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(Circulation. 2000;101:1919.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Social Support, Depression, and Mortality During the First Year After Myocardial Infarction
Presented in part at the American Psychosomatic Society Meeting, Vancouver, Canada, March 1999.
From the Departments of Psychiatry (N.F.-S., F.L.) and School of Nursing (N.F.-S), McGill University; the Research Center, Montreal Heart Institute (N.F.-S., F.L., G.G., A.M., M.J., M.T., M.G.B.); and the Departments of Psychiatry (N.F.-S., F.L.) and Medicine (M.J., M.T., M.G.B.), University of Montreal. Montreal, Canada.
Correspondence to Nancy Frasure-Smith, Research Center, Montreal Heart Institute, 5000 Belanger St E, Montreal, Quebec, Canada, H1T 1C8. E-mail frsm{at}icm.umontreal.ca
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Abstract |
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Background—We previously reported that depression after myocardial infarction (MI) increases the long-term risk of cardiac mortality. Other research suggests that social support may also influence prognosis. This article examines the interrelationships between baseline depression and social support in terms of cardiac prognosis and changes in depression symptoms over the first post-MI year.
Methods and Results—For this study, 887 patients completed the
Beck Depression Inventory (BDI) and the Perceived Social Support Scale
(PSSS) at about 7 days after MI. Some 32% had BDIs 
10, indicating
mild to moderate depression. One-year survival status was determined
for all patients. Follow-up interviews, including the BDI, were
conducted with 89% of survivors. There were 39 deaths (35 cardiac).
Elevated BDI scores were related to cardiac mortality
(P=0.0006), but PSSS scores and other measures of social
support were not. There was a significant interaction between
depression and the PSSS (P=0.016). The relationship
between depression and cardiac mortality decreased with increasing
support. Furthermore, residual change score analysis revealed
that among 1-year survivors who had been depressed at baseline, higher
baseline social support was related to more improvement in depression
symptoms than expected.
Conclusions—Post-MI depression is a predictor of 1-year cardiac mortality, but social support is not directly related to survival. However, very high levels of support appear to buffer the impact of depression on mortality. Furthermore, high levels of support predict improvements in depression symptoms over the first post-MI year in depressed patients. High levels of support may protect patients from the negative prognostic consequences of depression because of improvements in depression symptoms.
Key Words: myocardial infarction • depression • social support • prognosis
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Research has demonstrated that depression is related to poor prognosis in patients with established coronary artery disease (CAD), particularly in those recovering from myocardial infarction (MI).1 For example, we previously reported that depression is associated with a 3- to 4-fold increase in cardiac mortality over the first 18 months after an MI.2 3 Although secondary analysis of these data suggested that measures of social support have no direct relationship to prognosis after MI,4 other research has indicated that socially isolated patients or those who report low social support may also be at increased risk.5 6 7 However, the extent to which depression and social support have interrelated prognostic impacts in post-MI patients is unclear.
There is consistent evidence in a variety of settings that levels of depression symptoms correlate negatively with measures of social support and that depressed patients, including those with and without cardiac disease, report lower social support than nondepressed individuals.8 9 10 11 Furthermore, some longitudinal community surveys and studies of psychiatric patients also suggest that depressed patients with good support may experience more rapid symptom improvement and may be less likely to experience recurrences of depression.10 12 13 14 One recent report indicates that perceived social support during hospitalization for cardiac catheterization predicts changes in depression symptoms over the subsequent month.15 All this research suggests that the impact of depression on post-MI prognosis might vary, depending on the level of social support. However, this question has not been explored, and the sample size of our previous study was too small (n=222) to reliably examine these interrelationships. Therefore, the purpose of this article is to explore the relationships between depression and social support in terms of both cardiac prognosis and changes in depression symptoms over the first post-MI year.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Sample
The sample involves 887 patients who completed the BDI16 and PSSS17 during hospitalization for an acute MI. They were recruited in 2 separate projects: the Montreal Heart Attack Readjustment Trial (M-HART)18 and the Emotions and Prognosis Post-Infarct (EPPI) Study.2 3 M-HART was a randomized, controlled trial of psychosocial intervention for post-MI patients. The present study combines patients in the control group from that trial with those in the EPPI study, a prospective examination of psychosocial risk after MI. The procedures and data collection methods for the 2 studies were similar. Because methodological details have been provided in previous publications, only the major outlines will be given here.
