Depression: Take It to Heart

Depression is a serious medical condition that affects about 10% of Americans each year, and it affects twice as many women as men, regardless of race, ethnicity, or economic status.^1-3 Research has shown that people with depression are at a greater risk for developing heart disease.^1,4 But what's most troubling about this generally treatable disease is that it often goes unrecognized or untreated.¹ This issue of Know Her Heart  focuses on the association of depression and heart disease.

Depression and Heart Disease

Over the past decade, studies have indicated that depression is an independent risk factor for the development of cardiovascular disease and for increased cardiac morbidity and mortality.^4-8

• Patients with major depression have elevated coronary artery disease (CAD) mortality rates.⁴
• In the WISE^a study, women with elevated scores on the Beck Depression Inventory and a history of treatment for depression had significantly increased mortality and cardiovascular events, even after adjusting for other risk factors.⁹
• Depression is an independent risk factor for ischemic heart disease (IHD) and for increased cardiac morbidity and mortality.⁵

^a Women's Ischemia Syndrome Evaluation.
 

Physiologic Cardiovascular Effects of Depression

Depression and anxiety disorders may¹:

• Affect heart rhythms
• Increase blood pressure
• Alter blood clotting
• Lead to elevated insulin and cholesterol levels

Along with obesity, these risk factors form a group of signs and symptoms that may serve as both a predictor of and a response to heart disease.¹ Additionally, depression and anxiety may result in chronically elevated levels of stress hormones, such as cortisol and adrenaline, which signal a "fight or flight" reaction and may divert the body's metabolism away from the type of tissue repair needed in heart disease.¹

Also, extensive evidence indicates that acute or chronic mental stress triggers certain central nervous system responses, the cardiac effects of which may be modified by background factors such as atherosclerosis, prior myocardial infarction (MI), and degree of left-ventricular dysfunction.¹⁰ These cardiac effects can eventually result in ischemia, leading to sudden cardiac death or MI.¹⁰

Depression and Quality of Life in Cardiac Patients

Depressive symptoms have been shown to significantly undermine health-related quality of life (HRQOL) in patients with CAD, despite successful medical and surgical management.¹¹ Among 1024 patients with stable CAD, depressive symptoms were strongly associated with patient-reported health status, including¹²:

Women report more depression after MI than men.¹³ In 1 study using a tool used to assess HRQOL, post–first MI depression in women was significantly correlated with 5 measures¹³:

Additionally, depression in cardiovascular patients may cause a delay in seeking treatment,¹⁴ affect compliance with medication and secondary prevention strategies,^10,14 and result in unhealthy lifestyle choices.¹⁵ Noncompliance and unhealthy lifestyle choices can increase the risk for future cardiac events.¹³

Treatment for Depression Is Important

Depression and anxiety disorders often remain undiagnosed in primary care and cardiac patients.¹⁰ The results of the Heart and Soul Study suggest that, because depressive symptoms are associated with patient-reported health status in CAD, efforts to improve health status should include assessment and treatment of depressive symptoms.¹² (SOR: B) The fact that many women report depression after MI supports the importance of screening for depression in women post-MI.¹³ (SOR: C)

Although data on specific depression management strategies for cardiovascular patients are lacking,¹⁰ cognitive behavioral therapy, cardiac rehabilitation, and pharmacologic treatment may be indicated for these patients.¹⁶ (SOR: B) It has been shown that depressive mood may not be an obstacle to CAD patients participating in a behaviorally oriented rehabilitation program including exercise training (which may help improve mood).¹⁷ Depressive CAD patients should be encouraged to participate in cardiac rehabilitation programs.¹⁶ It has been suggested that adequate treatment of depression may help improve outcomes in patients with IHD or previous MI.^4,5 (SOR: C)

References
1. National Institutes of Mental Health. Depression and Heart Disease. Bethesda, MD: NIH/USDHHS; 2002. NIH publication 02-5004. 2. Reiger DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85-94. 3. National Institutes of Mental Health. Depression: What Every Woman Should Know. Bethesda, MD: NIH/USDHHS; 2000. NIH publication 00-3679. 4. Nemeroff CB, Musselman DL, Evans DL. Depression and cardiac disease. Depress Anxiety. 1998;8(suppl 1):71-79. 5. Rivelli S, Jiang W. Depression and ischemic heart disease: what have we learned from clinical trials? Curr Opin Cardiol. July 22, 2007;(4):286-291. 6. Ferketich AK, Schwartzbaum JA, Frid DJ, Moeschberger ML. Depression as an antecedent to heart disease among women and men in the NHANES I study. Arch Intern Med. 2000;160:1261-1268. 7. Penninx BWJH, Beekman ATF, Honig A, et al. Depression and cardiac mortality: results from a community-based longitudinal study. Arch Gen Psychiatry. 2001;58:221-227. 8. Ford DE, Mead LA, Chang PP, Cooper-Patrick L, Wang N-Y, Klag MJ. Depression is a risk factor for coronary artery disease in men. Arch Intern Med. 1998;158:1422-1426. 9. Rutledge T, Reis SE, Olson MB, et al. Depression symptom severity and reported treatment history in the prediction of cardiac risk in women with suspected myocardial ischemia: the NHLBI-sponsored WISE Study. Arch Gen Psychiatry. 2006;63:874-880. 10. Sheps DS, Sheffield D. Depression, anxiety, and the cardiovascular system: the cardiologist's perspective. J Clin Psychiatry. 2001;62(suppl 8):12-16. 11. Stafford L, Berk M, Reddy P, Jackson HJ. Comorbid depression and health-related quality of life in patients with coronary artery disease. J Psychosom Res. 2007;62(4):401-410. 12. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the Heart and Soul Study. JAMA. 2003;290(2):215-221. 13. White ML, Groh CJ. Depression and quality of life in women after a myocardial infarction. J Cardiovasc Nurs. 2007;22(2):138-144. 14. Skala JA, Freedland KE, Carney RM. Coronary heart disease and depression: a review of recent mechanistic research. Can J Psychiatry. 2006;51(12):738-745. 15. Bonnet F, Irving K, Terra JL, Nony P, Berthezene F, Moulin P. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis. 2005;178(2):339-344. 16. Zellweger MJ, Osterwalder RH, Langewitz W, Pfisterer ME. Coronary artery disease and depression. Eur Heart J. 2004;25:3-9. 17. Söderman E, Lisspers J, Sundin O. Impact of depressive mood on lifestyle changes in patients with coronary artery disease. J Rehabil Med. 2007;39(5):412-417.