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Heart Disease & Depression (transcript)
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(Dr. Peter Salgo)   
Welcome to Second Opinion where each week our health care team solves a real medical mystery. When we close this file in a half an hour from now, you'll not only know the outcome of this week's case, but you'll be able to better take charge of your own health care. I'm your host Dr. Peter Salgo and our story today concerns Fred. Well you've already met our special guests who are joining our cast of regulars; Primary Care Physician Dr. Lisa Harris and Health Reporter Christine Rogers. Nobody on this team, and I mean nobody knows the case, so we're going to get right to work. We're going to talk about Fred. Fred is 68 years old; he's been married to Helen, his wife for 40 years. They have 2 grown children; the children live out of state. Now Fred has been Helen's Primary Care Giver for the past 10 years because Helen has some severe Alzheimer's disease. Lisa, tell me a little bit about what Fred's life is like right now.

(Dr. Lisa Harris)     
It's probably very difficult so if he's taking care of someone with Alzheimer's disease it means he's probably ignoring his own health and hasn't been taking very good care of himself.

(Peter)    
What is his mental health like in terms of Care Givers who are immersed in the help of somebody else?

(Dr. Eric Caine)  
You know it's a 24/7 job. I think one of the questions that anybody's going to worry about both of them is how are they doing together and can he sustain it.

(Peter)     
Lisa as a Primary Care Doctor do you find that, do you find yourself watching these Care Givers more carefully than other people or are they pretty well managing themselves? 

(Lisa)    
Oh no they're not managing well at all and the support services that you can get in the community are reasonable limited and what I find is the longer the Care Giver has been attached to a patient, the harder it is for them to divorce themselves from the care and look at things objectively.

(Eric)   
One of the really other things that is going to be hard to know until we know Fred better and certainly I'd like to know as her Consultant as it were is, you know, what kind guy is he? Some men can ask for help, but a lot of men are stoic, one foot in front of the other; you know this is what got them through life.

(Peter)    
Would you like to know something about Fred's physical health?

(Lisa)    
Absolutely.

(Peter)     
Well I can tell you that Fred describes himself as robust. Not fat he says; I'm robust. He has mild high blood pressure and he's taking a Beta Blocker for that.

(Lisa)    
I'm sorry, what is mild?

(Dr. Gladys Velarde)   
What is mild?

(Laughing)

(Peter)    
Mild high blood pressure is what I have here. My guess is, it's somewhere around 150 systolic and around 90 diastolic and he's on a Beta Blocker and from what I can tell here, he's says it's controlled. He's got high LDL Cholesterol; his doctor put him on a statin and I don't have a number for his LDL Cholesterol since he's been on a statin. And there's something else here. There's a note that his Primary Care Physician has him on Elavil to help him sleep. Does this make sense to you?

(Kenneth Freedland)   
Well if he is having trouble sleeping, it's one of the kinds of medications that would be commonly prescribed for that. It might raise some concerns if he's having cardio vascular problems though.

(Eric)   
In fact I would disagree and say it makes no sense to me because Elavil is an old time antidepressant; Amitriptlyine and yes it has sleep inducing side effects, but it has cardiac effects, it has other systemic effects.

(Gladys)    
The first rule of medicine is do no harm and yes he's tolerated the medicine you say for 20 years so you can say by default he's not being harmed by it, but we don't know that and we would not want to perpetrate a wrong.

(Dr. Peter Salgo)   
Fred, when he's told about all of these things, and I'm sure he's had discussions with his Primary Care Physicians said I don't care. I'm concentrating on Helen, I'm not concentrating on myself, but he does take a friend's advice. One day he goes out for a walk to discover that in his absence his wife has tried to cook lunch and has set the stove on fire. He is advised to put his wife into a protected environment.  Fred vehemently disagrees. It sounds like something you were talking about; he's stoic about all that.

(Eric)   
Right.

(Lisa)    
It's a sense of failure.

(Peter)    
What's that?

(Lisa)    
It's a sense of failure I'm sure for him.

(Eric)   
Well he's the man.

(Peter)    
The doctors were very persuasive and Fred eventually does consent to put Helen into a protective environment.

(Eric)   
There's a flip side to this.

(Peter)    
Yeah?

