Marlene Grenon and Greg Zahner Discuss Link Between Depression and PAD In Vascular News
Marlene Grenon, M.D., C.M., and Greg Zahner, MSc discuss the link between depression and the increased risk of peripheral artery disease (PAD) in a story at Vascular News. Marlene Grenon is an associate professor in the Division of Vascular and Endovascular Surgery and Greg J. Zahner is a fourth year medical student at UCSF School of Medicine. The article is entitled, "Depression and Peripheral Artery Disease: The Intersectionality of Mental and Physical Wellbeing". Excerpts appear below followed by a link to the full article, which also contains footnote sources.
Psychotherapy and pharmacotherapy are the mainstays of depression treatment, but not enough research has been conducted to determine whether these treatments mitigate vascular risk. Due to the safety of depression treatment and its efficacy in treating depression symptoms, the American Heart Association (AHA) currently recommends selective serotonin reuptake inhibitors (SSRIs), cognitive therapy, and exercise for depressed patients with coronary artery disease.
No current guidelines exist for depression in PAD. While more research is needed before official guidelines are issued, the current evidence is certainly enough to warrant action. We believe there are tangible steps each vascular surgeon can and should take in their daily practice to mitigate the negative impact of co-morbid depression on PAD and improve the overall wellbeing of their patients.
You cannot treat a problem you cannot see
Whether or not asking about your patient’s emotional wellbeing or personal life is part of your clinical style, the importance of screening for depression is paramount and certainly relevant for improving clinical outcomes. The AHA recommends screening patients with heart disease for depression using the PHQ-2, which consists of two simple questions. Over the past two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things. Feeling down, depressed or hopeless. If they answer affirmatively to either question, then have them complete a PHQ-9 for more comprehensive screening. The PHQ-9 is 88% sensitive and 88% specific for major depression, and a score of 10 is used as the cut-off for moderate depression.
Once you have identified possible depression, do not let it go unaddressed
Just like a non-healing ulcer, depression can linger and cause problems for your patients now and down the road. Follow-up with them to make sure treatment is being pursued.
Know your limits and refer when necessary
Concerned about a potentially depressed patient not seeking treatment? Act and refer them to appropriate psychological, psychiatric, behavioural health, or wellness programmes. If you practise in an integrated health system, follow-up with their other providers and communicate your concerns with the patient’s primary care provider.
Motivated to do more? Think innovatively!
As evidence on the importance of vascular rehabilitation for PAD patients mounts, we must consider all aspects of a patient’s wellness. In the last year, we have partnered with the new University of California San Francisco (UCSF) Bridge’s Curriculum to launch a vascular rehab programme at the San Francisco VA Medical Center. Under supervision, medical students serve as health coaches during this 12-week programme aimed at secondary prevention. The programme is based on five pillars: exercise, diet/nutrition, smoking cessation, medication adherence, and stress management/mindfulness. In summary, data are accumulating supporting a close relationship between depression and PAD. Furthermore, depression should potentially be considered a risk factor for PAD, and the impact it has on patients’ outcomes should be recognised. It is time to engage in this conversation with our patients and amongst ourselves in order to develop optimal treatment strategies and hopefully improve outcomes.