Depression & Heart Disease

Up to 15 percent of patients with cardiovascular disease and up to 20 percent of patients who have undergone coronary artery bypass graft (CABG) surgery experience major depression.¹

Studies have shown that mental stress has a negative effect on a person’s heart health. In particular:

• Unmanaged stress can lead to high blood pressure, arterial damage, irregular heart rhythms and a weakened immune system.
• Patients with depression have been shown to have increased platelet reactivity, decreased heart variability and increased proinflammatory markers (such as C-reactive protein or CRP), which are all risk factors for cardiovascular disease.
• For people with heart disease, depression can increase the risk of an adverse cardiac event such as a heart attack or blood clots. For people who do not have heart disease, depression can also increase the risk of a heart attack and development of coronary artery disease.
• In one landmark study, the continued presence of depression after recovery increased the risk of death (mortality) to 17 percent within 6 months after a heart attack (versus 3 percent mortality in heart attack patients who didn’t have depression).²
• During recovery from cardiac surgery, depression can intensify pain, worsen fatigue and sluggishness, or cause a person to withdraw into social isolation. Patients who have had CABG and have untreated depression after surgery also have increased morbidity and mortality.
• Patients with heart failure and depression have an increased risk of being readmitted to the hospital, and also have an increased mortality risk.
• Early research findings have indicated there may be genetic factors that increase a patient’s risk of depression and risk of recurrent cardiac events after a heart attack.³
• Patients with heart disease and depression also perceive a poorer health status, as manifested by Quality of Life (QoL) studies. Furthermore, heart disease patients with depression have worse treadmill exercise and medication adherence than that of patients with heart disease who do not have depression.^{4, 5, 6}
• Negative lifestyle habits associated with depression – such as smoking, excessive alcohol consumption, lack of exercise, poor diet and lack of social support – interfere with the treatment for heart disease.
• Depression has been proven to be a such a risk factor in cardiac disease that the American Heart Association (AHA) has recommended that all cardiac patients be screened for depression using simple screening questions and an easy-to-administer survey called the Patient Health Questionnaire (PHQ-2).⁷

• A person’s family history, physical health, state of mind and environment.
• High levels of stress, life transitions, loss and many other factors.
• Imbalances in the chemicals that the body uses to control mood.

If you’re recovering from heart surgery, a heart attack, or another heart condition, temporary feelings of sadness and a depressed mood are common for the first few weeks.

However, treatment is necessary when depression is severe and accompanied by other symptoms (including withdrawal from activities, not responding when visiting with family and friends, increased negative thoughts and tearfulness).

Without treatment, depression can become worse. For heart patients, depression can contribute to an increased risk of heart attack and coronary disease. Talk to your health care provide who can diagnose and start depression treatment with safe antidepressants. Your health care provider also can refer you to a mental health specialist who can provide other appropriate treatment when necessary.

When depression is negatively affecting your life — such as causing increased difficulties with relationships or performance at work or at home, it is important for you to get help to prevent things from getting worse.

More specific reasons to seek help include:

• Your negative feelings, such as low mood or lack of experiencing pleasure, persist daily for 2 weeks or more.
• You find it increasingly difficult to participate in your recovery from heart disease. It is not uncommon for patients participating in cardiac rehabilitation to experience emotional difficulties during their physical recovery. A lack of mental drive or motivation, as well as a lack of confidence may indicate that depression has settled in.
• You have significant difficulty with your daily routine, social activities and/or work.
• You don’t have anyone in whom you can confide. If you don’t have anyone to share your thoughts with, it’s hard to know if what you’re thinking makes sense. Depression also has a tendency to make people more withdrawn and isolated, making it harder to receive social support during difficult times.
• You have suicidal thoughts or feelings. Suicide is an irreversible solution to problems and causes permanent harm not only to yourself, but also to family members and friends. If you are having thoughts of suicide, call your physician or local 24-hour suicide hotline right away, or go to the nearest emergency room for help.

