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Depressive disorder, as defined by standardised research criteria, is recorded in 13–19% of patients at the time of myocardial infarction (MI).1-7 The disorder is important in MI patients because depression is associated with several adverse outcomes: increased mortality,1 ,5-7 angina,2arrhythmias,2 ,6 ,8 rehospitalisation, prolonged disability, and continued smoking.
There is increasing evidence that depressed myocardial infarction patients have an increased mortality rate1-6; this effect appears to be independent of the severity of MI and is impressive. In the most quoted study, examining six month mortality, patients with major depression had an increased mortality rate: after adjusting for other factors (previous MI, age and Killip class) the adjusted hazard ratio was 3.3 (95% confidence intervals (CI) 1.96 to 4.68).1 At 18 months’ follow up the adjusted odds ratio was 6.6 for patients who had depressive symptoms shortly after the MI.5 If these results were replicated in the UK, the increased mortality associated with depressive disorder would represent approximately 20 000 patients per annum.
Severity and duration of depression
The association between depression and increased mortality is derived from studies including small numbers of depressed patients, and the studies are not entirely consistent. A number of methodological difficulties must be considered, namely that studies have varied in their measures of depression, the inclusion rates of patients and the proportions of men and women (table 1).1 ,2 ,6 ,9-12 All studies agree that depression in MI is independent of the severity of the infarction.