Effects of Citalopram and Interpersonal Psychotherapy on Depression in Patients With Coronary Artery Disease

Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 02/2007; 297(4):367-79. DOI: 10.1001/jama.297.4.367
Source: PubMed


Few randomized controlled trials have evaluated the efficacy of treatments for major depression in patients with coronary artery disease (CAD). None have simultaneously evaluated an antidepressant and short-term psychotherapy.
To document the short-term efficacy of a selective serotonin reuptake inhibitor (citalopram) and interpersonal psychotherapy (IPT) in reducing depressive symptoms in patients with CAD and major depression.
The Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy, a randomized, controlled, 12-week, parallel-group, 2 x 2 factorial trial conducted May 1, 2002, to March 20, 2006, among 284 patients with CAD from 9 Canadian academic centers. All patients met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for diagnosis of major depression of 4 weeks' duration or longer and had baseline 24-item Hamilton Depression Rating Scale (HAM-D) scores of 20 or higher.
Participants underwent 2 separate randomizations: (1) to receive 12 weekly sessions of IPT plus clinical management (n = 142) or clinical management only (n = 142) and (2) to receive 12 weeks of citalopram, 20 to 40 mg/d (n = 142), or matching placebo (n = 142).
The primary outcome measure was change between baseline and 12 weeks on the 24-item HAM-D, administered blindly during centralized telephone interviews (tested at alpha = .033); the secondary outcome measure was self-reported Beck Depression Inventory II (BDI-II) score (tested at alpha = .017).
Citalopram was superior to placebo in reducing 12-week HAM-D scores (mean difference, 3.3 points; 96.7% confidence interval [CI], 0.80-5.85; P = .005), with a small to medium effect size of 0.33. Mean HAM-D response (52.8% vs 40.1%; P = .03) and remission rates (35.9% vs 22.5%; P = .01) and the reduction in BDI-II scores (difference, 3.6 points; 98.3% CI, 0.58-6.64; P = .005; effect size = 0.33) also favored citalopram. There was no evidence of a benefit of IPT over clinical management, with the mean HAM-D difference favoring clinical management (-2.26 points; 96.7% CI, -4.78 to 0.27; P = .06; effect size, 0.23). The difference on the BDI-II did not favor clinical management (1.13 points; 98.3% CI, -1.90 to 4.16; P = .37; effect size = 0.11).
This trial documents the efficacy of citalopram administered in conjunction with weekly clinical management for major depression among patients with CAD and found no evidence of added value of IPT over clinical management. Based on these results and those of previous trials, citalopram or sertraline plus clinical management should be considered as a first-step treatment for patients with CAD and major depression. Identifier: ISRCTN15858091.

