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June 7, 2000
News this month Over the last decade, several studies have investigated the connection between heart disease and depression. People who have heart disease are likely to suffer from depression; people with depression appear more likely to develop heart disease. People with depression and heart disease are more likely to experience a second heart attack or to die of sudden cardiac death. A new study…underscores the prevalence
of long-term depression among heart attack survivors.
A new study published in the April 25 issue of Circulation underscores the prevalence of long-term depression among heart attack survivors. Nancy Frasure-Smith, PhD, associate professor of psychiatry at McGill University and a staff member of the Montreal Heart Institute, is the lead author of the study. Frasure-Smith and her colleagues followed 887 patients for a year following their heart attacks. The patients were evaluated for depression about a week after experiencing discharge from intensive care units using the Beck Depression Inventory (BDI), a standardized measure for diagnosing depression. They were also queried about the emotional support they receive from family and friends based on another standardized test, the Perceived Social Support Scale. Depression linked to mortality Depressed patients who also reported
high levels of social support from friends and family members were
more likely to overcome their depression.
However, the relationship between depression and cardiac mortality decreased with high scores on the social support inventory. Depressed patients who also reported high levels of social support from friends and family members were more likely to overcome their depression. About half of the patients who were depressed immediately after a heart attack remained depressed a full year after their illness. Short-term depression is common after a heart attack, according to Frasure-Smith, but these findings suggest if depression lingers and there is no strong social support system present for the patient, a second heart attack is more probable. Depression may lead to heart disease Depression may not only place heart
disease patients at risk for further heart disease-related illness,
it may also be an independent risk factor for a first heart attack.
In this study of 119 clinically stable Norwegian patients with congestive heart failure, severely depressed patients were about four times more likely to die within two years compared with nondepressed patients. During the study, 20 patients died, all from heart disease related complications. Of the depressed patients, 25 percent died, compared with 11.3 percent of the nondepressed patients. Depression may not only place heart disease patients at risk for further heart disease-related illness, it may also be an independent risk factor for a first heart attack. According to a study published in Circulation in 1996, depression may be a strong predictor of a heart attack. The study followed 1,551 Baltimore residents who had participated in a study documenting depression in the 1980s. About one-third (444) of these people were diagnosed with depression. Of these, 27, about 6 percent, had suffered heart attacks within 13 years compared to 37, about 3 percent, of the 1,107 people who were not diagnosed as depressed. …depression increased a person’s
chance of suffering from a heart attack by more than fourfold.
After making statistical adjustments to the data, the researchers,
lead by Dr. William Eaton of the Johns Hopkins School of Hygiene
and Public Health, found depression increased a person’s chance
of suffering from a heart attack by more than fourfold.
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Depression’s role in heart disease Several studies have shown it’s not uncommon for heart attack patients to experience mild or moderate depression. For many years we thought this depression was a natural reaction to the experience of having a heart attack, but new evidence indicates it is not. "Depression is a risk factor
for a first heart attack."
We are now learning depression is, in fact, a risk factor for a first heart attack. A significant percentage of patients who have a history of major depression go on to have heart attacks or die of sudden cardiac death. It is not normal or natural to be depressed after a heart attack, but some people, particularly those who may have experienced depression in the past, do become depressed and they may become chronically depressed. Reason for connection not well understood One holds the development of heart disease may be affected by biochemical changes that occur in depressed people such as the release of stress hormones. Their hearts beat faster even when they are asleep, and their heart rhythms do not adjust well to changes in activities. They tend to have high blood pressure and their blood may clot more easily, perhaps in response to an increase in secretion of stress hormones. Anger has also been identified as a risk factor for heart attack, and these same mechanisms may be responsible. Others believe depressed people neglect their health and don’t take their medications or watch their diet and exercise, making them more vulnerable to disease. I think the connection results from a combination of factors—environmental, personal and physical—that predispose some people to experience depression in certain stressful circumstances. For whatever reasons, they have not developed effective coping skills to deal with stress and may feel overwhelmed by circumstances. "Long-term depression is harmful
and needs to be recognized and treated."
Although we don’t know the causal connection between depression and heart disease, we do know long-term depression is harmful and needs to be recognized and treated. Physicians and other caregivers need to be particularly vigilant regarding the presence of depression in their patients. They should have some mechanism for screening their patients for depression and for following up a month after a patient’s heart attack to determine if the depression has abated. If it persists, caregivers should refer patients for treatment. Since it may be difficult for depressed people to seek help, family members and friends should also be familiar with depression’s warning signs and act as advocates for their loved ones, so they receive appropriate care. Treatment options I use a three-pronged approach:
Many depressed people engage in catastrophic or black and white thinking patterns that make it difficult for them to tackle life’s challenges effectively. Short-term therapy, usually six months or less, can be very helpful in treating depression. "Short-term therapy, usually
six months or less, can be very helpful in treating depression."
Some people who have more severe depression may need antidepressive medication in addition to therapy, but for many people, learning effective coping skills is most often sufficient. Role of social support Cardiac rehabilitation programs are beneficial on many levels. The benefits of diet and exercise are well-documented, but the group setting of rehab and the opportunity to share experiences with other heart disease patients are also effective in helping patients overcome short-term depression. My advice is to take depression seriously. If you or someone
close to you feels lethargic and uninterested in life or shows
some of the warning signs of depression for more than two weeks,
alert your physician. Dr. Burg is a clinical psychologist who specializes in the treatment of post heart attack depression. He practices in New Haven and serves as an assistant clinical professor of medicine at the Yale School of Medicine. |
