Long-term cardiac outcomes of depression screening, diagnosis and treatment in patients with acute coronary syndrome: the DEPACS study.

BACKGROUND: To investigate the impacts of depression screening, diagnosis and treatment on major adverse cardiac events (MACEs) in acute coronary syndrome (ACS). METHODS: Prospective cohort study including a nested 24-week randomised clinical trial for treating depression was performed with 5-12 years after the index ACS. A total of 1152 patients recently hospitalised with ACS were recruited from 2006 to 2012, and were divided by depression screening and diagnosis at baseline and 24-week treatment allocation into five groups: 651 screening negative (N), 55 screening positive but no depressive disorder (S), 149 depressive disorder randomised to escitalopram (E), 151 depressive disorder randomised to placebo (P) and 146 depressive disorder receiving medical treatment only (M). RESULTS: Cumulative MACE incidences over a median 8.4-year follow-up period were 29.6% in N, 43.6% in S, 40.9% in E, 53.6% in P and 59.6% in M. Compared to N, screening positive was associated with higher incidence of MACE [adjusted hazards ratio 2.15 (95% confidence interval 1.63-2.83)]. No differences were found between screening positive with and without a formal depressive disorder diagnosis. Of those screening positive, E was associated with a lower incidence of MACE than P and M. M had the worst outcomes even compared to P, despite significantly milder depressive symptoms at baseline. CONCLUSIONS: Routine depression screening in patients with recent ACS and subsequent appropriate treatment of depression could improve long-term cardiac outcomes.

Sleep problems associated with long-term mortality in acute coronary syndrome: Effects of depression comorbidity and treatment.

OBJECTIVES: The effects of sleep disturbance and its treatment on the prognosis of patients with acute coronary syndrome (ACS) are not well understood. This study investigated the impact of sleep disturbance on long-term all-cause mortality, according to depression comorbidity and treatment, in patients with ACS. METHODS: A cross-sectional baseline study and a nested 24-week double-blind escitalopram-placebo controlled trial were carried out from May 2007 to March 2013; 5-12-year follow-up for all-cause mortality was conducted. A total of 1152 patients with ACS were stratified by baseline depression comorbidity and treatment allocation into four groups: no depression (N = 706), depression on escitalopram (N = 149), depression on placebo (N = 151), and depression on medical care as usual (CAU; N = 146). Sleep disturbance was evaluated by the Leeds Sleep Evaluation Questionnaire. During the 5-12-year follow-up, Kaplan-Meyer event rates for all-cause mortality were calculated; hazard ratios (HRs) using Cox regression models were estimated after adjustment for a range of covariates. RESULTS: Worse sleep states at baseline increased long-term all-cause mortality in all patients (HRs 1.08-1.59). The associations between worse sleep states and long-term all-cause mortality were significant in patients without depression and in patients with depression who received CAU, but not in patients with depression who participated in the 24-week trial. CONCLUSIONS: Routine evaluations of sleep disturbance in ACS and further treatment allocation may contribute to reducing long-term mortality associated with the disease. TRIAL REGISTRATION: ClinicalTrials.gov Identifier for the 24 week drug trial, NCT00419471.

Sex differences in the genetic architecture of depression.

The prevalence and clinical characteristics of depressive disorders differ between women and men; however, the genetic contribution to sex differences in depressive disorders has not been elucidated. To evaluate sex-specific differences in the genetic architecture of depression, whole exome sequencing of samples from 1000 patients (70.7% female) with depressive disorder was conducted. Control data from healthy individuals with no psychiatric disorder (n = 72, 26.4% female) and East-Asian subpopulation 1000 Genome Project data (n = 207, 50.7% female) were included. The genetic variation between men and women was directly compared using both qualitative and quantitative research designs. Qualitative analysis identified five genetic markers potentially associated with increased risk of depressive disorder in females, including three variants (rs201432982 within PDE4A, and rs62640397 and rs79442975 within FDX1L) mapping to chromosome 19p13.2 and two novel variants (rs820182 and rs820148) within MYO15B at the chromosome 17p25.1 locus. Depressed patients homozygous for these variants showed more severe depressive symptoms and higher suicidality than those who were not homozygotes (i.e., heterozygotes and homozygotes for the non-associated allele). Quantitative analysis demonstrated that the genetic burden of protein-truncating and deleterious variants was higher in males than females, even after permutation testing. Our study provides novel genetic evidence that the higher prevalence of depressive disorders in women may be attributable to inherited variants.

