title: Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial.
abstract: BACKGROUND
  Depression and low perceived social support (LPSS) after myocardial infarction (MI) are associated with higher morbidity and mortality, but little is known about whether this excess risk can be reduced through treatment.
  
  
  OBJECTIVE
  To determine whether mortality and recurrent infarction are reduced by treatment of depression and LPSS with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after MI.
  
  
  METHODS
  Randomized clinical trial conducted from October 1996 to April 2001 in 2481 MI patients (1084 women, 1397 men) enrolled from 8 clinical centers. Major or minor depression was diagnosed by modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and severity by the 17-item Hamilton Rating Scale for Depression (HRSD); LPSS was determined by the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention.
  
  
  METHODS
  Cognitive behavior therapy was initiated at a median of 17 days after the index MI for a median of 11 individual sessions throughout 6 months, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the HRSD or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks.
  
  
  METHODS
  Composite primary end point of death or recurrent MI; secondary outcomes included change in HRSD (for depression) or ESSI scores (for LPSS) at 6 months.
  
  
  RESULTS
  Improvement in psychosocial outcomes at 6 months favored treatment: mean (SD) change in HRSD score, -10.1 (7.8) in the depression and psychosocial intervention group vs -8.4 (7.7) in the depression and usual care group (P<.001); mean (SD) change in ESSI score, 5.1 (5.9) in the LPSS and psychosocial intervention group vs 3.4 (6.0) in the LPSS and usual care group (P<.001). After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care (75.9%) and psychosocial intervention (75.8%). There were also no differences in survival between the psychosocial intervention and usual care arms in any of the 3 psychosocial risk groups (depression, LPSS, and depression and LPSS patients).
  
  
  CONCLUSIONS
  The intervention did not increase event-free survival. The intervention improved depression and social isolation, although the relative improvement in the psychosocial intervention group compared with the usual care group was less than expected due to substantial improvement in usual care patients.
authors.affiliation: Harvard University, Boston, MA, USA.
authors.forename: Lisa F
authors.initials: LF
authors.lastname: Berkman
authors.forename: James
authors.initials: J
authors.lastname: Blumenthal
authors.forename: Matthew
authors.initials: M
authors.lastname: Burg
authors.forename: Robert M
authors.initials: RM
authors.lastname: Carney
authors.forename: Diane
authors.initials: D
authors.lastname: Catellier
authors.forename: Marie J
authors.initials: MJ
authors.lastname: Cowan
authors.forename: Susan M
authors.initials: SM
authors.lastname: Czajkowski
authors.forename: Robert
authors.initials: R
authors.lastname: DeBusk
authors.forename: James
authors.initials: J
authors.lastname: Hosking
authors.forename: Allan
authors.initials: A
authors.lastname: Jaffe
authors.forename: Peter G
authors.initials: PG
authors.lastname: Kaufmann
authors.forename: Pamela
authors.initials: P
authors.lastname: Mitchell
authors.forename: James
authors.initials: J
authors.lastname: Norman
authors.forename: Lynda H
authors.initials: LH
authors.lastname: Powell
authors.forename: James M
authors.initials: JM
authors.lastname: Raczynski
authors.forename: Neil
authors.initials: N
authors.lastname: Schneiderman
mesh_terms: D000223:Adaptation, Psychological; D000928:Antidepressive Agents / Q000627:therapeutic use*; D015928:Cognitive Behavioral Therapy; D003863:Depression / Q000209:etiology* / Q000628:therapy*; D003866:Depressive Disorder / Q000209:etiology* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009203:Myocardial Infarction / Q000453:epidemiology / Q000523:psychology* / Q000628:therapy*; D016016:Proportional Hazards Models; D012307:Risk Factors; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D012944:Social Support; D016019:Survival Analysis
chemical_list: D000928:Antidepressive Agents; D017367:Selective Serotonin Reuptake Inhibitors