Vol 9, No 1- Neuropsychiatry and Cardiovascular Disease
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hen psychiatrists use the term “comorbidity”in connection with depression,they are almost always refer- ring to other psychiatric conditions,primarily anxiety or addictive disorders,and these do co-occur with depres- sion more often than would be expected by chance.1 However,vascular disease,particularly the association between depression and heart disease,is among the best- documented of all comorbidities.2Not only writers and poets,but our language itself refers to,“dying of a broken heart.”Almost all languages,in one way or another, express a very similar idea.However,in spite of this wide- spread popular acceptance,scientific evidence has been slow in emerging,and has turned out to be of a more complicated nature than expected. Cardiovascular disease in depressed patients Early epidemiological studies relating melancholia to heart disease found much higher rates of cardiovascular deaths in melancholic patients,but their use of hospitalized pop- ulations confounded the effects of depression and chronic institutionalization.3After the Second World War,more psychoanalytic formulations,primarily “type A personal- ity,”held sway.The time-urgent,angry,type A individual did seem significantly more vulnerable to heart disease, S t a t e  o f  t h e  a r t W Copyright © 2007 LLS SAS. All rights reserved www.dialogues-cns.org Depression and cardiovascular comorbidity Alexander H.Glassman,MD Depression has long had a popular link to cardiovascular disease and death. However, only during the last 15 years has scientific evidence supporting this common wisdom been available. Beginning in the early 1990s, there began to accumulate community-based epidemiological evidence that medically healthy, depressed patients followed for long periods of time were at increased risk of both car- diovascular disease and cardiac death. In the mid-1990s, evidence appeared to indicate that depression following a heart attack increased the risk of death. It is now appar- ent that depression aggravates the course of multiple car- diovascular conditions. There are two major unanswered questions. One is whether treating depression will reduce the risk of cardiovascular disease and death. Here, prelim- inary, but not definitive, evidence suggests that the sero- tonin reuptake inhibitors may be useful. The other unan- swered question regards the mechanisms that underlie this link between depression and cardiovascular disease. There is strong evidence linking platelet activation, autonomic activity, and inflammatory markers to both depression and heart disease, but why these links exist is far less clear. © 2007, LLS SAS Dialogues Clin Neurosci. 2007;9:9-17. Keywords:Antidepressant; comorbidity; cardiac mortality; cardiac risk factor; coro- nary disease; depression; depressive disorder; epidemiology; heart disease; major depression; myocardial infarction; sertraline; serotonin uptake inhibitors; smoking; SSRI; stroke; tricyclic; unstable angina; vascular disease Author affiliations:Professor of Psychiatry, Columbia University, New York, NY, USA; Chief of Clinical Psychopharmacology, New York State Psychiatric Institiute, New York, NY, USA Address for correspondence: Prof Alexander H. Glassman, Clinical Psychopharmacology, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA (e-mail: ahg1@columbia.edu)