Depression and Coronary Heart Disease in Women

heart disease

In a recent study published in the Journal of the American College of Cardiology, depressive symptoms were associated with an increased risk of fatal coronary Heart Disease (CHD) in relatively healthy women with no prior coronary disease. Depressive symptoms especially antidepressant use were also associated with sudden cardiac death (SCD).

One of the main advantages of this study was the prospective design and the inclusion of a large group (n=63,469) of women without coronary disease, stroke, or malignancy. They were followed for cardiovascular events and depression on follow-up between 1992 and 2004. Most prior studies were retrospective observational studies with depressed patients who often exhibit coronary risk factors, in most studies not all risk factors could be accounted or adjusted for in the statistical analysis. Many studies fail to record body mass index, serum lipids, physical inactivity, all of which might contribute to coronary heart disease.

The weak point of this study is the lack of proper diagnosis of the depression. As most often a diagnosis was based on an insufficient scale, this time the depression was defined on a 5-point mental health index score and antidepressant use. The questionnaire was administered every 2 years.

This way it is unclear whether it was real depression or those with severe cardiovascular disease who had a bad prognosis. Patients with severe somatic illness often present wit “depressive symptoms” which is only to be attributed to their worse somatic condition based on their medical condition.

A recent meta-analysis reported that when depression was identified from scores, it was less strongly associated with CHD than when diagnosed by experts

Because diagnosis with golden standard such as psychiatric experts with standardized clinical interview was not performed some nurses participating in this study might have had mild depression, depressive symptoms or have been misdiagnosed. Moreover, overlap between anxiety disorders, depressive disorder and somatoform disorders or comorbidity of these disorders can be confounding the results when solely a scale is used instead of expert diagnosis.

Another surprising result was that the use of antidepressant medications was associated with an elevated risk of sudden cardiac arrest (SCA), and that this explained most of the CHD events associated with major depression. Most subjects (61%) used selective serotonin reuptake inhibitors. Previous research is unclear whether SSRIS are related to SCA. Maybe it was just the “depression” alone? More studies are necesaary to solve this issue whether the “depression” or the antidepressants causes SCA. The prescription of antidepressants, if done properly, far outweighs the risk of SCA.

Why is this important?

Moreover, if antidepressant use merely indicates severe depression, these results could suggest that depression should actually be treated more aggressively. Thus, at the present time, the absence of proof that antidepressants might cause cardiac events is more relevant than conclusive proof that this effect is absent. Nevertheless, these findings are sufficiently sobering to warrant heightened clinical surveillance and to initiate studies to definitively address this relationship.
Narayan, S., & Stein, M. (2009). Do Depression or Antidepressants Increase Cardiovascular Mortality?The Absence of Proof Might Be More Important Than the Proof of AbsenceāŽ Journal of the American College of Cardiology, 53 (11), 959-961 DOI: 10.1016/j.jacc.2008.12.009

Whang, W., Kubzansky, L., Kawachi, I., Rexrode, K., Kroenke, C., Glynn, R., Garan, H., & Albert, C. (2009). Depression and Risk of Sudden Cardiac Death and Coronary Heart Disease in WomenResults From the Nurses’ Health Study Journal of the American College of Cardiology, 53 (11), 950-958 DOI: 10.1016/j.jacc.2008.10.060