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Nonpharmacologic Treatments for Depression in Patients With Coronary Heart Disease

From the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.

Address correspondence to James A. Blumenthal, PhD, Duke University Medical Center, Box 3119, Durham, NC 27710. Address reprint requests to Heather S. Lett, MA, Department of Psychiatry and Behavioral Sciences, Box 3119, Duke University Medical Center, Durham, NC 27710. E-mail: lett0002{at}mc.duke.edu

Objective: We review nonpharmacologic treatments for depression in patients with coronary heart disease (CHD), including psychological therapies such as cognitive behavior therapy (CBT) and interpersonal therapy (IPT), aerobic exercise, St. John’s wort (SJW), essential fatty acids (EFAs), S-Adenosylmethionine (SAMe), acupuncture, and chromium picolinate (CP).

Method: Medline searches and reviews of bibliographies were used to identify relevant articles. Each treatment was reviewed with particular attention paid to empirical support, as well as to potential mechanisms of action that might affect not only depression but also CHD endpoints.

Results: Nearly all randomized controlled trials (RCTs) of depression treatments have been conducted with non-CHD patients. These studies have provided the most support for psychological treatments, particularly CBT and IPT. Aerobic exercise, SJW, and SAMe also have considerable empirical support in otherwise healthy persons, but SJW may have undesirable side effects for CHD patients. Data for EFAs, CP, and acupuncture are limited; however, the use of aerobic exercise shows considerable promise for cardiac patients.

Conclusions: There are few RCTs of patients with clinical depression and CHD, and those that exist have significant methodological limitations. Nonetheless, there is preliminary evidence that nonpharmacologic treatments are effective for cardiac patients with depression. In terms of reducing depression, the most evidence exists for psychological treatments, particularly CBT and IPT. However, there is little evidence that such treatment would also improve CHD risk factors. Aerobic exercise offers more promise to improve both mental and physical health due to its effect on cardiovascular risk factors and outcomes and thus warrants particular attention in future trials.

Key Words: depression • coronary disease • nonpharmacologic treatment • complementary therapies • randomized clinical trials

Abbreviations: AMI = acute myocardial infarction; BT = behavior therapy; BMT = behavioral marital therapy; CBT = cognitive behavior therapy; CP = chromium picolinate; CHD = coronary heart disease; DHA = docosahexaenoic acid; ENRICHD = Enhancing Recovery in Coronary Heart Disease; EFA = essential fatty acid; EPA = ethyl-eicosapentanoate; HAM-D = Hamilton Rating Scale for Depression; IPT = interpersonal therapy; MDD = major depressive disorder; RCT = randomized controlled trial; SAMe = S-adenosylmethionine; SJW = St. John’s wort.

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