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DEPRESSION TRIALS FOR PATIENTS WITH HEART DISEASE: MOVING FORWARD Matthew M. Burg, Ph. D. Associate Clinical Professo

. DEPRESSION AND CHD. Prevalence of MDD Among ACS Patients: 15% - 20% of Clinically Meaningful Sxs: add'l 15%RR for developing CHD:Assoc. w/MDD: 2.69Assoc. w/Depressed Mood: 1.49RR for recurrent ACS / death: 2.3 ? 3.7 at 12 ? 24 mosOdds of AMI within 2 hrs of acute sadnes

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DEPRESSION TRIALS FOR PATIENTS WITH HEART DISEASE: MOVING FORWARD Matthew M. Burg, Ph. D. Associate Clinical Professo

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    2. Depression, a stress related factor has received considerable attention in recent years. Prevalence estimates for depression in post-ACS patients range from 15 to 35%, depending on symptom severity. A summary analysis published by Rugulies in 2002 reported a relative risk for development of CHD associated with depressed mood of 1.49 and with clinical depression of 2.69. Others have reported a relative risk of recurrent events or death after ACS ranging from 2.3 to 3.7 at 12 to 24-months. Depression, a stress related factor has received considerable attention in recent years. Prevalence estimates for depression in post-ACS patients range from 15 to 35%, depending on symptom severity. A summary analysis published by Rugulies in 2002 reported a relative risk for development of CHD associated with depressed mood of 1.49 and with clinical depression of 2.69. Others have reported a relative risk of recurrent events or death after ACS ranging from 2.3 to 3.7 at 12 to 24-months.

    10. ENRICHD Clinical Trial 1. 2,481 immediate post-MI patients with depression or low social support. 2. RCT to compare the efficacy of psychosocial intervention (CBT) vs. usual care. 3. Average 3.4 years of follow-up. 4. Primary endpoint = death + recurrent MI. 5. Intention to treat analysis

    11. ENRICHD: Kaplan-Meier Survival Curves: Depressed Only

    12. ENRICHD: Baseline to 6-month Changes in Depression and Social Support

    13. ENRICHD: Depression Change & Mortality Improvement in Percent of BDI Score N Died All Subgroup Deaths ? 2 219 14.6% 45% 3-6 152 5.3% 11% 7-10 189 5.8% 15% >10 298 6.3% 28% p<.0001

    15. ENRICHD: Hazard Ratios for Pre-specified Subgroups

    16. ENRICHD: Minority & Gender Minority women had greatest socio-economic disadvantage and the most serious medical history of any of the 4 gender/ethnic subgroups. Minority women had events at same age as Caucasian men (59 vs 60 years), and 6 years earlier than Caucasian women (66 years). Minority women appear to be a high risk group: AMI occurs early Accompanied by chronic illness (e.g., CHF) Socioeconomic disadvantage: What is a viable treatment?.

    26. Pathophysiology: Behavior Adherence and Depression Persistence vs. Remission Now here are our main results. This graph shows how adherence varied within our 3 depressive groups: never depressed, remittent depressed, and persistent depressed. The percent of patients who reported adhering is on the y-axis and the 5 measured behaviors are on the x-axis. We see that persistent depressed patients, in red, were less likely to quit smoking than remitted depressed and never depressed patients. Similarly, persistent depressed patients were less likely to take their medications, exercise, attend a cardiac rehabilitation program and modify their diet, and these differences were significant for all behaviors except diet modification. In contrast, there were no significant differences in adherence for any of the 5 behaviors between remittent and persistent depressed subjects.Now here are our main results. This graph shows how adherence varied within our 3 depressive groups: never depressed, remittent depressed, and persistent depressed. The percent of patients who reported adhering is on the y-axis and the 5 measured behaviors are on the x-axis. We see that persistent depressed patients, in red, were less likely to quit smoking than remitted depressed and never depressed patients. Similarly, persistent depressed patients were less likely to take their medications, exercise, attend a cardiac rehabilitation program and modify their diet, and these differences were significant for all behaviors except diet modification. In contrast, there were no significant differences in adherence for any of the 5 behaviors between remittent and persistent depressed subjects.

    27. We next examined the 3-month aspirin adherence of the Melancholic Depressed patients. We found that they took their aspirin on average 75% of the time, while Never depressed patients took it 87% of the time, and patients with Other depression took it 81% of the time. Controlling for GRACE risk score and the Charlson index, patients with Melancholic depression had significantly lower rates of adherence compared to Never depressed patients (p=.02). In contrast, there was no significant difference in adherence between the Other Depressed or Incident depressed groups (who adhered 100% in this sample) compared to the Never depressed group We next examined the 3-month aspirin adherence of the Melancholic Depressed patients. We found that they took their aspirin on average 75% of the time, while Never depressed patients took it 87% of the time, and patients with Other depression took it 81% of the time. Controlling for GRACE risk score and the Charlson index, patients with Melancholic depression had significantly lower rates of adherence compared to Never depressed patients (p=.02). In contrast, there was no significant difference in adherence between the Other Depressed or Incident depressed groups (who adhered 100% in this sample) compared to the Never depressed group

    28. Depression and Adherence Persistently / melancholic depressed post-ACS patients at highest risk for poor adherence No difference in adherence between Remitted and Never Depressed Remission of Depression precedes improvements in medication adherence, but not vice versa. Behavioral nature of adherence highlights its potential as a modifiable mediator of the relationship between depression and post-ACS MACE / ACM but for whom? Despite these limitations, we concluded that persistent depressed patients were at highest risk for poor adherence after acute coronary syndromes And that there were no significant differences in adherence between remitters and never depressed patients. Overall, these findings strengthened the theory that adherence is not only a mediator, but a potentially modifiable mediator of the relationship between depression and post-ACS mortality.Despite these limitations, we concluded that persistent depressed patients were at highest risk for poor adherence after acute coronary syndromes And that there were no significant differences in adherence between remitters and never depressed patients. Overall, these findings strengthened the theory that adherence is not only a mediator, but a potentially modifiable mediator of the relationship between depression and post-ACS mortality.

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