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SSRIs in Patients with Heart Disease

Although they are safe and modestly effective in treating depression, there's no evidence yet that they reduce cardiac morbidity or mortality.

Among patients with coronary artery disease (CAD), depression strongly predicts CAD mortality. Continued uncertainty about the safety and efficacy of antidepressant use in such patients led Canadian investigators to study 284 patients (mean age, 58) with CAD (most with prior myocardial infarction or coronary revascularization) who had major depressive disorder for at least 4 weeks. In a 2 x 2 intervention, subjects were randomized to receive either 12 weekly sessions of interpersonal therapy (IPT) or no IPT, and to receive either the selective serotonin reuptake inhibitor (SSRI) citalopram (20–40 mg/day) or placebo. All patients had standard weekly educational sessions.

Depression improved to a significantly greater extent in citalopram patients than in placebo patients (remission rate, 36% vs. 23%; number needed to treat to achieve remission in 1 patient, about 8). Patients receiving IPT did not have substantially greater improvement than those receiving only educational sessions (remission rate, 28% vs. 30%). Patients receiving citalopram were more likely to experience side effects common with SSRIs (e.g., somnolence, sexual dysfunction) than those receiving placebo, but there were no significant adverse events.

Comment: These data, combined with those from another trial (Journal Watch Aug 30 2002), show that SSRIs are safe and modestly effective for treating depression in CAD patients. However, no improvement in cardiac morbidity or mortality has been observed. As editorialists note, because depression can be safely treated in CAD patients, it would now be difficult to conduct additional placebo-controlled trials to determine whether SSRI therapy can influence morbidity and mortality.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine January 23, 2007

Citation(s):

Lespérance F et al. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: The Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA 2007 Jan 24/31; 297:367-79.

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• Medline abstract (Free)

Glassman AH and Bigger JT Jr. Antidepressants in coronary heart disease: SSRIs reduce depression, but do they save lives? JAMA 2007 Jan 24/31; 297:411-2.

• Original article (Subscription may be required)
• Medline abstract (Free)