Patients with symptoms of depression who have coronary artery disease showed improvement of their symptoms with use of the drug citalopram, but adding interpersonal psychotherapy did not appear to be of benefit, according to a study in the January 24/31 issue of JAMA.
Since the early 1990s, studies have reported prevalences of major depression between 17 percent and 27 percent in hospitalized patients with coronary artery disease (CAD). Most have also demonstrated that depression can have a negative effect on cardiac outcomes, according to background information in the article. While there is a need for studies evaluating interventions to prevent this, there have also been few adequate trials evaluating whether depression treatments are effective in reducing depressive symptoms in patients with CAD. None of these trials have simultaneously evaluated an antidepressant and short-term psychotherapy.
Francois Lespérance, M.D., of the Université de Montréal, and colleagues with the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial, evaluated the short-term effectiveness and tolerability of two depression treatments in patients with CAD: citalopram, a selective serotonin reuptake inhibitor (SSRI) antidepressant and interpersonal psychotherapy (IPT), a short-term, manual-based psychotherapy focusing on the social context of depression. The 12-week study included 284 patients with CAD from nine Canadian academic centers and was conducted from May 2002 to March 2006. All patients met criteria for a diagnosis of major depression of four weeks' duration or longer.
Participants were randomized: (1) to receive either 12 weekly sessions of IPT plus clinical management (n = 142) or clinical management only (n = 142) and (2) to receive either 12 weeks of citalopram (n = 142), or matching placebo (n = 142).
Clinical management involved weekly sessions with information about depression and medication use, reassurance, and encouragement of adherence to medication and the study protocol. Interpersonal psychotherapy involved sessions dealing with problems common in patients with CAD, including interpersonal conflicts, life transitions, grief, and loss.
The researchers found that citalopram was superior to placebo in reducing depressive symptoms in all efficacy measures. The remission and response rates and average changes on a depression measurement scale also consistently favored citalopram over placebo. The superiority of citalopram was apparent by 6 weeks. Although patients improved with both IPT and clinical management, there was no evidence of superiority for IPT, and remission and response rates did not differ between those two treatments.
The authors add that the benefits of citalopram extended to changes in perceived social support and daily function.
"Citalopram (or sertraline, as previously shown in [a different] trial) plus clinical management should be considered for the initial acute-phase treatment for major depression in patients with CAD. It remains to be demonstrated that any form of psychotherapy is superior to clinical management in reducing depression symptoms in this group," the researchers conclude.
(JAMA. 2007;297:367-379. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: This study was supported by a Canadian Institutes of Health Research (CIHR) Clinical Trials Program grant, the Fondation du Centre Hospitalier de l'Université de Montréal, and the Fondation de l'Institut de Cardiologie de Montréal. Citalopram and matching placebo were donated by Lundbeck Canada Inc. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Antidepressants in Coronary Heart Disease
In an accompanying editorial, Alexander H. Glassman, M.D., and J. Thomas Bigger, Jr., M.D., of the New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, comment on the findings of Lespérance and colleagues.
"The CREATE study, a 12-week trial involving 284 coronary heart disease (CHD) patients, provides further evidence for the antidepressant efficacy of SSRIs for patients with CHD. Because depression is a painful, often chronic condition; because it impairs adherence to physicians' advice, prescribed medication, and secondary prevention efforts; and because both sertraline and citalopram have evidence of efficacy and safety, clinicians should screen for depression in patients with CHD and maintain a low threshold for treatment with an SSRI. However, although there is suggestive evidence, whether SSRIs reduce cardiac events has not been established. For that a large, randomized clinical trial is urgently needed. Ironically, the compelling rationale for treating post-acute coronary syndrome depression can limit the possibility for studies to definitively establish whether SSRIs influence cardiac morbidity and mortality."
(JAMA. 2007;297:411-412. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Financial disclosures – none reported.
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