Why have we failed to show that effective treatment of depression in patients with comorbid coronary heart disease improves cardiac outcome?

摘要

IN PATIENTS WITH coronary heart disease (CHD), depression following myocardial infarction (MI) is associated with a 2-2.5-fold increased risk for severe adverse cardiovascular events and we have highly effective treatments for major depressive disorder (MDD). Why have large-scale studies of patients with depression and comorbid CHD repeatedly failed to show that effective treatment of depression improves cardiac outcome? We believe that the mismatch between instruments used in depression and those used in CHD is the most likely explanation.Using the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized trial as an example of this mismatch, the method used to assess depression was based on modified DSM-IV-TR criteria for either current MDD, minor depressive disorder with a history of past MDD, or dysthymia. The principle modification was mat current symptoms of depression must be present for 7 days instead of 14 days to facilitate enrollment and start treatment early. A structured version of the 17-item Hamilton Depression Rating Scale (HDRS) was integrated with the National Institute of Mental Health Diagnostic Interview Scale as modified for cardiac patients to form a new instrument: the Depression Interview and Structured Hamilton (DISH). According to the ENRICHD authors, the DISH produces accurate DSM-IV diagnoses, assesses the longitudinal course of the depressive disorder, and provides a reliable HDRS.