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Heart Disease & Depression
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Resource Description: 
This episode of Second Opinion explores the latest trends in diagnosis and treatment of depression.
This episode of Second Opinion covers what we all need to know about heart attack and heart health.
This episode of Second Opinion covers what metabolic syndrome is, its causes and consequences, and steps you can take to protect yourself from life-threatening medical problems.
This site is an excellent first place to turn to for more information on all cardiac concerns. Of particular interest is their article, "Stress and Heart Disease"
This site has a wealth of information on heart disease.
The National Institute of Mental Health is the lead federal government agency for research on mental and behavioral disorders. This is a link to a fact sheet that summarizes what heart disease patients need to know about depression.
The Depression and Bipolar Support Alliance, a non-profit organization, is the nation's leading patient-directed organization focusing on the most prevalent mental illnesses – depression and bipolar disorder. The organization fosters an understanding about the impact and management of these illnesses by providing up-to-date, scientifically based tools and information written in language the general public can understand.
This article originally appeared in the November-December 2003 FDA Consumer and contains revisions made in February 2004 and May 2004.
Episode number: 
302

Depression and heart disease are two of the most common health disorders in the U.S.  Now, research studies are revealing they're often common companions as well.

While the research is not definitive, it points to the premise that each may be a cause – or an effect – of the other.  In other words:

  • People who have heart disease are more likely to suffer from depression
  • People who are depressed may be at greater risk for developing heart disease

Additionally, people with heart disease who are depressed have an increased risk of death after a heart attack.

While researchers are still studying how depression might trigger heart problems, they have identified several mechanisms as potential culprits.

  • People with depression typically have decreased heart rate variability, which may cause dangerous heart arrhythmias or variations in blood pressure.
  • Mental distress seems to encourage platelets to clump together, creating an increased potential for the formation of blood clots.
  • Depressed people are more likely to develop well-known risk factors for heart disease such as hypertension, dyslipidemia, insulin resistance or glucose intolerance.
  • Increased levels of inflammatory proteins commonly found in patients with depression have been clearly linked to increased risk of heart attack.
  • Chronically elevated levels of stress hormones, such as cortisol and adrenaline can increase the work of the heart.
  • In the chronically stressed and depressed individual, the repair and healing systems of the body may be compromised.

Despite the research findings, depression often goes under diagnosed and under treated for a variety of reasons. 

  • Many people still view a mood disorder as a personal failure or a sign of personal weakness and are unwilling to tell their doctors about it.  Conversely, some doctors are reluctant to raise the subject with patients. At times, both doctors and their patients agree that "depression is natural" when someone has chronic illnesses, and thus tend to ignore its impact or fail to treat it adequately. Men, in particular, are less likely than women to reach out or admit they may be distressed, demoralized, or sad.
  • When patients report physical signs of depression, such as fatigue, headaches or changes in eating and sleeping patterns, physicians tend to focus on physical causes. 
  • After heart disease is diagnosed, doctors may interpret a patient's sadness, loss of joy and interest, sense of pessimism or hopelessness, demoralization, poor concentration and forgetfulness as a normal consequence of serious illness. One or several of these symptoms may be present fleetingly, but when sustained, they cannot be passed off as "just a reaction."
 

Quick Facts

  • Depression is one of the most common health disorders in the U.S., and heart disease is a leading cause of death.

  • Depression is an independent risk factor for the development of heart disease.

  • Depressed feelings are often a common reaction to heart disease.  About one in 20 Americans experiences major depression in a given year but the number goes up to about one in 5 individuals who survive a heart attack.

  • People with heart disease who are depressed have an increased risk of death after a heart attack compared to those who are not depressed.  

  • While depression is an important risk factor for death after heart attack, depression appears to have the greatest impact in the immediate months after heart attack.

  • Depression in patients with coronary heart disease is associated with treatment noncompliance including medications and cardiac rehabilitation.

  • Many heart patients with depression do not receive appropriate treatment for the depression. 

  • It is critical to treat both the depression and cardiac disorder in order to maximize a positive outcome.

  • Depression is an eminently treatable illness.  More than 80% of people with depression can be treated successfully with
    psychotherapy, medication or a combination of both.

 

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.

  • How do I know if I'm depressed or just have a case of the blues?

  • Are their other medical conditions that can produce similar symptoms?

  • Should I have tests to rule out other conditions?

  • What are the differences between mild, moderate and severe depression?

  • What can I do to limit my risk for heart disease because of my depression?

  • How does depression contribute to heart disease?

  • Are there other physical illnesses I may be more susceptible to because of my depression?

  • What are my treatment options?  If applicable:  Are my options limited because of my existing heart disease?

