

NR b NR Concordance: 80.8

#2 SCID nurse and BDl c NR NR Concordance: 13.5#3 Therapist interview and BDI NR NR Concordance: 11.5

Martin, 2000

HADS d all items / including

HADS Depression subscale

NR NR Internal consistenc

HADS-D; Exploratory factor a

Wojciechowski, 2000

#1 Zung e / SCL-90-Dep f NR NR Pearson correlation

1, 3, 6, 12 months 

#2 Zung SDS / Maastricht

Quest (vital exhaustion)

NR NR Pearson correlation

at 1, 3, 6, 12 month

#3 SCL-90-Dep / Maastricht

Quest (vital exhaustion)

NR NR Pearson correlation

at 1, 3, 6, 12 month
Evidence Table 5.3. Results of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Question 5) (

Study Test Sensitivity Specificity 

97

Strik, 2001 

#1 SCL-90 81.1% (for major and

minor depression), 95.5% (for majordepression only)

83.5% (for major and minordepression), 74% (for major depression only)

PPV h: 40% (for major and 36.8% (for major deNPV i: 

93.3% (for major an96.2% (for major de

#2 BDI 83.8% (for major and

minor depression), 81.8% (for majordepression only)

71.7% (for major and minordepression), 78.7% (for major depression only)

PPV: 25.3% (for major an33.3% (for major deNPV: 98.3% (for major a97.9% (for major de

Strik, 2001 

#3 HADS/ HADS-Depression

subscale

HADS 78.1% (for majorand minor depression),90% (for majordepression only); HADS-D j 75% (for

major and minordepression), 85% (formajor depression only)

HADS 85% (for major and minordepression), 84.3% (for majordepression only); HADS-D 77.6% (for major and minordepression), 74.8% (for majordepression only)

HADS PPV: 45.2% (for major an45.2% (for major deHADS NPV: 99.3% (for major an99.3% (for major deHADS-D PPV: 32.1% (for major an32.1% (for major deHADS-D NPV: 98.4% (for major an98.4% (for major deNote: There appeaoriginal article tableequal for both majodepression, which dother statistical dat

#4 17-item HAM-D k 76.3% (for major and

minor depression), 86.4% (for majordepression only)

86.0% (for major and minordepression ), 92.2% (for major depression only)

PPV: 40.7% (for major anNPV: 99.3% (for major an98.2% (for major de
Evidence Table 5.3. Results of Studies on Methods of Screening for Depression in Myocardial Infarction Patients (Question 5) (

Study Test Sensitivity Specificity 

98

Freedland, 2002

BDI / HAM-D NR NR Pearson correlation 

Martin,2003

HADS all items / includingHADS Depression subscale

NR NR Internal consistenc

0.87 for HADS, 0.70.88 for HADS, 0.80.90 for HADS, 0.8Confirmatory factor 

a Structured Clinical Interview for Diagnostic & Statistical Manual of Mental Disorders IV b Not reportedc Beck Depression Inventory d Hospital Anxiety and Depression Scalee Zung Self Rating Depression Scale f Symptom Check List 90g Myocardial infarction h Positive predictive value i Negative predictive value j Hospital Anxiety and Depression Scale - depression subscale k Hamilton Rating Scale for Depression
99

Evidence Table 6.1. Characteristics of Studies on Relation of Depression to Use of Treatment in Patients after Hospitalization fo

(Question 6)

Study Study Design Target Population Exclusion criteria Number of Study Sites Study Site Recruitment Period St

Blumenthal,1982

Pro cohort a Only MI b patients

(recent MI)

NR c Single center USA NR To determine w

physiological adetermine droprehabilitation p

Conn, 1991

Retro cohort d Only MI patients

(MI in preceding1-2 years )

Multiple MI; planned/receivedcardiac surgery; received dailyassistance from paid health careworker; institutionalized; unableto participate in interview

Single center USA NR To examine re

anxiety, depres

among older a

Druss, 2000

Retro cohort Only MI patients

(Medicare claimsfor MI)

Age < 65; transferred to/fromother facility; terminal illness;DNR f order

Mutlicenter USA Feb 1994 - Jul

1995

To assess whemental disordelower likelihood catheterization after acute MI. 

Ziegelstein, 2000

Pro cohort Only MI patients

(acute MI)

Unable to interview due to beingcognitive impairment/medicallyunstable; transferred to otherfacility; died < 48 hours post-MI

Single center USA NR To determine w

adherence to rintended to redevents after an 

Romanelli, 2002

Pro cohort Only MI patients

(acute MI)

Age < 65; major cognitiveproblems; unable to interviewdue to medical instability withinfirst 5days post-MI; comorbidnon-cardiac illness likely tocause death within the next6months; transferred to anotherfacility; died within first 48 hourspost-MI 

Single center USA NR To determine t

depression in iolder. 
Evidence Table 6.1. Characteristics of Studies on Relation of Depression to Use of Treatment in Patients after Hospitalization fo

(Question 6) (continued)

Study Study Design Target Population Exclusion criteria Number of Study Sites Study Site Recruitment Period St

100

Bennet, 2003

Pro cohort First acute MI Age > 75; prior MI; need for

cardiac surgery

Single center Europe NR To determine i

cognitive variafor CHD g after 

Lauzon, 2003

Pro cohort Only MI patients

(acute MI)

Non-English/non-Frenchspeaking; transferred fromanother hospital; physicallyincapable of responding to aquestionnaire; unable to giveinformed consent

Mutlicenter,10

Canada Dec 1996 -

Nov 1998

To measure thprognostic impsymptoms afteinfarction.

Whitmarsh, 2003

Pro cohort Only MI patients

(acute MI able toparticipate incardiacrehabilitation)

NR Single center Europe Oct 1999 - 

May 2000

To identify psynon-attendanc

Steeds, 2004

Pro cohort Only MI patients

(acute MI)

Age > 75; incapable of givingwritten; informed consent

Single center Europe 1999 - 2000 To determine t

elevated BDI h 

relation betweeprognosis in a MI. 

Strik, 2004

Pro cohort Only MI patients

(first MI)

Major psychiatric disordersother than affective disorder;cognitive dysfunction; nonDutch speaking; lived more than50km away from study center;comorbid life-threatening illness

Single center Europe NR To evaluate pr

year incidence depression in cpatients followievaluate whethdepression, anpredicted cardiup to 3 years p

a Prospective cohort
Evidence Table 6.1. Characteristics of Studies on Relation of Depression to Use of Treatment in Patients after Hospitalization fo

(Question 6) (continued)

101

b Myocardial infarctionc Not reportedd Retrospective cohort studye Quality of lifef Do not resuscitateg Coronary heart diseaseh Beck Depression Inventory
102

Evidence Table 6.2. Results of Studies of Relation of Depression to use of Treatment in Patients after Hospitalization for Myoca

(Question 6)

Study

Author,

Year

No. of

Subjects

 Mean Age Male

(%)

White

(%)

HTN a

(%)

DM b

(%)

Smoking

(%)

Lipid c

(%)

Killip Class d

(%)

Me

Blumenthal,1982

35 54 NRe NR NR NR NR NR NR NR 

Conn,1991

94 74 50 NR NR NR NR NR NR NR 

Druss,2000

5365f;

08288g

76 52f; 

