Depression in cardiovascular guidelines: what a 65-guideline systematic review found

Depression is more common in people with cardiovascular disease (CVD) than in the general population, and it complicates disease management, medication adherence and lifestyle change ^[1]. Co-occurring CVD and depression are associated with reduced quality of life, poorer outcomes and increased mortality ^[1]. A systematic review published in the European Heart Journal in 2025 examined a narrower question: how CVD clinical practice guidelines (CPGs) address depression, including whether they give practical management guidance ^[1].

What was studied

The authors ran a systematic search covering 2013 to 2024 and identified 65 CPGs published in English ^[1]. The guidelines spanned general CVD, heart failure, coronary artery disease, peripheral artery disease, stroke and aortic disease ^[1]. Stroke, as MedlinePlus defines it, is a loss of blood flow to part of the brain that can cause lasting brain damage, long-term disability or death ^[4]. The unit of analysis was the guideline document, not the patient, so the review describes what guidance says rather than how patients fare ^[1].

Recognition without instruction

The central finding is a gap between naming depression and giving recommendations for managing it ^[1].

• 71% of CPGs acknowledged depression as a risk factor ^[1].
• 12% referred to a dedicated CPG for comprehensive guidance ^[1].
• 23% provided both screening and treatment recommendations for depression management ^[1].

Most guidelines recognised depression, but fewer than a quarter gave both screening and treatment recommendations ^[1].

Who wrote the guidelines, and for whom

The composition of guideline panels and their intended populations varied ^[1].

• 12% of CPGs involved mental health professionals in their development ^[1].
• 24% focused on cardiac or stroke rehabilitation ^[1].
• 9% focused on women ^[1].

Recommendations were unevenly distributed across disease areas ^[1]. Stroke CPGs delivered the majority of depression recommendations (68%), which the authors describe as likely due to the involvement of neurologists ^[1]. Cardiac and stroke rehabilitation CPGs delivered 24% of recommendations, whereas women-specific CPGs offered no treatment recommendations ^[1].

The question of whether cardiovascular evidence applies equally to women and men has also been examined in a separate trial on a different topic ^[3]. REBOOT was a randomized trial of beta-blockers after myocardial infarction in patients with left ventricular ejection fraction above 40%, and its pre-specified sex subgroup analysis included 8438 patients, of whom 1627 were women ^[3]. In women, beta-blocker therapy was associated with a higher rate of the primary composite outcome of death, myocardial infarction or heart failure hospitalization (hazard ratio 1.45, 95% confidence interval 1.04-2.03), with no significant difference in men (P for interaction = .026) ^[3]. That trial does not concern depression and is included here only as context on sex differences in cardiovascular evidence ^[3].

Treatment content

Where guidelines named specific treatments, cognitive-behavioural therapy was the most recommended psychotherapeutic intervention, appearing in 29% of CPGs ^[1]. Selective serotonin reuptake inhibitors (SSRIs) were the pharmacotherapy most recommended, appearing in 20% of CPGs ^[1]. Only 3% of CPGs addressed drug-disease interactions associated with treating depression ^[1].

What the authors conclude

The authors state that depression negatively affects patients' lives irrespective of CVD outcomes ^[1]. They recommend that CVD guidelines systematically address depression, consistently involve mental health specialists, and deliver screening and treatment guidance tailored to distinct patient populations for holistic patient care ^[1].

Limitations

The design and reporting of this review constrain what it can show ^[1].

• The search was limited to English-language guidelines published between 2013 and 2024, so guidance in other languages or outside that window is not represented ^[1].
• The abstract reports what guideline documents contain; it does not report data on clinician adherence or on outcomes for patients treated under more detailed guidelines ^[1].
• The explanation that neurologists' involvement drove the higher share of stroke recommendations is framed by the authors as likely, not tested ^[1].
• Some figures describe shares of guidelines and others describe shares of recommendations, and the two denominators should not be compared directly ^[1].
• Women-specific guidelines made up 9% of the sample, so the absence of treatment recommendations in that group rests on few documents ^[1].
• The abstract does not state whether guideline quality was appraised or name the issuing bodies, which limits assessment from the abstract alone ^[1].
• The REBOOT findings come from a subgroup analysis of a single trial on a separate clinical question and do not bear on depression care ^[3].