  • What are the implications of not having treatment?

  • Is it safe to have heart surgery when I'm still feeling depressed?

  • If medication is prescribed:
    • How will I know if new symptoms are a side effect of my medication or more symptoms of the depression itself?
    • What medication side effects would make you take me off this medication and try another?
    • Is trial and error the only way to find the right medication for depression?

  • If psychotherapy is prescribed:
    • What type of psychotherapy do you suggest? Why?
    • How does psychotherapy help?

  • Can my depression be cured or just managed?

  • What should I do if I'm feeling suicidal?

  • Are there sources in the community to help me?

  • What does my family need to know?

Key Point 1

Stress in your life causes stress on your heart.  That stress can accelerate heart disease and can lead to a heart attack.

Depression and anxiety from stress tend to go hand-in-hand.  If you suffer from one of these mental disorders it's likely you're also affected by the other.  The latest medical research has added a third disorder to the mix, this time a physical one.  Over the last decade researchers have raised the possibility that depression and anxiety can set the stage for heart disease as well as complicate its outcome.

Stress is an inevitable part of life.  But just what is stress?  Simply put, stress refers to the body's response to change.  Of course, not all stress is bad and both good and bad stress affects different people in different ways.  However, continued ongoing stress can cause chronic anxiety and depression in some individuals. 

How does stress affect the heart?

  • Anxiety and stress make your heart work harder. When you're under stress, your body's "fight-or-flight" response is triggered - your body tenses, your blood pressure rises, and your heart beats faster.
  • Stress hormones may damage the lining of the arteries. When damage occurs, platelets in the blood adhere to the injured walls in an attempt to promote healing, resulting in a thickening of the arterial wall.
  • Stress releases fatty acids and glucose into the bloodstream. These can be converted into natural fat and cholesterol creating deposits that decrease blood flow.
  • Stress increases the likelihood that an individual will smoke, overeat, consume caffeinated beverages, self-medicate with drugs or alcohol and lead a sedentary lifestyle.  (According to research from the University of Maryland, smoking cigarettes or consuming excessive caffeine can raise the heart rate an average of 14 beats per minute. This effect, when combined with stress, can cause the heart rate to increase as much as 38 beats a minute.)
  • Stress can interfere with the body's ability to repair itself, including slower repair of injuries to the heart.    

What causes stress?

Stress is part of every day living.  Driving.  Deadlines at work.  Family disagreements.  And, not all stress is negative.  A job promotion is equally exhilarating and anxiety-provoking. For some individuals, stress may serve as an adaptive response to important challenges, which can lead to outstanding performance and achievements. But, feeling too much for too long may have negative health consequences. Stress may arise from highly significant negative life events – like the loss of a job. Stressful life events have a clear association with heart disease. Chronic negative emotions have an insidious corrosive effect and may contribute to heart disease as well.  These kinds of stresses may be caused by:

  • Lack of a sense of control over one's life
  • Relentless time pressures
  • Environments that contribute to low self esteem
  • Changes in life style or environment that require adjustments
  • Unsatisfactory social supports
  • Poor health habits
  • Poor coping skills
  • Loss, including the biological vulnerabilities of aging

Illness itself is profoundly stressful.  For example, individuals who have had a heart attack and fail to adjust to their illness have higher death rates in the first six months after the event than their better-adjusted peers.  And, the demands of care giving for a loved one can be extraordinarily stressful.  Care givers often ignores their own physical and emotional needs, sacrificing themselves to their task.    

How is stress measured?

It's not easy to measure the effect of life stresses on any given individual's health or to predict how that individual will respond to it.  However, scientists have developed a number of instruments to help physicians and mental health professionals rate factors such as an individual's sense of powerlessness, hopelessness, hostility, anger, life event strains and coping skills. 

It's difficult for an average individual to identify how much stress he or she has.  If you believe you have stress or have unexplained symptoms you should talk to your doctor about it. 
  
Common symptoms of stress and depression:

 

Physical

Emotional

Mental/Behavioral

Restlessness
Muscle tension
Clenched jaws or grinding teeth
Heart palpitations
Stomach disorders
Poor sleep 
Headaches
Unusual weight gain or loss
General aches and pains
Anxiety/worry
Irritability/anger
Guilt
Feeling powerless and frustrated
Negative thinking
Crying
Apathy
Mood swings
Sense of failure
Inability to see meaning in life
Indecisiveness
Inability to concentrate
Memory lapses
Loss of sense of humor
Aggressiveness
Interpersonal problems
Loss of sex drive
Increased use of cigarettes, 
   alcohol or drugs
Changes in appetite
    

Key Point 2

Depression can accelerate heart disease or be an effect of it.  Both the heart and the head need to be treated appropriately.

