Psychological therapies for depression and cardiovascular risk: evidence from national healthcare records in England

Abstract

Aims: People with depression are up to 72% more at risk to develop cardiovascular disease (CVD) in their lifetime. Evidence-based psychotherapies are first-line interventions for the treatment of depression and are delivered nationally in England through the National Health Service via the Improving Access to Psychological Therapy (IAPT) primary care programme. It is currently unknown whether positive therapy outcomes may be associated with cardiovascular risk reduction. This study aimed to examine the association between psychotherapy outcomes for depression and incident CVD.

Methods and results: A cohort of 636 955 individuals who have completed a course of psychotherapy was built from linked electronic healthcare record databases of national coverage in England: the national IAPT database, the Hospital Episode Statistics (HES) database, and the HES-ONS (Office of National Statistics) mortality database. Multivariable Cox models adjusting for clinical and demographic covariates were run to estimate the association between reliable improvement from depression and the risk of subsequent incidence of cardiovascular events. After a median follow-up of 3.1 years, reliable improvement from depression symptoms was associated with a lower risk of new onset of any CVD [hazard ratio (HR): 0.88, 95% confidence interval (CI): 0.86, 0.89], coronary heart disease (HR: 0.89, 95% CI: 0.86, 0.92), stroke (HR: 0.88, 95% CI: 0.83, 0.94), and all-cause mortality (HR: 0.81, 95% CI: 0.78, 0.84). This association was stronger in the under 60 compared with the over 60 for all outcomes. Results were confirmed in sensitivity analyses.

Conclusion: Management of depression through psychological interventions may be associated with reduced risk of CVD. More research is needed to understand the causality of these associations.

Keywords: Cardiovascular disease; Coronary heart disease; Depression; Electronic healthcare records; Evidence-base psychological therapies; Primary healthcare; Stroke.

Structured Graphical Abstract

A retrospective cohort of 636 955 individuals was followed up for a median of 3 years after receiving a course of psychological therapy in primary care in England. After adjustment for clinical and demographic factors, those whose depression symptoms improved after therapy were 12% less likely to experience a cardiovascular event than those who did not. Legend: NHS, National Health Service; IAPT, Improving Access to Psychological Therapies, IAPT is delivering psychological therapies for depression across England. CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval. Cumulative incidence rates were estimated using the Nelson-Aalen method.

Figure 1

Study flow chart. IAPT, Improving Access to Psychological Therapies; HES, Hospital Episode Statistics; CV, cardiovascular; IMD, Index of Multiple Deprivation.

Figure 2

Nelson-Aalen curve of cumulative incidence of CVD (A), CHD (B), stroke (C), and all-cause mortality (D), by improvement status after therapy. CVD, cardiovascular disease; CHD, coronary heart disease; IAPT, Improving Access to Psychological Therapies.

Figure 3

Adjusted hazard ratios for CVD associated with reliable improvement from depression (vs. no improvement from depression). Note: Models includes reliable improvement from depression indicator (yes vs. no), demographic covariates (age, gender, ethnicity, IMD quintile) and clinical covariates (baseline PHQ-9 and GAD-7 scores, psychotropic medications, long-term health condition, diabetes or hypertension at baseline, reason for ending treatment, year of appointment, number of sessions). Age, Baseline PHQ score, IMD rank were fitted as categorical variables. Model includes time-dependent covariates for reliable improvement, age category, psychotropic mediations, long-term health condition, year of appointment, and reason for ending treatment.