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History of Depression and Survival After Acute Myocardial Infarction

From the Department of Psychiatry (R.M.C., K.E.F., B.S.), Washington University School of Medicine, St. Louis, Missouri; Department of Psychiatry (J.A.B.), Duke University Medical Center, Durham, NC; Department of Psychiatry (P.d.J.), University of Groningen, Groningen, Netherlands, and University of Tilburg, Netherlands; Department of Psychiatry (K.W.D.), Columbia University College of Physicians and Surgeons, New York, New York; National Heart, Lung, and Blood Institute (S.M.C.), Bethesda, Maryland; and the Department of Medicine (A.S.J.), Mayo Clinic, Rochester, Minnesota.

Address correspondence and reprint requests to Robert M. Carney, Behavioral Medicine Center, 4320 Forest Park Ave Suite 301, Saint Louis, MO 63108. E-mail: carneyr{at}bmc.wustl.edu

Objective: To compare survival in post-myocardial (MI) participants from the Enhancing Recovery In Coronary Heart Disease (ENRICHD) clinical trial with a first episode of major depression (MD) and those with recurrent MD, which is a risk factor for mortality after acute MI. Recent reports suggest that the level of risk may depend on whether the comorbid MD is a first or a recurrent episode.

Methods: Survival was compared over a median of 29 months in 370 patients with an initial episode of MD, 550 with recurrent MD, and 408 who were free of depression.

Results: After adjusting for an all-cause mortality risk score, initial Beck Depression Inventory score, and the use of selective serotonin reuptake inhibitor antidepressants, patients with a first episode of MD had poorer survival (18.4% all-cause mortality) than those with recurrent MD (11.8%) (hazard ratio (HR) = 1.4; 95% Confidence Interval (CI) = 1.0–2.0; p = .05). Both first depression (HR = 3.1; 95% CI = 1.6–6.1; p = .001) and recurrent MD (HR = 2.2; 95% CI = 1.1–4.4; p = .03) had significantly poorer survival than did the nondepressed patients (3.4%). A secondary analysis of deaths classified as probably due to a cardiovascular cause resulted in similar HRs, but the difference between depression groups was not significant.

Conclusions: Both initial and recurrent episodes of MD predict shorter survival after acute MI, but initial MD episodes are more strongly predictive than recurrent episodes. Exploratory analyses suggest that this cannot be explained by more severe heart disease at index, poorer response to depression treatment, or a higher risk of cerebrovascular disease in patients with initial MD episodes.

Key Words: depression • depression history • acute myocardial infarction • mortality

Abbreviations: MI = myocardial infarction; MD = major depression; ENRICHD = Enhancing Recovery In Coronary Heart Disease; DISH = Depression Interview and Structured Hamilton; BDI = Beck Depression Inventory; HR = hazard ratio; SSRI = selective serotonin reuptake inhibitor; HAM-D = Hamilton Rating Scale for Depression; UC = usual care; LVEF = left ventricular ejection fraction; ACS = acute coronary syndrome; HADS = Hospital Anxiety and Depression Scale.