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VOLUME 8 NUMBER 2 • JUNE 2011
85
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Key Points
•
Depression after MI is common,
affecting almost half of all
patients
•
Depression after MI increases
morbidity and mortality
•
A survey of practice nurses
shows that post-MI depression
is under-recognised and may be
under-treated
•
Training gives practitioners more
confidence in detecting and
treating depression after MI
•
Safe and effective treatments for
depression in post-MI patients
are available in primary care
D
epression after myocardial infarction (MI) is extremely common, affecting almost half of all
patients. The combination of MI and depression reduces the chance of recovery and makes it
much more likely that patients will have another cardiac event. Depressed patients are also
less likely to get back to work and they use health services more than those who are not depressed.
BEATING THE POST-MI BLUES:
IMPROVING DETECTION AND TREATMENT
OF DEPRESSION AFTER A HEART ATTACK
Prevention in Practice
Joanne Haws
Independent Nurse Consultant in CVD
Primary Care Cardiovascular Society,
London
We carried out a survey to investigate the perceptions,
attitudes and skills of primary care practitioners in rec-
ognising and treating depression in patients following
an MI to explore how this important co-morbidity is
managed in practice. Readers of the British Journal
of Primary Care Nursing (BJPCN) were invited to par-
ticipate in an online survey, together with readers of
the Primary Care Cardiovascular Journal. The survey
results show that although primary healthcare practi-
tioners realise that depression after MI is a significant
problem, many underestimate quite how common it is
and have received little or no training in recognising or
managing depression.
Around 180 000 people are admitted to hospital
with an MI each year. Depression in the first year after
MI is extremely common, affecting approximately half
of all patients, with a peak in occurrence around three
months after the event.
The effects of depression are long lasting, increas-
ing the risk of death for up to five years after an MI.
Depressed patients are less likely to get back to work,
and use health services more than those who do not
develop depression. It may be surprising, then, to learn
that if a post-MI patient is depressed there is only a
one in ten chance that it will be picked up. Depression
has considerable stigma attached to it. Perhaps as a
consequence, your patients may be reluctant to tell you
that they feel down or depressed. Increased clinical at-
tention needs to be paid to the role of co-morbid de-
pression, both as a predictor and a consequence of MI.
It is not just moderate to severe depression that re-
sults in poorer outcomes – even mild depression has
been shown to be associated with increased morbid-
ity and mortality. Why depression is a risk factor for
poor prognosis in post-MI patients remains unclear.
Potential explanations include altered neuroendocrine
function, problems with adhering to recommended
medical treatment and cardiotoxic side effects of anti-
depressant therapy (particularly tricyclics).
Patients with depression also seem to be less likely
to make the lifestyle changes that are required to re-
duce their overall cardiovascular risk. This observation
is perhaps explained by the low self-efficacy and mo-
tivation that are part of the constellation of depression
symptoms.
HOW CAN YOU SCREEN FOR DEPRESSION
AFTER MI?
There is evidence that interventions that aim to in-
crease public and clinician awareness about depres-
sion and training for practitioners in detecting and
treating depression may be effective. Researchers
have compared different methods of screening pa-
tients in primary care, including the ‘two question’ test
(see box on the next page).
More comprehensive screening tools – with better
specificity – include the Hospital Anxiety and Depres-
sion Scale (HADS) and the Patient Health Question-
naire-9 (PHQ9):
•
HADS is a14-itemself-report scale (withseven items
relating to depression and seven relating to anxie-
ty). Some symptoms that may occur in depression,
including fatigue, sleep, appetite and weight loss,
might be caused by physical illness, so the HADS
does not have questions relating to these. In gen-
eral practice, the HADS has good sensitivity (90%)
and specificity (86%) for detecting depression.
Professor Richard Gray
Professor of Nursing and Honorary Nurse
Consultant, Faculty of Health, University of
East Anglia, Norwich
S Afr J Diabetes Vasc Dis 2011;
8
:
85–87.
