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From the Department of Rehabilitation Psychology, Institute of Psychology, University of Freiburg, Germany (J.B., M.S.); and the Department of Psychosomatic Medicine, University of Goettingen, Germany (C.H.-L.).
Address correspondence and reprint requests to Jürgen Barth, PhD, University of Freiburg, Institute of Psychology, Department of Rehabilitation Psychology, Freiburg, Germany. E-mail: mail{at}juergen-barth.de
BACKGROUND: Prospective studies on physically healthy subjects have shown an association between depression and the subsequent development of coronary heart disease (CHD). The relative risk in meta-analytic aggregation is 1.64 (confidence interval [CI], 1.29–2.08) for any CHD event. However, the adverse impact of depression on CHD patients has not yet been the subject of a meta-analysis.
OBJECTIVE: To quantify the impact of depressive symptoms (eg, BDI, HADS) or depressive disorders (major depression) on cardiac or all-cause mortality. We analyzed the strength of the relationship, the time dependency, and the differences in studies using depressive symptoms or a clinical diagnosis as predictors of mortality.
METHOD: English and German language databases (Medline, PsycInfo, PSYNDEX) from 1980 to 2003 were searched for prospective cohort studies. Sixty-two publications were identified. The inclusion criteria were met by 29 publications reporting on 20 studies. A random model was used to estimate the combined overall effect as crude odds ratios (OR) or adjusted hazard ratios (HR [adj]).
RESULTS: Depressive symptoms increase the risk of mortality in CHD patients. The risk of depressed patients dying in the 2 years after the initial assessment is two times higher than that of nondepressed patients (OR, 2.24; 1.37–3.60). This negative prognostic effect also remains in the long-term (OR, 1.78; 1.12–2.83) and after adjustment for other risk factors (HR [adj], 1.76; 1.27–2.43). The unfavorable impact of depressive disorders was reported for the most part in the form of crude odds ratios. Within the first 6 months, depressive disorders were found to have no significant effect on mortality (OR, 2.07; CI, 0.82–5.26). However, after 2 years, the risk is more than two times higher for CHD patients with clinical depression (OR, 2.61; 1.53–4.47). Only three studies reported adjusted hazard ratios for clinical depression and supported the results of the bivariate models.
CONCLUSIONS: Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients. The results are limited by heterogeneity of the results in the primary studies. There is no clear evidence whether self-report or clinical interview is the more precise predictor. Nevertheless, depression has to be considered a relevant risk factor in patients with CHD.
Key Words: depression, • coronary heart disease, • mortality, • meta-analysis, • depressive symptoms, • risk factor.
Abbreviations: AMI = acute myocardial infarction;; AP = angina pectoris;; BDI = Beck Depression Inventory;; CABG = coronary artery bypass graft;; CHD = coronary heart disease;; CI = confidence interval;; DIS = Diagnostic Interview Schedule;; DS = Zerssen Self-Rating Scale;; DSM = Diagnostic and Statistical Manual of Mental Disorders;; ECG = electrocardiogram;; f/u = follow-up period;; GMS = Global Mood Scale;; HADS = Hospital Anxiety and Depression Scale;; HDL = high-density lipoprotein;; HPA = hypothalamic–pituitary–adrenocortical axis;; HR (adj) = adjusted hazard ratio;; IL = interleukin;; LVEF = left ventricular ejection fraction;; Medline = database of the U.S. National Library of Medicine;; MI = myocardial infarction;; MD = major depression;; OR = odds ratio;; PSE = Present State Examination;; PsycInfo = database of the American Psychological Association;; PSYNDEX = database of the Center for Psychological Information and Documentation at the University of Trier, Germany;; PTCA = percutaneous transluminal coronary angioplasty;; RR = relative risk;; SBP = systolic blood pressure;; SCID = Structured Clinical Interview for DSM;; SDS = Zung Self-Rating Depression Scale;; TNF = tumor necrosis factor.
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E. J. C. de Geus Genetic pleiotropy in depression and coronary artery disease. Psychosom Med, March 1, 2006; 68(2): 185 - 186. [Full Text] [PDF]
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J. M. McCaffery, N. Frasure-Smith, M.-P. Dube, P. Theroux, G. A. Rouleau, Q. Duan, and F. Lesperance Common genetic vulnerability to depressive symptoms and coronary artery disease: a review and development of candidate genes related to inflammation and serotonin. Psychosom Med, March 1, 2006; 68(2): 187 - 200. [Abstract] [Full Text] [PDF]
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T. Rutledge, S. E. Reis, M. Olson, J. Owens, S. F. Kelsey, C. J. Pepine, S. Mankad, W. J. Rogers, G. Sopko, C. E. Cornell, et al. Depression is associated with cardiac symptoms, mortality risk, and hospitalization among women with suspected coronary disease: the NHLBI-sponsored WISE study. Psychosom Med, March 1, 2006; 68(2): 217 - 223. [Abstract] [Full Text] [PDF]
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J. Denollet, S. S. Pedersen, A. T.L. Ong, R. A.M. Erdman, P. W. Serruys, and R. T. van Domburg Social inhibition modulates the effect of negative emotions on cardiac prognosis following percutaneous coronary intervention in the drug-eluting stent era Eur. Heart J., January 2, 2006; 27(2): 171 - 177. [Abstract] [Full Text] [PDF]
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H. Spindler and S. S. Pedersen Posttraumatic Stress Disorder in the Wake of Heart Disease: Prevalence, Risk Factors, and Future Research Directions Psychosom Med, September 1, 2005; 67(5): 715 - 723. [Abstract] [Full Text] [PDF]
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S. Maggi Review: depression may increase mortality in coronary heart disease Evid. Based Ment. Health, August 1, 2005; 8(3): 66 - 66. [Full Text] [PDF]
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S. C. Matthews, R. A. Nelesen, and J. E. Dimsdale Depressive Symptoms Are Associated With Increased Systemic Vascular Resistance to Stress Psychosom Med, July 1, 2005; 67(4): 509 - 513. [Abstract] [Full Text] [PDF]
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R. M. Carney, K. E. Freedland, and D. S. Sheps Depression is a Risk Factor for Mortality in Coronary Heart Disease Psychosom Med, November 1, 2004; 66(6): 799 - 801. [Full Text] [PDF]
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