What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Ischemic heart disease (n=35000). Intervention: Major depression vs. No major depression. Primary outcome: Incident ischemic heart disease (RR 1.56, 95% CI 1.30 to 1.87).

What does this research mean for the field?

Major depression significantly increases the risk of developing incident ischemic heart disease (relative risk 1.56) and is responsible for approximately 3% of the global ischemic heart disease burden. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

November 26, 2013Open Access

The contribution of major depression to the global burden of ischemic heart disease: a comparative risk assessment

Key Result

Major depression significantly increased the risk of developing incident ischemic heart disease with a pooled relative risk of 1.56.

Study Design

Type

Meta-Analysis (n=35,000)

Structured PICO

Does major depression increase the risk of developing ischemic heart disease?

Population

Populations assessed in studies identified through a systematic review for the Global Burden of Disease Study 2010

Intervention

Major depression (diagnosed by clinician or non-clinician raters adhering to DSM or ICD classifications)

Comparator

Absence of major depression

Outcome

Development of ischemic heart disease (IHD) and attributable burden (DALYs, years of life lost, years lived with disability)hard clinical

Major depression is an independent risk factor for ischemic heart disease, accounting for nearly 3% of global IHD DALYs and highlighting the need for depression assessment in high-risk patients.

Main Result

Effect estimate: RR 1.56 (95% CI 1.30 to 1.87)

Limitations

Assumption of a causal relationship between depression and IHD remains to be definitively established.
Potential confounding by related risk factors such as smoking, diet, physical activity, obesity, and comorbid anxiety.
Lack of geographic representativeness, as studies originated only from the USA and the Netherlands.
Significant heterogeneity between included studies (I2 = 67.1%).
Potential for overestimation of effect size due to apparent publication bias.
Few included studies used well-validated instruments for clinical diagnosis of major depressive disorder.
Exclusion of 'silent' asymptomatic IHD may have led to an underestimation of the association.

Abstract

BACKGROUND: Cardiovascular disease and mental health both hold enormous public health importance, both ranking highly in results of the recent Global Burden of Disease Study 2010 (GBD 2010). For the first time, the GBD 2010 has systematically and quantitatively assessed major depression as an independent risk factor for the development of ischemic heart disease (IHD) using comparative risk assessment methodology. METHODS: A pooled relative risk (RR) was calculated from studies identified through a systematic review with strict inclusion criteria designed to provide evidence of independent risk factor status. Accepted case definitions of depression include diagnosis by a clinician or by non-clinician raters adhering to Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) classifications. We therefore refer to the exposure in this paper as major depression as opposed to the DSM-IV category of major depressive disorder (MDD). The population attributable fraction (PAF) was calculated using the pooled RR estimate. Attributable burden was calculated by multiplying the PAF by the underlying burden of IHD estimated as part of GBD 2010. RESULTS: The pooled relative risk of developing IHD in those with major depression was 1.56 (95% CI 1.30 to 1.87). Globally there were almost 4 million estimated IHD disability-adjusted life years (DALYs), which can be attributed to major depression in 2010; 3.5 million years of life lost and 250,000 years of life lived with a disability. These findings highlight a previously underestimated mortality component of the burden of major depression. As a proportion of overall IHD burden, 2.95% (95% CI 1.48 to 4.46%) of IHD DALYs were estimated to be attributable to MDD in 2010. Eastern Europe and North Africa/Middle East demonstrate the highest proportion with Asia Pacific, high income representing the lowest. CONCLUSIONS: The present work comprises the most robust systematic review of its kind to date. The key finding that major depression may be responsible for approximately 3% of global IHD DALYs warrants assessment for depression in patients at high risk of developing IHD or at risk of a repeat IHD event.

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