(Dr. Eric Caine)  
Now Fred has failed so how can he help and how can he still be in charge even when he gets help? It becomes really one of the fundamental...

(Dr. Lisa Harris)   
The giveaway phrase...

(Gladys)    
This has really become a very complicated matter now.

(Lisa)    
His role in life was to take care of his wife and that's, this is not his role anymore. He doesn't know how to handle it.

(Eric)   
Whatever it means, it's going to be a big transition for it, so now being, I don't know if it's true, but at least pushed to do this, if not forced by the circumstances to do it. I'd worry for him.

(Peter)     
I want to focus on that word you're worried. You're worried you're worried. Why is everybody worried about Fred?

(Lisa)     
I'm very fearful. This guy's a time bomb. He's 68 years old, he's overweight, he's on a drug that can increase his cardiovascular risk and he's got high cholesterol and now he's stressed. So what are we doing? This guy is he's going to explode. He's going to end up having a heart attack.

(Peter)    
So you're hearing a little tick, tick, tick, tick?

(Lisa)    
Yes I do.

(Dr. Peter Salgo)   
Alright well let me give you a little more history here because even though Helen is in a protected environment, Fred still feels as if he has to be the Care Giver here so what Fred takes it upon himself to do from 8:00 in the morning until bedtime, 7 days a week, 7 days a week is to go to Helen's nursing home and be at her side. It doesn't sound less stressful to me for her to be in this environment. Does it to you?

(Christine Rogers)  
No, it sounds like he needs to find some sort of support or outlet for him. I mean, he's dedicated obviously his life to his wife and I don't think that stress is going to decrease whether she's in the house or out. I think he needs some other support.

(Peter)     
Well one morning in November Fred is getting dressed to go for his usual visit to the nursing home when he begins to experience something really dreadful. He feels crushing, substernal; right here, chest pain. He's having difficulty breathing and he's nauseated as well. He knows something is wrong. Lisa what should he do?

(Lisa)    
Go straight to the Emergency Room; 911.

(Peter)    
Straight to the Emergency Room; 911. What was it like for you? What were your symptoms, what did you do?

(Linda Pikuet)     
Yes I had a heart attack and it was very a-typical, very a-typical.

(Peter)    
How so?

(Linda)      
I did not feel any chest pressure; I did not feel any on-pain. I felt all burning and heartburn and I was getting sick, which I didn't think was part, was a symptom of Heart Disease.

(Peter)    
When you say sick you mean nausea?

(Linda)      
I was, yes, you know I was vomiting and I was very weak. At that point I thought it was maybe just indigestion from pasta at dinner.

(Gladys)    
If I may interject for a minute.

(Linda)     
Yes.

(Gladys)    
What you're expressing Linda; it's not so uncommon, especially in women.

(Peter)    
But you called the doctor at some point?

(Linda)      
Yes and I was taking...

(Dr. Peter Salgo)   
Why, did the symptoms just keep getting worse?

(Linda)      
Because they came on very suddenly and it didn't go away.

(Peter)    
What did they tell you?

(Linda Pikuet)     
They kept asking my history because it wasn't my own physician I was speaking to, it was an on-call doctor, but they asked what I had for dinner. I did ask if I should go to the hospital and I was told that if I felt I, if I really felt I should.

(Laughing)

(Eric)   
Please make the professional decision for me; yes, yes.

(Peter)    
I want to find out what happened. You eventually wound up at the hospital right?

(Linda)      
This was Friday night. I didn't get to the hospital until Monday.

(Lisa)    
Oh my goodness.

(Peter)    
Monday?

(Linda)      
Saturday I went to...

(Dr. Lisa Harris)   
The Urgent Care,

(Linda)     
Thank you, facility and I was just poked twice and oh, classic acid reflux and I was given Prevacid. No one gave me an EKG.

(Lisa)    
There was an angel watching over you.

(Linda)      
Monday I went to work; very stressful, you know a stressful job and I went to work. I was not feeling well again by 10:00, thinking oh I should call my own doctor and maybe get some more, a higher dosage of Prevacid and that's when I went to my own doctor and they sent me by, they gave me an EKG in my Primary Care Physicians office and they sent me by ambulance to the hospital and came in and said, guess what? You had a heart attack Friday night.

