To the Editor: In the report of the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial, Dr Lespérance and colleagues1 conclude that the first step in the treatment of such patients with major depression and coronary artery disease should begin with citalopram or sertraline. While this conclusion seems well founded based on the data from CREATE and those of prior trials, there are some questions related to the generalizability of their findings that must be addressed.
The mean age of patients in CREATE was 58.2 years, which differs considerably from the mean age of patients in the United States with coronary disease. The average age of US patients with a first myocardial infarction is 65.8 years for men and 70.4 years for women.2 This is approximately 7.5 and 12 years older than the patients in CREATE, respectively. This is important since age may influence the response to pharmacologic antidepressant therapy and to interpersonal psychotherapy. For example, the Maintenance Therapies in Late-Life Depression study showed that among patients aged 70 years and older with major depression, only the group that received the combination of antidepressant therapy and interpersonal psychotherapy sustained their remission.3 Miller et al4 stated that “this finding argues for the greater need for elders to receive a psychosocial treatment in addition to pharmacotherapy to address the needs of this group and to maintain wellness from a recurrence of depression over the long term.” Lespérance et al cite studies reporting limited clinical benefit of antidepressants over placebo in elderly individuals and comment that selective serotonin reuptake inhibitors (SSRIs) may have less effect in individuals experiencing first episodes of major depression late in life.1
Some physicians may consider drugs like citalopram and sertraline as first-line treatment for patients with depression and coronary artery disease because of greater comfort with drug therapy and the limited availability of clinicians with appropriate training and expertise in interpersonal psychotherapy. Although CREATE allows this decision to be based on more evidence, the topic is still an appropriate one to address with patients who are more representative of the general population with coronary disease, particularly with older patients.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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