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Increase in Heart Surgery Mortality from SSRIs or Depression?

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Duke Health News 919-660-1306

DURHAM, N.C. -- Duke University Medical Center researchers
have found that patients who were using a class of
anti-depression drugs known as selective serotonin reuptake
inhibitors (SSRI) prior to undergoing coronary artery bypass
surgery have significantly higher death and rehospitalization
rates up to five years after the procedure than patients who
were not on SSRIs.

The researchers said that, based on the results of their
analysis of more than 4,700 heart patients, that physicians
treating heart surgery patients should not only screen for
depression prior to surgery, but that they should also pay
closer attention to the long-term psychiatric care of patients
deemed to be depressed.

"While many studies have shown that depression is just as
important a cardiac risk factor as hypertension and smoking,
there are still many in the field who do not fully appreciate
this mind-body link," said Glen Xiong, M.D., who presented the
results of the Duke study May 25, 2005, during the annual
scientific sessions of the American Psychiatric Association in
Atlanta.

"This under-appreciation may be because of the stigma
associated with mental health issues," said Xiong, a resident
in Duke's Medicine-Psychiatry program. "Many think that
patients who have just had a heart attack are depressed and
that with time, they'll get over it. Our study would indicate
that these are the very patients who need to be followed more
closely."

Their analysis of 4,794 heart surgery patients at Duke from
1999 to 2003 found that 5.1 percent of patients were taking
SSRIs prior to surgery. When the researchers then checked
survival rates four years later, they found that 75.1 percent
of patients taking SSRIs were still alive, compared to 84.9
percent who weren't taking SSRIs.

"However, when we looked at the 30 days mortality following
the operation, both groups were about the same," Xiong said.
"It's only when patients get farther out from surgery that the
mortality rates begin to increase among patients who were
taking SSRIs prior to the heart surgery. We believe that this
increase is due more to the underlying depression itself than
medication use. It appears that for our study, SSRI usage
serves as a marker for the depressed patients."

The researchers added that depression is associated with
many physiological and psychosocial characteristics that likely
explain why depressed patients tend to fare worse over
time.

The researchers also found that those patients taking SSRIs
were as a group significantly more often white than those who
were not (85.8 percent vs. 76.2 percent) and female (43.9
percent vs. 29 percent). The SSRI group also was more likely to
have diabetes, high blood pressure and increased cholesterol
levels when compared to the non-SSRI group.

"We also know that depressed patients are less likely to
take their medications, go to the doctor or rehab program
regularly, eat healthy diets or stop smoking," Xiong continued.
"It is precisely for these reasons we believe that these
high-risk surgery patients need to receive appropriate
treatment for depression."

"In our cohort of patients, only five percent were taking
SSRIs, which we believe greatly under-represents the number of
depressed heart patients," said Duke internist and psychiatrist
Wei Jiang, M.D., Xiong's mentor and a senior member of the
research team. "Nationally, it is believed that up to twenty
percent of heart patients are depressed. This raises that
concern that many depressed patients are being under-treated
for their depression, and that we can save lives if we identify
and treat depression appropriately."

"In many ways, this study raises more questions than it
answers," Jiang continued. "It raises questions of how we treat
depression in hearts disease – we need to see it as a
long-term, chronic condition. I think we need to conduct
longer-term studies to see if anti-depression medications and
psychotherapy can influence the mortality rates for these
patients."

Xiong added: "Just as importantly, we need to see if we
should introduce a depression screening tool in our standard
treatment for patients with heart disease. Should we be
screening and monitoring for depression more regularly, like we
do for hypertension and hypercholesterolemia?"

The study was supported by Duke's Department of Psychiatry
and the Duke Clinical Research Institute.

Other members of the Duke team were Kristin Newby, M.D., Bob
Clare, Linda Shaw, Peter Smith M.D., Kenneth Mahaffey, M.D.,
Chris O'Connor, M.D. and Ranga Krishnan, M.D.

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