46g

92f; 

91g

42f;

41g

22f; 

26g

23f;

15g

NR NR EF 

14f

EF 29fEF 52h

Ziegelstein; 2000

35i;

169j; 

31k; 

173l

46i; 

55j; 42k; 54l

46i; 

59j; 52k;58l

NR 71i;

62j;71k;

63l

31i; 

30j;36k;

31l

31i;

27j; 29k;

27l

69i; 

61j; 71k; 

60l

Class II:31i, 37j, 32k, 35l; 

Class III:32i, 37j, 32k, 35l; Class IV:31i, 37j, 32k, 35l

37i;

23j; 23k25l

Romanelli; 2002

35h; 

118m

75h; 

74m

57h; 

55m

97h; 

90m

71h; 

70m

49h; 

33m

NR 57h; 

60m

Class > I: 54h; 49m

EF 50h 

Bennet;2003

37 62 73 NR NR NR NR NR NR NR 

Lauzon; 2003

191h; 

359m

60h; 

60m

75h; 

81m

94h; 

97m

34h; 

36m

16h;

16m

40h;

40m

35h; 

39m

Class I: 81h; 83m

NR 

Whitmarsh; 2003

93 64 76 100 NR NR 61 NR NR NR 

Steeds; 2004

62n; 

69o

NR NR NR NR NR NR NR NR NR 

Strik; 2004

63h; 

143m

59 67h; 

80m

NR NR NR 10h; 

13m

35h; 29m NR EF 

56h

a Hypertension b Diabetes

c Hyperlipedemia d Killip Class I - IVe Not reported f Mental disorders
Evidence Table 6.2. Results of Studies of Relation of Depression to use of Treatment in Patients after Hospitalization for Myoca

(Question 6) (continued)

103

g No mental disordersh Depressedi BDI >10j BDI <10k Major depression/dysthymial No major depression/dysthmiam Not depressedn BDI 12o BDI < 12 
104

Evidence Table 6.3. Assessment of Study Quality in Studies of Depression to Use of Treatment in Patients after Hospitalization Infarction (Question 6)

Author, 

Year

Representativeness 

of 

Study Population

Description of 

Therapy and

Management

Description of 

Assessment

Protocol

Outcomes 

and 

Follow-Up

Statistical 

Analyses

Bias 

and 

Confoundin

Conn, 1991

90% 17% 100% 71% 0% 0% 

Druss, 2000

15% 0% 50% 25% 25% 0% 

Ziegelstein,2000

85% 9% 50% 50% 84% 100% 

Strik, 2004

75% 58% 50% 50% 67% 0% 

Steeds, 2004

40% 0% 100% 50% 50% 0% 

Blumenthal,1982

25% 0% 25% 100% 75% 25% 

Whitmarsh,2003

60% 0% 88% 17% 50% 25% 

Romanelli,2002

75% 25% 50% 50% 50% 0% 

Lauzon, 2003

65% 33% 100% 100% 33% 0% 

Representativeness: Percentage score was based on a total maximum score of 10 points. This included assessment of how well the study described the 

(2 points), inclusion/exclusion criteria (2 points), non-participating patients (2 points), patient characteristics at enrollment (2 patients), and whether thseries or randomly selected sample (2 patients).Bias and Confounding: Percentage score was based on a total maximum score of 10 points. This included assessment of whether the decision to obtain 

affected by results of the study instrument (2 points), whether there was blinding of test interpretation (2 patients), whether interpretation of the study 

or more independent observers (2 patients), whether interpretation of the reference test was performed by two or more independent observers (2 pointstandard and study test were measured before interventions were started with knowledge of test results (2 points).Description of Therapy: Percentage score was based on a total maximum score of 6 points. This included assessment of how well the study described 

given (2 points), whether the study described details of the psychiatric treatment given (2 points), and whether there was adequate description of other Description of Assessment: Percentage score was based on a total maximum score of 4 points. This included assessment of the description of methods 

depression (2 points), and the description of the interpretation criteria for a diagnosis of depression (2 points).
Evidence Table 6.3. Assessment of Study Quality in Studies of Depression to Use of Treatment in Patients after Hospitalization 

Infarction (Question 6) (continued)

105

Test Interpretation: Percentage score was based on a total maximum score of 12 points. This included assessment of the description of interpretation cdepression (2 points) and of the reference test (2 points), whether individuals receiving the study test also received the reference test (2 points), whethperformance and index of variability was reported for the study test (2 points), whether methods for calculating test reproducibility were described (2 authors described how indeterminate results were handled (2 patients).Outcomes and Follow-up: Percentage score was based on a total maximum score of 6 points. This included assessment of whether the study reported 

withdrawals or those lost to follow-up (2 points), the percentage of patients withdrawn or lost to follow-up (2 points), and whether the same tools for dused for baseline and follow-up (2 points).Statistical Analyses: Percentage score was based on a total maximum score of 8 points. This included assessment of whether statistical tests were clea

whether loss to follow-up was handled appropriately (2 points), whether adjustment was made for confounding (2 points), and whether confidence int

patients).Conflict of Interest: Percentage score was based on a total maximum score of 2 points. This involved determination of whether the study identified the 

involvement of the funding agency.
106

Evidence Table 6.4. Results of Studies on the Relation of Depression to Use of Treatment after Hospitalization for Myocard

(Question 6)

Study

Author,

Year

Study Group Diagnosis of MI

Method of

Assessing

Depression 

Used for

Analysis

No. of

Subjects Follow-Up

Cardiac

Cath a

(% )

PTCA b

(%)

CABG c

(%)

Druss, 2000

Major depression/affective ICD-9 d ICD-9 315 16 mos e 33 f 9 8 

No mental disorders 108288 16 mos 44 f 17 13 

Ziegelstein, 2000

Major depression/dysthmia Pain, EKG g,

CPK-MB h

SCID i

BDI j > 10

31 4 mos NR NR NR 

Not depressed 173 4 mos NR NR NR 

Romanelli, 2002

Depressed(BDI $10) Pain, EKG,

CPK-MB

SCID

35 4 mos NR NR NR 

Not depressed 118 4 mos NR NR NR 

Lauzon, 2003

Depressed NR

BDI-10

191 30 d k 57 32 7 

Not depressed NR 359 30 d 47 25 8 Depressed NR

BDI-10

191 1 yr l 67 39 19 

Not depressed NR 359 1 yr 55 30 16 

Steeds,2004

Depressed Pain, 

EKG, CPK-MB

BDI-12

62 32 mos NR NR NR 

Not depressed 69 32 mos NR NR NR 

Strik, 2004

Depressed/Minor depression Pain, EKG, 

ASAT m

SCID

63 1 yr NR 36 NR 

Not depressed 143 1 yr NR 36 NR 

a Cardiac catheterizationb Percutaneous transluminal coronary angioplastyc Coronary artery bypass graft d The International Statistical Classification of Diseases and Related Health Problemse Monthsf p < 0.001g Electrocardiogram h Creatine phosphokinase - muscle brain
Evidence Table 6.4. Results of Studies on the Relation of Depression to Use of Treatment after Hospitalization for Myocard

(Question 6) (continued)

107

i Structured Clinical Interview for Diagnostic & Statistical Manual of Mental Disorders IV j Beck Depression Inventoryk Dayl Yearm Aspartate aminotransferase
Excluded Studies 

Ades PA, Savage PD, Tischler MD, et al. Determinants of 

disability in older coronary patients. Am Heart J 2002; 

143(1): 151-6. 