• Get dressed every day.
• Practice stress management and relaxation techniques.
• Get out and walk daily.
• Follow your prescribed exercise regimen.
• Ask your health care provider about a cardiac rehabilitation program.
• Resume hobbies and social activities you enjoy.
• Share your feelings with your spouse, friend or a member of the clergy.
• During your recovery from surgery or a recent hospitalization, visits with friends should be limited to 15 minutes at first. Then, increase the amount of time spent with visitors, depending on how you feel.
• Get a good night’s sleep.
• Eat well-balanced, nutritious meals and follow your prescribed dietary guidelines.
• Ask your health care provider about support groups that may help you cope. Support groups are available for patients who have had heart surgery and their families.
• Don’t use harmful habits to cope, such as smoking, using drugs, drinking excessively or overeating. These harmful habits increase your risk for heart disease and stroke.

The biggest hurdle to diagnosing and treating depression is recognizing that someone is suffering from it. Unfortunately, approximately half of the people who experience depression are never diagnosed or treated for their illness. And not getting treatment can be life-threatening: up to 10 percent of people battling depression commit suicide.

Your health care provider can evaluate your condition by asking you to describe your symptoms. Since patients recovering from a medical illness, hospitalization or surgical procedure experience some common symptoms of depression including fatigue and insomnia,your health care provider will pay attention to these additional symptoms of depression:

• Withdrawal from activities
• Lack of reactivity from visits with family and friends Increased negative thoughts
• Tearfulness

Sometimes, symptoms of depression can be made worse by certain medications, a physical disorder, virus or illness. Your health care provider may perform a physical exam or laboratory tests to determine if there is a physical cause for your depressive symptoms.

Your health care provider will also evaluate your personal and family medical history, as well as any history of drug or alcohol use.

Although there are no specific blood tests used to diagnose depression, there are various screening tools and diagnostic criteria used to make the proper diagnosis.

The U.S. Preventive Services Task Force has recommended that clinicians ask two screening questions for depression, known as the Patient Health Questionnaire (PHQ-2), including:

1. Over the past 2 weeks, have you felt down, depressed, or hopeless?
2. Over the past 2 weeks, have you felt little interest or pleasure in doing things?

If you answer yes to both of these questions, there is a high likelihood of clinical depression, and your health care provider can provide recommendations to help you get the treatment you need. Your health care provider can also administer the Patient Health Questionnaire 9 (PHQ-9), a nine-item question list that can better define your depression and guide treatment.

There are many treatments for depression. Major depressive disorder may be treated with antidepressants, psychotherapy (supportive counseling or “talk therapy”), or a combination of both. Newer, safer antidepressant medications, such as SSRIs (selective serotonin reuptake inhibitors) have an established safety record and are safe for cardiac patients. The antidepressants sertraline (Zoloft) and citalopram (Celexa) have been the best studied, are effective and safe in patients with heart disease, and also are available in generic forms.

Psychotherapy can increase a person’s social support and help the patient develop more positive thinking patterns. Brief supportive models of talk therapy appear to be the most appropriate for helping the depression that cardiac patients experience.

A healthy lifestyle including regular exercise, proper sleep, a well-balanced diet, as well as relaxation and stress management techniques can help you manage depression. In a recent intervention trial, physical exercise was found to have a significant effect on depression.⁸

Major intervention studies — both pharmacologic (SADHART, CREATE) and psycho-therapeutic (ENRICHD) — have been performed in patients who are clinically depressed after a heart attack. These studies are helping clinicians better understand the link and treatment of depression and heart disease and guide optimal treatments. Patients with a previous history of depression or who are experiencing severe depression can be the best responders to medication intervention.^{9, 10, 11, 12, 13}

Conclusion

Early detection and treatment of depression in heart patients are crucial to improve a patient’s quality of life and possibly prevent a recurrent coronary event. When left untreated, depression can worsen heart disease and increase the risk of a heart attack. Safe treatments are available to help you cope with depression and help you manage your heart disease.

The support and involvement of family and friends can be crucial in helping someone who is depressed. Living with a depressed person can be very difficult and stressful on family members and friends.

