© Copyright 2001 Physicians Postgraduate Press, Inc. One personal copy may be printed Ballenger et al. 24 J Clin Psychiatry 2001;62 (suppl 8) epressive disorders and cardiovascular conditions are closely interrelated. Compared with the general Consensus Statement on Depression, Anxiety, and Cardiovascular Disease James C. Ballenger, M.D.; Jonathan R. T. Davidson, M.D.; Yves Lecrubier, M.D.; and David J. Nutt, M.D., Ph.D. (International Consensus Group on Depression and Anxiety); and Steven P. Roose, M.D.; and David S. Sheps, M.D. The International Consensus Group on Depression and Anxiety held the meeting “Focus on Depression and Anxiety Disorders in General Medicine,” October 7–8, 1999, in Funchal, Madeira. The Consensus Meeting was supported by an unrestricted educational grant from SmithKline Beecham Pharmaceuticals. Reprint requests to: James C. Ballenger, M.D., Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, 171 Ashley Ave., Charleston, SC 29425- 0742. severe depression develop more severe cardiovascular dis- ease, but there are data showing that patients with more severe anxiety develop more severe cardiovascular dis- ease. In a large study of male health care professionals, Kawachi et al. 12 showed an association between panic phobic symptoms and an excess risk of sudden cardiovas- cular death. Anxiety disorders, such as panic disorder and phobic disorder, often start early in life and develop chronically. They frequently lead to secondary depression and are a risk factor for the development of cardiovascular disease and for later sudden cardiac death. The presence of an anx- iety disorder can bring people into a high-risk group at an earlier age in their life. Depression is not only a risk factor for cardiovascular disease but is also a strong predictor of mortality in pa- tients with manifest ischemic heart disease. 9 Among survi- vors of acute myocardial infarction, the increased risk of cardiovascular mortality is not restricted to patients with major depression but also extends to those patients with subsyndromal depressive symptoms. At 18 months after myocardial infarction, the mortality rate is reported to be the same in depressed patients who failed to meet full cri- teria for major depression as in those meeting criteria for major depression (17%). 13 Vulnerability to cardiovascular risk increases with age in depressed patients, and it is most significant in the population aged over 60 years, which is the most rapidly growing segment of the world population. For example, a significant and substantial excess risk of death, myocar- dial infarction, or stroke in hypertensive patients aged over 70 years has been associated with an increase in de- pressive symptoms over time. 14 Also, elderly men (aged over 70 years) newly diagnosed with depression are re- ported to be almost twice as likely to have a cardiovascu- lar event as men without a history of depression. 15 It is accepted clinical practice that primary care physi- cians will consider risk factors for coronary artery disease when evaluating patients aged over 40 years and will inter- vene to decrease cardiovascular risk if they find hyperten- sion, elevated cholesterol, or obesity. We feel strongly that depression and anxiety should be included in this model. D population, individuals suffering from depression have an increased risk of sudden cardiovascular death, and the risk is highest in the presence of concomitant cardiovascular disease. 1,2 Similarly, patients with cardiovascular disease suffer from major depression more frequently than ex- pected. More than 20% of subjects with angiographic evi- dence of coronary heart disease have concomitant major depression. Also, up to 20% of survivors of recent acute myocardial infarction meet diagnostic criteria for major depression, and the presence of depression is associated with an increased 6-month mortality, compared with non- depressed survivors. 3–8 At our consensus meeting on depressive and anxiety disorders in general medicine, the International Consensus Group on Depression and Anxiety reviewed depression, anxiety, and the cardiovascular system from the perspec- tives of both the cardiologist and the psychiatrist. This ar- ticle sets forth our views on the management of comorbid depression and anxiety in the cardiovascular patient on the basis of the current state of knowledge and identifies areas of further research. DEPRESSION AND ANXIETY AS RISK FACTORS FOR CARDIOVASCULAR DISEASE Good evidence indicates that clinical depression is an independent risk factor for the development of coronary artery disease, 9,10 and equally compelling evidence indi- cates an association between anxiety and coronary artery disease. 11 It is not yet known whether patients with more