Psychiatry - November 2008 - (Page 46)

[the interface] outset correlated with highe subsequent risks of mortality from CVD or myocardial infarction.6 Similar data have emerged from Hungary. In a community sample of over 12,000 individuals, Kopp et al7 found that depression was a meaningful contributory factor to subsequent premature cardiovascular mortality. Compared with nondepressed controls, Gromova et al8 found that depressed Russian men had a twotimes-higher risk of subsequent myocardial infarction. Finally, Boulware et al9 found, among dialysis patients, a relationship between explored this relationship. For example, in a study of 468 patients with myocardial infarction, de Jonge et al10 found that those with new onset depression (as opposed to ongoing or recurrent depressions, or no depression at all) were at an increased risk of post-infarction cardiovascular events. Among over 500 women with cardiac ischemia, Rutledge et al11 found an association between depressive symptoms and a subsequent increased incidence of cardiac events and death. In a similar vein, among post-myocardialinfarction patients with current data suggest that current depression in those with existing CVD has a negative impact on medical outcome. Specifically, higher levels of depression are associated with greater risks of subsequent cardiovascular events as well as mortality. depression and subsequent cardiovascular events and deaths. The preceding studies proffer several tentative conclusions. First, depressive symptoms (not necessarily formal Diagnostic and Statistical Manual of Mental Disorders [DSM] diagnoses, such as major depression or dysthymia) are associated with a higher risk of CVD as well as more forthcoming cardiac events and mortality. Second, these data come from a number of different patient, community, and national samples, and probably reflect a universal phenomenon. depression, Jaffe et al12 found an increased risk of nonfatal reinfarction or death. Sherwood et al13 examined outpatients with ventricular ejection fractions of 40 percent or less (i.e., those with heart failure) and determined that current depression increased the risk for cardiovascular hospitalization as well as death. The preceding data suggest that current depression in those with existing CVD has a negative impact on medical outcome. Specifically, higher levels of depression are associated with greater risks of subsequent cardiovascular events as well as mortality. THE EFFECTS OF CURRENT DEPRESSION ON EXISTING CVD The preceding data indicate that, among other contributory variables (e.g., lifestyle, obesity), depression appears to modestly predict for higher rates of CVD and mortality. What about the effects of current depression in the presence of existing CVD? Several investigators have 46 Psychiatry 2008 [ N O V E M B E R ] ETIOLOGICAL POSSIBILITIES What might explain the relationship between depression and CVD? A number of authors have offered hypotheses, both pathophysiological and psychosocial. Pathophysiological hypotheses. Garcia-Gomez et al14 suggest that the relationship between depression and CVD might be explained by dysfunction in the central autonomic network, specifically in the areas of the hippocampus, prefrontal cortex, and brain stem nuclei. They propose that dysfunction in these areas results in lowered levels of serotonin, sympathetic excess, and a loss of cardiac vagal tone. Bounhoure et al15 suggest that the relationship may be mediated by sympathetic stimulation, endothelial dysfunction, low heart rate variability, and abnormal platelet function. Fenton and Stover16 implicate dysregulation in the hypothalamic-pituitary-adrenal axis. Finally, Parissis et al17 propose immune activation, inflammation, hypercoagulation, cardiac rhythm disturbances, and metabolic disorders as possible explanations. It is worth noting that several investigators have identified mechanisms that do not seem to mediate the relationship between depression and CVD. These empirical dead ends include cardiovascular reactivity18,19 and inflammatory markers.20 Psychosocial hypotheses. Various psychosocial factors have also been recently explored. For example, Kamphuis et al21 found that in men depression was associated with physical inactivity, and that during a 10-year follow-up period, physical inactivity was subsequently associated with greater cardiovascular mortality. Spernak and colleagues found an association between depression and less adherence to a postoperative cardiac rehabilitation program.22 Fenton and Stover16 discuss the negative impact of poor diet on CVD in depressed individuals. Finally, among the depressed, Parissis et al17 implicate poor self care, continued smoking, low motivation, nonadherence with treatment, and low participation in cardiac rehabilitation programs. Summary. While empirically elusive, it is likely that there are

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Psychiatry - November 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Measuring Adverse Events in Psychiatry Nonsuicidal Self Injury in Adolescents Relative Tolerability of Alzheimer's Disease Treatments Biracial Identity Development and Recommendations in Therapy Depression and Cardiovascular Disease: Just an Urban Legend? Three Risk Management Basics Journal Watch Classified Advertising Information for Authors

Psychiatry - November 2008

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