Antidepressant Prior to Bypass May Reduce Postop Pain

Megan Brooks

June 05, 2013

Taking an antidepressant for 2 to 3 weeks before coronary artery bypass graft (CABG) surgery and continuing it for 6 months after surgery may speed mental health recovery and reduce postoperative pain in patients who are mildly depressed before surgery, a study from France indicates.

"Cardiac operations are frightening for most patients as they realize that there is a risk of death. The most interesting conclusion of our study is that antidepressant therapy allows for a faster postoperative mental health recovery," Sidney Chocron, MD, PhD, Department of Thoracic and Cardiovascular Surgery, University Hospital Jean Minjoz in Besançcon, told Medscape Medical News.

"The second interesting conclusion is that antidepressant therapy also has a beneficial effect on postoperative pain. This conclusion is perhaps linked to the previous one, as pain intensity is subjective and depends on the patient's mood," Dr. Chocron said.

The findings are published in the May issue of Annals of Thoracic Surgery. The study was funded by H. Lundbeck A/S.

An Option in All CABG Patients?

The double-blind phase 4 study involved 361 adults with stable angina scheduled for CABG. They were randomly assigned to the selective serotonin reuptake inhibitor escitalopram, 10 mg daily (n = 182), or placebo (n = 179) from 2 to 3 weeks before to 6 months after the surgery.

The 2 groups were compared for postoperative mortality, morbidity, and quality of life. Preoperative and operative characteristics were balanced between the 2 groups.

Escitalopram treatment did not affect mortality or complications after CABG, the researchers say. However, it did improve patient mental health.

In the 6-month postoperative treatment period, the Beck Depression Inventory (BDI) Short Form and Short Form-36 (SF-36) Mental Component Summary scores were better overall in the escitalopram group than in the placebo group for all patients (P = .015 and P = .014, respectively) and for preoperatively depressed patients (P = .002 and P = .005, respectively).

SF-36 Pain scores were also better overall with escitalopram (P = .026) in the preoperatively depressed subset.

Dr. Chocron said it's important to note that "the analysis of all treated patients showed a benefit for all CABG patients irrespective of whether they were depressed before the operation. Consequently, the treatment can be proposed to all CABG patients, subject to contraindications."

"Nevertheless, the subanalysis showed that antidepressant therapy was not beneficial in preoperative nondepressive patients, but the statistical power of the subanalyses is always lower than that of the principal analysis. Hence, due to this loss of statistical power, it is possible that the subanalysis could not detect the benefit for patients that were not depressed before the operation," he said.

In Dr. Chocron's view, "the best candidates for preop antidepressant therapy are patients even slightly depressive before the operation, but this treatment can be prescribed in all CABG patients, subject to contraindications."

The authors also note that the prevalence of preoperative depression identified in their study (39% with BDI > 3) is in line with estimates made elsewhere for patients scheduled for heart surgery.

Problem Not Trivial

Todd K. Rosengart, MD, a cardiothoracic surgeon with Baylor College of Medicine, Houston, Texas, wasn't involved in the study, but reviewed it for Medscape Medical News.

He said depression after cardiac surgery is a "real problem that is not trivial for some, everything from seeing patients weep after surgery to mood swings to clinical depression. Whether it's the emotional piece of facing this very significant event in your life and facing your mortality or whether it is a chemical imbalance, it's probably a combination."

"It certainly seems like antidepressant therapy is helpful and is very reasonable and it appears to be completely safe," Dr. Rosengart said.

The study was funded by H. Lundbeck A/S, Copenhagen, Denmark. The authors and Dr. Rosengart have disclosed no relevant financial relationships.

Ann Thoracic Surg. 2013;95:1609-1618. Abstract


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