Depression can strike anyone. However, research over the past twodecades has shown that people with heart disease are more likely tosuffer from depression than otherwise healthy people, and conversely,that people with depression are at greater risk for developing heartdisease.1 Furthermore, people with heart disease who aredepressed have an increased risk of death after a heart attack comparedto those who are not depressed.2 Depression may make itharder to take the medications needed and to carry out the treatmentfor heart disease. Treatment for depression helps people manage bothdiseases, thus enhancing survival and quality of life.Heart disease affects an estimated 12.2 million American women and men and is the leading cause of death in the U.S.3While about 1 in 20 American adults experiences major depression in agiven year, the number goes to about one in three for people who havesurvived a heart attack.4,5
Depression and anxiety disorders may affect heart rhythms, increaseblood pressure, and alter blood clotting. They can also lead toelevated insulin and cholesterol levels. These risk factors, withobesity, form a group of signs and symptoms that often serve as both apredictor of and a response to heart disease. Furthermore, depressionor anxiety may result in chronically elevated levels of stresshormones, such as cortisol and adrenaline. As high levels of stresshormones are signaling a "fight or flight" reaction, the body'smetabolism is diverted away from the type of tissue repair needed inheart disease.
Despite the enormous advances in brain research in the past 20years, depression often goes undiagnosed and untreated. Persons withheart disease, their families and friends, and even their physiciansand cardiologists (physicians specializing in heart disease treatment)may misinterpret depression's warning signs, mistaking them forinevitable accompaniments to heart disease. Symptoms of depression mayoverlap with those of heart disease and other physical illnesses.However, skilled health professionals will recognize the symptoms ofdepression and inquire about their duration and severity, diagnose thedisorder, and suggest appropriate treatment.
Depression Facts
Depression is a serious medical condition that affects thoughts,feelings, and the ability to function in everyday life. Depression canoccur at any age. NIMH-sponsored studies estimate that almost 10percent of American adults, or about 19 million people age 18 andolder, experience some form of depression every year.4Although available therapies alleviate symptoms in over 80 percent ofthose treated, less than half of people with depression get the helpthey need.4,6
Depression results from abnormal functioning of the brain. Thecauses of depression are currently a matter of intense research. Aninteraction between genetic predisposition and life history appear todetermine a person's level of risk. Episodes of depression may then betriggered by stress, difficult life events, side effects ofmedications, or other environmental factors. Whatever its origins,depression can limit the energy needed to keep focused on treatment forother disorders, such as heart disease.
Heart Disease Facts
Heart disease includes two conditions called angina pectoris andacute myocardial infarction ("heart attack"). Like any muscle, theheart needs a constant supply of oxygen and nutrients that are carriedto it by the blood in the coronary arteries. When the coronary arteriesbecome narrowed or clogged and cannot supply enough blood to the heart,the result is coronary heart disease. If not enough oxygen-carryingblood reaches the heart, the heart may respond with pain called angina.The pain is usually felt in the chest or sometimes in the left arm andshoulder. (However, the same inadequate blood supply may cause nosymptoms, a condition called silent angina.) When the blood supply iscut off completely, the result is a heart attack. The part of the heartthat does not receive oxygen begins to die, and some of the heartmuscle may be permanently damaged.
Chest pain (angina) or shortness of breath may be the earliest signsof heart disease. A person may feel heaviness, tightness, pain,burning, pressure, or squeezing, usually behind the breastbone butsometimes also in the arms, neck, or jaws. These signs usually bringthe person to a doctor for the first time. Nevertheless, some peoplehave heart attacks without ever having any of these symptoms.
Risk factors for heart disease other than depression include highlevels of cholesterol (a fat-like substance) in the blood, high bloodpressure, and smoking. On the average, each of these doubles the chanceof developing heart disease. Obesity and physical inactivity are otherfactors that can lead to heart disease. Regular exercise, goodnutrition, and smoking cessation are key to controlling the riskfactors for heart disease.