Subjects were recruited from consecutive admissions for an acute non–procedure-related MI in 10 Montreal area hospitals between 1991 and 1994. Exclusion criteria included other life-threatening conditions; inability to speak English or French; cognitive impairment or physical inability to complete the in-hospital interview; living too far to return to the hospital for follow-ups; and physician refusal, participation in other research, or early discharge. Some 63.6% of 2512 patients meeting selection requirements agreed to take part. This included 222 patients in the EPPI study and 684 in the M-HART control group (the 692 in the treatment group are not included in the present report). Of these 906 individuals, 887 completed baseline measures of depression and social support and constitute the current sample. Patients ranged from 24 to 88 years of age (mean±SD, 59.3±11.2 years). For 76.3%, the index MI was their first infarct. There were 279 women (31.5%).
Procedures
Structured baseline interviews were conducted by trained
research assistants soon after patients were transferred from intensive
care to medical wards. The 21-item self-report BDI was used to assess
symptoms of depression. BDI scores 10 are considered to indicate at
least mild to moderate levels of depression symptoms.19 In
the remainder of this report, we refer to these patients as
"depressed." Patients also responded to the PSSS, a 12-item
self-report scale that assesses perceived availability and satisfaction
with support received from family, friends, and a "special person."
Five other measures of social support were obtained: whether patients
felt they had any close friends or any close relatives, the total
number of friends and relatives whom patients considered close and saw
or talked to on a monthly basis, and 2 demographic indicators often
used as proxy measures of support, marital status and whether patients
were living alone. Close friends and relatives were defined as
"people you feel at ease with, can talk to about private matters, or
can call on for help." A variety of demographic and medical history
variables, including sex, age, education, smoking at the time of
the MI, previous treatment for hypertension, and previous MI, were also
assessed. Data obtained from hospital charts included Killip
class,20 left ventricular ejection fraction
(n= 868), treatment with a thrombolytic at admission,
prescription of hypoglycemic medications or insulin at discharge, and
revascularization (coronary angioplasty or
bypass) before or during the index admission.
One-year follow-up interviews, including the BDI, were conducted at home with 758 of the surviving patients (89.4%). Those who were not available for follow-up interviews differed significantly from others on only 2 baseline variables. Noncompleters were more likely to be women (P=0.051) and had lower PSSS scores (P=0.002).
Survival status was obtained for all patients at 365 days after discharge. Initial data were obtained from interviews with patients or family members and from Quebec Medicare data. Additional information about causes and dates of death came from hospital charts and autopsy reports (when available). Causes of death were independently classified as cardiac and noncardiac by 2 cardiologists who were blinded to baseline data and, in the case of the M-HART study, to treatment group.
Data Analysis
Data were analyzed with SPSS for Windows (version
9.0).21 Statistical tests were 2 sided. P
0.05
were considered statistically significant, with P0.10 and
P>0.05 classified as marginal. The importance of baseline
measures of social support, as well as their interactions with baseline
depression, in predicting 1-year cardiac mortality was assessed by use
of logistic regression procedures.
One difficulty in measuring change is that extreme scorers are likely to show more change when assessed a second time than people with more moderate initial scores (regression to the mean). To adjust for this problem, we used residual change score analysis to assess changes in BDI scores between baseline and 1 year in survivors.22 23 Multiple linear regression analysis was used first to predict a follow-up score for each subject on the basis of his or her initial BDI score and the degree of change in the sample as a whole. The difference between this predicted score and the actual follow-up BDI score for each subject constituted the residual change score. These scores indicate whether the observed degree of change for a particular subject was greater or less than the change predicted linearly by his or her baseline score. A positive residual change score means that a patient had fewer depression symptoms at 1 year than expected. A negative score means that a patient had more depression symptoms than expected. The relationships between baseline measures of social support and residual BDI change scores were examined with ANOVA and multiple linear regression procedures. These analyses also assessed the main effects of baseline depression and the interaction between depression and each baseline variable.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Baseline Psychosocial Measures
Table 1
shows the degree of
intercorrelation among the baseline measures of social support and Beck
Depression Inventory (BDI) scores. Other than the relationship between
marital status and living with others, the measures were not highly
interrelated. In fact, the level of correlation between our indexes of
support and depressive symptoms suggests that they share at most 
5%
of variance and tap largely independent psychosocial constructs.