(Peter)    
So you're sitting there and you're hitting a stonewall. Do you know what Fred did? Would you like to know what Fred did?

(Lisa)    
Yes.

(Peter)    
Fred called 911 and got taken to the Emergency Room. What do you do?

(Gladys)    
Immediately other than the obvious, looking for vitals and getting your data, because your data is very important.

(Dr. Peter Salgo)   
Okay.

(Dr. Gladys Velarde)    
There is some basic treatment that goes at the onset of receiving a patient like this so it is oxygen and maximizing the oxygen carrying capacity so the blood that gets through is maximally oxygenated.

(Peter)    
Right.

(Gladys)    
And an aspirin, which hopefully if he didn't already...

(Peter)    
They gave him an aspirin.

(Gladys)    
Pretty much, maybe some clot medications, depending on what region, what region of the country Fred is. You know that is another debatable issue.

(Peter)    
They did get a cardiogram on Fred. I'll give you the technical interpretation was that he had a heart attack.

(Lisa)    
What did it show?

(Peter)    
They found 3 critical arteries and they put in 3 stints to open up those arteries. Fred has gone to the cath labs, he has gotten stints, they put him on a cocktail that he's been on Statins and Beta Blocker; he's put on Aspirin and Clepiticril, another blood thinning drug. He's been in the hospital now for 5 days. Now during that time, he has not had the opportunity to visit Helen. No one has even bothered to ask Fred about his wife, where she is, what's going on and Fred has not volunteered. And by the way, in this time nobody has called Fred's private doctor, his Primary Care Physician. He's not in a hospital where his Primary Care Physician has privileges. So the Primary Care doc doesn't know that he's there.

(Gladys)    
Huge mistake.

(Peter)    
Huge mistake you think.

(Gladys)    
Well made, very, made difficult by Fred's own not asking.

(Christine)   
Isn't that tough you put the onus on the patient?

(Eric)   
Well we know Fred's not forthcoming.

(Christine)  
Right, right.

(Eric)   
But.

(Dr. Peter Salgo)   
Fred may not even be forth coming in this.

(Eric)   
We don't know what Fred's mental state is at this point. I mean, you know he's been brought in acutely and that kind of thing. It is tough on the patient. You'd think that either the doctor or the social workers or the ...

(Lisa)    
Somebody would ask.

(Gladys)    
Somebody should ask.

(Dr. Eric Caine)  
Somebody should say what's going on in, what's going on in your life Fred?

(Peter)    
Well what's happening here is that Fred isn't asking questions. The hospital has run out of their allotted time to take care of Fred's heart attack and they say medically it's time for you to go home. Should Fred, in your view, not the view of the docs here, in your view should Fred go home to the empty house that he's about to go home to?

(Christine)  
Absolutely not. I don't think so. I'm wondering where his 2 kids are. You know I know they're out of state, but I mean no I don't think he's prepared to do that.

(Dr. Gladys Velarde)   
Actually his silence is really, speaks volumes for depression.

(Christine)  
Yes, I'd worry about that a lot for him, that he's already; we know he's isolated himself to a degree even when his wife was still living at home with him.

(Lisa)    
Fred is a 68-year-old stoic kind of guy and that generation, particularly males; I'm going to generalize a little bit here. He's not going to come out and tell his doctor that I'm worried about going home to an empty house.

(Peter)    
So, you've been through this. What is Fred's mental status like now? What is he thinking? What is he feeling? Is he worried about going home and taking care of himself do you think after a heart attack?

(Linda)     
Absolutely. He's worried about himself; he's worried about his future. It's all very intimidating for him, even being in the hospital for 5 days. I mean you have medical professionals coming in every hour on the hour, you have students coming in, you have nurses coming in who don't even identify themselves half the time.

(Gladys)    
Linda did you have a stressful life, obviously not as Fred's, but any stressful situation that might, that you think?

(Linda Pikuet)    
I have, I had a stressful job, and you know I definitely feel stress contributed to my heart attack.

(Peter)    
Let me ask what seems to me to be the critical question at this moment. The question is, why now? Why right now did Fred have his heart attack? His wife is in a protected environment for the first time...

(Dr. Lisa Harris)   
He's under stress. He's under a lot of life changing...