Synergistic effects of depression and NR3C1 methylation on prognosis of acute coronary syndrome.

High levels of methylation in the GR gene (nuclear receptor subfamily 3, group C, member 1; NR3C1) have been associated with depression and cardiovascular risk. This study aimed to investigate whether NR3C1 methylation status was associated with the long-term prognosis of acute coronary syndrome (ACS) considering depression and cardiovascular status at the early phase of ACS. A total of 969 patients with recent ACS were recruited at a tertiary university hospital in Korea. Baseline evaluations were made from 2007 to 2012, including DSM-IV depressive disorder, NR3C1 methylation, and various demographic and clinical characteristics such as cardiovascular risk markers. Over a 5~12 year follow-up after the index ACS, time to major adverse cardiac event (MACE) was investigated using Cox regression models. Higher NR3C1 methylation status was associated with depression and several cardiovascular risk markers at baseline. NR3C1 hypermethylation predicted worse long-term prognosis of ACS only in the presence of depressive disorder with significant synergistic interaction terms and independent of potential confounding factors. Synergistic effects of depressive disorder and NR3C1 hypermethylation on long-term cardiac outcomes in ACS were found. NR3C1 methylation status represents a candidate prognostic biomarker for ACS in combination with a diagnosis of depressive disorder. Further research is needed to ascertain the generalisability of these findings.

Validation of the Korean Version of the 15-Item Community Assessment of Psychic Experiences in a College Population.

OBJECTIVE: To investigate the reliability and validity of the Korean version of the Community Assessment of Psychic Experiences-15 item positive scale (CAPE-15) in college students. METHODS: This study had two stages: initial screening with self-report questionnaires including the CAPE-15, and semi-structured interviews to investigate the instrument's diagnostic validity. The initial screening involved 1,749 college students. The modified Korean version of Prodromal Questionnaire-16 item (mKPQ-16) was also administered. The criteria for ultra-high risk (UHR) of psychosis in the Comprehensive Assessment of At-Risk Mental States (CAARMS) were the gold standard for diagnosis. RESULTS: Twelve of the interviewed subjects met the CAARMS criteria for UHR of psychosis. The area under the receiver operating characteristic curve was highest (0.936) for the CAPE-15 distress score (p<0.001). The use of 6 as the cutoff for the CAPE-15 distress score resulted in the best balance of sensitivity (91.7%) and specificity (85.2%), with a favorable positive predictive value of 32.4%. The coefficients of correlation between the CAPE-15 and mKPQ-16 were significant. CONCLUSION: The Korean version of the CAPE-15 is a good instrument for screening for psychosis risk in collegiate settings. The validation of this scale could contribute to the early identification of psychosis in the Korean community.

Impact of depression at early and late phases following acute coronary syndrome on long-term cardiac outcomes.

BACKGROUND: Depression has been associated with worse cardiac outcomes in patients with acute coronary syndrome, while no study has investigated trajectory of depression and ACS prognosis. This study investigated associations of depressive disorder within 2 weeks (early) and at 1 year (late) after ACS with major adverse cardiac event (MACE). METHOD: In 757 ACS patients recruited in 2007-2012 and evaluated for depressive disorder at the two time-points, 5-12 year follow-up for MACE was conducted. RESULTS: MACE incidence was significantly higher in patients with depressive disorder at early or late phase of ACS than those without, regardless of status at the other time point; however, highest incidence was found following depression at both time points. LIMITATION: The follow-up for depressive disorder was made at only one point. CONCLUSION: Depression evaluation thus needs consideration both early and late post-ACS.

