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Depression is a known risk factor for mortality after an acute myocardial infarction. Patients with treatment-responsive depression may have a better prognosis than those with treatment-resistant depression.
We sought to determine whether mortality following acute myocardial infarction was associated with treatment-resistant depression.
Follow-up began after myocardial infarction and continued until death or censorship. Depression was counted as present if diagnosed any time during the study period. Treatment for depression was defined as receipt of 12 or more weeks of continuous antidepressant therapy at a therapeutic dose during follow-up. Treatment-resistant depression was defined as use of two or more antidepressants plus augmentation therapy, receipt of electroconvulsive therapy or use of monoamine oxidase inhibitors. Mean duration of follow-up was 39 months.
During follow-up of 4037 patients with major depressive disorder who had had a myocardial infarction, 6.9% of those with insufficiently treated depression, 2.4% of those with treated depression and 5.0% of those with treatment-resistant depression died. A multivariable survival model that adjusted for sociodemographics, anxiety disorders, beta-blocker use, mortality risk factors and health service utilisation indicated that compared with treated patients, insufficiently treated patients were 3.04 (95% CI 2.12–4.35) times more likely and patients with treatment-resistant depression were 1.71 (95% CI 1.05–2.79) times more likely to die.
All-cause mortality following an acute myocardial infarction is greatest in patients with depression who are insufficiently treated and is a risk in patients with treatment-resistant depression. However, the risk of mortality associated with treatment-resistant depression is partly explained by comorbid disorders. Further studies are warranted to determine whether changes in depression independently predict all-cause mortality.
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David J. Vinkers, Psychiatrist
17 March 2012
Dear Editor,
With much interest, we read the article by Scherrer et al. in the February issue of The Journal. (1). The authors show that insufficient treatment or treatment resistance of depression in 4037 patients after a myocardial infarction (mean age 58.8; standard deviation 10.4) is associated with increased mortality. As the authors point out in the discussion, insufficient treatment or treatment resistance of depression may reflect non-adherence to medical care, which may explain the increasedmortality risk. This is also supported by the finding that the relationship between depression and mortality was most strongly associatedwith marital status (table 4: OR 2.84; 95 % CI: 2.00-4.02).
Our findings in the Leiden 85-plus Study among older people aged 85 years and older in the general population are in line with the study by Scherrer et al. We found that both cardiovascular and non-cardiovascular mortality were increased in depressed older people (2), especially when depression was accompanied by feelings of loneliness (3). Our combined findings suggest that motivational depletion, not a specific cardiovascular mechanism, leads to the increased mortality in depressed persons (4). In depressed patients who do not respond to treatment, treatment alternatives which increase motivation are needed to decrease mortality.
References:1. Scherrer JF, Chrusciel T, Garfield LD, Freedland KE, Carney RM, Hauptman PJ, et al. Treatment-resistant and insufficiently treated depression and all-cause mortality following myocardial infarction. Br J Psychiatry 2012; 200: 137-42.
2. Vinkers DJ, Stek ML, Gussekloo J, Van Der Mast RC, Westendorp RG. Does depression in old age increase only cardiovascular mortality? The Leiden 85-plus Study. Int J Geriatr Psychiatry 2004; 19: 852-7.
3. Stek ML, Vinkers DJ, Gussekloo J, Beekman AT, van der Mast RC, Westendorp RG. Is depression in old age fatal only when people feel lonely? Am J Psychiatry 2005; 162: 178-80.
4. Vinkers DJ, Gussekloo J, Stek ML, van der Mast RC, Westendorp RG. Does depression specifically increase cardiovascular mortality? Arch Intern Med 2005; 165: 119.
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Conflict of interest: None declared
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