Dickens et al (Reference Dickens, McGowan and Percival2006) stress the importance of detection and treatment of anxiety and depression for quality of life after myocardial infarction and point to the mediating role of energy and fatigue.

We agree that depression following myocardial infarction predicts long-term quality of life and we recently showed that this effect persists after controlling for cardiac condition and quality of life at 3 months post-myocardial infarction (Reference de Jonge, Spijkerman and van den Brinkde Jonge et al, 2006). However, it is unclear whether and how detection and treatment of depression can counter these effects. In the SADHART study Glassman et al (Reference Glassman, O'Connor and Califf2002) found that the effects of sertraline were modest and appeared to be restricted to depression with an onset before the infarction, but Dickens et al found that depression and anxiety which were present before myocardial infarction did not predict quality of life. In the ENRICHD trial (Reference Berkman, Blumenthal and BurgBerkman et al, 2003), cognitive–behavioural therapy had modest effects on depressive symptoms at 6 months post-infarction in patients with depression and social isolation, but these effects diminished over time. In the EXIT trial (Reference Appels, Bar and van der PolAppels et al, 2005), where the focus of treatment was explicitly on vital exhaustion, only some intervention effects were observed and these were modified by the presence of a previous cardiac history.

We agree with Dickens et al that there is a need for improved detection and treatment of depression and anxiety following myocardial infarction but several questions need to be addressed. These include ‘can the effects of depression and anxiety be linked to specific subgroups of emotional disorders based on symptoms and/or onset?; ‘can interventions that were developed in general psychiatry be applied to depression post-myocardial infarction or should they be adapted?’; and ‘how can psychiatric interventions be integrated into regular cardiac aftercare?’