(Peter)    
He's under stress.

(Christine Rogers)  
It was a big life change for him.

(Peter)    
Are you telling me that stress can give you a heart attack is what I guess I'm asking?

(Gladys)    
Well that's the million-dollar question. We, you can't imagine that how difficult it would be to correlate one thing directly. If the causative effect was stress has really not been proven and in my opinion, will probably never be proven. We do have situations and case reports mostly where we have seen that a particular event was associated with an acute coronary event.

(Kenneth)    
Well we have more than case reports. For instance, around the time of major earthquakes there have been documented spikes in sudden cardiac deaths.

(Gladys)    
That is correct, but it is very hard to say that it was that that was the cause of the actual rupture of the plaque or the obstruction in the artery.

(Lisa)    
What we're hearing here is the difference between the scientist wanting to know the exact mechanism of what caused the myocardial rupture at that time versus from a more Primary Care approach and from a mental health approach. We know that stress in a life will have a myriad of effects on a person's life health and well-being.

(Eric)   
But I actually think the real question is not why now, but what's next?

(Dr. Peter Salgo)   
Is that right?

(Eric)   
I think the question of what's next is critical because you've basically got a guy who says, look I don't want help. He only under extreme duress, which is to say, pressure in the chest calls 911 and only under that circumstance does he end up in the hospital.

(Peter)    
But you want to know what happens next? I'm going to tell you what happens next. We're going to pause just for a minute and sort of take a breath; take stock of where we are and point out that stress in your life, I think it's fair to say can cause stress on your heart. That stress can accelerate heart disease and in some way, admittedly we don't know the perfect biochemistry of this; can lead to a heart attack. Well let me tell you about Fred because Fred goes home, he does go home to an empty house and he goes back to taking care of Helen everyday, right off the bat, 5 days out. But Helen died. Helen died.

(Christine)  
Oh no.

(Peter)    
One month after Fred's heart attack. The kids fly in finally to be with him I guess. He calls them since no one else is taking care of him at this time and although they're very sad, they express the opinion that now although father will be grieving, he's got his life back and his stress level should go down at this point. You're giving me a look.

(Christine)   
Yes, having...

(Peter)     
Are they way off base?

(Christine)  
Yes I think so because having had some experience in that with people in that similar situation, that doesn't relieve the burden at all. People on the outside will think well dad doesn't have to take care of mom anymore; he doesn't have to worry about that. But I think in fact if someone, it sounds like Fred has been so dedicated to his wife for so long, I don't see his stress really being minimized.

(Eric)   
That was his reason for being.

(Lisa)    
He's a suicide risk and a recurrent heart attack risk.

(Peter)    
Let me jump forward now to the funeral. This is Helen's funeral. The children are with him and Fred becomes acutely short of breath. This time the children call 911 and in the ambulance Fred has shortness of breath, a rapid heart beat, he's hungry for air, he's sweating profusely and he denies feeling any pain this time compared to the first time he had some symptoms. What's going on here Gladys?

(Gladys)    
Well he could easily be having another acute coronary syndrome.

(Peter)    
Fred's chest x-ray shows a lot of fluid in his chest. His cardiogram is unchanged and they rule him out; the blood tests and all shows that he has not had another heart attack. What would you give him right away?

(Gladys)     
Well I would be, I would be wondering if he's gone into what we call Congestive Heart Failure because he hasn't been taking his medicines maybe.

(Dr. Peter Salgo)   
Well they call it Congestive Heart Failure. I can tell you they gave him some Morphine, they gave him some Lasix; a diuretic and they gave him some Nitrates and they stop his Elavil. Is everybody fine with what they did?

(Eric)   
No.

(Peter)    
Why not?

(Eric)   
Well rapidly stopping an antidepressant could be a good way, a good I'm putting in quotes now, to trigger a depression.

(Peter)    
They never called psychiatry for any assistance. Now if he was on a psychiatric service and he had a heart attack, they would have called a cardiologist. Why don't people call a psychiatrist?

(Dr. Eric Caine)  
Why do you think?

(Christine)  
You know why this case bothers me? It sounds like when he initially went to the hospital, nobody called the Primary Care Physician. His second trip, nobody's calling the psychiatrist. It sounds like this poor gentlemen...

