Depression in Heart Patients

Two of every five patients who experience acute coronary syndrome (ACS) will have depression—a very important psychosocial predictor of poor cardiovascular prognosis.

“A growing body of evidence suggests that mental health problems complicate physical health conditions and that this relationship worsens clinical outcomes, increases hospitalization, and adversely affects quality of life,” Joseph A. Ladapo, MD, PhD, of New York University in New York City.

He and colleagues predicted that treatment of depression after ACS would be cost effective and improve patient outcomes.  They conducted a randomized, controlled study comparing enhanced depression care with usual care in patients with ACS and persistent depression 3 months after discharge.  Ladapo and colleagues defined enhanced depression care as problem-solving psychotherapy, antidepressant use or both.

Their conclusion at the close of the 6-month, prospective trial involving 157 patients was that treatment for depression reduced total per-patient healthcare costs by more than 40% and was cost effective for almost all patients.

An assessment of quality of life showed improved health utility in the intervention group.  Interviews 6 months after discharge showed that in the intervention group 51% were using antidepressants or anxiolytics and 75% had visited a mental health specialist at least once for a total cost of $1,083.  In the control group 30% were using antidepressants or anxiolytics and 35% had seen a mental health professional, for an average of $554.

The extra costs for the intervention group were more than offset by the significant reduction in hospitalization for ACS and heart failure (5% vs. 16%), with a mean cost savings of $1,782 for the intervention group and unmeasured improvement in quality of life.

Total healthcare costs averaged $1,857 in the intervention group and $2,797 for the usual-care arm, resulting in an adjusted difference of $1,229, which did not achieve statistical significance (P=0.09). Because the intervention was cost saving, the investigators could not calculate a cost-effectiveness ratio.

The research was reported in Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.4448, and was supported by the National Heart, Lung, and Blood Institute; the Health Resources and Services Administration; and the American Heart Association.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 26.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Antidepressants in Dementia

As many as 20% of patients with dementia may also have depression.  The usual treatment is a selective serotonin reuptake inhibitor or a noradrenergic and specific serotonergic antidepressant.  But some research has questioned the effectiveness of these treatments.

In a study published in The Lancet, (volume 378, Issue 9789, pages 403 - 411, 30 July 2011), Sube Banerjee MD, a London-based expert in old age psychiatry, and his colleagues concluded that because there was an absence of benefit compared with placebo and increased risk of adverse events, the practice of using these antidepressants should be reevaluated.

“Depression is one of the most important co-morbidities in dementia.  It is a source of great distress yet the treatments we use are not proven,” said Dr. Banerjee.

In their parallel-group, double-blind, placebo-controlled study of more than 326 patients with Alzheimer’s dementia, decreases in depression scores at 13 and 39 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (Zoloft) or 108 who received mirtazapine (Remeron).

“I am surprised by just how unequivocal our findings are,” said lead author Banerjee, professor of mental health and aging at King’s College London, Institute of Psychiatry, United Kingdom.  “The present practice of use of these antidepressants with usual care for first-line treatment of depression in Alzheimer’s disease should be reconsidered,” write the authors.

“The message is to think before using antidepressants for depression in dementia.  It may well be that these symptoms will resolve with the problem-solving and information-giving that is implicit in good-quality dementia care,” added Dr. Banerjee. The investigators suggest that antidepressants be reserved for “individuals whose depression has not resolved within 3 months of referral, apart from those in whom drug treatment is indicated by risk or extreme severity.”

Funding for this study was provided by the UK National Institute of Health Research HTA Programme.

Hmmm... Chocolate!

Chocolates

Food of the Gods

Hmmm. Truffles or chips, mousse or bars. No matter how you like it, there is nothing else like chocolate. But that delicious slice of cocoa-laced cake is often served with a helping of guilt. Maybe you shouldn’t feel so bad after all—it turns out chocolate has a good side.

Benefits

We all know it can soothe the soul, but did you know chocolate can also lower blood pressure and reduce the risk of heart disease and blood clots, according to a study published by the American Heart Association. Flavonoid compounds in dark chocolate are also the same healthful antioxidants found in fruits, vegetables, tea, and red wine. Chocolate even appears to reduce bad cholesterol (low density lipoprotein) while increasing good HDL (high density lipoprotein) cholesterol.

Chocolate also contains tryptophan, an amino acid that increases levels of serotonin, a natural antidepressant and stress reducer. And eating chocolate increases the body’s endorphin levels, thereby elevating mood and reducing pain. Dark chocolate also seems to improve the body’s use of insulin and glucose sensitivity, and it is rich in potassium and magnesium, and contains vitamins A, B1, B2, D, and E.

The Downside

Of course some of the benefits of eating chocolate are offset by its high fat, sugar, and calorie content. For example, a cup of broccoli and a cup of sliced apples have 20 and 57 calories respectively, while a cup of chocolate has 1,000 calories or more.

Not All Chocolate is Equal

The amount of beneficial flavonoids in chocolate depends on the type of cocoa bean and the methods used in processing. For instance, Dutch process” greatly reduces flavonoid content. White chocolate has no flavonoids since it has no “cocoa mass” and is not technically chocolate at all.

Dark chocolate, on the other hand, has fewer calories and two to four times the amount of flavonoids found in milk chocolate. Milk binds to the beneficial antioxidants, making them unavailable. To get the full benefits of antioxidants, you should avoid drinking milk with your dark chocolate. The ideal dark chocolate will have a “cocoa mass” content of at least 70%.  With chocolate—the darker, the better.

Thank the Mayans

2,000 years ago the Mayans of Mexico and Central America began cultivating the pods of the cocoa tree that grew wild in the jungle. When mixed with water, chili peppers, and cornmeal, the ground cocoa beans made a spicy, frothy drink. Later the Aztecs adopted the bitter cocoa drink, usually enjoyed only by royalty and the privileged class. Spanish conquistadors brought cocoa beans to Europe in the 1500s where experiments with adding sugar to the new product flourished. The rest is history.

Indulge

So next time you want to indulge your sweet tooth with the silky, smooth, velvety texture of your favorite chocolate, enjoy it without guilt—you could be lowering your blood pressure!

For more information about Pathways Home Health, Hospice & Private Duty please visit our website at www.pathwayshealth.org.