- Email: [email protected]
My APPROACH to the depressed patient after a myocardial infarction
Author’s Accepted Manuscript My APPROACH to the depressed patient after a myocardial infarction Heidi T. May
www.elsevier.com/locate/tcm
PII: DOI: Reference:
S1050-1738(16)30152-9 http://dx.doi.org/10.1016/j.tcm.2016.09.006 TCM6342
To appear in: Trends in Cardiovascular Medicine Cite this article as: Heidi T. May, My APPROACH to the depressed patient after a myocardial infarction, Trends in Cardiovascular Medicine, http://dx.doi.org/10.1016/j.tcm.2016.09.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
My APPROACH to the Depressed Patient After a Myocardial Infarction*
Heidi T May, PhD, MSPH, FACC Depression following a myocardial infarction (MI) is known to increase the risk of complications, hospitalizations, and death. Therefore, screening for depression following an MI is strongly encouraged. All post-MI patients should be administered a validated depression questionnaire, such as the Patient Health Questionnaire (PHQ)-9. The American Heart Association (AHA) recommends a two-step depression screening method, consisting of the PHQ-2 followed by the PHQ-9, if indicated. Identifying the severity of depressive symptoms is important for determining the optimal treatment plan. For all post-MI patients, cardiac rehabilitation and an exercise plan should be prescribed, which not only helps with heart health, but can also help with mood. For patients who score positive for depressive symptoms (PHQ-9 >10), a history of past episodes of depression should be made. If it is found that the patient has had recurrent episodes of depression, consultation with the behavioral health team is highly recommended, regardless of depressive symptom severity. For an MI patient who has a PHQ-9 score of 10 to 19, cognitive behavioral therapy and/or an antidepressant, preferably a select serotonin reuptake inhibitor (SSRI) such as sertraline, should be prescribed. The SSRI class is the first choice of antidepressants to be used because of their demonstrated improvement in depressive symptoms in cardiac patients and a reduced risk for arrhythmias compared with other classes. For most post-MI patients, antidepressant medication is the preferred choice because of compliance. Behavioral therapy requires a patient to leave home or place of work to attend a session that can take anywhere from 30 minutes to an hour, which is a substantive amount of time for many individuals. These sessions coupled with the addition of new cardiology-related appointments decrease the likelihood of compliance. However, it may be more effective long-term because it treats depressive symptoms by helping patients identify, address, and solve life problems that contribute to their depressive symptoms. The ease of taking a pill, which can be coupled with taking new cardiac-related medications, time, and cost, makes antidepressants the treatment of choice. However, ultimately the choice of depressive symptom treatment should be discussed with the patient and his or her family. For patients with a PHQ-9 >20, the involvement of a behavioral health team is needed so that the appropriate treatment strategy is identified and delivered to the patient. Since depressive symptoms can be repressed or suppressed at the MI hospitalization, patients should be rescreened within 2 or 3 months following the event. At any time that the cardiologist feels uncertain in
treating the patient, a behavioral health consultation and/or referral should be made. Ongoing evaluation of depressive symptoms should be made since depression is an independent risk factor, but it can also affect adherence to medical and life-style strategies, which leads to poor clinical outcomes.
Epidemiologist, Cardiovascular Department, Intermountain Heart Institute, Murray, UT. Email: [email protected]
*First published on PracticeUpdate on August 8, 2016. Republished with permission.
www.elsevier.com/locate/tcm
PII: DOI: Reference:
S1050-1738(16)30152-9 http://dx.doi.org/10.1016/j.tcm.2016.09.006 TCM6342
To appear in: Trends in Cardiovascular Medicine Cite this article as: Heidi T. May, My APPROACH to the depressed patient after a myocardial infarction, Trends in Cardiovascular Medicine, http://dx.doi.org/10.1016/j.tcm.2016.09.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
My APPROACH to the Depressed Patient After a Myocardial Infarction*
Heidi T May, PhD, MSPH, FACC Depression following a myocardial infarction (MI) is known to increase the risk of complications, hospitalizations, and death. Therefore, screening for depression following an MI is strongly encouraged. All post-MI patients should be administered a validated depression questionnaire, such as the Patient Health Questionnaire (PHQ)-9. The American Heart Association (AHA) recommends a two-step depression screening method, consisting of the PHQ-2 followed by the PHQ-9, if indicated. Identifying the severity of depressive symptoms is important for determining the optimal treatment plan. For all post-MI patients, cardiac rehabilitation and an exercise plan should be prescribed, which not only helps with heart health, but can also help with mood. For patients who score positive for depressive symptoms (PHQ-9 >10), a history of past episodes of depression should be made. If it is found that the patient has had recurrent episodes of depression, consultation with the behavioral health team is highly recommended, regardless of depressive symptom severity. For an MI patient who has a PHQ-9 score of 10 to 19, cognitive behavioral therapy and/or an antidepressant, preferably a select serotonin reuptake inhibitor (SSRI) such as sertraline, should be prescribed. The SSRI class is the first choice of antidepressants to be used because of their demonstrated improvement in depressive symptoms in cardiac patients and a reduced risk for arrhythmias compared with other classes. For most post-MI patients, antidepressant medication is the preferred choice because of compliance. Behavioral therapy requires a patient to leave home or place of work to attend a session that can take anywhere from 30 minutes to an hour, which is a substantive amount of time for many individuals. These sessions coupled with the addition of new cardiology-related appointments decrease the likelihood of compliance. However, it may be more effective long-term because it treats depressive symptoms by helping patients identify, address, and solve life problems that contribute to their depressive symptoms. The ease of taking a pill, which can be coupled with taking new cardiac-related medications, time, and cost, makes antidepressants the treatment of choice. However, ultimately the choice of depressive symptom treatment should be discussed with the patient and his or her family. For patients with a PHQ-9 >20, the involvement of a behavioral health team is needed so that the appropriate treatment strategy is identified and delivered to the patient. Since depressive symptoms can be repressed or suppressed at the MI hospitalization, patients should be rescreened within 2 or 3 months following the event. At any time that the cardiologist feels uncertain in
treating the patient, a behavioral health consultation and/or referral should be made. Ongoing evaluation of depressive symptoms should be made since depression is an independent risk factor, but it can also affect adherence to medical and life-style strategies, which leads to poor clinical outcomes.
Epidemiologist, Cardiovascular Department, Intermountain Heart Institute, Murray, UT. Email: [email protected]
*First published on PracticeUpdate on August 8, 2016. Republished with permission.