In cases of moderate to severe psychological distress a combination of psychological therapy and medication may be most useful. Where medication may be required it is important to ensure that the individual is referred to a suitably qualified health professional for assessment and consideration for prescribed medication therapy.

Communication with the patient’s General Practitioner is an important component of support for patients showing signs of psychological distress. The GP can refer a patient to see a psychologist.  (In Australia, if a GP creates a mental health plan the patient is eligible for several Medicare funded sessions.)

For many patients, depression symptoms will spontaneously improve over time. Watchful waiting, monitoring, and brief support might serve as a useful strategy before implementing more intensive psychological intervention in some patients with lower depression scores.

The Cardiac Blues resources serve as a useful adjunct to support for patients, normalising distress but alerting patients to the risk of depression.

Behavioural activation, including exercise and resuming activities that were once enjoyed, can help to reduce severity of depression symptoms. This can be done by encouraging the patient to engage in a given activity on a daily basis.

Be aware that many people self-medicate symptoms of depression with drugs and alcohol. Assessment and treatment of drug and alcohol abuse can help in the management of depression symptoms.

In cardiovascular disease (CVD) there is no evidence to show which management approach for depression and anxiety is superior in reducing symptoms, and no single approach has yet been shown to reduce cardiovascular events or total mortality.

Psychological therapies can produce small but significant improvements in anxiety and depression, especially if they target “type A” behaviours such as anger and hostility.[#whalley-b-rees-k-davies-p-et-al.-2011] Evidence to date suggests that frontline options include Cognitive Behaviour Therapy and Problem Solving Therapy. [#tully-pj-higgins-r]

• Several antidepressants including selective serotonin reuptake inhibitors (SSRIs) such as sertraline have also been shown to be safe and effective at reducing depressive symptoms in people with coronary heart disease but there are no trials comparing drug and psychological therapies.[#baumeister-h-hutter-n-bengel-j.-2011] The recent UPBEAT study showed that aerobic exercise and sertraline were equally effective at reducing depressive symptoms in patients with coronary heart disease.[#blumenthal-ja-sherwood-a-babyak-ma-et-al.-2012]
• Combining drug and non-drug treatments may deliver the best results. The COPES study enrolled patients with depression persisting for 3 months or more following an acute coronary syndrome. A stepped approach to depression treatment based on the patient’s individual preferences used a combination of drug treatment (with a choice of antidepressants) and problem-solving therapy combined with additional social support and follow-up. Importantly, in addition to reduced depression, this study showed a reduction in major cardiac events and costs of care.[#davidson-kw-rieckmann-n-clemow-l-et-al.-2010,#ladapo-ja-schaffer-ja-fang-y-et-al.-2012]

Heart failure

In heart failure (HF) two small trials of CBT have shown promising improvements in depressive symptoms although they also included exercise.[#gary-ra-dunbar-sb-higgins-mk-et-al.-2010,#kostis-jb-rosen-rc-cosgrove-n-et-al.-1994] Exercise itself may also alleviate depression in HF, with the largest randomised controlled trial of exercise training in HF (HF-ACTION) showing a small but statistically significant reduction in depression scores in exercisers.[#blumenthal-ja-babyak-ma-oconnor-c-et-al.-2012] Two small trials have also suggested that exercise training may assist anxiety.[#kulcu-dg-kurtais-y-tur-g-et-al.-2007,#koukouvou-g-kouidi-e-iacovides-a-et-al.-2004]

Although several small trials have suggested that antidepressants benefit HF patients,[#echols-mr-jiang-w.-2011] the largest study of drug therapy is the SADHART-CHF study which randomised 469 adults with HF and clinical depression to sertraline or placebo for 12 weeks. Sertraline did not significantly improve depression symptoms compared with placebo, with significant improvements seen in both groups.[#oconnor-cm-jiang-w-kuchibhatla-m-et-al.-2010] The study involved fortnightly nurse telephone, home or clinical follow-up, which may have provided a level of support and intervention to account for the improvement in both groups. Preliminary results of a larger and longer duration trial (MOOD-HF) suggest that SSRI is no better than placebo.[#angermann-c-gelbrich-g-stoerk-s-et-al.-2015]

Some examples of psychological therapies that may be considered include:

• Cognitive Behaviour Therapy (CBT)

CBT focuses on identifying and changing unhelpful thinking and behavioural processes in order to improve emotional and behavioural problems. The modern "third wave" of CBT merges CBT with mindfulness to produce Mindfulness-Based CBT, Acceptance and Commitment Based Therapy, and Metacognitive Therapy. For more complex personalities, CBT is sometimes integrated with other therapies: e.g., Schema Focused Therapy or Cognitive Analytic Therapy.

• Psychodynamic therapy

This aims to provide the individual with a better understanding of themselves. The therapy helps identify common and repeating interpersonal patterns and assists the individual to develop more productive patterns of relating to self and to others. Chris Allan's blog has a range of relevant links.

• Narrative therapy

Narrative therapy, (see www.dulwichcentre.com.au), explores the dominant and alternative stories of the individual’s life. Narrative therapists deconstruct the dominant, powerful stories by ‘externalising’ the issue as the problem and not as part of the person’s essential being. They assist the individual to co-construct alternative stories that can bring a new sense of identity and a new future.

• Relaxation therapy

Relaxation therapy may include breathing exercises, visualisation activities, progressive muscle relaxation, tai chi, meditation and mindfulness exercises. Relaxation therapy incorporated into traditional cardiac interventions reduces perceived stress, and this reduction is believed to decrease the progression of cardiac disease.[#neve-a-alves-a-ribeiro-f-et-al.-2009]