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By Catherine Robertson Souter
In a recent study published by "Psychosomatic Medicine," researchers
at VA Connecticut Healthcare System found a link between depression
in patients prior to coronary artery bypass graft surgery (CABG)
and post-surgery morbidity.
The study published results of data first collected in 1996 and
1997 using a test group of 89 male veterans who were about to undergo
the surgery. The men were assessed for medical, surgical and psychosocial
risk factors and were asked to complete the Beck Depression Inventory.
A total of 25 of the 89 men scored 10 or higher on the Beck test.
After taking the medical, surgical and psychosocial risk factors
into account, researchers found that, after six months, the depression
index could accurately predict cardiac re-hospitalization, continued
surgical pain, and a failure in the men of returning to previous
activity levels.
"There is pretty substantial literature that has shown depression
to be a significant factor in medical outcomes for patients with
coronary disease," says Matthew Burg, Ph.D., chief of the health
psychology section at VA Connecticut, associate professor of medicine
at Yale School of Medicine and associate professor of psychiatry
at Mt. Sinai School of Medicine.
"There has also been literature hinting that depression might play
a role in outcomes for patients who undergo bypass surgery. We followed
up on these data to see if depression would add any significant
prediction to outcomes both in the short term and then, in a follow-up
paper, in a longer term," Burg says.
The VA team has compiled data from a two-year follow up with the
same test group and plans to publish it later this summer. When
asked if the results are similar, Burg adds, "Actually, in two years,
it's related to mortality."
While the results of the study are not surprising, they do show
that changes need to be made in treatment of patients. A depression
screening, for example, would help isolate those for whom mental
health treatment might be a necessary course of action in conjunction
with medical treatment.
"Taken in context with the larger body of literature, this study
is saying that depression is a psychological factor along with other
already identified psychological factors that warrant attention,
at least in the cardiac population," says Burg. "A patient should
be assessed to see if he does indeed have symptoms of depression
and what the severity of those symptoms are and whether the severity
is sufficient to warrant a clinical diagnosis or whether its sub-syndromal
(which these two studies along with a host of other studies would
suggest is also important)."
It is not clear how depression affects the outcomes for coronary
patients. One thought is that depression causes people to ignore
guidelines for a healthy lifestyle. On the other hand, there is
some question as to the physiological effects that depression has
on the body.
"We need to gain a better understanding of how this psychological
factor is connected to medical outcome - whether depressed people
don't take care of themselves or if depression is associated with
some physical processes that have a negative effect on the individual
as far as their hearts are concerned and in particular, the vascular
system or the electrical conduction system," Burg says.
Studies are underway to show that treatment of depression would
significantly alter the medical outcome for coronary patients. According
to Burg, no such current data exists. Burg's team at the VA has
no plans to continue the CABG study, but are conducting similar
studies.
"We have a number of other studies ongoing," he says. "For example,
we have some studies trying to get a better understanding of how
depression is contributing to medical outcomes. The data that we
collect will inform subsequent treatment studies to see if we can
alter the medical prognostic course by treating depression and in
particular, by more selectively targeting the treatment for depression
to those factors that might be making a person with coronary disease
vulnerable to depression."
As the body of evidence grows and the line between medical and
mental health care narrows, future treatment could more regularly
incorporate both psychological and physical aspects. "As we get
a better understanding of the mechanisms, this will help inform
treatment studies to see if we can alter that course by treating
that depression."
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