Tips for Family

Here are some suggestions for living with a depressed person that may make things easier for you and more beneficial for the depressed person:

• Encourage the depressed person to seek professional help. Make sure an assessment is done by a trained mental health professional so the proper diagnosis and treatment can be initiated without delay.
• Educate yourself and your family about depression so you can understand what your family member is experiencing. There are many organizations and support groups that can provide more information.
• Know that depression is a disorder with biological, psychological, and interpersonal components; it is not a personal weakness or failure.
• Help your family member follow the prescribed treatment plan and practice the coping techniques and problem-solving skills he or she is learning during psychotherapy.
• Make sure medications are available if prescribed, attend therapy sessions with your family member if needed, encourage the patient to follow recommended lifestyle changes and follow up with the proper health care providers.
• Recognize that depression is often expressed as hostility, rejection and irritability.
  Offer consistent support to your loved one. This can be draining, but it is one of the most important parts of a treatment plan. People with depression can feel alone and isolated. Giving consistent support and understanding are critical.
• Adopt an interaction style that puts the depressed person in charge. For example, instead of suggesting, “Let’s go to the movies tonight,” try this: “I’d like to see a movie tonight. Which one of these do you want to see with me?”
  Remember that treatment is effective and your loved one will start to improve in 2 to 3 weeks, achieving full improvement in a couple of months. Notice and praise any significant improvement.
• Reward your family member with opportunities such as visiting friends or going out for activities. Don’t force these, though.
• Take breaks from the depressed person from time to time. It will help both of you.
• Consider family or marital therapy: these forms of therapy bring together all those affected by depression and help them learn effective ways to cope together.
• Consider support from community support groups, either for the depressed person, or for you as the family member.

¹ Reference: Jiang W, Davidson JRT. Antidepressant therapy in patients with ischemic heart disease. American Heart Journal, November 2005. 150(5):871-881.

² Reference: Frasure-Smith N, et al. Depression following myocardial infarction: Impact on 6-month survival. JAMA, October 20, 1993. 270(15):1819-1825.

³ Reference: Nakatani D, et al. Influence of serotonin transporter gene polymorphism on depressive symptoms and new cardiac events after acute myocardial infarction. American Heart Journal, October 2005. 150(4):652-658.

⁴ Ruo B, et al. Depressive symptoms and health-related quality of life: the Heart and Soul Study. JAMA, July 9, 2003. 290(2):215-221.

⁵ Gehi AK, et al. Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: the Heart and Soul Study. Archives of Internal Medicine, November 2005. 165(2):2508-2513.

⁶ Gehi AK, et al. Relation of self-reported angina pectoris to inducible myocardial ischemia in patients with known coronary artery disease: the Heart and Soul Study. The American Journal of Cardiology, September 15, 2003. 92(6):705-707.

⁷ Litchman JH, et al. Depression and coronary heart disease: Recommendations for screening, referral and treatment. A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation, Oct 21 2008. 118(17):1768-1775.

⁸ Blumenthal JA, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine 2007. 69(7):587-596.

⁹ Lesperance F, et al. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: The Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA, 2007. 297(4):367-379.

¹⁰ Frasure-Smith N., et al. Design and rationale for a randomized, controlled trial of interpersonal psychotherapy and citalopram for depression in coronary artery disease (CREATE). Psychosomatic Medicine, 2006. 68:87-93.

¹¹ Glassman AH, et al. Onset of major depression associated with acute coronary syndromes: relationship of onset, major depressive disorder history, and episode severity to sertraline benefit. Archives of General Psychiatry, 2006. 63(3):283-288.

¹² Glassman AH, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA, 2002. 288(6):701-709.

¹³ Writing Committee for the ENRICHD Investigators. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Disease patients (ENRICHD) randomized trial. JAMA, 2003. 289(23):3106-3116.

Additional Resources:

• Cardiovascular Behavioral Health Clinic: 216.444.9353 or 800.223.2273, ext. 49353
• Department of Psychiatry and Psychology: 216.636.5860 or 800.223.2273, ext. 65860
• www.psychiatry.org*, American Psychiatric Association
• Psychology Topics*, American Psychological Association
• Depression, American Psychological Association*

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