Over the last decade, evidence has been mounting that depression may be a risk factor for heart disease, and conversely, having heart disease often causes depression.

Multiple studies suggest that those with depression are more likely to develop heart disease. In the case of a Johns Hopkins study of 1,000 male medical students the increase was twofold.  Other studies propose that the more severe the depression, the greater the risk. 

While depression is an independent risk factor for the development of heart disease it's also an emotional reaction to heart disease itself.  According to the Journal of the American Medical Association about one in 20 Americans experiences major depression in a given year but the number goes up to about one in 5 individuals who survive a heart attack.

The evidence that depression may both cause and complicate heart disease is getting stronger.  But, can treatment for depression prevent cardiac problems?  Intuitively it would seem so, but researchers are just beginning to publish studies on the topic.  One study from Duke University Medical Center found that a stress-management program cut the chances that a heart patient would suffer a heart attack or need surgery by 74 percent. Another from Emory University School of Medicine has found that giving the antidepressant paroxetine to heart attack survivors made their platelets less "sticky" and reduced their risks of developing blood clots.  

The conclusion, at this point, is that recognizing and treating depression is very important to maximize heart health as well as quality of life. 

More than 80% of people with depression can be treated successfully with psychotherapy, medication or a combination of both.  Physicians often recommend a patient with mild depression try cognitive behavioral therapy or interpersonal psychotherapy first.  Medication can be added if needed or might be the first choice if the depression is more severe.  For individuals with hearth disease, newer medications, such as selective serotonin reuptake inhibitors are effective with fewer cardiovascular side effects than previous drugs.  Family, friends and physicians all need to be aware of and watchful for the patient's tendency to dwell on thoughts of suicide.

You can take steps to control stress and fight depression.  Talk to your doctor and consider getting guidance from a trained therapist. 

Common coping techniques:

 

Life Skills

Relaxation

Counseling

Eat and drink sensibly
If you smoke, stop
Exercise regularly
Get enough rest
Recognize good things about yourself
Set reasonable expectations for yourself
Say "no" to unreasonable demands
Find time to relax every day
Warm baths
Relaxing music
Massage
Deep breathing
Stress relieving exercise
Meditation
Guided imagery
Biofeedback
Get new perspective
Learn new behaviors
Learn relaxation techniques
    

Key Point 3

Depression is not a normal state of mind – in the elderly or in people of any age.  The transition from being depressed to being suicidal can be difficult to pick up.

Medical professionals today estimate that potentially one in five Americans will experience a diagnosable mental health disorder during a lifetime, including depression. That's 44 million adults and 4 million children.  However, it is not a normal state of being. 

Suicide is the ninth leading reported cause of death in the United States. Statistics show that:

  • Almost all people who kill themselves intentionally have a diagnosable mental disorder
  • The primary at-risk populations include young adults and elderly persons
  • Although depression is more often diagnosed in women, more men than women die from suicide - more than a 3-to-1 ratio
  • As many as two thirds of older individuals who complete suicide have seen a physician within a month of their death -- according to one study, 20% of older patients who committed suicide visited their primary care physician on the same day as their suicide

Both doctors and patients often have difficulty identifying the signs of depression because it can show itself in so many different ways.  Suicide can be even more difficult to predict.

  • Suicidal individuals may or may not give warnings of their intent
  • They may be socially isolated, so there are no friends and family to help identify the seriousness of the situation
  • Physicians are accustomed to treating patients who want to live rather than die – questions about suicidal ideation are normally not part of a routine medical evaluation
  • Risk assessment techniques are imprecise

Many primary care physicians are becoming more proactive in dealing with depressed patients and sending them to mental health professionals.  The rest of us need to be vigilant as well with friends or family members who show signs of increasing depression.    

Warning signs include:

  • Expressions of hopelessness
  • Admission of suicidal thoughts – those who admit to an organized plan of action are at greater risk
  • Previous attempts at suicide or a family history of suicide
  • Marked changes in behavior, attitudes or appearance
  • Giving away prized possessions/putting affairs in order
  • Lack of future plans
  • Self destructive behavior
  • Withdrawal from friends and family
  • Signs of stress and depression

Things you can do:

  • Ask the person if they have had thoughts of suicide
  • Actively listen and take what he or she has to say seriously
  • Encourage the individual to identify things that might make a difference
  • Persuade the individual to see a professional (if necessary, arrange it)
  • Take steps to help them end their isolation

Medline Plus

Medline Description: 

Conduct an off-site search for Heart Disease & Depression information from MedlinePlus.  These up-to-date search results are based on search terms specific toSecond Opinion Key Points.

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