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Context: To improve outcomes of patients with myocardial infarction (MI), a number of
treatments are typically recommended, including medications, revascularization procedures,
behavior and lifestyle changes, and cardiac rehabilitation. Co-existent depression may influence
the recovery of patients with MI in a number of important ways reviewed in this report.
Objectives: Depression is manifested by a number of symptoms, including depressed mood,
diminished interest or pleasure, and low self-esteem. These symptoms may occur in patients
recovering from an MI and have the potential to adversely impact recovery.
In this report, we
examined the evidence addressing the following questions:
- In patients with acute MI, what is the prevalence of depression during the initial hospitalization?
- What percentage of patients with post-MI depression continue to have depression one or more months after initial hospital discharge?
- What is the association of post-MI depression with outcomes or with surrogate markers of cardiac risk, independent of other predictors of post-MI outcomes?
- Do post-MI patients with depression have better outcomes with depression treatment compared to those
- without depression treatment?
- What are the performance characteristics (e.g., sensitivity, specificity, reliability and predictive value) of instruments or methods that are used to screen for depression following an acute MI?
- Does the use of cardiac treatment for patients with acute MI differ for those with and without depression?
Data Sources: The Johns Hopkins University Evidence-based Practice Center (EPC) team
searched electronic databases for literature published through March 2004. The team identified
additional articles by hand-searching the table of contents of 16 relevant journals for appropriate
citations from October 2003 to April 2004, by querying experts, and by reviewing references in
pertinent review articles identified during abstract review and in eligible articles during the
article review process.
Study Selection: Paired investigators reviewed the abstracts of identified citations to select
studies that addressed the questions, reported on human subjects, and were written in English.
Some questions had additional eligibility criteria. During the abstract review process, emphasis
was placed on identifying all articles that could have original data that might address the
Data Collection and Analysis: Paired reviewers confirmed the relevance of each article to the
research questions and abstracted data in a serial manner; the quality of each eligible study was
assessed independently by each reviewer.
Main Results: The search identified 86 articles with original data that addressed the questions.
Results were as follows:
- The evidence indicated that the prevalence of major depression is about 20 percent in patients hospitalized for MI and that of potentially significant symptoms of depression an additional 10 to 47 percent.
- Few studies reported the prevalence of depression in patients at the time of the hospitalization and then re-assessed those same patients at followup, but the studies indicated that most patients with depression during the initial MI hospitalization remain depressed 1 to 4 months later.
- Post-MI depression is associated with a significantly increased risk of subsequent death, and of cardiac re-admission and poor quality of life during the first year. There is limited evidence that post-MI depression is associated with surrogate markers of cardiac risk.
- In post-MI patients with depression, psychosocial intervention improves depression but not other outcomes. In post-MI patients with depression, selective serotonin re-uptake inhibitors (SSRIs) improve depression and some surrogate markers of cardiac risk, but no studies of sufficient power address the question of whether this treatment improves survival.
- There is insufficient data to adequately assess the performance characteristics of instruments or methods used to screen for depression during the initial MI hospitalization, but most commonly used screening instruments or rating scales have adequate sensitivities and specificities when used within 3 months after initial hospitalization.
- Patients with post-MI depression exhibit lower adherence to prescribed medications and secondary
- prevention measures compared to those without depression. The literature was too limited or heterogeneous to make conclusions about whether there are significant differences in cardiac medication prescription or cardiac procedure use in post-MI patients based on the presence or absence of depression.
Conclusions: Evidence is consistent that in patients with MI, depression is common at the time
of the hospitalization and persists for at least several months after hospital discharge without
treatment. Post-MI depression is associated with a significantly increased risk of subsequent
death, and of cardiac re-admission and poor quality of life during the first year.
exists to indicate that both psychosocial interventions and SSRIs are effective in improving
depression in MI survivors, but there is no evidence that either decreases mortality or cardiac
Although it is not clear whether the frequency of prescription of cardiac medications or
use of cardiac procedures is different based on the presence of depression, there is relatively
strong evidence that those with post-MI depression have lower adherence to prescribed
medications and secondary prevention measures than those without depression.
Post-Myocardial Infarction Depression
Evidence-based Practice Center: Johns Hopkins University
Topic Nominator: American Academy of Family Physicians (AAFP)
Current as of May 2005