July 6, 2005
Antidepressants May Improve Heart Attack Survival
But the evidence is not conclusive, researchers say
A study intended to see if psychotherapy could help heart attack patients who suffer from depression has instead shown that antidepressant medication improves survival.While psychotherapy had little effect, an antidepressant drug reduced the risk of death or a second heart attack by 43 percent, said the report in the July issue of the journal Archives of General Psychiatry.
"Our study provides much stronger evidence than we've ever had before that antidepressants are safe and may benefit these patients," said Dr. C. Barr Taylor, professor of psychiatry and behavioral sciences at Stanford University School of Medicine, and lead author of the report.
But even though a previous study produced similar evidence of the beneficial effects of antidepressants after a heart attack, the new finding may not translate directly into clinical practice, said Dr. Alexander H. Glassman, professor of psychiatry at Columbia University, who wrote an accompanying editorial in the journal.
"These are rather striking findings," Glassman said. "However, both studies are flawed. Neither one of them is a definitive study."
The flaw in the new study is that it was not originally designed to examine the effect of antidepressant treatment, Glassman said. Instead, nearly 2,500 patients were divided into two groups, one getting psychotherapy and the other getting no such therapy. The analysis looked at the 28 percent of patients in the therapy group and the 20 percent of those in the nontherapy group who were given antidepressants called selective serotonin reuptake inhibitors because of the severity of their depression, he said.
"You don't take a flawed study and say this should be a standard of care," Glassman said.
Glassman was also a leader of the previous study, done in 2002, which also treated depressed heart patients with Zoloft. It, too, was flawed because it included only 369 patients, not nearly enough to provide statistically significant evidence of benefit, he said.
"The truth is that this will not be made a standard of care unless you have definitive evidence," Glassman said.
Such proof would come only from a large-scale study involving perhaps thousands of people diagnosed with depression after a heart attack, he said. But no such trial is in sight, Glassman added.
The incidence of depression among people who suffer a heart attack is high. A report issued in May by physicians at the Johns Hopkins University School of Medicine found that one of every five heart attack patients suffers from depression.
"This hasn't been generally recognized by cardiologists," said Dr. Richard Lange, chief of clinical cardiology at Hopkins. "That is why this report was needed to examine the issue."
Should cardiologists routinely give such patients an antidepressant? "At this point, a clinician has to use his judgment," Glassman said. "There is not enough evidence to mandate what physicians should do."
In his practice, Lange said, "I try to ascertain if a patient has evidence of depression. If there is evidence of depression, I offer use of an antidepressant, usually in collaboration with a psychiatrist."
On Friday, the U.S. Food and Drug Administration issued a second warning that people taking selective serotonin reuptake inhibitors may be at greater risk of suicidal behavior. The agency recommended that adults being treated with antidepressants, particularly those being treated for depression, should be watched closely for worsening of depression and for increased suicidal thinking or behavior.
For more on depression and heart disease, visit the National Institute of Mental Health.