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DALLAS, Sept. 29 -- Patients with coronary heart disease should be screened early and regularly for depression, according to a scientific statement issued by the American Heart Association.

Two questions can identify patients whose psychological state should be evaluated by the entire nine-question screening tool, a multidisciplinary writing committee said in the statement, published online in advance of the Oct. 21 issue of Circulation.

Patients with even mild symptoms of depression should be referred to a specialist for a more comprehensive psychiatric evaluation, it added. The statement has the endorsement of the American Psychiatric Association.

"The statement was prompted by the growing body of evidence that shows a link between depression in cardiac patients and a poorer long-term outlook," Erika Froelicher, R.N., Ph.D., of the University of California San Francisco and co-chair of the working group that produced the statement.

Multiple studies have shown that major depression is associated with worse prognosis in patients with coronary disease. Moreover, most studies have demonstrated a dose-response relationship: Increasing severity of depression is associated with earlier and more severe cardiac events, the statement authors said.

Countering the argument that the association is explained entirely by severity of cardiac disease, the authors pointed out that depression's effect on coronary disease remains significant after adjustment for potential confounders.

The AHA recommends use of the Patient Health Questionnaire (PHQ-9) to screen coronary disease patients for depression. All patients should be asked: Over the past two weeks, how often have you been bothered by the following two symptoms?

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless

Patients who answer in the affirmative to either question should be evaluated by means of seven additional questions that explore how often the patient has been bothered in the past two weeks by:

1. Trouble falling asleep, staying asleep, or sleeping too much
2. Feeling tired or having little energy
3. Poor appetite or overeating
4. Feeling bad about yourself, that you are a failure, or that you have let yourself or your family down
5. Trouble concentrating on things such as reading the newspaper or watching television
6. Moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you have been moving around a lot more than usual
7. Thinking that you would be better off dead or that you want to hurt yourself in some way.

Each question is assigned a score of 0-3, representing the frequency range from "Not at all" to "Nearly every day."

Three treatment strategies have proven useful for managing patients who have coronary disease and depression: antidepressant drugs, cognitive behavioral therapy, and physical activity, such as aerobic exercise and cardiac rehabilitation.

The working group found evidence to support the use of the selective serotonin reuptake inhibitors sertraline and citalopram as first-line antidepressant therapy.

Cognitive behavioral therapy has proven beneficial either alone or in combination with antidepressants.

Physical activity offers benefits for depression and cardiac rehabilitation. An exercise prescription should be individualized to the health status and circumstances of each patient.

As a final recommendation, the working group called for coordination of care between physical and mental health specialists to ensure that the heart disease and depression are both adequately treated and do not have adverse consequences for each other.

Several members of the working group reported financial relationships involving the pharmaceutical and medical device industries.

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