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Some 32.0% of patients had baseline BDI scores 10, indicative of at
least mild to moderate depression. Comparisons of the depressed (BDI
10) and nondepressed patients on measures of social support appear in
Table 2. The depressed had significantly
lower Perceived Social Support Scale (PSSS) scores, were less likely to
report having 1 close friend, were less likely to be married, and
were less likely to be living with 1 others than the nondepressed.
However, there were no depression-related differences in reports of
having 1 close relative or the mean number of close friends and
relatives in monthly contact.
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Cardiac Mortality at 1 Year
By 1 year, there were 39 deaths (35 cardiac). As reported
previously,24 the depressed were at significantly
increased risk of 1-year cardiac mortality (OR=3.36; 95% CI=1.68 to
6.70; P=0.0006). Although the depressed differed from the
nondepressed in a number of background characteristics (described in
detail elsewhere),24 the depression-related
difference in cardiac mortality remained significant
(P=0.0013) after controlling for
multivariate predictors of 1-year cardiac mortality,
including age, Killip class, and the interactions between sex and
non–Q-wave MI, sex and left ventricular ejection fraction,
and sex and smoking.
Although no measure of social support showed any overall relationship
with cardiac mortality (all P0.45), there was a
significant interaction between the continuous PSSS score and baseline
depression (P=0.016). None of the other interactions between
measures of social support and depression were significant (all
P>0.20).
The interaction between depression and the PSSS score, divided into
quartiles for illustrative purposes, is shown in Figure 1. At very low levels of perceived social
support, the impact of depression on prognosis was quite marked. For
patients in the middle ranges of perceived support, the link between
depression and survival was still apparent. However, among patients in
the highest quartile of perceived social support, there was no
depression-related increase in cardiac mortality.
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The interaction of depression and perceived social support with 1-year cardiac mortality remained significant (for continuous PSSS, P=0.047) after adjustment for all variables included in the multivariate model derived in our previous research (age, Killip class, and the interactions between sex and non–Q-wave MI, sex and left ventricular ejection fraction, and sex and smoking).
These results suggest some role for perceived social support in predicting and possibly preventing depression-related cardiac mortality. One mechanism by which perceived support could buffer the impact of depression on prognosis is by reducing depression symptoms over time. This issue is the focus of the remaining analyses.
Changes in Symptoms of Depression at 1 Year
Rates of depression remained high at 1 year. Although some 29.8%
of the survivors had been depressed in hospital, 26.0% were depressed
at 1 year. This included 52.7% of those who had been depressed in
hospital and 14.7% of those not originally depressed. On average,
patients who had been depressed in hospital experienced a decline of
5 points in their BDI scores by 1 year, and the nondepressed showed
an increase of 1 point (P<0.0001), reflecting, in part,
an expected regression to the mean. Therefore, we assessed
relationships between baseline variables and changes in BDI scores
by calculating residual change scores.
Results of multiple linear regression analyses showed no
overall relationships between baseline measures of social support and
residual BDI change scores. However, there were significant
interactions between baseline depression and 5 of the 6 measures of
social support. Figure 2 shows the
significant interactions. In that figure, the PSSS score and the number
of close friends and relatives in regular contact are divided into
quartiles for illustrative purposes. For each interaction, the
x axis (at the 0 point) represents the degree of
change that would be expected in the BDI score on the basis of the BDI
level at baseline. Mean values above the axis indicate that a
particular group had fewer depression symptoms at 1 year than
predicted, with higher positive means indicating better outcomes. Mean
values below the axis show groups with more depression symptoms than
predicted, with more negative values indicating worse outcomes. For the
PSSS score, we see that among people who were not depressed at
baseline, perceived social support was unrelated to changes in
depression symptoms. Average residual change scores were all0.
However, among people who had been depressed at baseline, residual
changes in depression symptoms were related to perceived social
support. Those with the lowest perceived social support tended to show
more depression symptoms than expected (values below the x
axis), whereas those with the highest perceived support showed markedly
fewer depression symptoms than expected. The patterns for all
interactions were similar. In short, social support had an impact on
BDI score changes in patients who had been depressed at baseline. There
was relatively little evidence of a relationship between social support
and changes in depression symptoms in the nondepressed. Depressed
patients who had the least social support (ie, those with lower PSSS
scores, those with no relatives whom they perceived as close, those
with lower numbers of regular interactions with friends and relatives
whom they perceived as close, those who were unmarried, and those who
lived alone) tended to experience more symptoms of depression at 1 year
than would have been expected on the basis of their baseline BDI
scores. In contrast, depressed patients with higher support tended to
show fewer depression symptoms than predicted. The only social support
measure unrelated to BDI changes was whether patients reported having
any close friends.
