Psychological and pharmacological interventions for depression in patients with coronary artery disease
- PMID: 34910821
- PMCID: PMC8673695
- DOI: 10.1002/14651858.CD008012.pub4
Psychological and pharmacological interventions for depression in patients with coronary artery disease
Abstract
Background: Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis.
Objectives: To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.
Search methods: We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions.
Selection criteria: We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects.
Data collection and analysis: Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes.
Main results: Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I2 = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I2 = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I2 = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I2 = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I2 = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I2 = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention.
Authors' conclusions: In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.
Trial registration: ClinicalTrials.gov NCT00998400 NCT04986969 NCT04799899 NCT04529148.
Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
Phillip Tully: Dr Tully reports receiving salary from the National Health and Medical Research Council of Australia. Dr Tully reports receiving salary and his institution received grant payment from the Alzheimer's Drug Discovery Foundation. Dr Tully has received royalties from Springer and Lambert Academic Publishing. Dr Tully reports receiving payment for development of educational presentations from the Mental Health Professionals Network. Dr Tully reports receiving payment for editorial services from Elsevier.
Ser Yee Ang: none to declare.
Emily JL Lee: none to declare.
Eileen Bendig: EB is an author of an included study, but was not involved in the data extraction or ratings of bias or quality for that study.
Natalie Bauereiss: NB is an author of an included study, but was not involved in the data extraction or ratings of bias or quality for that study.
Jürgen Bengel: JB is an author of an included study, but was not involved in the data extraction or ratings of bias or quality for that study.
Harald Baumeister: HB is an author of an included study, but was not involved in the data extraction or ratings of bias or quality for that study.
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Update of
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Psychological and pharmacological interventions for depression in patients with coronary artery disease.Cochrane Database Syst Rev. 2011 Sep 7;2011(9):CD008012. doi: 10.1002/14651858.CD008012.pub3. Cochrane Database Syst Rev. 2011. Update in: Cochrane Database Syst Rev. 2021 Dec 15;12:CD008012. doi: 10.1002/14651858.CD008012.pub4. PMID: 21901717 Free PMC article. Updated.
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- Richards SH, Campbell JL, Dickens C, Anderson R, Gandhi M, Gibson A, et al. A feasibility study and pilot RCT to establish methods for assessing the acceptability, and clinical effectiveness and cost effectiveness of enhanced psychological care in cardiac rehabilitation services for patients with new onset depression compared with treatment as usual: the CADENCE Study. Health Technology Assessments 2017;22:1-220. - PMC - PubMed
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Carney 2012 {published data only}
Carney 2019 {published data only}
CHAMPS 2016 {published data only}
Chang 2020 {published data only}
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COINCIDE 2012 {published data only}
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COPES 2010 {published data only}
Doering 2013 {published data only}
ENHANCED 2016 {published data only}
Fu 2006 {published data only}
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Giltay 2011 {published data only}
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InterHerz 2012 {published data only (unpublished sought but not used)}
Jang 2018 {published data only}
Kachkovskii 2006 {published data only}
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Liang 2019 {published data only}
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Lin 2014 {published data only}
Lv 2016 {published data only}
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Mohapatra 2005 {published data only}
MOSAIC 2013 {published data only}
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- O’Doherty V, Carr A, McGrann A, O’Neill JO, Dinan S, Graham I, et al. A controlled evaluation of mindfulness-based cognitive therapy for patients with coronary heart disease and depression. Mindfulness 2014;6:405–16.
Park 2013 {published data only}
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- Park JH, Tahk SJ, Bae SH, Son YJ. Effects of a psychoeducational intervention for secondary prevention in Korean patients with coronary artery disease: a pilot study. International Journal of Nursing Practice 2013;19:295-305. - PubMed
PATHWAY Group MCT {published data only}
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- Wells A, McNicol K, Reeves D, Salmon P, Davies L, Heagerty A, et al. Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY Group MCT): study protocol for a randomised controlled trial. Trials 2018;19(1):215. [DOI: 10.1186/s13063-018-2593-8] - DOI - PMC - PubMed
PATHWAY Home MCT {published data only}
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- Wells A, McNicol K, Reeves D, Salmon P, Davies L, Heagerty A, et al. Metacognitive therapy home-based self-help for cardiac rehabilitation patients experiencing anxiety and depressive symptoms: study protocol for a feasibility randomised controlled trial (PATHWAY Home-MCT). Trials 2018;19(1):444. [CLINICALTRIALS.GOV:: NCT03129282] [DOI: 10.1186/s13063-018-2826-x] - DOI - PMC - PubMed
Pogosova 2004 {published data only}
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Rollman 2009 {published data only}
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Schrader 2005 {published data only}
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SU.FOL.OM3 2012 {published data only}
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TEAMcare 2010 {published data only}
Tsai 2012 {published data only}
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Vasiuk 2010 {published data only}
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Veith 1982 {published data only}
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WELL.ME 2012 {published data only}
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References to studies awaiting assessment
Ahangarezaiezadeh 2017 {published data only (unpublished sought but not used)}
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- Ahangarezaiezadeh S, Oladrostam N, Nemotplahi A. The effect of positive thinking on stress, anxiety and depression in coronary heart disease. Nursing and Midwifery Journal 2017;15:339-48.