Interaction between BDNF val66met polymorphism and personality on long-term cardiac outcomes in patients with acute coronary syndrome.

BACKGROUND: The prognostic role of BDNF val66met polymorphism on long-term cardiac outcomes in acute coronary syndrome (ACS) has been unclear. Environmental factors may modify the association, but these have not been investigated to date. This study aimed to investigate the potential interactive effects of BDNF val66met polymorphism and personality traits, one of the main environmental prognostic factors of ACS, on major adverse cardiac events (MACEs) in patients with ACS. METHODS: A total of 611 patients with recent ACS were recruited at a university hospital in Korea. Baseline evaluations from 2007 to 2012 assessed BDNF val66met polymorphism and personality using the Big Five Inventory, which yielded two personality clusters (resilient and vulnerable) and five dimensions (extraversion, agreeableness, conscientiousness, neuroticism, and openness). Over a 5~12 year follow-up after the index ACS, times to MACE were investigated using Cox regression models after adjustment for a range of covariates. RESULTS: The BDNF val66met polymorphism modified the associations between vulnerable personality type and worse long-term cardiac outcomes in ACS patients with significant interaction terms, in that the associations were statistically significant in the presence met allele. Similar findings were observed for the individual personality dimensions of agreeableness and neuroticism. CONCLUSIONS: Gene (BDNF val66met polymorphism) x environment (personality traits) interactions on long-term cardiac outcomes were found in ACS.

Association between Obsessive-Compulsive Symptoms and Long-Term Cardiac Outcomes in Patients with Acute Coronary Syndrome: Effects of Depression Comorbidity and Treatment.

OBJECTIVE: The role of obsessive-compulsive symptoms (OCS) in patients with acute coronary syndrome (ACS) is not well elucidated. This study investigated the association between OCS and the long-term prognosis of ACS in tandem with depression comorbidity and treatment. METHODS: A cross-sectional baseline study and a nested 24-week double-blind escitalopram-placebo controlled trial were carried out between May 2007 and March 2013, and then a 5-12-year follow-up for major adverse cardiac events (MACE) was conducted. A total of 1,152 patients with ACS were stratified by baseline depression comorbidity and treatment allocation into four groups: no depression (706 patients), depression and taking escitalopram (149 patients), depression and taking a placebo (151 patients), and depression and receiving medical care as usual (CAU; 146 patients). OCS were evaluated using the Symptom Checklist-90-Revised Obsessive-Compulsive symptom domain. During the follow-up, Kaplan-Meier event rates for MACE outcomes were calculated, and hazard ratios were estimated using Cox regression models after adjusting for a range of covariates. RESULTS: A higher OCS score at baseline was associated with a worse ACS prognosis after adjusting for relevant covariates and across MACE outcomes. This association varied according to the depression comorbidity. The association was significant in patients without depression and depressive patients receiving placebos and CAU, but not in depressive patients on escitalopram. CONCLUSION: Evaluating OCS and depression is recommended during the early phase of ACS. Treatment for OCS may improve the longterm cardiac outcomes of patients with ACS.

Feasibility of using laser-induced breakdown spectroscopy for analyzing deposit formation change of molybdenum disulfide on gas diffusion electrode due to coating method.

This study aimed to evaluate the relationship between the performance of electro-catalysis and the uniformity of molybdenum disulfide (MoS2) on carbon electrodes deposited according to three different coating methods, namely, drop-casting, brushing, and spraying. The electrochemical kinetics can be determined by how uniformly the catalyst is coated throughout the entire surface of the electrodes. Laser-induced breakdown spectroscopy was employed to investigate the uniformity and loading quantity of MoS2 on the electrode surface. The most uniform coating was achieved with the spraying method followed by brushing and drop-casting.

