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VOLUME 8 NUMBER 2 • JUNE 2011
•
The PHQ-9 scores each of the nine DSM-IV depression criteria on a
0 (not at all) to 3 (nearly every day) scale. Scores of 5, 10, 15, and
20 represent cut-off points for mild, moderate, moderately severe and
severe depression, respectively. A total score
≥
10 has 88% sensitivity
and specificity for major depression.
In primary care, it is a Quality and Outcomes Framework (QOF) re-
quirement to ask patients with CVD the ‘two question’ test annually. It is
also a national standard within cardiac rehabilitation programmes that
patients are screened for depression using the HADS. As yet, it is not
known whether national implementation of these standards has resulted
in increased recognition of depression in the post-MI population and if
more patients are actively being treated.
TREATING DEPRESSION
The good news is that depression is a very treatable illness. For patients
with milder depression, first-line intervention should generally take the
form of education, support, simple problem solving and careful monitoring
for the worsening of depressive symptoms. Exercise is also a recognised
treatment for depression, with the added benefit of cardioprotective effects.
For patients with moderate to severe depression, treatment with an
antidepressant medicine – typically with a selective serotonin reuptake in-
hibitor (SSRI) – should be the first-line approach, combined with exercise
and problem-solving techniques. SSRIs exert their effect by delaying the
reuptake of serotonin, one of the key neurotransmitters modulating mood,
raising levels in the brain.
Practitioners may be hesitant about the use of antidepressants after MI
because of the potential for cardiac side effects. While this may be true for
older tricyclic antidepressants (TCAs), clinical trials have established the
safety of SSRIs in post-MI patients (see Table 1).
Systematic reviews of psychological interventions, particularly cognitive
behavioural therapy (CBT), have established benefit in the treatment of
depression.
SURVEY OF PRIMARY CARE PRACTITIONERS
We need to get to grips with depression in post-MI patients. Given that
much of the routine care that patients receive is provided by primary care
nurses, we felt it would be informative to better understand their attitudes
and reported practice. In total, 707 readers of BJPCN responded to a
survey, including questions about how common depression is in post-MI
patients, issues about the impact of depression in post-MI patients, chal-
lenges in diagnosis and management and understanding of the evidence
base for intervention.
One of the key observations from our survey is that practice nurses
think that depression is a lot less common in patients after MI than it actu-
ally is. In fact, nine out of 10 practice nurses under-estimated the percent-
age of patients that develop depression after an MI. Is this because many
people are not screening patients (using tools such as the ‘two question
test’)? This does not appear to be the case; in our survey more than two-
thirds of respondents stated that they always ask patients these questions
to screen for depression (see Table 2).
So why is depression not being detected in post-MI patients? It is not
because you don’t think depression is important. The survey showed gen-
eral acknowledgement that depression has considerable negative impact
on clinical outcomes.
Prevention in Practice
SA JOURNAL OF DIABETES & VASCULAR DISEASE
The ‘two question’ test for depression screening
Q1. During the last month, have you often been bothered by
feeling down, depressed or hopeless?
Q2. During the last month, have you often been bothered by
little interest or pleasure in doing things?
If a patient answers ‘yes’ to both questions, this test has 96% sensitiv-
ity (the proportion of people that are actually depressed) for detecting
depression, but only 57% specificity (the percentage of non-depressed
people who are identified as not having the depression).
It is a Quality and Outcomes Framework (QOF) requirement to ask
patients with CVD the ‘two question’ test annually.
Table 1. Key trials establishing the safety and benefit of SSRIs
after MI
ENRICHD
Cognitive behavioural therapy plus SSRIs for post-MI patients with depression
improved depression and social isolation, but did not increase event-free
survival.
Berkman LF Blumenthal J, Burg M, et al. Effects of treating depression and low per-
ceived social support of clinical events after myocardial infarction: the Enhancing Recov-
ery in Coronary Health Disease Patients (ENRICHD) Randomised Trial. J Am Med Assoc
2003;
289
: 3106–16.
SADHART
A study with sertraline in patients who had been hospitalised for acute MI or
unstable angina showed no adverse effects on cardiac function, including left
ventricular ejection fraction and other cardiac measures.
Glassman AH, O’Connor CM, Califf RM. Sertraline treatment for major depression in
patients with acute MI or unstable angina. J Am Med Assoc 2002;
288
: 701–9.
CREATE
This trial showed the effectiveness and safety of citalopram with weekly
clinical management for major depression in patients with coronary artery
disease and major depression.
Lesperance F, Frasure-Smith N, Koszycki D, et al. Effects of citalopram and interper-
sonal psychotherapy on depression in patients with coronary artery disease: the Canadian
Cardiac Randomised Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE)
Trial. J Am Med Assoc 2007;
297
: 367–79.
