Depression in Patients Recovering from a Myocardial Infarction
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GRAND ROUNDS At The Johns Hopkins Bayview Medical Center Depression in Patients Recovering From a Myocardial Infarction Roy C. Ziegelstein, MD Depression is common among patients recovering from a myocardial infarc- CASE PRESENTATION tion (MI). Approximately 1 in 6 patients with MI experience major depres- A 56-year-old man was admitted to the sion and at least twice as many as that have significant symptoms of de- hospital with an acute non–Q-wave pression soon after the event. Post-MI depression is an independent risk factor myocardial infarction (MI). His course for increased mortality. Although the mechanism responsible for this asso- was complicated by postinfarction an- ciation has not yet been defined, depression is clearly associated with poor gina and 3-vessel coronary artery dis- compliance with risk-reducing recommendations, with abnormalities in au- ease was found at angiography. He un- tonomic tone that may make patients more susceptible to ventricular ar- derwent uncomplicated coronary rhythmias, and with increased platelet activation. Coronary revasculariza- bypass graft surgery and was dis- charged 5 days later. tion procedures also appear to be used less often in those with post-MI The patient had a history of hyper- depression than in comparable patients without mood disorder. Ongoing tension and hyperlipidemia. He had no research will address whether treating depression improves prognosis. Un- other significant past medical or psy- til this question is answered, efforts should focus on enhancing adherence chiatric history. For the last 35 years, to treatment regimens in this group of patients, who are clearly at risk for he worked 14 to 18 hours a day as a noncompliance. Cardiac rehabilitation programs and increasing levels of so- steel cutter doing “bull work,” which cial support may help improve symptoms and should be recommended to he said was “a constant strain on you.” all patients. Treatment of depression itself should be individualized until safety The patient’s wife says he is a stub- born man who is “bullheaded.” Four- and efficacy are determined for antidepressant therapy in patients who re- teen months before admission, he was cently have had an MI. wading with his wife by the seashore, JAMA. 2001;286:1621-1627 www.jama.com complained of chest pain, slumped over, and had to be dragged ashore. He now present most of the day almost ev- low mood is common after an MI and was brought by ambulance to the hos- ery day since hospital discharge. The pa- may adversely affect a person’s quality pital, and shortly after arrival he left the tient said that he frequently cried now, of life, overall sense of well-being, and hospital against medical advice be- often for no obvious reason. He re- ability to actively participate in recov- cause, “I always gotta’ go. I can’t sit still.” ported feeling very unhappy and be- ery. It was noted that the importance of Three weeks after his recent hospi- coming disgusted with himself when he symptoms of depression after an MI is talization, the patient was seen for rou- reflected on some aspects of his life that dependent primarily on their severity tine follow-up. He reported feeling well now appeared to him as a series of fail- and denied chest discomfort or short- ures. He also experienced guilt about Author Affiliation: Department of Medicine, Divi- sion of Cardiology, Johns Hopkins Bayview Medical ness of breath. His only complaint was some of the possible effects his lifestyle Center, Johns Hopkins University School of Medi- feeling “very bored.” Although he had had had on his health. He specifically cine, Baltimore, Md. Financial Disclosure: Dr Ziegelstein served as an in- a great deal of social contact with fam- said that his heart attack was his “fault vestigator for the Sertraline Antidepressant Heart At- ily and friends, he was spending most because I didn’t take care of myself.” The tack Randomized Trial (SADHART). of the day in his house. He complained patient did not report any change in ap- Corresponding Author and Reprints: Roy C. Ziegel- stein, MD, Department of Medicine, Division of Car- of being restless and bored because he petite, weight, or sleep habits. He de- diology, Johns Hopkins Bayview Medical Center, 4940 thought he could not do his usual ac- nied thoughts of harming himself or feel- Eastern Ave, Baltimore, MD 21224-2780 (e-mail: [email protected]). tivities. He said that for many years he ing that he would be better off dead. Grand Rounds at The Johns Hopkins Medical Insti- would experience low mood around After these symptoms were elicited, tutions Section Editors: David B. Hellmann, MD, D. William Schlott, MD, Stephen D. Sisson, MD, The