A Comparative Study of Burnout, Stress, and Resilience among Emotional Workers.

OBJECTIVE: To investigate associations between stress, resilience, and burnout in three emotional job sectors. METHODS: We conducted a multi-group comparative study using structural equation modeling and latent mean analysis. In total, 806 participants (403 call center consultants, 270 mental health workers, and 133 school counselors) completed self-administered questionnaires including the Perceived Stress Scale, Korean version of the Connor-Davidson Resilience Scale, and Maslach Burnout InventoryGeneral Survey. RESULTS: Stress had significant direct effects on resilience and burnout, and resilience had significant direct effects on burnout in all groups. Resilience partially mediated these relationships among call center consultants and school counselors. Stress and burnout were highest in call center consultants, followed, in order, by mental health workers and school counselors. Resilience was highest in school counselors, followed, in order, by mental health workers and call center consultants. The effect size of the latent mean difference was highest for burnout, followed, in order, by resilience and stress. Psychiatry Investig. CONCLUSION: Our findings suggest that stress caused by emotional labor can contribute to burnout. Interventions targeted at different sectors are needed to reduce burnout.

Longitudinal associations of stressful life events and social support deficits with later functioning in patients with acute coronary syndrome: Social factors for functioning in ACS.

BACKGROUND: In this study we investigated associations between stressful life events (SLEs) and social support deficit (SSD), which we evaluated within 2 weeks of an acute coronary syndrome (ACS) episode, and changes in functioning, disability, and quality of life (QOL) over a 1-year follow-up period. METHOD: In total, 1152 patients were recruited at baseline within 2 weeks of an ACS episode, and 828 were followed up for 1 year thereafter. The occurrence of SLEs was identified at baseline using the "List of Threatening Events", and the participants were categorized into absent or present SLE groups. The SSD was evaluated using the Social Support Scale and was dichotomatized into low or high SSD groups. We measured social and occupational functioning, disability, and quality of life (QoL) at both examinations. The associations between the baseline SLE and SSD with functional changes over 1 year were estimated using repeated-measures analyses of covariance with relevant covariates. RESULTS: The presence of SLEs and high SSD at baseline independently predicted worsening of functional disability and QoL over the 1-year follow-up period, after adjustment. Moreover, the coexistence of both present SLE and high SSD indicates negative effects that are more severe on functional outcomes. CONCLUSIONS: SLEs and SSD at an early phase of ACS predicted chronically poorer functioning and QoL outcomes. Preventive and therapeutic efforts should include strategies to identify and manage psychosocial risk factors in ACS patients.

Modifying effects of depression on the association between BDNF methylation and prognosis of acute coronary syndrome.

AIMS: Brain-derived neurotrophic factor (BDNF) plays important roles in angiogenesis, inflammation, and neuronal plasticity. BDNF methylation has been extensively investigated in depression, but not in cardiac diseases. We asked whether BDNF methylation status is associated with a major adverse cardiac event (MACE), inflammation, and the association with depression comorbidity and its treatment in patients with acute coronary syndrome (ACS). METHODS AND RESULTS: A cross-sectional baseline study and nested 24 week double-blind escitalopram placebo-controlled trial (ClinicalTrial.gov identifier NCT00419471) were performed from 2006 to 2012, with 5-12 year follow-up for MACE. Patients with recent ACS (969 total) were divided into four groups according to depression comorbidity at baseline and treatment allocation: 591, absent depression; 127, depression on escitalopram; 128, depression on placebo; 123, depression on care as usual (CAU). BDNF methylation was measured in leucocyte DNA, and multiple demographic and clinical characteristics including interleukin 6 were evaluated as covariates at baseline. The primary outcome, time to first MACE (a composite of all-cause mortality, myocardial infarction and percutaneous coronary intervention), was investigated using Cox regression models after adjustment for covariates. Interleukin 6 level was significantly higher in patients with higher BDNF methylation values. Higher BDNF methylation was associated with increased MACE independent of confounding factors [HR (95% CI) = 1.45 (1.17-1.78)]. This association was significant in patients without depression [HR (95% CI) = 1.39 (1.01-1.90)] and depressive patients on placebo [HR (95% CI) = 1.72 (1.02-3.02)] or CAU [HR (95% CI) = 1.53 (1.01-2.61)], but not in those treated with escitalopram [HR (95% CI) = 1.00 (0.51-1.95)]. CONCLUSION: BDNF methylation was significantly associated with prognosis of ACS. Escitalopram may mitigate the deleterious effect of higher BDNF methylation in depressive patients with ACS. Further research is needed to elucidate the mechanistics and to assess the generalisability of these findings.

