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

Lisa F. Berkman, James Blumenthal, Matthew Burg, Robert M. Carney, Diane Catellier, Marie J. Cowan, Susan M. Czajkowski, Robert De Busk, James Hosking, Allan S Jaffe, Peter G. Kaufmann, Pamela Mitchell, James Norman, Lynda H. Powell, James M. Raczynski, Neil Schneiderman, Raczynski

Research output: Contribution to journalArticle

1328 Citations (Scopus)

Abstract

Context: 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. Design, Setting, and Patients: 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. Intervention: 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. Main Outcome Measures: 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.

Original languageEnglish (US)
Pages (from-to)3106-3116
Number of pages11
JournalJournal of the American Medical Association
Volume289
Issue number23
DOIs
StatePublished - Jun 18 2003

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Social Support
Coronary Disease
Myocardial Infarction
Depression
Cognitive Therapy
Disease-Free Survival
Social Isolation
Mortality
Serotonin Uptake Inhibitors
Group Psychotherapy
Random Allocation
Diagnostic and Statistical Manual of Mental Disorders
Infarction
Antidepressive Agents
Patient Care
Therapeutics
Randomized Controlled Trials
Outcome Assessment (Health Care)
Morbidity
Equipment and Supplies

ASJC Scopus subject areas

  • Medicine(all)

Cite this

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. / Berkman, Lisa F.; Blumenthal, James; Burg, Matthew; Carney, Robert M.; Catellier, Diane; Cowan, Marie J.; Czajkowski, Susan M.; De Busk, Robert; Hosking, James; Jaffe, Allan S; Kaufmann, Peter G.; Mitchell, Pamela; Norman, James; Powell, Lynda H.; Raczynski, James M.; Schneiderman, Neil; Raczynski.

In: Journal of the American Medical Association, Vol. 289, No. 23, 18.06.2003, p. 3106-3116.

Research output: Contribution to journalArticle

Berkman, LF, Blumenthal, J, Burg, M, Carney, RM, Catellier, D, Cowan, MJ, Czajkowski, SM, De Busk, R, Hosking, J, Jaffe, AS, Kaufmann, PG, Mitchell, P, Norman, J, Powell, LH, Raczynski, JM, Schneiderman, N & Raczynski 2003, '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', Journal of the American Medical Association, vol. 289, no. 23, pp. 3106-3116. https://doi.org/10.1001/jama.289.23.3106
Berkman, Lisa F. ; Blumenthal, James ; Burg, Matthew ; Carney, Robert M. ; Catellier, Diane ; Cowan, Marie J. ; Czajkowski, Susan M. ; De Busk, Robert ; Hosking, James ; Jaffe, Allan S ; Kaufmann, Peter G. ; Mitchell, Pamela ; Norman, James ; Powell, Lynda H. ; Raczynski, James M. ; Schneiderman, Neil ; Raczynski. / 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. In: Journal of the American Medical Association. 2003 ; Vol. 289, No. 23. pp. 3106-3116.
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abstract = "Context: 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. Design, Setting, and Patients: 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. Intervention: 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. Main Outcome Measures: 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.",
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T1 - Effects of Treating Depression and Low Perceived Social Support on Clinical Events after Myocardial Infarction

T2 - The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial

AU - Berkman, Lisa F.

AU - Blumenthal, James

AU - Burg, Matthew

AU - Carney, Robert M.

AU - Catellier, Diane

AU - Cowan, Marie J.

AU - Czajkowski, Susan M.

AU - De Busk, Robert

AU - Hosking, James

AU - Jaffe, Allan S

AU - Kaufmann, Peter G.

AU - Mitchell, Pamela

AU - Norman, James

AU - Powell, Lynda H.

AU - Raczynski, James M.

AU - Schneiderman, Neil

AU - Raczynski,

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N2 - Context: 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. Design, Setting, and Patients: 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. Intervention: 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. Main Outcome Measures: 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.

AB - Context: 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. Design, Setting, and Patients: 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. Intervention: 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. Main Outcome Measures: 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.

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