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From the Department of Psychiatry, Washington University School of Medicine, St. Louis, MO (R.M.C., K.E.F.); Department of Psychiatry, Duke University Medical Center, Durham, NC (J.A.B); Department of Biostatistics, University of North Carolina, Chapel Hill, NC (M.Y.); Department of Psychiatry, University of Washington, Seattle WA (R.C.V.); Department of Psychiatry, Yale University, New Haven, CT (M.M.B.); Department of Psychiatry, University of Alabama Birmingham, AL (C.C.); Department of Psychiatry, University of Miami, Miami FL (P.G.S.); National Heart, Lung, and Blood Institute, Bethesda, MD (P.G.K., S.M.C.); Department of Medicine, Mayo Clinic, Rochester, MN (A.S.J.).
Address correspondence and reprint requests to Robert M. Carney, PhD, Behavioral Medicine Center, Washington University School of Medicine, 4625 Lindell Avenue, Suite 420, St. Louis, MO 63108. E-mail: carneyr{at}bmc.wustl.edu
OBJECTIVE: The Enhancing Recovery in Coronary Heart Disease study was a multicenter clinical trial in which patients with depression and/or low perceived social support after an acute myocardial infarction were randomly assigned to an intervention consisting of cognitive behavior therapy and, in some cases, sertraline, or to usual care. There was no difference in survival between the groups. A possible reason why the intervention failed to affect survival is that too many patients with mild, transient depression were enrolled. Another is that some patients died too soon to complete the intervention. This analysis evaluates whether there was a difference in late (ie, 
6 months after the myocardial infarction) mortality among initially depressed patients who had a Beck Depression Inventory score 10 and a past history of major depression, and who completed the 6-month post-treatment assessment. It also examines the relationship between change in depression and late mortality.
METHODS: Out of the 1,165 (47%) of the Enhancing Recovery in Coronary Heart Disease study participants who met our criteria, 57 died in the first 6 months, and 858 (409 usual care, 449 intervention) completed the 6-month assessment. Cox regression was used to analyze survival.
RESULTS: The intervention did not affect late mortality. However, intervention patients whose depression did not improve were at higher risk for late mortality than were patients who responded to treatment.
CONCLUSIONS: Patients whose depression is refractory to cognitive behavior therapy and sertraline, two standard treatments for depression, are at high risk for late mortality after myocardial infarction.
Key Words: depression, • depressive disorder, • myocardial infarction, • mortality, • cognitive therapy.
Abbreviations: MI = myocardial infarction;; ENRICHD = the Enhancing Recovery in Coronary Heart Disease study;; UC = usual care;; INT = intervention;; CBT = cognitive behavior therapy;; BDI = Beck Depression Inventory;; DSM-IV = Diagnostic and Statistical Manual IV;; HR = hazard ratio;; LVEF = left ventricular ejection fraction.
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