(Dr. Gladys Velarde)   
He has to move out of town.

(Lisa)    
Yeah.
(Laughing)

(Peter)    
Should they have called you?

(Kenneth)    
I should point out that most depression treatment is delivered by Primary Care Physicians; it's not my CCU docs or cardiologists.

(Lisa)    
Exactly.

(Eric)   
Or psychiatrists.

(Kenneth)    
And it's not by psychiatrists either. More of it is by Primary Care Physicians. 
(Peter)    
Well in order to make a diagnosis, you've got to recognize it. What are the symptoms of depression? I can tell you there's a note here that his cardiologists think he's depressed. So what are the symptoms of it?

(Kenneth)    
Two keys symptoms are a loss of interest in usual activities or a loss of the ability to experience pleasure and the other is feeling sad or down. Those are 2 key symptoms. There are a number of others, including feeling guilty, which I imagine he has a lot to feel guilty about. Some of the symptoms are ones that may be related to his heart or may be related to depression and include fatigue, sleep problems, appetite problems, changes in weight, and of course suicidal ideation.

(Peter)    
What's the relationship between depression and a heart attack?

(Kenneth Freedland)   
Depression is a risk factor for the development of coronary heart disease and once you have coronary disease, it's a risk factor for having a heart attack or actually dying from heart disease.

(Dr. Peter Salgo)   
But I mean you sound to me as if you're ascribing a cause for heart disease to depression; other words people who are depressed, in some way this causes them to have heart disease.

(Kenneth)    
That has not been firmly established. It's a risk factor, but we don't yet know whether it's causally implicated in the development of Arteriosclerosis or in causing heart attacks or sudden cardiac death.

(Peter)    
Let's pause here for just a minute and sum up where we've gotten to. Depression, I think it's fair to say can accelerate heart disease or be an affect of heart disease. The chicken and the egg thing really do come up here. Both the heart and the head need to be treated appropriately and I get the sense that our panel is disturbed, that that's not what's happening. Let me tell you a little bit more about what happens next to Fred. Fred gets prescriptions for his heart medications, we've discussed them, he gets enrolled in some cardiac rehab program and he's told to follow up with his Primary Care Doctor to treat his depression.

(Lisa)    
There's a lot of other psychosocial stuff that you have to consider that's going on with this guy. He's now had 2 hospitalizations; we don't know what his insurance plan is like and whether or not he's able to make those payments, he's leaving with at least 3, probably 4 or 5 drugs from the hospital that may have a $30 to $40 co pay for each one. You don't know if he's able to get those. They took him off the one thing that was probably keeping him reasonably stable for depression or stress or anything else and tell him, now it's on you to figure out, to find your Primary Care Physician, make an appointment and get in an advocate for yourself when he's really not in the position to do that.

(Gladys)    
A recipe for failure.

(Eric)   
Nor has he ever gone and said I need help.

(Dr. Lisa Harris)   
One thing that really bugs me is that Fred thinks he's taking Elavil for sleep and now they're telling him he's depressed and go find your Primary Care Physician for a new, a new drug. There's a lot of stigma associated with depression.

(Christine)  
But isn't that the health professional also asking the right questions and in this case was Fred ever asked those right questions that would have put him on the right track.

(Eric)   
We don't know.

(Lisa)    
We don't know.

(Peter)    
Lisa, you're the Primary Care Physician. If you had been told all of this story, what would your concerns have been for Fred and what would you have done which nobody is doing for Fred right now?

(Lisa)    
Number one was that he was depressed from the very beginning and that he needed to see a mental health provider from the very beginning when his wife, when he was at home taking care of his wife with the Alzheimer's. Certainly as these events began to unfold, he absolutely should have been seeing a mental health provider.  You've got stuff going on with your emotions that require a specialty.

(Peter)    
Let me tell you what happened with Fred. He was in fact severely depressed. Three days after he was discharged from the hospital, Fred used the gun that he owned to kill himself.

(Lisa)    
That's right. Where did you find him?

(Peter)    
He committed suicide.  What went wrong here? Lisa you want to start?