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There was no evidence that demographic factors, including age, sex, and education, or most measures of cardiac risk or history were linked to changes in depression symptoms. Only 2 baseline variables were significantly related to residual BDI change scores, Killip class (P=0.002) and diabetes (P=0.002). Regardless of whether or not they had been depressed at baseline, patients with advanced Killip class and those who were diabetic tended to have more depression symptoms at 1 year than expected at baseline. There was also a significant interaction between diabetes and baseline depression (P=0.012), showing that diabetics who had been depressed in hospital were particularly likely to have more depression symptoms at 1 year than expected on the basis of their baseline BDI scores.
Each of the significant interactions of depression and social support in relation to residual BDI change scores remained at least marginally significant after controlling for these measures of disease severity (for PSSS by depression, P=0.054; for number of close friends and relatives in regular contact by depression, P=0.001; for any close relatives by depression, P=0.089; for married by depression, P=0.011; and for living with others by depression, P=0.057).
To examine the relative importance of the different measures of
social support in mediating changes in depression symptoms in patients
who had been depressed at baseline, we restricted analyses to
this group and carried out stepwise multiple regression
analyses to predict residual changes in BDI scores. With
forward stepping, the PSSS score entered on the first step, followed by
the number of close friends and relatives in monthly contact. Whether
the patient lived alone entered on the third step (see Table 3). The same variables were selected
by backward stepping. Thus, there is evidence that perceptions of
social support, reported frequency of social interaction, and a
demographic proxy variable for social support (whether patients
lived with others) have independent impacts on 1-year changes in
depression symptoms in post-MI patients who are depressed during
hospitalization.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Although there is increasing evidence that depression has an impact on survival in patients with various manifestations of CAD1 and there have been studies linking social support with prognosis,5 6 7 to the best of our knowledge, this is the first paper to examine the impact of the 2 variables in combination after MI. We observed that as previously reported, depressed patients were at significantly increased risk of post-MI mortality. However, this was not true for those who perceived very high levels of social support. Not only were depressed individuals with high support at baseline not at increased risk of cardiac mortality, but also their depression symptoms were more likely to improve than those of the depressed with low to moderate support. Furthermore, we found that 3 different measures of social support had independent relationships with improvements in depression: higher scores on a measure of perceived social support, a greater number of close friends and relatives with whom the patient had regular monthly contact by phone or in person, and living with
1 person. It appears that good
support can constitute a sort of "psychotherapy of everyday
life,"25 with multiple aspects of interactions with
other significant people helping to reduce depression symptoms in
depressed post-MI patients even without formal treatment. Thus, the
impact of social support on improvements in depression symptoms, which
has often been demonstrated in psychiatric and community
samples,13 is also present in patients recovering from
MI. However, like other researchers working with patients with
CAD,26 we found that overall rates of depression at 1 year
remained high, indicating a need for appropriate intervention
strategies beyond naturally occurring support for many patients. We also found, as have others studying noncardiac groups,9 that depressed patients perceived less social support, were less likely to have close friends, were more likely to be unmarried, and were more likely to be living alone than nondepressed patients, but we also found that depressed and nondepressed patients did not differ in their reported frequency of monthly contacts with friends and relatives. However, the direction of causality between social support and depression, if there is a causal influence, is far from clear. It has been argued that inadequate social support and isolation from others lead to depression, particularly in the face of life crises.27 There is also evidence that depressed individuals exhaust the resources of their support networks and alienate those around them, leading to less support.28 Finally, there is what is sometimes called the "plaintive set" or negative lens of depression in which perceptions of social support are distorted, so the depressed individual does not perceive the support that is available.29
The present study has several limitations. The data involve secondary analysis of data collected from 2 previous studies, including the control group from a randomized trial of psychosocial intervention, and slightly fewer than two thirds of eligible patients agreed to take part. Although this percent of acceptance is better than in many randomized trials, it is clear that results cannot be generalized to the type of patient who is unwilling or unable to complete detailed psychosocial assessments and accept the possibility of psychosocial treatment. Furthermore, women and patients who perceived low support at baseline were less likely to accept 1-year follow-up interviews than other patients were. However, 89% of survivors were interviewed, and depression at baseline was not related to lack of follow-up, so it is unlikely that the lack of interview data biased the results with regards to depression improvement in well-supported patients. It may, however, have resulted in an underestimation of the impact of low social support on 1-year changes in depression. In addition, although a long-term study is underway, patients have not been followed long enough beyond 1 year to allow direct evaluation of the impact of changes in depression symptoms on prognosis. We can only speculate that lack of improvement in depression over the first post-MI year may be related to long-term mortality.