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Available from: Louis T van Zyl, Mar 21, 2014
    • "Con respecto a los tratamientos, se han desarrollado diferentes estudios, tanto ensayos clínicos aleatorizados como estudios multicéntricos, para evaluar la eficacia de la intervención de la depresión en la salud física y la CV de los pacientes con ECV. El SADHART (Jiang et al., 2011; Jiang et al., 2008), el ENRICHD (Berkman et al., 2003; Carney et al., 2004) y el Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) (Lespérance et al., 2007; van Zyl et al., 2009) son algunos de los estudios más reconocidos en este campo. Estos estudios no han logrado evidenciar los beneficios cardiovasculares que se esperan al intervenir la depresión (Lichtman et al., 2014; Stewart et al., 2014) a tal punto que algunos autores sostienen que es necesario mirar el costo-beneficio de su evaluación rutinaria en pacientes cardíacos (Lim, 2014). "
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    ABSTRACT: Studies have found a strong association between depressive symptoms and major depression and cardiac morbidity and mortality increased after acute coronary syndrome (ACS); however it has also been reported evidence against this association. This difference in results may explain why depression has not yet been accepted by the American Heart Association as a risk factor for poor prognosis in patients with CVD. In this article depression is discussed as a risk factor of poor prognosis in patients who have had ACS and the factors that may influence the divergence of results in the studies. Our conclusions show that depression is related with a worse prognosis in ACS patients specifically when the symptomatology occurred after the event or when it is a treatment-resistant disorder. Cognitive and somatic symptoms and also comorbid anxiety are bad prognosis indicators. Resumen Numerosos estudios han encontrado una asociación robusta entre los síntomas depresivos o la depresión mayor y un incremento en la morbilidad y la mortalidad cardiaca posterior a un síndrome coronario agudo (SCA); sin embargo, también se ha reportado evidencia en contra. Debido a esta divergencia, la depresión aún no ha sido aceptada por la Asociación Americana del Corazón como un factor de riesgo para un mal pronóstico en pacientes con enfermedades cardiovasculares. En este artículo se aborda el tema de la depresión en pacientes que han tenido un SCA y los factores que pueden influir en la divergencia de los resultados mencionada. Se concluye que la depresión se relaciona con un peor pronóstico en estos pacientes, específicamente cuando su presencia es posterior al evento o se trata de un cuadro resistente al tratamiento. Los síntomas cognitivos y somáticos son indicadores de mal pronóstico, así como la presencia de ansiedad comórbida.
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    • "Conventional psychological treatments for depression, such as cognitive behavioural therapy (CBT) and problem-solving treatment, can improve depression, although effects in individuals with chronic physical illnesses have generally been small to moderate [8-10]. For some therapies no demonstrable benefits of the psychotherapeutic intervention are found [11]. One psychosocial nursing intervention was far from clinically significant and was associated with worsening of psychological state by increasing distress in some patients [12]. "
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    ABSTRACT: Depression is common in people with chronic physical illness and is associated with worse medical outcomes. Cognitive behavioural therapy and problem-solving improve depression, although usually have small to moderate effects among people with chronic physical illness. Behavioural activation interventions for depression, which aim to increase positive reinforcement from the environment by encouraging individuals to increase pleasant/rewarding activities, have been reported to be equivalent to cognitive behavioural therapy. However, the effectiveness of behavioural activation interventions for depression in individuals with chronic physical illness is unclear. The aims of this systematic review are to identify the extent to which different forms of behavioural activation have been used as a treatment for depression in this population, examine the effectiveness of the interventions, and identify any adaptations which have been made specifically to the interventions for individuals with a range of chronic physical illnesses.Methods/design: Electronic databases will be systematically searched using terms relevant to behavioural activation and depression, and the subset of studies in people with chronic physical illnesses will be identified by manual searching. References and citations of eligible studies will be searched and experts in this field will be contacted to identify additional papers. All study designs will be included in this review to allow for a more extensive identification of the extent of different forms of behavioural activation interventions. The different forms of behavioural activation and the specific chronic physical health conditions for which this intervention has been used will be reviewed narratively. For the effectiveness of the interventions, if sufficient randomised controlled trials have been undertaken the results will be meta-analysed. Non-randomised studies will be narratively synthesised and adaptations to the interventions will also be narratively reviewed. The findings will inform the design, development and subsequent evaluation of a behavioural activation intervention for depression in people with a chronic physical illness. PROSPERO registration number: CRD42013004500.
    Full-text · Article · Nov 2013 · Systematic Reviews
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    • "Tricyclics and monoamine oxidase inhibitors have a variety of adverse effects that can hinder adequate treatment, e.g., anticholinergic effects, arrhythmias, orthostatic hypotension, and tachycardia. Conversely, novel antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), mirtazapine, and bupropion do not present these effects (22,23). However, SSRIs interact with cytochrome P450, an issue that can limit their use, since cardiac patients often use several drugs (24). "
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    ABSTRACT: Patients with clinical diseases often present psychiatric conditions whose pharmacological treatment is hampered due to hazardous interactions with the clinical treatment and/or disease. This is particularly relevant for major depressive disorder, the most common psychiatric disorder in the general hospital. In this context, nonpharmacological interventions could be useful therapies; and, among those, noninvasive brain stimulation (NIBS) might be an interesting option. The main methods of NIBS are repetitive transcranial magnetic stimulation (rTMS), which was recently approved as a nonresearch treatment for some psychiatric conditions, and transcranial direct current stimulation (tDCS), a technique that is currently limited to research scenarios but has shown promising results. Therefore, our aim was to review the main medical conditions associated with high depression rates, the main obstacles for depression treatment, and whether these therapies could be a useful intervention for such conditions. We found that depression is an important and prevalent comorbidity in a variety of diseases such as epilepsy, stroke, Parkinson's disease, myocardial infarction, cancer, and in other conditions such as pregnancy and in patients without enteral access. We found that treatment of depression is often suboptimal within the above contexts and that rTMS and tDCS therapies have been insufficiently appraised. We discuss whether rTMS and tDCS could have a significant impact in treating depression that develops within a clinical context, considering its unique characteristics such as the absence of pharmacological interactions, the use of a nonenteral route, and as an augmentation therapy for antidepressants.
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