title: Association of antidepressant and atypical antipsychotic use with cardiovascular events and mortality in a veteran population.
abstract: OBJECTIVE
  To determine the patterns of antidepressant and atypical antipsychotic use in a veteran population with depression, and to determine if an association exists between specific antidepressant classes and atypical antipsychotics and the occurrence of cardiovascular events and all-cause mortality.
  
  
  METHODS
  Retrospective, cross-sectional study.
  
  
  METHODS
  Primary care clinic at a Veterans Affairs hospital.
  
  
  METHODS
  A total of 1136 patients diagnosed with depression who were receiving antidepressant monotherapy (664 patients) or no antidepressant therapy (472 patients [controls]) between June 2009 and December 2010.
  
  
  RESULTS
  Data on patient demographics, disease diagnoses, laboratory data, and drug therapy profiles were collected through medical record review. Of the 1136 patients, the mean patient age was 61 years, 90% were men, and 77% were smokers. Mean body mass index was 30.4 kg/m(2) , blood pressure 126/73 mm Hg, hemoglobin A1c 6%, low-density lipoprotein cholesterol level 106.7 mg/dl, and Framingham score 17. Patients receiving antidepressant monotherapy were grouped according to antidepressant class; selective serotonin reuptake inhibitors (SSRIs) were most common. Concomitant use of atypical antipsychotics was more common with the serotonin-norepinephrine reuptake inhibitor (venlafaxine), SSRI, and serotonin receptor antagonist (trazodone) classes (p=0.0067). After adjusting for demographics, concomitant drugs, and comorbidities, SSRI use was significantly associated with lower all-cause mortality (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.19-0.71, p=0.0028). Notably, noradrenergic and specific serotonergic antidepressant (mirtazapine) use was significantly associated with higher prevalence of heart failure (OR 3.26, 95% CI 1.029-10.38, p=0.0445). Use of atypical antipsychotics was significantly associated with a higher prevalence of cerebrovascular events (OR 2.23, 95% CI 1.29-3.83, p=0.0036) and all-cause mortality (OR 2.05, 95% CI 1.03-4.1, p=0.04).
  
  
  CONCLUSIONS
  Our results favor treatment of depression with SSRIs among patients at increased cardiovascular risk due to the potential mortality benefit of this class of drugs. Atypical antipsychotics should be used with caution in the elderly population. Mirtazapine use in patients with heart failure and depression deserves further investigation.
authors.affiliation: Primary Care Service, Veterans Administration Central California Health Care System, Fresno, California; Department of Medicine, University of California, San Francisco, Fresno Medical Education Program, Fresno, California.
authors.forename: Tushar
authors.initials: T
authors.lastname: Acharya
authors.forename: Sabeena
authors.initials: S
authors.lastname: Acharya
authors.forename: Steven
authors.initials: S
authors.lastname: Tringali
authors.forename: Jian
authors.initials: J
authors.lastname: Huang
mesh_terms: D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use*; D014150:Antipsychotic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000209:etiology / Q000503:physiopathology; D003430:Cross-Sectional Studies; D003866:Depressive Disorder / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D005260:Female; D006333:Heart Failure / Q000453:epidemiology; D006801:Humans; D008297:Male; D008803:Mianserin / Q000009:adverse effects / Q000031:analogs & derivatives / Q000627:therapeutic use; D008875:Middle Aged; D000078785:Mirtazapine; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D014728:Veterans
chemical_list: D000928:Antidepressive Agents; D014150:Antipsychotic Agents; D008803:Mianserin; D000078785:Mirtazapine; D017367:Selective Serotonin Reuptake Inhibitors
keywords: antidepressant; atypical antipsychotics; cardiovascular; mortality