Negative Life Events and Problematic Internet Use as Factors Associated With Psychotic-Like Experiences in Adolescents.

Objectives: Psychotic-like experiences (PLEs) and problematic internet use (PIU) are common in adolescents. However, little is known about the association between PLEs and PIU among adolescents. The present study examined the associations between PLEs and PIU and negative life events among adolescents. Methods: In total, 1,678 adolescents attending high school were recruited for a cross-sectional survey. They completed self-reported assessments of PLEs using the Prodromal Questionnaire-16 (PQ-16) and measures of depression, anxiety, self-esteem, internet use, and negative life events using the Center for Epidemiological Studies Depression Scale (CES-D), the State-Trait Anxiety Inventory (STAI), the Rosenberg Self-Esteem Scale (RSES), the Korean Scale for Internet Addiction (K-scale), and the Lifetime Incidence of Traumatic Events for Children (LITE-C), including cybersexual harassment and school violence. Results: A total of 1,239 subjects (73.8%) scored at least 1 on the PQ-16. The mean total and distress PQ-16 scores were significantly higher in students who used mental health services. The total and distress prodromal questionnaire-16 (PQ-16) scores were positively correlated with the CES-D, STAI-S, STAI-T, LITE-C, and K-scale scores but negatively correlated with the RSES score. Hierarchical linear regression analysis revealed that PLEs were significantly associated with a high K-scale score and the incidence of negative life events, such as LITE-C, cybersexual harassment, and bully-victims. Conclusion: Our results demonstrate that PIU and negative life experiences were significantly associated with PLEs in adolescents. Assessment and therapeutic intervention with regard to internet use as a coping strategy for stress are needed to prevent the development of clinical psychotic symptoms.

Problematic smartphone use and related factors in young patients with schizophrenia.

INTRODUCTION: The present study aimed to examine smartphone use in young patients with schizophrenia and to explore factors that may affect the severity of problematic smartphone use. METHODS: A total of 148 schizophrenia patients aged 18 to 35 years completed self-administered questionnaires exploring sociodemographic characteristics; Smartphone Addiction Scale (SAS), the Big Five Inventory-10 (BFI-10), the Hospital Anxiety and Depression Scale (HADS), the Perceived Stress Scale (PSS), and the Rosenberg Self-Esteem Scale (RSES). All were also assessed using the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) Scale and the Personal and Social Performance (PSP) Scale. RESULTS: The mean subject age was 27.5 ± 4.5 years. No significant differences in the SAS scores occurred between gender, jobs, and level of education. The Pearson r-correlation test showed that the SAS scores were significantly positively correlated with HADS anxiety, PSS, and BFI-10 neuroticism scores; it was negatively correlated with RSES, BFI-10 agreeableness, and conscientiousness scores. In the stepwise linear regression analysis, the severity of PSU was significantly associated with both high anxiety and low agreeableness. DISCUSSION: Our results suggest that specific groups of patients with schizophrenia may require special care to prevent problematic smartphone use.

Physical Health Literacy and Health-related Behaviors in Patients with Psychosis.

