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June 18, 2003

Depression—A Cardiac Risk Factor in Search of a Treatment

Author Affiliations

Author Affiliations: Department of Psychiatry (Drs Frasure-Smith and Lespérance), School of Nursing (Dr Frasure-Smith), and Department of Epidemiology and Biostatistics (Dr Frasure-Smith), McGill University; Research Center, Montreal Heart Institute (Drs Frasure-Smith and Lespérance); Department of Psychiatry (Drs Frasure-Smith and Lespérance), University of Montreal; and Research Center, Centre Hospitalier de l'Université de Montréal (Drs Frasure-Smith and Lespérance), Montreal, Quebec.

JAMA. 2003;289(23):3171-3173. doi:10.1001/jama.289.23.3171

The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) trial1 published in this issue of THE JOURNAL is the largest controlled trial of psychotherapy ever completed. In this study, the first multisite behavioral trial funded by the National Heart, Lung, and Blood Institute (NHLBI), the ENRICHD investigators enrolled 2481 post–myocardial infarction (MI) patients from 73 hospitals in 8 US cities in a 6-month course of weekly cognitive behavior therapy (CBT) vs usual care. Three quarters of the study patients had depression, with the remainder included because of low perceived social support (LPSS). The goal was to determine whether treating depression and LPSS would reduce mortality and recurrent infarction. The intervention produced small, statistically significant decreases in depression symptoms and small, significant increases in perceived support. These differences did not translate into any benefit in event-free survival during a mean follow-up of 29 months, so the study is a negative trial. However, much was learned over the course of the ENRICHD trial, and more will be learned as the investigators and others try to understand why results were not as expected. The study also demonstrates that psychologists, psychiatrists, and cardiologists can successfully collaborate to test complicated intervention protocols with large numbers of patients from multiple sites. For these reasons, the ENRICHD trial will remain a standard of comparison for many years.

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