No data on when MI occurred relative to when 

depression assessed 

Ades PA, Waldmann ML, McCann WJ, et al. Predictors of 

cardiac rehabilitation participation in older coronary 

patients. Arch Intern Med 1992; 152(5): 1033-5. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Ahto M, Isoaho R, Puolijoki H, et al. Coronary heart 

disease and depression in the elderly--a population-based 

study. Fam Pract 1997; 14(6): 436-45. 

No data on when MI occurred relative to when 

depression assessed 

Al-Ruzzeh S, Mazrani W, Wray J, et al. The Clinical 

Outcome and Quality of Life Following Minimally 

Invasive Direct Coronary Artery Bypass Surgery. J Card 

Surg 2004; 19(1): 12-16. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Appels A, Hoppener P, and Mulder P. A questionnaire to 

assess premonitory symptoms of myocardial infarction. Int 

J Cardiol 1987; 17(1): 15-24. 

Does not apply 

Baer PE Cleveland SE Montero AC. Improving postmyocardial infarction recovery status by stress management 

training during hospitalization. J Card Rehab 1985; 5(4): 

191-197. 

Does not apply 

Baker RA, Andrew MJ, Schrader G, et al. Preoperative 

depression and mortality in coronary artery bypass surgery: 

preliminary findings. Anz J Surg 2001; 71(3): 139-42. 

No data on when MI occurred relative to when 

depression assessed 

Beck CA, Joseph L, Belisle P, et al. Predictors of quality of 

life 6 months and 1 year after acute myocardial infarction. 

Am Heart J 2001; 142(2): 271-9. 

Does not apply 

Bennett P, Brooke S. Intrusive memories, post-traumatic 

stress disorder and myocardial infarction. Br J Clin Psychol 

1999; 38 ( Pt 4): 411-6. 

Does not apply 

Bennett P, Lowe R, Mayfield T, et al. Coping, mood and 

behaviour following myocardial infarction: results of a 

pilot study. Cor Health Care 1999; 3(4): 192-8. 

Does not apply 

Bennett P, Mayfield T, Norman P, et al. Affective and 

social-cognitive predictors of behavioural change following 

first myocardial infarction. Br J Health Psychol 1999; 4(3): 

247-256. 

Does not apply 

Bennett P, Owen RL, Koutsakis S, et al. Personality, social 

context and cognitive predictors of post-traumatic stress 

disorder in myocardial infarction patients. Psychol Health 

2002; Vol 17(4): 489-500. 

Does not apply 

Berkman L, Jaffe A, Carney R, et al. Enhancing recovery in 

coronary heart disease (ENRICHD) study intervention: 

Rationale and design. Psychosom Med 2001; 63(5): 747-

755. 

No original data 

Berkman LF, Leo-Summers L, and Horwitz RI. Emotional 

support and survival after myocardial infarction. A 

prospective, population-based study of the elderly. Ann 

Intern Med 1992; 117(12): 1003-9. 

Does not apply 

Bhatia MS, Tiwari A, Balkrishna, et al. Type A behaviour, 

life events & myocardial infarction. Indian J Med Res 

1990; 92: 95-100. 

Does not apply 

Bianchi G, Fergusson D, and Walshe J. Psychiatric 

antecedents of myocardial infarction. Med J Aust 1978; 

1(6): 297-301. 

Published before 1980 

Billing E, Lindell B, Sederholm M, et al. Denial, anxiety, 

and depression following myocardial infarction. 

Psychosom 1980; 21(8): 639-41, 644-5. 

Does not apply 

Black JL, Allison TG, Williams DE, et al. Effect of 

intervention for psychological distress on rehospitalization 

rates in cardiac rehabilitation patients. Psychosom 1998; 

39(2): 134-43. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Blair AJ, Leakey PN, Rust SR, et al. Locus of control and 

mood following myocardial infarction. Cor Health Care 

1999; 3(3): 140-4. 

Does not apply 

Boone T. Patient reactions to the exercise staff, program 

and prescription following myocardial infarction. Am Corr 

Ther J 1986; Vol 40(3): 62-67. 

Does not apply 

Bremer Schulte M, Pluym B, and Van Schendel G. 

Reintegration with Duos: A self-care program following 

myocardial infarction. Patient Educ Counsel 1986; Vol 

8(3): 233-244. 

Does not apply 
Brezinka V, Dusseldorp E, and Maes S. Gender differences 

in psychosocial profile at entry into cardiac rehabilitation. J 

Cardiopulm Rehabil 1998; 18(6): 445-9. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Brown JH. Depression after myocardial infarction. Can 

Med Assoc J 1976; 114(3): 187. 

Published before 1980 

Brown MA, Munford A. Rehabilitation of post MI 

depression and psychological invalidism: a pilot study. Int J 

Psych Med 1983-1984; 13(4): 291-8. 

Case report or case series 

Brown N, Melville M, Gray D, et al. Quality of life four 

years after acute myocardial infarction: short form 36 

scores compared with a normal population. Heart 1999; 

81(4): 352-8. 

Does not apply 

Bruhn JG, Chandler B, and Wolf S. A psychological study 

of survivors and nonsurvivors of myocardial infarction. 

Psychosom Med 1969; 31(1): 8-19. 

Published before 1980 

Bruhn JG, Paredes A, Adsett CA, et al. Psychological 

predictors of sudden death in myocardial infarction. J 

Psychosom Res 1974; 18(3): 187-91. 

Published before 1980 

Buchanan LM, Cowan M, Burr R, et al. Measurement of 

recovery from myocardial infarction using heart rate 

variability and psychological outcomes. Nurs Res 1993; 

42(2): 74-8. 

Does not apply 

Burrel G, Sundin O, Stroem G, et al. Heart and lifestyle: A 

Type A treatment program for myocardial infarction 

patients. Scand Behav Ther 1986; Vol 15(3): 87-93. 

Does not apply 

Byrne DG. Illness behaviour and psychosocial outcome 

after a heart attack. Br J Clin Psychol 1982; 21 (Pt 2): 145-

6. 

No original data 

Carinci F, Nicolucci A, Ciampi A, et al. Role of 

interactions between psychological and clinical factors in 

determining 6-month mortality among patients with acute 

myocardial infarction. Application of recursive partitioning 

techniques to the GISSI-2 database. Gruppo Italiano per lo 

Studio della Sopravvivenza nell' Infarto Miocardico. Eur 

Heart J 1997; 18(5): 835-45. 

Does not apply 

Carney RM, Freedland KE, Clark KA, et al. Psychosocial 

adjustment of patients arriving early at the emergency 

department after acute myocardial infarction. Am J Cardiol 

1992; 69(3): 160-2. 

Does not apply 

Carney RM, Freedland KE, Eisen SA, et al. Major 

depression and medication adherence in elderly patients 

with coronary artery disease. Health Psychol 1995; 14(1): 

88-90. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Carney RM, Freedland KE, Smith L, et al. Relation of 

depression and mortality after myocardial infarction in 

women. Circ 1991; 84(4): 1876-7. 