OBJECTIVE: : This study compared the levels of knowledge of physical illnesses and patterns of health behaviors between patients with psychosis and the general population. METHODS: : A total of 712 participants were included in the study; 292 patients with a schizophrenia spectrum disorder and 420 healthy controls matched for age and gender. Questionnaires were administered to study participants to determine the level of knowledge of chronic physical illnesses such as cancer, hypertension, and diabetes mellitus and health-related behavior. Results from the two study groups were compared to identify differences in knowledge of physical illness and health-related behaviors. RESULTS: : Compared with healthy controls, patients with psychosis were less likely to undergo regular medical check-ups and engage in exercise. Patients with psychosis had poorer knowledge of physical illnesses, and were more likely to smoke, be overweight, or have diabetes. Patients with psychosis were significantly less likely to acknowledge the importance of early detection of cancer and controlling hypertension and diabetes, independent of education and type of medical insurance. Patients who smoked were significantly less likely to agree with the statement on the relationship between smoking and physical illnesses. Patients not undergoing regular medical check-ups were significantly less likely to agree with statements concerning the need for cancer screening. CONCLUSION: : Patients with psychosis demonstrated lower levels of knowledge of physical illnesses and a lack of understanding of preventive behaviors. Low levels of knowledge were associated with poor health-related behaviors. Education of physical health should be provided to patients with psychosis.

Suicidal Ideation Predicts Functioning and Quality of Life Over One Year after Acute Coronary Syndrome.

OBJECTIVE: This study investigated the associations of suicidal ideation (SI) evaluated within 2 weeks after an acute coronary syndrome (ACS) episode with functioning, disability, and quality of life (QOL) at a 1-year follow-up assessment. METHODS: This study recruited 1152 consecutive patients within 2 weeks of a confirmed ACS episode; 828 of these patients who were followed up 1 year later comprised the study sample. SI was determined at baseline using the "suicidal thoughts" item of the MontgomeryÅsberg Depression Rating Scale. At both examinations, social and occupational functioning were measured by the Social and Occupational Functioning Assessment Scale (SOFAS), disability was estimated by World Health Organization Disability Assessment Schedule-12 (WHODAS-12), and QOL was assessed using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF). Baseline covariates included sociodemographic data, depression characteristics, cardiovascular risk factors, and current cardiac status. RESULTS: SI at baseline was independently associated with less improved or decreased scores on the SOFAS, WHODAS-12, and WHOQOL-BREF over 1 year after adjusting for relevant covariates. CONCLUSION: SI within 2 weeks of an ACS episode predicted poorer functioning and QOL at a 1-year follow-up assessment. Thus, the simple evaluation of SI in patients with recently developed ACS could be helpful in screening for functioning and QOL during the chronic phase of this disease.

Prevalence and predictors of major depressive disorder in bereaved caregivers at 6 and 13 months.

OBJECTIVE: Depressive symptoms are common in bereaved caregivers; however, there have been few prospective studies using a structured interview. This study investigated the prevalence and preloss predictors of major depressive disorder (MDD) in bereaved caregivers of patients in a palliative care unit. METHOD: This prospective cohort study collected caregiver sociodemographic and psychological data before the death of a palliative care unit patient, including MDD, care-burden, coping style, and hopeful attitude. Postloss MDD was assessed 6 and 13 months after death, and a multivariate logistic regression analysis was conducted to identify its predictors.ResultOf 305 caregivers contacted, 92 participated in this study. The prevalence of preloss MDD was 21.8%; the prevalences of postloss MDD were 34.8% and 24.7% at 6 and 13 months, respectively. Preloss MDD predicted postloss MDD at 6 months (odds ratio [OR] = 5.38, 95% confidence interval [CI95%] = 1.29, 22.43); preloss nonhopeful attitude and unemployment status of caregivers predicted postloss MDD at 13 months (OR = 8.77, CI95% = 1.87, 41.13 and OR = 7.10, CI95% = 1.28, 39.36, respectively).Significance of resultsApproximately 35% of caregivers suffered from MDD at 6 months postloss, but the prevalence of MDD decreased to about 25% at 13 months. Preloss MDD significantly predicted postloss MDD at 6 months, whereas hopeful attitude and unemployment at baseline were significantly associated with postloss MDD at 13 months.

