Antidepressant therapy with a selective serotonin reuptake inhibitor improves symptoms of depression in patients who have had an acute coronary syndrome event, but additional interpersonal psychotherapy does not appear to be beneficial, according to an article in the January 24 issue of the Journal of the American Medical Association.

Since the early 1990s, studies have reported prevalence rates of major depression between 17 percent and 27 percent in hospitalized patients with coronary artery disease. Most have also demonstrated that depression can have a negative effect on cardiac outcomes, according to background information in the article. Few adequate trials have evaluated whether treatments for depression are effective in reducing symptoms in these. None of these trials have simultaneously evaluated an antidepressant and short-term psychotherapy.

Francois Lesperance, MD, of the Universite de Montreal, and colleagues with the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial evaluated the short-term effectiveness and tolerability of two treatments for this patient population: citalopram, a selective serotonin reuptake inhibitor, and interpersonal psychotherapy, a short-term, manual-based therapy focusing on the social context of depression.

The 12-week study included 284 patients treated for coronary artery disease-related events in nine Canadian academic centers and was conducted from May 2002 to March 2006. All patients met criteria for a diagnosis of major depression of four weeks' duration or longer.

Participants were randomized to 12 weekly sessions of interpersonal psychotherapy plus clinical management, clinical management only, or 12 weeks of either citalopram or oral placebo.

Clinical management involved weekly sessions with information about depression and medication use, reassurance, and encouragement of adherence to medication and the study protocol. Interpersonal psychotherapy involved sessions dealing with problems common in patients with coronary artery disease, including interpersonal conflicts, life transitions, grief, and loss.

Citalopram was superior to placebo in reducing depressive symptoms in all efficacy measures. The remission and response rates and average changes on a depression measurement scale also consistently favored citalopram over placebo. The superiority of citalopram was apparent by 6 weeks. Although patients improved with both interpersonal therapy and clinical management, there was no evidence of superiority for interpersonal therapy, and remission and response rates did not differ between those two treatments.

The authors added that the benefits of citalopram extended to changes in perceived social support and daily function.

"Citalopram (or sertraline, as previously shown in a different trial) plus clinical management should be considered for the initial acute-phase treatment for major depression in patients with coronary disease. It remains to be demonstrated that any form of psychotherapy is superior to clinical management in reducing depression symptoms in this group," the researchers concluded.

In an accompanying editorial, Alexander H. Glassman, MD, and J. Thomas Bigger, Jr., MD, of the New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, commented on the findings of Lesperance and colleagues.

"The CREATE study, a 12-week trial involving 284 coronary heart disease (CHD) patients, provides further evidence for the antidepressant efficacy of SSRIs for patients with CHD. Because depression is a painful, often chronic condition; because it impairs adherence to physicians' advice, prescribed medication, and secondary prevention efforts; and because both sertraline and citalopram have evidence of efficacy and safety, clinicians should screen for depression in patients with CHD and maintain a low threshold for treatment with an SSRI. However, although there is suggestive evidence, whether SSRIs reduce cardiac events has not been established. For that a large, randomized clinical trial is urgently needed. Ironically, the compelling rationale for treating post-acute coronary syndrome depression can limit the possibility for studies to definitively establish whether SSRIs influence cardiac morbidity and mortality."