Negative Psychological Constructs that Impact

Coronary Artery Disease (CAD)


Chaddha et al, (2016) state people who are depressed are twice as likely to those who are not depressed to develop a myocardial infarction. Lichtman et al. (2008) assert that more than 60 prospective studies and numerous meta-analyses have linked depression with reduced prognosis for individuals with coronary heart disease.

Chronic depression has been associated with the progression of coronary artery disease, decreased health-related quality of life, poor physical functioning, recurrent cardiac events, and a 2 to 2.5 fold increased risk of mortality (Chauvet-Gelinier & Bonin, 2017). Depression often impairs adherence to health behaviors and promotes adverse physiological effects including inflammation, endothelial dysfunction, platelet hyperactivity, and autonomic nervous system abnormalities, all of which can cause adverse cardiac outcomes. Pharmacologic and psychotherapeutic interventions appear to be safe and effective at reducing depressive symptoms in patients with cardiovascular disease and may improve cardiac outcomes (Teply, et al., 2016).

Huffman, Celano, Beach, Motiwala, Januzzi (2013) developed a model describing the potential mechanisms linking depression and cardiac disease (above). They concluded depression in cardiac patients resulted in the following physiological changes: elevated platelet activity, increased inflammation, hypothalamic–pituitary–adrenal axis dysfunction, decreased heart rate variability, endothelial dysfunction, and Brain-derived neurotrophic factor (BDNF). Depression also impaired health promoting behaviors such as adherence to low-fat diet, exercise, smoking cessation, and medication adherence (Chauvet-Gelinier & Bonin, 2017).

Treatment of depression includes antidepressant drugs, cognitive behavioral therapy, and physical activity.
Antidepressant drugs:

Selective serotonin reuptake inhibitor (SSRI) antidepressants

sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), and paroxetine (Paxil) are recommended for patients with depression and CAD. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are not recommended because of their cardiotoxic side effects (Teply, et al., 2016); Glassman et al., 1993).

Comparisons of SSRI antidepressants with TCAs and MOAIs and their cardiovascular side effects continue to be studied. Large studies such as the one by Spindelegger et al. (2014) of 169,278 psychiatric inpatients showed MOA inhibitors to have the most cardiotoxic effects, followed by tricyclic antidepressants with the least cardiotoxic effects of the SSRI antidepressants.

Teply, et al. (2016) reviewed several studies of antidepressant medications. They found the new selective serotonin reuptake inhibitors (SSRIs) to be well tolerated, with good efficacy in cardiovascular patients.

Taylor et al. (2005) examined the effects of antidepressant medication on the morbidity and mortality of 1,834 post MI patients. Mortality or recurrences of MI was significantly lower in patients taking SSRIs than non-users of antidepressants or those taking non SSRI medications. Similar results were found by Mavrides & Nemeroff (2013) in their review of 61 articles about the use of antidepressants with patients with CAD.

Zhang, Chen, Ma (2018) found geriatric depression as a prevalent risk factor associated with morbidity and mortality of cardiovascular disease. Antidepressive therapy, improvement in psychological and social function continue to be investigated for efficacy in reducing increased cardiovascular risk in the elderly population.

Additional researchers found patients in the American Heart Association Heart Failure (HF) stages C and D have additional challenges with depression. Patients with heart failure and those undergoing implantable cardioverter-defibrillator (ICD) placement have an increased risk of depression. They exhibit a combined score of 56% for depressive symptoms and MDD (Rutledge et al., 2006; Magyar-Russell et al. 2011). In addition, patient’s undergoing coronary artery bypass graft surgery (CABG) show increased symptoms of depression (Tully & Baker, 2012). The depression has been shown to impact negatively on adjustments to devices and recovery from surgery.

Foss-Nieradko, Stepnowska, & Piotrowicz (2012) conducted a prospective comparison on the effects of chronic depression, incidental depression, and no depression on outcomes after coronary artery bypass grafting. After a two-year study, they found cardiac events occurred more frequently among patients with chronic depression but not incidental depression when compared with patients with no depressive symptoms.

Assessment and Treatment for Depression

The American Heart Association recommends "Routine screening for depression in patients with CHD in various settings, including the hospital, physician’s office, clinic, and cardiac rehabilitation center. The opportunity to screen for and treat depression in cardiac patients should not be missed, as effective depression treatment may improve health outcomes (Lichtman et al. (2008)."

The following depression scales are exceptionally brief and easy to administer

Patient Health Questionnaire 2 (PHQ-2)
How Often Little Interest or Pleasure in Doing Things - Score 4 Point Scale
How Often Feel Depressed - Score 4 Point Scale
Total Score= ≥ 3 is suggestive of elevated symptoms of depression.
(Kroenke K., 2003)

Patient Health Questionnaire-9 (PHQ-9)
How Often Little Interest or Pleasure in Doing Things Score 4 Point Scale
How Often Feel Depressed Score 4 Point Scale
How Often Trouble Sleeping Score 4 Point Scale
How Often Feel Tired Score 4 Point Scale
How Often Poor Appetite or Overeating Score 4 Point Scale
How Often Feeling Bad about Yourself or Feeling Like a Failure or Have Let Yourself or Your Family Down Score 4 Point Scale
How Often Difficulty Concentrating Reading Newspaper or Watching Television Score 4 Point Scale
How Often Moving or Speaking So Slowly that Other People Could Have Noticed or Opposite So Fidgety or Restless that You Have Been Moving Around More Score 4 Point Scale
How Often Thoughts You Would be Better Off Dead or Hurting Yourself Some Way Score 4 Point Scale
Total Score of ≥9 may indicate depression
Problems Make It Difficult to Do Work Take Care of Things at Home or Get Along with Other People 4 Point Scale
(Kroenke K., 2001)

Instant Feedback:

Assessment of depression is an essential part of care of a patient with cardiac disease.

Treatment of depression includes antidepressant drugs, cognitive behavioral therapy, and physical activity.

Antidepressant drugs

Therapy and social support

Social support

Physical Activity/Exercise

Depression can be a barrier to physical activity needed not only to improve cardiovascular health but also to reduce the depressive symptoms.

The American Heart Association recommends 150 minutes a week of moderate aerobic exercise. This would apply to patients in stages A and B with the approval of their physician. Patients in stages C and D should be given exercise recommendations based on their cardiac condition. Some muscle-strengthening activity can also produce benefits (AHA, 2014).

Instant Feedback:

Which of the following are efficacious methods of treating depression? (Select best answer)
Antidepressant medication
Social support
All of the above