Elsevier

Clinical Psychology Review

Volume 28, Issue 2, February 2008, Pages 288-306
Clinical Psychology Review

Depression and coronary heart disease: A review of the epidemiological evidence, explanatory mechanisms and management approaches

https://doi.org/10.1016/j.cpr.2007.05.005Get rights and content

Abstract

There is compelling evidence that depression is an independent risk factor for both the development of Coronary Heart Disease (CHD) and for worsening prognosis once CHD is established. Given the increasing awareness of the high prevalence of co-morbid depression in individuals with CHD, clinical psychologists are likely to become increasingly involved in the care of cardiac patients. It is imperative therefore, that they are aware of the complex relationship between depression and CHD and are familiar with the pharmacological and psychological interventions most likely to be effective in these patients. The following review explores the epidemiological evidence for the relationship between depression and CHD, examines the biological, behavioral and social mechanisms that may account for this relationship, and considers the findings of the psychological and pharmacological intervention trials seeking to improve outcomes for depressed cardiac patients. Collaboration across a range of disciplines is needed to establish a program of research and professional education and to develop clinical practice guidelines and pathways which support the implementation of best practice in the assessment and management of co-morbid depression in people with and at risk of CHD. Clinical psychologists are well-equipped to take a lead in this important endeavor.

Section snippets

Etiological studies

Table 1 lists the nine systematic reviews of the literature (Bunker et al., 2003, Jiang et al., 2002, Kubzansky and Kawachi, 2000, Kuper et al., 2002, Lett et al., 2004, Musselman et al., 1998, Rozanski et al., 1999), including two meta-analyses (Rugulies, 2002, Wulsin and Singal, 2003), that have investigated the etiological link between depression and CHD in recent years. The 25 individual studies included in these reviews used predominantly community-based samples free of CHD at baseline and

Measurement of depression

As outlined above, in both etiological and prognostic studies depression was defined and measured in a variety of ways rendering comparison across studies problematic. In the vast majority of these studies, the presence of depression was determined by scores on a self-report screening instrument, with higher scores generally considered to indicate major depression and less elevated scores indicating minor depression. While many studies demonstrated a positive correlation and indeed a dose

Proposed mechanisms linking depression and CHD

While the mechanisms linking depression and CHD are not well understood, a number of relationships have been identified which demonstrate the plausibility and coherence of a causal relationship. These include both direct biological mechanisms and indirect pathways mediated through behavioral, lifestyle and social factors. A summary of the evidence for these mechanisms follows.

Interventions for cardiac patients with co-morbid depression

A range of lifestyle, psychosocial and pharmacological interventions has been applied in the management of patients with co-morbid depression. The aim of such interventions is to reduce the increased risk of morbidity and mortality associated with co-morbid depression in cardiac patients. However, the value of treating depression in cardiac patients is increasingly being recognized in its own right. A review of the current evidence for the management of depression in cardiac patients follows.

Discussion

This review has demonstrated that the evidence for a link between depression and CHD is compelling. Depression is a major complicating factor in patients with CHD; at the same time, CHD is a major complicating factor in depression and clinical psychologists need to take account of this in their clinical practice. The increased risk of subsequent morbidity and mortality from CHD associated with depression is in the order of 1.5–2 fold. Depression is even more strongly associated with adverse

Acknowledgment

This review was carried out by the first author in partial fulfillment of the requirements for a Masters in Clinical Psychology from Macquarie University under the supervision of the second author. The authors also thank the NSW Division of the National Heart Foundation of Australia for their support of this review as well as associated work related to the psychosocial needs of patients with heart disease. The authors acknowledge the helpful comments made by two anonymous reviewers.

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