Letter 

Carney RM, Freedland KE, Stein PK, et al. Change in heart 

rate and heart rate variability during treatment for 

depression in patients with coronary heart disease. 

Psychosom Med 2000; 62(5): 639-47. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Carney RM, Rich MW, Tevelde A, et al. Major depressive 

disorder in coronary artery disease. Am J Cardiol 1987; 

60(16): 1273-1275. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Carney RM, Freedland KE, Stein PK, et al. Effects of 

depression on QT interval variability after myocardial 

infarction. Psychosom Med 2003; Vol 65(2): 177-180. 

Does not apply 

Carney RM, Rich MW, Freedland KE, et al. Major 

depressive disorder predicts cardiac events in patients with 

coronary artery disease. Psychosom Med 1988; 50(6): 627-

33. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Cassem NH, Hackett TP. Psychiatric consultation in a 

coronary care unit. Ann Intern Med 1971; 75(1): 9-14. 

Published before 1980 

Catipovic-Veselica K, Marosevic L, Ilakovac V, et al. 

Bortner type A scores and eight basic emotions for 

survivors of ventricular fibrillation and left ventricular 

failure during acute myocardial infarction. Psychol Rep 

1996; 79(3 Pt 2): 1195-202. 

Does not apply 

Cay EL, Philip AE, and Stuckey NA. Ten years in cardiac 

rehabilitation. Psych Fennica 1981; Suppl: 19-31. 

Does not apply 

Cay EL, Vetter N, Philip AE, et al. Psychological reactions 

to a coronary care unit. J Psychosom Res 1972; 16(6): 437-

47. 

Published before 1980 

Cay EL, Vetter N, Philip AE, et al. Psychological status 

during recovery from an acute heart attack. J Psychosom 

Res 1972; 16(6): 425-35. 

Published before 1980 
Chalfont L, Bennett P. Personality and coping: their 

influence on affect and behaviour following myocardial 

infarction. Coronary Health Care 1999; 3(3): 110-6. 

Does not apply 

Chiou A, Potempa K, and Buschmann MB. Anxiety, 

depression and coping methods of hospitalized patients 

with myocardial infarction in Taiwan. Int J Nurs Stud 1997; 

34(4): 305-11. 

Unable to review 

Cleophas TJ, de Jong SJ, Niemeyer MG, et al. Changes in 

life-style in men under sixty years of age before and after 

acute myocardial infarction: a case-control study. Angiol 

1993; 44(10): 761-8. 

Does not apply 

Coelho R, Ramos E, Prata J, et al. Acute myocardial 

infarction: psychosocial and cardiovascular risk factors in 

men. J Cardiovasc Risk 1999; 6(3): 157-62. 

Does not apply 

Cohen L, Stokhof LH, van der Ploeg HM, et al. Identifying 

patients recovering from a recent myocardial infarction 

who require and accept psychological care. Psychol Rep 

1996; 79(3 Pt 2): 1371-7. 

Does not apply 

Collins JA, Rice VH. Effects of relaxation intervention in 

phase II cardiac rehabilitation: replication and extension. 

Heart Lung 1997; 26(1): 31-44. 

Does not apply 

Conn VS, Taylor SG, and Abele PB. Myocardial infarction 

survivors: age and gender differences in physical health, 

psychosocial state and regimen adherence. J Adv Nurs 

1991; 16(9): 1026-34. 

Does not apply 

Conn VS, Taylor SG, and Casey B. Cardiac rehabilitation 

program participation and outcomes after myocardial 

infarction. Rehabil Nurs 1992; 17(2): 58-62. 

Does not apply 

Conroy RM, McGowan E, and Mulcahy R. Improved 

subjective health in patients in a post coronary 

rehabilitation programme. Ir J Psychol Med 1989; Vol 6(1): 

30-34. 

Does not apply 

Cossette S, Frasure-Smith N, and LespĂ©rance F. Nursing 

approaches to reducing psychological distress in men and 

women recovering from myocardial infarction. Intl J Nurs 

Stud 2002; 39(5): 479-94. 

Does not apply 

Cossette S, Frasure-Smith N, and Lesperance F. Clinical 

implications of a reduction in psychological distress on 

cardiac prognosis in patients participating in a psychosocial 

intervention program. Psychosom Med 2001; Vol 63(2): 

257-266. 

Unable to review 

Coyne KS, Lundergan CF, Boyle D, et al. Relationship of 

infarct artery patency and left ventricular ejection fraction 

to health-related quality of life after myocardial infarction: 

the GUSTO-I Angiographic Study experience. Circ 2000; 

102(11): 1245-51. 

Does not apply 

Crane PB, McSweeney JC. Exploring older women's 

lifestyle changes after myocardial infarction. Medsurg 

Nursing 2003; 12(3): 170-6 . 

Does not apply 

Czajkowski SM. Effects of Treating Depression and Low 

Perceived Social Support on Clinical Events after 

Myocardial Infarction: The Enhancing Recovery in 

Coronary Heart Disease Patients (ENRICHD) Randomized 

Trial. J Am Med Assoc 2003; 289(23): 3106-3116. 

Duplicate citation 

Daly J, Elliott D, Cameron-Traub E, et al. Health status, 

perceptions of coping, and social support immediately after 

discharge of survivors of acute myocardial infarction. Am J 

Crit Care 2000; 9(1): 62-9. 

No usable data 

Deems P, Duyvis DJ, Beunderman R, et al. Myocardial 

infarction: One year later. Gedrag: Tijdschrift voor 

Psychologie 1984; Vol 12(5): 46-54. 

Does not apply 

Denollet J. Emotional distress and fatigue in coronary heart 

disease: the Global Mood Scale (GMS). Psychol Med 

1993; 23(1): 111-21. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Denollet J, Brutsaert DL. Personality, disease severity, and 

the risk of long-term cardiac events in patients with a 

decreased ejection fraction after myocardial infarction. Circ 

1998; 97(2): 167-73. 

Does not apply 

Denollet J, Brutsaert DL. Reducing emotional distress 

improves prognosis in coronary heart disease: 9-Year 

mortality in a clinical trial of rehabilitation. Circ 2001; 

104(17): 2018-2023. 

Does not apply 

Denollet J, Sys SU, and Brutsaert DL. Personality and 

mortality after myocardial infarction. Psychosom Med 

1995; 57(6): 582-91. 

Does not apply 

Denollet J, Sys SU, Stroobant N, et al. Personality as 

independent predictor of long-term mortality in patients 

with coronary heart disease. Lancet 1996; 347(8999): 417-

21. 

Does not apply 

Desai MM, Rosenheck RA, Druss BG, et al. Mental 
disorders and quality of care among postacute myocardial 

infarction outpatients. J Nerv Ment Dis 2002; 190(1): 51-3. 

Does not apply 

Dimsdale JE, Hackett TP, Hutter AM, et al. The association 

of clinical, psychosocial, and angiographic variables with 

work status in patients with coronary artery disease. J 

Psychosom Res 1982; 26(2): 215-221. 

Does not apply 

Doerfler LA, Pbert L, and DeCosimo D. Symptoms of 

posttraumatic stress disorder following myocardial 

infarction and coronary artery bypass surgery. Gen Hosp 

Psychiatry 1994; 16(3): 193-9. 

