Mallik S, Spertus JA, Reid KJ, Krumholz HM, Rumsfeld JS, Weintraub WS, Agarwal P, Santra M, Bidyasar S, Lichtman JH, Wenger NK, Vaccarino V

Arch Intern Med. 2006;166:876-883.

Background:

Depression is prevalent in cardiovascular populations and is associated with a broad range of adverse outcomes. Among patients with acute myocardial infarction (AMI), depressive symptoms independently predict cardiac mortality, worse patient health status, and higher costs of care. In the community, depression is most common in women and younger adults, placing younger women at particularly higher risk.

Objective:

This study aimed to assess differences in the prevalence of depression according to sex and age among AMI patients. The authors hypothesized that depression is more common in younger women than in other demographic groups.

Methods:

A total of 2,498 AMI patients (1,284 patients <=60 years; 814 women and 1,684 men) were enrolled from 19 US centers in the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery study between January 2003 and June 2004. Depression was assessed at the time of hospitalization and was defined as a Primary Care Evaluation of Mental Disorders Brief Patient Health Questionnaire (PHQ) score of 10 or higher. The PHQ is a validated questionnaire with a sensitivity of 88% and a specificity of 88% forthe diagnosis of major depression.

Results:

Major depression, as defined by PHQ score, was common and was seen in 22.3% of patients with AMI. Younger (<=60 years) patients had higher mean PHQ scores than older patients (6.4 vs 5.0; P < .001), and women had higher mean PHQ scores than men (6.8 vs 5.2; P < .001). Only 27% of depressed patients (31% women and 24% men) had a history of depression. When stratified by both age and sex, younger women had the highest PHQ scores (8.2; P < .001 for the sex-age interaction). The prevalence of depression was 40% in women aged 60 years or younger, 21% in women older than 60 years, 22% in men aged 60 years or younger, and 15% in men older than 60 years. In a logistic model adjusted for the study center, race, medical history, and coronary heart disease risk factors, the odds of depression for women 60 years or younger were significantly higher than for the other sex-age groups and were 3.1 times higher than the reference group of men older than 60 years.

Discussion:

This study confirms that depression is common in patients with AMI, and that overall, women have a higher prevalence of depression than men. This study also shows a remarkably higher rate of depression among younger women (<=60 years) with AMI. Even after adjusting for various demographic, behavioral, medical, and clinical factors, the odds of depression among this subgroup remained significantly higher than for the other groups. Because depression after AMI has been associated with adverse outcomes, younger women, a high-risk group compared with men, may particularly benefit from aggressive screening and treatment of post-AMI depression.

Comment:

It is important to recognize depression among patients with AMI, as depression during hospitalization for AMI confers a 3 to 5 times higher adjusted odds for death by 6 months. One limitation of this study was the absence of a confirmatory diagnosis of clinical depression in these patients. Furthermore, because the PHQ measures represent present-state depressive symptoms, it is unclear whether these were secondary to the AMI or began before the coronary event. More importantly, however, depression was largely unrecognized and untreated in this study, and only 18% of the depressed patients were discharged with prescriptions for antidepressants. Although it is unknown whether treatment of depression post-AMI confers additional benefit in reducing mortality, depression remains a serious condition and deserves attention. Patients with moderate-severe symptoms of depression post-AMI warrant at least close follow-up, with prompt referral and treatment if indicated.

SL