• depression
• stress
• coronary artery disease

• CAD, coronary artery disease
• FMD, flow mediated dilatation
• HT, hydroxytryptamine
• ICAM-1, intercellular adhesion molecule-1
• IL, interleukin
• MCP-1, monocyte chemoattractant protein-1
• TNFα, tumour necrosis factor α

There is rapidly growing interest in the interactions between heart and mind. Evidence is accumulating from epidemiological and clinical studies that psychosocial factors contribute to coronary artery disease (CAD). Depression is a common problem with a high degree of associated disability, and has been the focus of much of this work. Depressed individuals are more likely to develop angina, or fatal or non-fatal myocardial infarction, than their non-depressed counterparts. A review of the prospective epidemiological cohort studies into depression and the subsequent development of CAD has shown a possible aetiologic role for depression or hopelessness in eight out of eight studies, even after adjustment for traditional cardiovascular risk factors.¹ Overall these studies show a relative risk of approximately twofold of developing CAD for depressed compared with non-depressed groups, with some studies showing a dose–response effect in which greater exposure to depression leads to a higher incidence of coronary events.² For example, a four year follow up of the Amsterdam longitudinal ageing study reported a relative risk of cardiac mortality of 1.6 for individuals with depressive symptoms, and 3.8 for those with clinically diagnosed depression, after adjustment for age, sex, education, smoking, alcohol, hypertension, body mass index, diabetes, stroke, and cancer.²

The John Hopkins precursors study³ followed 1190 medical students for a median of 37 years, and found a median interval of 15 years between the first episode of depression and the first coronary event. This suggests a chronic underlying link, with depression pre-dating the development of clinical CAD. Duration of symptoms themselves may also influence the risk of mortality.⁴ More recently, it has been found in the Whitehall II study that British civil servants with elevated scores on the general health …