Cardiac psychiatry — post-ACS depression, trials, safety (MEQ)

(i) Formulation and prognosis. Concurrent post-ACS major depression (depressive disorder due to another medical condition when the ACS is the aetiological context): anhedonia, insomnia, passive SI, rehab refusal with fatalistic cognitions at day 10.^[1][2] Depression after MI is linked to worse early prognosis (classic Frasure-Smith signal) and is framed by AHA as a risk factor for poor prognosis after ACS.^[2][3] Also consider comorbid anxiety/ACS-PTSD symptoms driving rehab avoidance.^[8]

(ii) Assessment and investigations. Cardiac dossier (NSTEMI, stents, dual antiplatelets, beta-blocker/ACE/statin, EF if known), full MSE and structured suicide risk, collateral, substance/sleep, PHQ-type screen if helpful.^[1] Before SSRI: ECG/QTc, electrolytes (Na), renal/hepatic function; review bleeding risk with dual antiplatelets.^[1][4]

(iii) Treatment and trial literacy. Multimodal: clinical management, behavioural activation toward cardiac rehab, smoking cessation, adherence support; collaborative care models (MOSAIC) improve depression/anxiety after recent cardiac events.^[1][7] First-line SSRI: sertraline 25–50 mg oral daily, titrate toward 50–200 mg as tolerated (SADHART safety/efficacy anchor for post-ACS depression), monitoring GI effects, hyponatraemia, bleeding, sexual side effects.^[4] CREATE: citalopram effective vs placebo in CAD with clinical management, but IPT did not beat clinical management alone — and high-dose citalopram needs QTc caution, so sertraline is often preferred here.^[6] ENRICHD honesty: treating depression/low social support with CBT (± antidepressant) improved psychosocial outcomes but did not reduce death or recurrent MI — do not promise reinfarction prevention as the reason to treat.^[5] Avoid amitriptyline first-line post-ACS (arrhythmia/overdose risk).^[1]

(iv) Beta-blocker, risk, disposition. Do not stop evidence-based beta-blocker solely for a universal "causes depression" myth; treat depression while protecting secondary prevention unless cardiology agrees a switch is needed for a clear reason.^[1] Suicide safety plan, observation as indicated, least-restrictive legal pathway if risk escalates. Disposition: stepwise rehab re-engagement, GP/CL follow-up, collaborative care if available, review response in 2–4 weeks, document bleeding counselling.^[1][7]