Does not apply 

Dorn J, Naughton J, Imamura D, et al. Correlates of 

compliance in a randomized exercise trial in myocardial 

infarction patients. Med Sci Sports Exerc 2001; 33(7): 

1081-9. 

Does not apply 

Drory Y, Kravetz S, and Florian V. Psychosocial 

adjustment in patients after a first acute myocardial 

infarction: the contribution of salutogenic and pathogenic 

variables. Israel Study Group on First Acute Myocardial 

Infarction. Arch Phys Med Rehabil 1999; 80(7): 811-8. 

Does not apply 

Elias MF, et al. A behavioral study of middle-aged chest 

pain patients: Physical symptom reporting, anxiety, and 

depression. Exper Aging Research 1982; Vol 8(1, Pt 2): 45-

51. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Esteve LG, Valdes M, Riesco N, et al. Denial mechanisms 

in myocardial infarction: their relations with psychological 

variables and short-term outcome. J Psychosom Res 1992; 

36(5): 491-6. 

Does not apply 

Fedoroff JP, Lipsey JR, Starkstein SE, et al. 

Phenomenological comparisons of major depression 

following stroke, myocardial infarction or spinal cord 

lesions. J Affect Disord 1991; 22(1-2): 83-9. 

Does not apply 

Fielding R. Depression and acute myocardial infarction: a 

review and reinterpretation. Soc Sci Med 1991; 32(9): 

1017-28. 

No original data 

Fogel J, Fauerbach JA, Ziegelstein RC, et al. Quality of life 

in physical health domains predicts adherence among 

myocardial infarction patients even after adjusting for 

depressive symptoms. J Psychosom Res 2004; 56(1): 75-

82. 

Does not apply 

Follick MJ, Ahern DK, Gorkin L, et al. Relation of 

psychosocial and stress reactivity variables to ventricular 

arrhythmias in the Cardiac Arrhythmia Pilot Study (CAPS). 

Am J Cardiol 1990; 66(1): 63-7. 

Does not apply 

Frasure-Smith N, Lesperance F, Gravel G, et al. Social 

support, depression, and mortality during the first year after 

myocardial infarction. Circ 2000; 101(16): 1919-24. 

Does not apply 

Frasure-Smith N, Lesperance F, and Julien P. Major 

depression is associated with lower omega-3 fatty acid 

levels in patients with recent acute coronary syndromes. 

Biol Psychiatry 2004; 55(9): 891-6. 

Does not apply 

Frasure-Smith N, Lesperance F, and Talajic M. Depression 

and 18-month prognosis after myocardial infarction. Circ 

1995; 91(4): 999-1005. 

Does not apply 

Frasure-Smith N, Lesperance F, and Talajic M. The impact 

of negative emotions on prognosis following myocardial 

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14(5): 388-98. 

Does not apply 

Frasure-Smith N, Lesperance F, and Talajic M. The 

prognostic importance of depression, anxiety, anger, and 

social support following myocardial infarction: 

Opportunities for improving survival. 2000; 203-228. 

Book chapter 

Friedmann E, Thomas SA. Pet ownership, social support, 

and one-year survival after acute myocardial infarction in 

the Cardiac Arrhythmia Suppression Trial (CAST). Am J 

Cardiol 1995; 76(17): 1213-7. 

No data on when MI occurred relative to when 

depression assessed 

Friedmann E, Thomas SA. Pet ownership, social support, 

and one-year survival after acute myocardial infarction in 

the Cardiac Arrhythmia Suppression Trial (CAST). 1998; 

187-201. 

No data on when MI occurred relative to when 

depression assessed 

Froese A, Hackett TP, Cassem NH, et al. Trajectories of 

anxiety and depression in denying and nondenying acute 

myocardial infarction patients during hospitalization. J 

Psychosom Res 1974; 18(6): 413-20. 

Published before 1980 

Fukunishi I, Hattori M. Mood states and Type A behavior 

in Japanese male patients with myocardial infarction. 

Psychother Psychosom 1997; 66(6): 314-8. 

Does not apply 

Gallagher R, McKinley S, and Dracup K. Effects of a 

telephone counseling intervention on psychosocial 

adjustment in women following a cardiac event. Heart 

Lung 2003; 32(2): 79-87. 

Patients with MI not reported separately and MI 
patients represent less 50% of sample 

Glassman AH, Roose SP, and Bigger Jr. JT. The safety of 

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No original data 

Gonzalez-Jaimes EI, Turnbull-Plaza B. Selection of 

psychotherapeutic treatment for adjustment disorder with 

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Med Res 2003; 34(4): 298-304. 

Does not apply 

Gonzalez MB, Snyderman TB, Colket JT, et al. Depression 

in patients with coronary artery disease. Dep 1996; 4(2): 

57-62. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Griego LC. Physiologic and psychologic factors related to 

depression in patients after myocardial infarction: a pilot 

study. Heart Lung 1993; 22(5): 392-400. 

Case report or case series 

Gross R, Kindler S. Occurrence of high levels of 

posttraumatic stress disorder symptoms in patients who had 

survived a myocardial infarction or coronary artery bypass 

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Letter 

Grossarth-Maticek R, Kanazir DT, Vetter H, et al. Smoking 

as a risk factor for lung cancer and cardiac infarct as 

mediated by psychosocial variables. A prospective 

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Does not apply 

Guinjoan SM, De Guevara MS, Correa C, et al. Cardiac 

parasympathetic dysfunction related to depression in older 

adults with acute coronary syndromes. J Psychosom Res 

2004; 56(1): 83-8. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Guiry E, Conroy RM, Hickey N, et al. Psychological 

response to an acute coronary event and its effect on 

subsequent rehabilitation and lifestyle change. Clin Cardiol 

1987; 10(4): 256-60. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Hallas CN, Thornton EW. Effects of SSRI antidepressant 

treatment upon mood status and blood pressure reactivity to 

demand in coronary patients. Coronary Health Care 2000; 

4(1): 2-9. 

Does not apply 

Hallstrom T, Lapidus L, Bengtsson C, et al. Psychosocial 

factors and risk of ischaemic heart disease and death in 

women: a twelve-year follow-up of participants in the 

population study of women in Gothenburg, Sweden. J 

Psychosom Res 1986; 30(4): 451-9. 

Does not apply 

Hamalainen H, Smith R, Puukka P, et al. Social support 

and physical and psychological recovery one year after 

myocardial infarction or coronary artery bypass surgery. 

Scand J Public Health 2000; 28(1): 62-70. 

Does not apply

Havik OE, Maeland JG. Changes in smoking behavior after 

a myocardial infarction. Health Psychol 1988; 7(5): 403-20. 

Does not apply 

Herrmann C, Brand-Driehorst S, Kaminsky B, et al. 

Diagnostic groups and depressed mood as predictors of 22-

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1998; 60(5): 570-7. 

Study population mixed and MI patients not reported 

separately 

Hevey D, Brown A, Cahill A, et al. Four-week 

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21. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Hlatky MA, Haney T, Barefoot JC, et al. Medical, 

psychological and social correlates of work disability 

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1986; 58(10): 911-5. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Honig A. Depression after first myocardial infarction. 8th 

Congress of the Association of European Psychiatrists. 

London, UK. 7-12th July, 1996. 