Because high levels of perceived social support predict improvements in depression symptoms over the first post-MI year and appear to reduce the impact of baseline depression on cardiac mortality over the same period, evaluation of the efficacy of social support–related interventions in treating depression in post-MI patients is clearly warranted. Results also suggest that clinicians can be reasonably optimistic when depressed patients have very positive perceptions of support availability, have large social networks with whom they are in regular contact, or are living with others. In comparison, the combination of depression and poor social support is associated with a substantial increase in risk of mortality over at least the first post-MI year, as well as with continuing chronic depression in survivors. Clinicians should be alert to the potential consequences of this combination and consider expanding their assessment of post-MI depression to include a few simple questions like those used in our research to find out about the patient’s views of the availability and adequacy of support and help from friends and family members.
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Acknowledgments |
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This work was supported by grants from the US National Heart, Lung, and Blood Institute, Health Canada, the Joint Research Grant Program in Mental Health of the Fonds de la recherche en santé du Québec and the Quebec Council of Social Research, the Pierre David Fund, and the Montreal Heart Institute Research Fund.
Received August 23, 1999; revision received November 4, 1999; accepted November 29, 1999.
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 V. S. Fan, S. D. Ramsey, N. D. Giardino, B. J. Make, C. F. Emery, P. T. Diaz, J. O. Benditt, Z. Mosenifar, R. McKenna Jr, J. L. Curtis, et al. Sex, Depression, and Risk of Hospitalization and Mortality in Chronic Obstructive Pulmonary Disease Arch Intern Med, November 26, 2007; 167(21): 2345 - 2353. [Abstract] [Full Text] [PDF]
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R. C. Ziegelstein, B. D. Thombs, K. Parakh, D. E. Stewart, S. E. Abbey, and S. L. Grace The Brain and the Heart: Independent or Interactive? J. Am. Coll. Cardiol., May 1, 2007; 49(17): 1824 - 1824. [Full Text] [PDF]
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 S. Rajagopalan, S. Dellegrottaglie, A. L. Furniss, B. W. Gillespie, S. Satayathum, N. Lameire, A. Saito, T. Akiba, M. Jadoul, N. Ginsberg, et al. Peripheral Arterial Disease in Patients With End-Stage Renal Disease: Observations From the Dialysis Outcomes and Practice Patterns Study (DOPPS) Circulation, October 31, 2006; 114(18): 1914 - 1922. [Abstract] [Full Text] [PDF]
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N. Frasure-Smith, D. Koszycki, J. R. Swenson, B. Baker, L. T. van Zyl, M.-A. Laliberte, B. L. Abramson, J. Lambert, G. Gravel, and F. Lesperance Design and Rationale for a Randomized, Controlled Trial of Interpersonal Psychotherapy and Citalopram for Depression in Coronary Artery Disease (CREATE) Psychosom Med, January 1, 2006; 68(1): 87 - 93. [Abstract] [Full Text] [PDF]
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H. S. Lett, J. A. Blumenthal, M. A. Babyak, T. J. Strauman, C. Robins, and A. Sherwood Social Support and Coronary Heart Disease: Epidemiologic Evidence and Implications for Treatment Psychosom Med, November 1, 2005; 67(6): 869 - 878. [Abstract] [Full Text] [PDF]
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A. Sherwood, A. L. Hinderliter, L. L. Watkins, R. A. Waugh, and J. A. Blumenthal Impaired Endothelial Function in Coronary Heart Disease Patients With Depressive Symptomatology J. Am. Coll. Cardiol., August 16, 2005; 46(4): 656 - 659. [Abstract] [Full Text] [PDF]
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J. H.K. Vogel, S. F. Bolling, R. B. Costello, E. M. Guarneri, M. W. Krucoff, J. C. Longhurst, B. Olshansky, K. R. Pelletier, C. M. Tracy, R. A. Vogel, et al. Integrating Complementary Medicine Into Cardiovascular Medicine: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine) J. Am. Coll. Cardiol., July 5, 2005; 46(1): 184 - 221. [Full Text] [PDF]