Heart disease is treated in a number of ways, depending on howserious it is. For many people, heart disease is managed with lifestylechanges and medications, including beta-blockers, calcium-channelblockers, nitrates, and other classes of drugs. Others with severeheart disease may need surgery. In any case, once heart diseasedevelops, it requires lifelong management.
Get Treatment for Depression
Effective treatment for depression is extremely important, as thecombination of depression and heart disease is associated withincreased sickness and death. Prescription antidepressant medications,particularly the selective serotonin reuptake inhibitors, are generallywell-tolerated and safe for people with heart disease. There are,however, possible interactions among certain medications and sideeffects that require careful monitoring. Therefore, people beingtreated for heart disease who develop depression, as well as people intreatment for depression who subsequently develop heart disease, shouldmake sure to tell any physician they visit about the full range ofmedications they are taking.
Specific types of psychotherapy, or "talk" therapy, also can relievedepression. Ongoing research is investigating whether these treatmentsalso reduce the associated risk of a second heart attack. Preventiveinterventions based on cognitive-behavior theories of depression alsomerit attention as approaches for avoiding adverse outcomes associatedwith both disorders. These interventions may help promote adherence andbehavior change that may increase the impact of availablepharmacological and behavioral approaches to both diseases.
Exercise is another potential pathway to reducing both depressionand risk of heart disease. A recent study found that participation inan exercise training program was comparable to treatment with anantidepressant medication (a selective serotonin reuptake inhibitor)for improving depressive symptoms in older adults diagnosed with majordepression.7 Exercise, of course, is a major protective factor against heart disease as well.
Use of herbal supplements of any kind should be discussed with aphysician before they are tried. Recently, for example, scientists havediscovered that St. John's wort, an herbal remedy sold over-the-counterand promoted as a treatment for mild depression, can have harmfulinteractions with some other medications.
Treatment for depression in the context of heart disease should bemanaged by a mental health professional—for example, a psychiatrist,psychologist, or clinical social worker—who is in close communicationwith the physician providing the heart disease treatment. This isespecially important when antidepressant medication is needed orprescribed, so that potentially harmful drug interactions can beavoided. In some cases, a mental health professional that specializesin treating individuals with depression and co-occurring physicalillnesses such as heart disease may be available.
While there are many different treatments for depression, they mustbe carefully chosen by a trained professional based on thecircumstances of the person and family. Recovery from depression takestime. Medications for depression can take several weeks to work and mayneed to be combined with ongoing psychotherapy. Not everyone respondsto treatment in the same way. Prescriptions and dosing may need to beadjusted. No matter how advanced the heart disease, however, the persondoes not have to suffer from depression. Treatment can be effective.
Other mental disorders, such as bipolar disorder (manic-depressiveillness) and anxiety disorders, may occur in people with heart disease,and they too can be effectively treated. For more information aboutthese and other mental illnesses, contact NIMH.
Remember, depression is a treatable disorder of the brain.Depression can be treated in addition to whatever other illnesses aperson might have, including heart disease. If you think you may bedepressed or know someone who is, don't lose hope. Seek help fordepression.
References
1Nemeroff CB, Musselman DL, Evans DL. Depression and cardiac disease. Depression and Anxiety, 1998; 8(Suppl 1): 71-9.
2Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation, 1995; 91(4): 999-1005.
3Morbidity and mortality: 2000 chart book on cardiovascular, lung, and blood diseases. National Heart, Lung, and Blood Institute, 2000.
4Regier DA, Narrow WE, Rae DS, et al. The defacto mental and addictive disorders service system. EpidemiologicCatchment Area prospective 1-year prevalence rates of disorders andservices. Archives of General Psychiatry, 1993; 50(2): 85-94.
5Lesperance F, Frasure-Smith N, Talajic M. Major depression before and after myocardial infarction: its nature and consequences. Psychosomatic Medicine, 1996; 58(2): 99-110.
6National Advisory Mental Health Council. Health care reform for Americans with severe mental illnesses. American Journal of Psychiatry, 1993; 150(10): 1447-65.
7Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Archives of Internal Medicine, 1999; 159(19): 2349-56.
Excerpt from Depression and Heart Disease, National Institute of Mental Health