Does not apply 

Horlick L, Cameron R, Firor W, et al. The effects of 

education and group discussion in the post myocardial 

infarction patient. J Psychosom Res 1984; 28(6): 485-92. 

Does not apply 

Horsten M, Mittleman MA, Wamala SP, et al. Depressive 

symptoms and lack of social integration in relation to 

prognosis of CHD in middle-aged women. The Stockholm 

Female Coronary Risk Study. Eur Heart J 2000; 21(13): 

1072-80. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Huijbrechts IP, Duivenvoorden HJ, Deckers JW, et al. 

Modification of smoking habits five months after 

myocardial infarction: relationship with personality 

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Does not apply 

Ickovics JR, Viscoli CM, and Horwitz RI. Functional 

recovery after myocardial infarction in men: the 

independent effects of social class. Ann Intern Med 1997; 

127(7): 518-25. 

Does not apply 
Johnston M, Pollard B, and Hennessey P. Construct 

validation of the hospital anxiety and depression scale with 

clinical populations. J Psychosom Res 2000; 48(6): 579-84. 

Reports depression as a continuous variable 

Jones DA, West RR. Psychological rehabilitation after 

myocardial infarction: multicentre randomised controlled 

trial. BMJ 1996; 313(7071): 1517-21. 

Does not apply 

Julkunen J, Idaenpaeaen-Heikkilae U, and Saarinen T. 

Type A behaviour, anxiety, and the first-year prognosis of a 

myocardial infarction. 1990; 331-337. 

Does not apply 

Julkunen J, Saarinen T. Psychosocial predictors of recovery 

after a myocardial infarction: Development of a 

comprehensive assessment method. Ir J Psychol 1994; Vol 

15(1): 67-83. 

Does not apply 

Kavanagh T, Shephard RJ, and Tuck JA. Depression after 

myocardial infarction. Can Med Assoc J 1975; 113(1): 23-

7. 

Published before 1980 

Kisely S, Guthrie E, Creed F, et al. Predictors of mortality 

and morbidity following admission with chest pain. J R 

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Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Kishi Y, Robinson RG, and Kosier JT. Suicidal ideation 

among patients during the rehabilitation period after lifethreatening physical illness. J Nerv Ment Dis 2001; 189(9): 

623-8. 

Does not apply 

Kishi Y, Robinson RG, and Kosier JT. Suicidal ideation 

among patients with acute life-threatening physical illness: 

patients with stroke, traumatic brain injury, myocardial 

infarction, and spinal cord injury. Psychosom 2001; 42(5): 

382-90. 

Study population mixed and MI patients not reported 

separately 

Kishida H, Saito T, Fukuma N, et al. Combination of 

ambulatory electrocardiographic monitoring and 

psychological testing in coronary artery disease patients. 

Jpn J Med 1990; 29(4): 384-90. 

Does not apply 

Koenig HG, Meador KG, Cohen HJ, et al. Depression in 

elderly hospitalized patients with medical illness. Arch 

Intern Med 1988; 148(9): 1929-36. 

Study population mixed and MI patients not reported 

separately 

Kohn LM, Sleet DA, Carson JC, et al. Life changes and 

urinary norepinephrine in myocardial infarction. J Human 

Stress 1983; 9(2): 38-45. 

Does not apply 

Kozmar D, Catipovic-Veselica K, Galic A, et al. 

Depression in acute coronary syndrome. Psychol Rep 2003; 

93(3 Pt 2): 1105-8. 

Reports depression as a continuous variable 

Kugler J, Dimsdale JE, Hartley LH, et al. Hospital 

supervised vs home exercise in cardiac rehabilitation: 

effects on aerobic fitness, anxiety, and depression. Arch 

Phys Med Rehabil 1990; 71(5): 322-5. 

Depression status at baseline not available 

Kuijpers PMJC, Hamulyak K, Strik JJMH, et al. Betathromboglobulin and platelet factor 4 levels in postmyocardial infarction patients with major depression. 

Psych Res 2002; Vol 109(2): 207-210. 

Duplicate citation 

Kurosawa H, Shimizu Y, Nishimatsu Y, et al. The 

relationship between mental disorders and physical 

severities in patients with acute myocardial infarction. Jpn 

Circ J 1983; 47(6): 723-8. 

No validated depression measure used 

Ladwig KH, Lehmacher W, Roth R, et al. Factors which 

provoke post-infarction depression: results from the postinfarction late potential study (PILP). J Psychosom Res 

1992; 36(8): 723-9. 

Does not apply 

Ladwig KH, Roll G, Breithardt G, et al. Post-infarction 

depression and incomplete recovery 6 months after acute 

myocardial infarction. Lancet 1994; 343(8888): 20-3. 

Does not apply 

Laghrissi-Thode F, Wagner WR, Pollock BG, et al. 

Elevated platelet factor 4 and beta-thromboglobulin plasma 

levels in depressed patients with ischemic heart disease. 

Biol Psych 1997; 42(4): 290-5. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Lane D, Carroll D, Ring C, et al. Do depression and anxiety 

predict recurrent coronary events 12 months after 

myocardial infarction? Q J Med 2000; 93(11): 739-44. 

Does not apply 

Lane D, Carroll D, Ring C, et al. Predictors of attendance at 

cardiac rehabilitation after myocardial infarction. J 

Psychosom Res 2001; 51(3): 497-501. 

Does not apply 

Lee H, Kohlman GC, Lee K, et al. Fatigue, mood, and 

hemodynamic patterns after myocardial infarction. Appl 

Nurs Res 2000; 13(2): 60-9. 

Does not apply 

Leineweber C, Kecklund G, Janszky I, et al. Poor sleep 

increases the prospective risk for recurrent events in 

middle-aged women with coronary disease: The Stockholm 

Female Coronary Risk Study. J Psychosom Res 2003; 
54(2): 121-127. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Leon AC, Portera L, and Walkup JT. The development and 

evaluation of the brief depression screen in medically ill 

disability claimants. Int J Psychiatry Med 2001; 31(4): 389-

400. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Levine JB, Covino NA, Slack WV, et al. Psychological 

predictors of subsequent medical care among patients 

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1996; 16(2): 109-16. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Lewin B, Robertson IH, Cay EL, et al. Effects of self-help 

post-myocardial-infarction rehabilitation on psychological 

adjustment and use of health services. Lancet 1992; 

339(8800): 1036-40. 

Does not apply 

Linden B. Evaluation of a home-based rehabilitation 

programme for patients recovering from acute myocardial 

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Does not apply 

Liu-JD and Zheng-H. Efficacy of fluoxetine in the 

treatment of depression in patients with acute myocardial 

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Incorrect citation 

Lloyd GG, Cawley RH. Distress or illness? A study of 

psychological symptoms after myocardial infarction. Br J 

Psychiatry 1983; 142: 120-5. 

Does not apply 

Lloyd GG, Cawley RH. Psychiatric morbidity after 

myocardial infarction. Q J Med 1982; 51(201): 33-42. 

Does not apply 

Lloyd GG, Cawley RH. Psychiatric morbidity in men one 

week after first acute myocardial infarction. Br Med J 

1978; 2(6150): 1453-4. 

Published before 1980 

MacKenzie G. Role patterns and emotional responses of 

women with ischemic heart disease 4 to 6 weeks after 

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9-15. 