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Cai 2012 {published data only (unpublished sought but not used)}
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- Cai JM, Xie DY. Clinical analysis on deanxit treating unstable angina patients with anxiety-depression. Heart 2012;98 Suppl 2:GW23-e1783.
CoroDep 2019 {published data only}
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Gu 2017 {published data only (unpublished sought but not used)}
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References to ongoing studies
Ahmadi 2018 {published data only (unpublished sought but not used)}
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- IRCT20180312039056N2. Effectiveness of rumination-focused cognitive-behavioral therapy on improvement depression and anxiety in patients with coronary heart disease. trialsearch.who.int/Trial2.aspx?TrialID=IRCT20180312039056N2 (first received 14 October 2018).
Ardakani 2020 {published data only}IRCT20140126016374N2
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COMBAT‐DS 2021 {published data only}
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- NCT04986969. Online Cognitive Behavioral Therapy for Depressive Symptoms in Rural Patients With Cardiac Disease (COMBAT-DS). clinicaltrials.gov/ct2/show/NCT04986969 (first received 3 August 2021).
eMindYourHeart 2021 {published data only}
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- Pedersen SS, Andersen CM, Ahm R, Skovbakke SJ, Kok R, Helmark C, et al. Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation (eMindYourHeart trial): a randomised controlled trial protocol. BMC Cardiovascular Disorders 2021;21:20. [HTTPS://CLINICALTRIALS.GOV/: NCT04172974] - PMC - PubMed
Firouzjaei 2017 {published data only (unpublished sought but not used)}
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Geng 2018 {published data only (unpublished sought but not used)}
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- ChiCTR1800014291. Effect of guanxin danshen dropping pill on clinical anxiety, depression, heart rate variability and cardiovascular prognosis in patients with coronary heart disease after PCI combined with anxiety or depression. trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR1800014291 (first received 4 January 2018). [WHO CLINICAL TRIAL ID: chictr1800014291]
Hamzehpour 2020 {published data only}IRCT20190525043700N2
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Irfan 2020 {published data only}
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Jazayeri 2017 {published data only}IRCT201702262394N36
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Luberto 2021 {published data only}
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- MBCT via group videoconferencing for acute coronary syndrome patients with depressive symptoms: a pilot RCT. Ongoing study. April 2021. Contact author for more information.
Ma 2014 {published data only (unpublished sought but not used)}
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- Ma WL. The therapeutic effect of statins on patients with depression after acute coronary syndrome. trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR-IPR-14005672 (date of registration 15 December 2014). [WHO CLINICAL TRIAL ID: ChiCTR-IPR-14005672]
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- Mohammadian R. The efficacy of cognitive-behavioral therapy based on rumination on depression, anxiety and hostility in cardiac patients. https://www.irct.ir/trial/36370 (registration date 27 March 2019)).
Moudi 2016 {published data only (unpublished sought but not used)}
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Qiaoning 2019 {published data only}ChiCTR1900023457
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- Effect of guanxindanshen dropping pills on quality of life and cardiovascular prognosis of patients with depression or anxiety after PCI for coronary heart disease. Ongoing study. 1 March 2017. Contact author for more information.
Sourizahi 2017 {published data only (unpublished sought but not used)}
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Yang 2020 {published data only (unpublished sought but not used)}
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- The efficacy and safety of Ginkgo biloba dropping pills in the treatment of coronary heart disease with stable angina pectoris and depression. Ongoing study. 20 September 2020. Contact author for more information.
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