(Lisa)    
Well there were a number of things that went, that went wrong and you know hindsight is 20/20. Certainly, initially he was a guy that had one thing that he was living for and he lost that initially. He then developed disease and illness in his own self and all of that culminated, to me I would think in a sense of failure. He was then taken off the one drug that was probably stabilizing him to some degree and left without, without options and without hope and without recourse. And unfortunately...

(Christine Rogers)   
This case makes me angry.

(Peter)    
it makes you angry?

(Christine)   
Yeah it does because it should have been avoided.

(Dr. Peter Salgo)   
Kenneth is it preventable? If he fits the profile, he's having a heart attack his life is so stressful. Could anything have been done to keep him from killing himself?

(Kenneth)    
Yes it is potentially preventable and one of the important things to remember is that just handing somebody an antidepressant, especially when they're under so much stress isn't necessarily going to be enough.

(Lisa)    
It's not enough.

(Gladys)    
That's an excellent point.

(Kenneth)    
If all you hear is the word depression and you think, well a pill is going to solve all of this; it's not going to be enough to solve all of that.

(Eric)   
There were 2 hospital admissions and at least during one of them there should have been a formal review of his social and psychological circumstances and that's really mandatory at any hospital admission of this sort. And the second one coming at the point of his wife's funeral is like holding up a road sign, you know a big sign saying beware what's going on with this fellow.

(Peter)    
How common is it? I mean, we're all talking here about this horrible event, this terrible death. How common is something like this in heart patients, in stressed patients?

(Gladys)    
Depression after a Myocardial Infarction, you see it on rounds in about 25% of your patients so that would be a low estimate of those that can actually tell you or that you can...

(Kenneth)    
About 15 to 18% have major depression after a Myocardial Infarction and of those people; about half of them were already depressed at the time of the heart attack.

(Eric)   
I think the thing that, I would take this another way. I'd say among the people who kill themselves at this age, almost all of them have depression and medical, the jargon is Medical Cobarbidity; coexisting major medical problems.

(Peter)    
Okay let's pause just for one more moment here. Just to point out that depression is not a normal state of mind in the elderly or in anybody of any age for that matter. The transition by the way from being depressed to being suicidal can be difficult to pick up. You've heard the kind of interviewing technique, the kind of questions that really it takes to elicit that kind of response. Now of course you didn't go that path. How are you doing?

(Dr. Eric Caine)  Well we can tell actually.

(Laughing)

(Linda)     
No I didn't go that path. I had very low depression, but it was, you know, a major adjustment. There were major changes in my life. Obviously I left my job because I didn't want to deal with the stress anymore, you know the, my own definition of myself changed.

(Eric)   
I'm curious. Did anyone ever ask you whether you had suicidal thoughts?

(Linda)     
No, no.

(Eric)   
What would have, how would you have felt if they had?

(Linda)     
I would have been angry, insulted. I would have been mortified because that's just not me. That is a good point, though because people would not want to admit that I think in a lot of situations. I certainly would never have wanted to admit that because that wouldn't have been part of my persona.

(Eric)   
It wasn't anymore a part of stoic Fred's persona either. This idea that I can take care of things, that I can handle things so clinicians sometimes get caught in the trap of feeling very reticent, very shy of not asking.

(Dr. Lisa Harris)   
Often, right.

(Christine)  
And that's where we have to be astute clinicians and look beyond...

(Lisa)    
Absolutely.

(Christine)  
Look beyond what you're presenting.

(Lisa)    
And that's a much better approach.

(Peter)    
I want to thank all of you for being here. This has just been a tremendous discussion. Thank you for sharing your experiences with us. We're delighted you're doing well.

(Linda)     
You're welcome. Yes, thank you. Certainly I am.

(Dr. Peter Salgo)   
Again, thank you all for being here. We covered a lot of ground today. What I want to do is sum up some of the key things that you need to remember. Stress in your life causes stress on your heart and that stress can accelerate heart disease and can lead to a heart attack. Depression can accelerate heart disease or it can be an affect of heart disease, both the heart and the head need to be treated appropriately. Depression is not a normal state of mind in the elderly or in people of any age for that matter. The transition from being depressed to being suicidal can be difficult to pick up and it's an obligation for everybody involved with somebody who's under stress with heart disease and other issues to really be sensitive to that. and of course our final message is this; taking charge of your health means being informed and having quality communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

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