No usable data 

Maeland JG, Havik OE. Psychological predictors for return 

to work after a myocardial infarction. J Psychosom Res 

1987; 31(4): 471-81. 

Depression not reported separately 

Maeland JG, Havik OE. Use of health services after a 

myocardial infarction. Scand J Soc Med 1989; 17(1): 93-

102. 

Does not apply 

Marchionni N, Fattirolli F, Fumagalli S, et al. Determinants 

of exercise tolerance after acute myocardial infarction in 

older persons. J Am Geriatr Soc 2000; 48(2): 146-53. 

Does not apply 

Mayou R, Foster A, and Williamson B. Psychosocial 

adjustment in patients one year after myocardial infarction. 

J Psychosom Res 1978; 22(5): 447-53. 

Published before 1980 

Mayou RA, Thompson DR, Clements A, et al. Guidelinebased early rehabilitation after myocardial infarction: A 

pragmatic randomised controlled trial. J Psychosom Res 

2002; 52(2): 89-95. 

Does not apply 

McGee HM, Johnston M, Pollard B, et al. Does myocardial 

infarction have a greater impact on women than on men? 

Testing hypotheses about the effects of gender role models 

and responsibilities. Eur Rev of Appl Psychol 2000; Vol 

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No data on when MI occurred relative to when 

depression assessed 

Mendes de Leon CF, DiLillo V, Czajkowski S, et al. 

Psychosocial characteristics after acute myocardial 

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Rehabil 2001; 21(6): 353-362. 

Does not apply 

Milani RV, Lavie CJ. Behavioral differences and effects of 

cardiac rehabilitation in diabetic patients following cardiac 

events. Am J Med 1996; 100(5): 517-23. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Milani RV, Lavie CJ. Prevalence and effects of cardiac 

rehabilitation on depression in the elderly with coronary 

heart disease. Am J Cardiol 1998; 81(10): 1233-6. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Milani RV, Lavie CJ, and Cassidy MM. Effects of cardiac 

rehabilitation and exercise training programs on depression 

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132(4): 726-732. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Moser DK, Dracup K. Psychosocial recovery from a 

cardiac event: the influence of perceived control. Heart 

Lung 1995; 24(4): 273-80. 

Reports depression as a continuous variable 

Naismith LD, Robinson JF, Shaw GB, et al. Psychological 

rehabilitation after myocardial infarction. Br Med J 1979; 

1(6161): 439-42. 

Published before 1980 

Nir Z, Neumann L. Motivation patterns, self-esteem, and 
depression of patients after first myocardial infarction. 

Behav Med 1990; 16(2): 62-6. 

Reports depression as a continuous variable 

O'Carroll RE, Smith KB, Grubb NR, et al. Psychological 

factors associated with delay in attending hospital 

following a myocardial infarction. J Psychosom Res 2001; 

51(4): 611-614. 

Reports depression as a continuous variable 

Obier K, Haywood LJ. Psycho-social problems of coronary 

care unit patients. J Natl Med Assoc 1971; 63(6): 425-8. 

Published before 1980 

Oldridge N, Furlong W, Feeny D, et al. Economic 

evaluation of cardiac rehabilitation soon after acute 

myocardial infarction. Am J Cardiol 1993; 72(2): 154-61. 

Does not apply 

Oldridge N, Guyatt G, Jones N, et al. Effects on quality of 

life with comprehensive rehabilitation after acute 

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Does not apply 

Oldridge N, Perkins A, and Hodes Z. Comparison of three 

heart disease specific health-related quality of life 

instruments. Monaldi Arch Chest Dis 2002; 58(1): 10-8. 

Does not apply 

Oldridge N, Streiner D, Hoffmann R, et al. Profile of mood 

states and cardiac rehabilitation after acute myocardial 

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Does not apply 

Paeivaerinta A, Verkkoniemi A, Niinistoe L, et al. The 

prevalence and associates of depressive disorders in the 

oldest-old Finns. Soc Psychiatry Psychiatr Epidemiol 1999; 

Vol 34(7): 352-359. 

No data on when MI occurred relative to when 

depression assessed 

Palinkas LA. Psychosocial therapy reduced the risk of 

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Brief of article 

Pathy MS, Peach H. Disability among the elderly after 

myocardial infarction: a 3-year follow-up. J R Coll 

Physicians Lond 1980; 14(4): 221-3. 

No validated depression measure used 

Peach H, Pathy J. Disability in the elderly after myocardial 

infarction. J R Coll Physicians Lond 1979; 13(3): 154-7. 

Published before 1980 

Pedersen SS, Middel B, and Larsen ML. Posttraumatic 

stress disorder in first-time myocardial infarction patients. 

Heart Lung 2003; 32(5): 300-7. 

Does not apply 

Pedersen SS, Middel B, and Larsen ML. The role of 

personality variables and social support in distress and 

perceived health in patients following myocardial 

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Does not apply 

Petersen LA, Normand SL, Druss BG, et al. Process of care 

and outcome after acute myocardial infarction for patients 

with mental illness in the VA health care system: are there 

disparities? Health Serv Res 2003; 38(1 Pt 1): 41-63. 

Does not apply 

Pitzalis MV, Iacoviello M, Todarello O, et al. Depression 

but not anxiety influences the autonomic control of heart 

rate after myocardial infarction. Am Heart J 2001; 141(5): 

765-71. 

Does not apply 

Plevier CM, Mooy JM, Marang-Van de Mheen PJ, et al. 

Persistent impaired emotional functioning in survivors of a 

myocardial infarction? Qual Life Res 2001; 10(2): 123-32. 

Does not apply 

Pratt LA, Ford DE, Crum RM, et al. Depression, 

psychotropic medication, and risk of myocardial infarction. 

Prospective data from the Baltimore ECA follow-up. Circ 

1996; 94(12): 3123-9. 

Does not apply 

Pruneti CA, L'Abbate A, and Steptoe A. Personality and 

behavioral changes in patients after myocardial infarction. 

Res Commun Psychol Psychiatry Behav 1993; 18(1-2): 37-

51. 

Does not apply 

Enhancing recovery in coronary heart disease (ENRICHD): 

baseline characteristics. Am J Cardiol 2001; 88(3): 316-22. 

Does not apply 

Rabilloud M, Cao D, Riche B, et al. Impact of selected 

geographical and clinical conditions on thrombolysis rate in 

myocardial infarction in three departments of France. Eur J 

Epidemiol 2001; 17(7): 685-91. 

Does not apply 

Rahe RH, Ward HW, and Hayes V. Brief group therapy in 

myocardial infarction rehabilitation: three- to four-year 

follow-up of a controlled trial. Psychosom Med 1979; 

41(3): 229-42. 

Published before 1980 

Raskind M, Veith R, Barnes R, et al. Cardiovascular and 

antidepressant effects of imipramine in the treatment of 

secondary depression in patients with ischemic heart 

disease. Am J Psychiatry 1982; 139(9): 1114-7. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Riegel B, Gocka I. Gender differences in adjustment to 

acute myocardial infarction. Heart Lung 1995; 24(6): 457-

66. 

Does not apply 
Riegel BJ. Contributors to cardiac invalidism after acute 

myocardial infarction. Coron Artery Dis 1993; 4(2): 215-

20. 