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K. Z. Bambauer, O. Aupont, P. H. Stone, S. E. Locke, M. G. Mullan, J. Colagiovanni, and T. J. McLaughlin The Effect of a Telephone Counseling Intervention on Self-Rated Health of Cardiac Patients Psychosom Med, July 1, 2005; 67(4): 539 - 545. [Abstract] [Full Text] [PDF]
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R. C. Ziegelstein, S. Y. Kim, D. Kao, J. A. Fauerbach, B. D. Thombs, U. McCann, J. Colburn, and D. E. Bush Can Doctors and Nurses Recognize Depression in Patients Hospitalized With an Acute Myocardial Infarction in the Absence of Formal Screening? Psychosom Med, May 1, 2005; 67(3): 393 - 397. [Abstract] [Full Text] [PDF]
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A Steptoe and D L Whitehead Depression, stress, and coronary heart disease: the need for more complex models Heart, April 1, 2005; 91(4): 419 - 420. [Abstract] [Full Text] [PDF]
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A. Rozanski, J. A. Blumenthal, K. W. Davidson, P. G. Saab, and L. Kubzansky The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: The emerging field of behavioral cardiology J. Am. Coll. Cardiol., March 1, 2005; 45(5): 637 - 651. [Abstract] [Full Text] [PDF]
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D. V. Iosifescu, A. A. Nierenberg, J. E. Alpert, M. Smith, S. Bitran, C. Dording, and M. Fava The Impact of Medical Comorbidity on Acute Treatment in Major Depressive Disorder Focus, January 1, 2005; 3(1): 69 - 75. [Abstract] [Full Text] [PDF]
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J. Barth, M. Schumacher, and C. Herrmann-Lingen Depression as a Risk Factor for Mortality in Patients With Coronary Heart Disease: A Meta-analysis Psychosom Med, November 1, 2004; 66(6): 802 - 813. [Abstract] [Full Text] [PDF]
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 R. K. Bode, A. W. Heinemann, P. Semik, and T. Mallinson Relative Importance of Rehabilitation Therapy Characteristics on Functional Outcomes for Persons With Stroke Stroke, November 1, 2004; 35(11): 2537 - 2542. [Abstract] [Full Text] [PDF]
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B. Bankier, J. L. Januzzi, and A. B. Littman The High Prevalence of Multiple Psychiatric Disorders in Stable Outpatients With Coronary Heart Disease Psychosom Med, September 1, 2004; 66(5): 645 - 650. [Abstract] [Full Text] [PDF]
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F. Mookadam and H. M. Arthur Social Support and Its Relationship to Morbidity and Mortality After Acute Myocardial Infarction: Systematic Overview Arch Intern Med, July 26, 2004; 164(14): 1514 - 1518. [Abstract] [Full Text] [PDF]
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C. C. Cherrington, D. K. Moser, T. A. Lennie, and C. W. Kennedy Illness Representation After Acute Myocardial Infarction: Impact On In-Hospital Recovery Am. J. Crit. Care., March 1, 2004; 13(2): 136 - 145. [Abstract] [Full Text] [PDF]
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 M. J. Zellweger, R. H. Osterwalder, W. Langewitz, and M. E. Pfisterer Coronary artery disease and depression Eur. Heart J., January 1, 2004; 25(1): 3 - 9. [Abstract] [Full Text] [PDF]
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 D. V. Iosifescu, A. A. Nierenberg, J. E. Alpert, M. Smith, S. Bitran, C. Dording, and M. Fava The Impact of Medical Comorbidity on Acute Treatment in Major Depressive Disorder Am J Psychiatry, December 1, 2003; 160(12): 2122 - 2127. [Abstract] [Full Text] [PDF]
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K. M. A. MacMahon and G. Y. H. Lip Psychological Factors in Heart Failure: A Review of the Literature Arch Intern Med, March 11, 2002; 162(5): 509 - 516. [Abstract] [Full Text] [PDF]
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N. Frasure-Smith and F Lesperance Coronary artery disease, depression and social support only the beginning Eur. Heart J., July 1, 2000; 21(13): 1043 - 1045. [PDF]
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F. Lesperance, N. Frasure-Smith, M. Talajic, and M. G. Bourassa Five-Year Risk of Cardiac Mortality in Relation to Initial Severity and One-Year Changes in Depression Symptoms After Myocardial Infarction Circulation, March 5, 2002; 105(9): 1049 - 1053. [Abstract] [Full Text] [PDF]
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