Johns holidays or anniversaries of deaths of their importance was discussed with the Hopkins Hospital, Baltimore, Md; David S. Cooper, MD, family members but that this feeling was patient and his wife. They were told that Contributing Editor, JAMA. ©2001 American Medical Association. All rights reserved. (Reprinted) JAMA, October 3, 2001—Vol 286, No. 13 1621 DEPRESSION AFTER MYOCARDIAL INFARCTION and duration. The patient and his wife (7) difficulty concentrating, (8) psycho- with physical illness, including MI.5 were told that if his depressed mood be- motor retardation or agitation, and (9) During the office visit 3 weeks after dis- gan to affect his eating and sleeping hab- suicidal ideation. Major depression is di- charge from the hospital, the patient its or to impair his ability to concen- agnosed when 5 or more of these symp- presented herein scored 14 on the BDI. trate, then specific treatment and referral toms have been present most of the day He had several symptoms of depres- to a mental health provider would be rec- nearly every day for more than 2 weeks. sion, including depressed mood and ommended. He and his wife were told To diagnose major depression, at least low self-esteem. Although there had that if he began to have thoughts of 1 of the symptoms has to be either de- been times in the past when he expe- harming himself or wished he were dead, pressed mood, diminished interest, or di- rienced these symptoms for brief peri- referral and treatment should be imme- minished pleasure.1 Dysthymia is char- ods, they had been persistent since his diate and hospitalization may be indi- acterized by 2 or more of these symptoms MI. The patient’s wife noted that he cated. They were told that they would present for more days than not for at least even cried the previous evening while be called to reassess the status of 2 years. they were watching The Highlander,a his mood disturbance in 1 week. The The Beck Depression Inventory movie “about a man getting his head cut patient was informed that it was (BDI)2 may be used to determine the off.” The patient’s wife said he was sit- possible that his symptoms would im- presence and severity of symptoms of ting quietly and suddenly started cry- prove over the next few weeks but that depression but is not appropriate for ing at the theme song. Indeed, the pa- antidepressant therapy might be indi- making the diagnosis of the syndrome tient cried during the office visit when cated if they did not. of major depression. The BDI is a 21- he explained that the song “Who Wants Participation in a cardiac rehabilita- item self-report questionnaire scored to Live Forever?” is played as the main tion program was strongly recom- from 0 to 3 on each item. The total score character, who is immortal, grieves over mended as being potentially helpful to ranges from 0 to 63, with higher scores the death of the woman he loves. his physical and emotional health. The indicating greater levels of distress. Al- Post-MI depression is common.6 Ma- patient enrolled in a phase 2 cardiac re- though a patient who scores 10 to 20 jor depression is found in about 1 in 6 habilitation program, and his symp- points on the BDI would be consid- patients soon after MI and at least twice toms of depression were monitored by ered to have symptoms of at least mild as many have significant symptoms of de- telephone calls and by the supervisor to moderate depression, such an indi- pression (TABLE 1).3,7-12 Most patients of the rehabilitation program. Both the vidual would probably not meet crite- with major depression soon after MI will patient and his wife noted improve- ria for a diagnosis of the syndrome of remain depressed months afterwards. ment in his symptoms over the next few major depression. Nevertheless, even More than 3 out of 4 individuals who are weeks. without a diagnosis of major depres- found to have major depression in the sion, a patient with a BDI score of 10 hospital soon after MI are still de- DISCUSSION or greater is at increased risk of post-MI pressed 3 months later.7 By contrast, only Depression is manifested by a number of mortality during the first 18 months af- about 1 of every 3 patients with less se- symptoms including (1) depressed ter hospital discharge.3 Other easy-to- vere symptoms soon after MI, like the pa- mood, (2) diminished interest or plea- use rating scales are also available to as- tient presented, are still depressed 3 sure in all, or almost all, activities, (3) low sess depression, including the Hospital months later.7 This does not diminish the self-esteem, (4) sleep disturbance, (5) Anxiety and Depression Scale,4 which potential importance of depressive symp- changes in appetite, (6) loss of energy, may be particularly useful for patients toms after MI because even minor de- Table 1.