Does not apply 

Riegel BJ, Dracup KA. Does overprotection cause cardiac 

invalidism after acute myocardial infarction? Heart Lung 

1992; 21(6): 529-35. 

Does not apply 

Roberts SL. Cognitive model of depression and the 

myocardial infarction patient. Prog Cardiovasc Nurs 1989; 

4(2): 61-70. 

No original data 

Rosen JL, Bibring GL. Psychological reactions of 

hospitalized male patients to a heart attack. Age and socialclass differences. Psychosom Med 1966; 28(6): 808-21. 

Published before 1980 

Rumsfeld JS, Magid DJ, Plomondon ME, et al. History of 

depression, angina, and quality of life after acute coronary 

syndromes. Am Heart J 2003; 145(3): 493-9. 

Does not apply 

Runions J. A program for psychological and social 

enhancement during rehabilitation after myocardial 

infarction. Heart Lung 1985; 14(2): 117-25. 

No original data 

Saito M, Fuseno H, Honda T, et al. Clinical problems in the 

management of patients with acute myocardial infarction 

from its onset to the patients' return to work. Jpn Circ J 

1983; 47(6): 686-95. 

Does not apply 

Saks K, Kolk H, Allev R, et al. Health status of the older 

population in Estonia. Croat Med J 2001; 42(6): 663-8. 

Does not apply 

Salisbury H. Home-based myocardial infarction 

rehabilitation. Health Visitor 1997; 70(7): 265-6. 

No original data 

Sarantidis D, Thomas A, Iphantis K, et al. Levels of 

anxiety, depression and denial in patients with myocardial 

infarction. Eur Psychiatry 1997; 12(3): 149-151. 

Does not apply 

Sauer WH, Berlin JA, and Kimmel SE. Selective serotonin 

reuptake inhibitors and myocardial infarction. Circ 2001; 

104(16): 1894-8. 

Does not apply 

Schleifer SJ, Macari-Hinson MM, Coyle DA, et al. The 

nature and course of depression following myocardial 

infarction. Arch Intern Med 1989; 149(8): 1785-9. 

Does not apply 

Schomer HH, Noakes TD. The psychological effect of 

exercise training on patients after a myocardial infarction. 

A pilot study. S Afr Med J 1983; 64(13): 473-5. 

Does not apply 

Schwarcz G, Lopez-Toca R. Continued lithium treatment 

after myocardial infarction. Am J Psychiatry 1982; 139(2): 

255. 

Letter 

Sengupta AN, Sengupta M. Psychological reaction after 

myocardial infarction. J Indian Med Assoc 1972; 58(7): 

241-2. 

Published before 1980 

Serebruany VL, Glassman AH, Malinin AI, et al. Enhanced 

platelet/endothelial activation in depressed patients with 

acute coronary syndromes: evidence from recent clinical 

trials. Blood Coagul Fibrinolysis 2003; 14(6): 563-7. 

Does not apply 

Sesso HD, Kawachi I, Vokonas PS, et al. Depression and 

the risk of coronary heart disease in the Normative Aging 

Study. Am J Cardiol 1998; 82(7): 851-6. 

Does not apply 

Sherrard H. Counselling after a myocardial infarction 

improved mood for patients and their partners and 

decreased patient functional limitations [commentary on 

Johnston M, Foulkes J, Johnston DW, et al. Impact on 

patients and partners of inpatient and extended cardiac 

counseling and rehabilitation: a controlled trial. Psychsom 

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2000; 3(1): 21. 

Meeting abstract 

Sihm I, Dehlholm G, Hansen ES, et al. Psychic 

vulnerability and type-A behavior among young Danish 

male survivors of acute myocardial infarction. Nordisk 

Psykiatrisk Tidsskrift 1991; Vol 45(6): 451-456. 

Does not apply 

Silverstone PH. Depression and outcome in acute 

myocardial infarction. Br Med J (Clin Res Ed) 1987; 

294(6566): 219-20. 

Does not apply 

Silverstone PH. Depression increases mortality and 

morbidity in acute life-threatening medical illness. J 

Psychosom Res 1990; 34(6): 651-7. 

Study population mixed and MI patients not reported 

separately 

Singh J, Singh S, Singh A, et al. Sex life and psychiatric 

problems after myocardial infarction. J Assoc Physicians 

India 1970; 18(5): 503-7. 

Published before 1980 

Sloan RP, Bigger JT Jr. Biobehavioral factors in Cardiac 

Arrhythmia Pilot Study (CAPS). Review and examination. 

Circ 1991; 83(4 Suppl): II52-7. 

No original data 

Soederman E, Lisspers J, and Sundin O. Depression as a 

predictor of return to work in patients with coronary artery 
disease. Soc Sci Med 2003; Vol 56(1): 193-202. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Soloff PH. Medically and surgically treated coronary 

patients in cardiovascular rehabilitation: a comparative 

study. Int J Psychiatry Med 1978-1979; 9(1): 93-106. 

Published before 1980 

Spittle B, JAmes B. Psychosocial factors and myocardial 

infarction. Aust N Z J Psychiatry 1977; 11(1): 37-43. 

Published before 1980 

Stansfeld SA, Sharp DS, Gallacher JE, et al. A population 

survey of ischaemic heart disease and minor psychiatric 

disorder in men. Psychol Med 1992; 22(4): 939-49. 

Does not apply 

Stein PK, Carney RM, Freedland KE, et al. Severe 

depression is associated with markedly reduced heart rate 

variability in patients with stable coronary heart disease. J 

Psychosom Res 2000; Vol 48(4-5): 493-500. 

Does not apply 

Stern MJ, Gorman PA, and Kaslow L. The group 

counseling v exercise therapy study. A controlled 

intervention with subjects following myocardial infarction. 

Arch Intern Med 1983; 143(9): 1719-25. 

Does not apply 

Stern MJ, Pascale L, and Ackerman A. Life adjustment 

postmyocardial infarction: determining predictive 

variables. Arch Intern Med 1977; 137(12): 1680-5. 

Published before 1980 

Stern MJ, Pascale L, and McLoone JB. Psychosocial 

adaptation following an acute myocardial infarction. J 

Chronic Dis 1976; 29(8): 513-26. 

Published before 1980 

Stewart RA, North FM, West TM, et al. Depression and 

cardiovascular morbidity and mortality: cause or 

consequence? Eur Heart J 2003; 24(22): 2027-37. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Sundin O, Lisspers J, Hofman-Bang C, et al. Comparing 

multifactorial lifestyle interventions and stress management 

in coronary risk reduction. Int J Behav Med 2003; 10(3): 

191-204. 

Patients with MI not reported separately and MI 

patients represent less 50% of sample 

Surtees PG, Wainwright NWJ, Khaw K-T, et al. Functional 

health status, chronic medical conditions and disorders of 

mood. Br J Psychiatry 2003; 183: 299-303. 

Does not apply 

Sykes DH, Arveiler D, Salters CP, et al. Psychosocial risk 

factors for heart disease in France and North Ireland: The 

prospective epidemiological study of myocardial infarction 

(PRIME). Int J Epidemiol 2002; 31(6): 1227-1234. 

Does not apply 

Sykes DH, Hanley M, Boyle DM, et al. Work strain and the 

post-discharge adjustment of patients following a heart 

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Does not apply 

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