The role of depression in the primary prevention of cardiovascular disease

To the Editor: The latest guidelines for the management of absolute cardiovascular disease (CVD) risk released by the National Vascular Disease Prevention Alliance1 question the utility of conventional risk assessment methods to accurately estimate cardiovascular risk of individuals with depression. Subsequently, these guidelines advocate that individuals assessed for CVD risk be assessed for depression and other psychosocial factors. This appears to be a promising advance, as the current scope of CVD prevention and management activities in medical and public health spheres remains somewhat limited to more traditional risk factors.

Indeed, the World Health Organization identifies tobacco, alcohol use, physical inactivity and poor diet as the key risk factors for CVD.2 Notwithstanding the importance of these factors and their contribution to conditions that accelerate the onset of CVD (eg, hypertension, hypercholestero-laemia, obesity), it is now clear that depression is also an important risk factor for CVD. For individuals with both conditions, depression commonly begins decades before clinical manifestation of CVD.3 Such evidence not only provides important insights into the pathogenesis of CVD, but also highlights a unique opportunity for CVD prevention through early intervention in depressed populations.

The de-emphasis on depression in primary CVD prevention to date is likely for two reasons: first, the remaining gaps in our understanding of the relationship between depression and CVD, and particularly, of the key mediators underpinning this association; and second, the lack of a sound evidence base for suitable interventions. It has been argued that “we urgently need randomized studies ... to establish which treatment is most effective in reducing the risk for CVD”.4 We can help close this research gap by improving our understanding of the role of depression in the pathogenesis of CVD, and developing interventions that target depressed individuals for reduction of CVD risk.

As the contribution of CVD and mental disorders to Australia’s disease burden remains substantial,5 with each a National Health Priority Area, there is an urgent need to expand on existing primary prevention strategies to reduce the CVD-related burden in this country. We need a greater emphasis on promoting CVD risk reduction in populations with poor mental health, which are particularly susceptible to the onset of CVD. The acknowledge-ment and inclusion of mental health assessment in these latest guidelines appears an important step in expanding on putative risk factors.