Interviewer: How can we improve quality of life in these patients?
Dr. Alberto: The most important thing would be to treat depression, as it has been established that depression more accurately predicts quality of life than other factors, such as lifestyle or other comorbidities. However, treatments that reduce depressive symptoms do not necessarily result in improved quality of life. Psychotherapy might be more effective as it directly targets general well-being. A recent meta-analysis by Hofmann et al concluded that both psycho-pharmacological treatment and cognitive behavioural treatment improved quality of life in depressed patients. Specific interventions should include enhancing socialisation (as isolation is a risk factor), treatment adherence and self-care.
Interviewer: You mentioned before that there are specific measures to combat depression in patients who have suffered a cardiac event?
Dr. Alberto: Fortunately, most hospitals now have cardiac rehabilitation programs, which are a crucial element in the recovery of these patients. They form an essential component of the comprehensive management of cardiac patients, largely to reduce the detrimental emotional, psycho-social, and physical consequences of cardiac events.
Interviewer: How should these patients be treated then?
Dr. Alberto: These patients should be attended by a multidisciplinary team of coordinated professionals that include: a cardiologist, a rehabilitation specialist, nursing staff, a psychologist and a psychiatrist.
Interviewer: How is treatment organised?
Dr. Alberto: Treatment can be divided into different areas, such as cardiac monitoring, physical exercise and mental-health treatment. Even though I will focus on the latter, let me just give some pointers about physical rehab. Exercise training is useful for these patients, not only because of the effects on the heart, but also because it has an impact on mood. It is known that supervised physical exercise reduces the rates of depression in patients recovering from a cardiac event and could even reduce the dose of antidepressant medication. Psychological treatment is necessary for most of these patients for several reasons, the principal one being that it can be difficult to come to terms with a life-threatening experience and patients benefit from the guidance of a trained professional.
Interviewer: How are patients treated psychologically then?
Dr. Alberto: Patients usually receive cognitive behaviour therapy (CBT) which, according to Beck and Dozois, aims to counteract psychological disorders or problems that arise from dysfunctional thoughts, feelings, and behaviours that develop early in life and can become activated in response to stress. Patients are trained to modify negative and distorted thoughts, change maladaptive behaviours, and develop new coping mechanisms and skills. CBT has been proven to be useful for depression after a cardiac event.
Interviewer: What about antidepressant medication? Is it safe?
Dr. Alberto: Antidepressant medication is only used for those cases identified and diagnosed of major depressive disorder; they have proven to be an effective treatment for depression. When considering antidepressants, one has to bear in mind several aspects that include safety, tolerability and efficacy. There is evidence that while some medications have the better efficacy, others have shown more tolerability. Antidepressants are generally considered safe in cardiac populations, but different classes have been associated with different risks. Almost all selective serotonin receptor re-uptake inhibitors (SSRI) are safe as they have little effect on the electrical activity of the heart, except for escitalopram. In the benefit/risk assessment, it is clear that the benefits of treating depression with antidepressants in a patient recovering from a cardiac event is much higher than the risk of any side effects that could undermine their well-being. Overall, SSRIs have good efficacy in treating depression and, for reasons of safety, are the antidepressants of choice. All this said, the importance of potential interactions between antidepressants and cardiovascular medications should be considered when treating depression in cardiac patients.
Interviewer: How would you sum up everything we have spoken about?
Dr. Alberto: The key points would be:
• Depression frequently appears after a cardiac event and it has been linked with increased morbidity and mortality.
• Depression is an independent risk factor for cardiovascular-related death and all-cause mortality.
• Depression is often under-diagnosed and under-treated in patients with cardiovascular disease.
• To date, there is no specific test to assess depression in patients with cardiovascular disease.
• Compared with men, women have higher rates of depression and higher mortality rates after a myocardial infarction.
• Antidepressants are generally safe, effective and well tolerated.