In patients with cardiovascular disease (CVD), depression is common, persistent, and associated with worse health-related quality of life, recurrent cardiac events, and mortality. Both physiological and behavioral factors—including endothelial dysfunction, platelet abnormalities, inflammation, autonomic nervous system dysfunction, and reduced engagement in health-promoting activities—may link depression with adverse cardiac outcomes. Because of the potential impact of depression on quality of life and cardiac outcomes, the American Heart Association has recommended routine depression screening of all cardiac patients with the 2- and 9-item Patient Health Questionnaires. However, despite the availability of these easy-to-use screening tools and effective treatments, depression is underrecognized and undertreated in patients with CVD. In this paper, we review the literature on epidemiology, phenomenology, comorbid conditions, and risk factors for depression in cardiac disease. We outline the associations between depression and cardiac outcomes, as well as the mechanisms that may mediate these links. Finally, we discuss the evidence for and against routine depression screening in patients with CVD and make specific recommendations for when and how to assess for depression in this high-risk population. 1. Introduction Depression in cardiac disease is common, persistent, underrecognized, and deadly. Over the past 20 years, research has found that not only is depression more common in cardiac patients than in the general population, but depression is also a risk factor for cardiac morbidity and mortality, independent of traditional risk factors. This link between depression and cardiac morbidity likely involves both physiologic and behavioral effects of depression. Fortunately, screening for depression in cardiac patients is straightforward, and methods of diagnosis essentially parallel those for major depressive disorder (MDD) diagnosis in other settings. In this paper, we will review the epidemiology, course, impact, pathogenesis, and diagnostic assessment of depression in patients with cardiovascular disease (CVD). We will define depression as either elevated depressive symptoms on a validated depression scale or a formal diagnosis of MDD. Of note, we will not specifically address treatment of depression in cardiac patients, a topic that is worthy of its own separate review and that has been recently reviewed in detail [1]. 2. Prevalence of Depression in Cardiac Patients Depression is highly prevalent in cardiac patients. Between 31–45% of patients with
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