Methylation of the glucocorticoid receptor gene associated with depression in patients with acute coronary syndrome.

OBJECTIVE: The present study investigated the longitudinal effects of NR3C1 1 F exon methylation on the risk of depression following ACS and treatment outcomes. METHODS: In total, 969 patients admitted for recent ACS were recruited within 2 weeks of ACS; 711 of these patients were followed up at 1 year. Depressive disorder was diagnosed according to DSM-IV criteria and included prevalent depressive disorder at baseline and incident or persistent depressive disorder at follow-up based on depression status at the two examinations. Of the 378 baseline participants who were diagnosed with depression, 255 participated in a randomized double-blind placebo-controlled trial of escitalopram, while the remaining 123 were managed with the usual medical treatment for ACS.NR3C1 1 F exon methylation was measured using peripheral blood samples, and various demographic and clinical characteristics were assessed as covariates. RESULTS: Higher NR3C1 1 F exon methylation levels were independently associated with prevalent depressive disorder at baseline but not with incident or persistent depressive disorder at follow-up based on logistic regression analyses adjusted for covariates. The effects of escitalopram on the remission of depressive symptoms was not influenced by NR3C1 1 F exon methylation status in ACS patients, but a placebo effect on the remission of depressive symptoms was observed, particularly in patients with lower methylation levels. CONCLUSIONS: ACS patients with higher NR3C1 1 F exon methylation levels were at higher risk of developing depressive disorder within 2 weeks of ACS. Additionally, adequate antidepressant treatment may be effective for the remission of depressive symptoms regardless of NR3C1 1 F exon methylation status.

Social support deficit and depression treatment outcomes in patients with acute coronary syndrome: Findings from the EsDEPACS study.

OBJECTIVES: This study aimed to investigate whether social support deficit has moderating effects on depressive and cardiac outcomes in an antidepressant trial for depressed patients with acute coronary syndrome as a secondary analysis using Escitalopram for DEPression in acute coronary syndrome study (ClinicalTrial.gov registry number: NCT00419471). METHODS: In total, 217 acute coronary syndrome patients with Diagnostic and Statistical Manual of Mental Disorders, 4th edition depressive disorders were randomized into two groups that received escitalopram (N = 108) or placebo (N = 109) for 24 weeks. Social support deficit was evaluated by validated scales at study entry. Depressive outcomes were measured using the Hamilton Depression Rating Scale, the Montgomery Asberg Depression Rating Scale, and the Beck Depression Inventory. Cardiac outcomes included echocardiography (left ventricular ejection fraction and wall motion scores), electrocardiography (heart rate, PR interval, QRS duration, and QTc duration), and laboratory test results (troponin I and creatine kinase-MB). RESULTS: A higher social support deficit at baseline was significantly associated with less improvement in Hamilton Depression Rating Scale, Montgomery Asberg Depression Rating Scale, Beck Depression Inventory scores, and serum troponin I levels after adjustment for corresponding baseline scores, covariates associated with social support deficit at baseline, and treatment status. The strength of these associations was more prominent in the placebo group compared to the escitalopram group. CONCLUSIONS: Evaluation of social support deficit in depressed acute coronary syndrome is important, and particularly during the acute phase, depressed acute coronary syndrome patients with social support deficit should be treated more carefully to improve treatment outcomes, given that social support deficit was predictive of poorer depressive and cardiac outcomes during the 24-week treatment period. Acute coronary syndrome patients with social support deficit should be treated more carefully to improve treatment outcomes.