Given the strong connections between depression and cardiac disease, treating both illnesses is vital to a longer life
By Donna Jackel
Mounting evidence suggests that depression significantly raises the risk of heart attack and stroke. That may be due in large part to behaviors characteristic of low mood. When we are depressed, we are less inclined to exercise and more apt to overeat, smoke, and, in some cases, abuse alcohol or illicit drugs. Nearly every week, it seems, a new study comes out showing a link between inactivity and heart disease.
Many studies also show that cardiac patients with depression have twice the risk of dying within two years following a heart attack or stroke compared to patients without depression. So building a healthier lifestyle may not only improve your mood, but could prolong your life.
A recent study of Vietnam veterans points to the long-term physical consequences of depression. Researchers at Washington University School of Medicine (WUSM) in St. Louis surveyed the health data of 1,200 veterans, all male twins, over a 12-year period from 1992 to 2005. The study found that veterans who had depression in 1992 were almost twice as likely to develop heart disease as those who had no history of depression.
“We knew that some of the genes that contribute to depression also contribute to heart disease,” says Jeffrey Scherrer, PhD, research assistant professor of psychiatry at WUSM and lead author of the study. But the researchers found that twins who had a high genetic risk common to depression and heart disease, but never developed depression, had no increased risk of heart disease. This “strongly suggests” that depression itself is a significant risk factor for heart disease, Scherrer says.
We all know the ABCs of good health: exercise regularly, don’t smoke, eat lots of fruits and vegetables and limit fatty foods. A five-year study, published in The Journal of the American Medical Association (JAMA) in November 2008, found that heart patients with depression are less likely to maintain those healthy habits. Researchers followed 1,000 patients from northern California who had heart disease. The 20 percent who also had diagnosed depression were more likely to have “cardiac events” such as strokes or heart attacks due to poor health behaviors, says epidemiologist Mary Whooley, MD, lead author of the study.
“They weren’t exercising, they weren’t taking their medication [consistently], they were smoking more often,” explains Whooley, a staff physician at the San Francisco VA Medical Center.
Emotional stress stresses the body
Less well understood are the physiological effects arising from depression, stress and anxiety. Alfred Bove, MD, PhD, president of the American College of Cardiology and a cardiologist at Temple University Hospital in Philadelphia, says that some data suggest anxiety and depression cause chronic stimulation of the sympathetic nervous system— the area that activates the fight-or-flight response—which damages the heart and circulatory system.
To alleviate the physical symptoms of anxiety, such as a racing heart, Bove sometimes prescribes medication that blocks the release of adrenalin. Known as beta blockers, these drugs are more commonly used to treat high blood pressure.
The physical wear and tear due to stress can also be reduced by learning techniques to manage depression and anxiety, says Heather Tulloch, PhD, a clinical psychologist at the University of Ottawa Heart Institute. Using cognitive behavioral therapy, Tulloch helps patients identify the stressors in their lives—be it work, health concerns or relationship issues. “It’s amazing to me how many people come in feeling stressed out and then when I ask what happened that day, they don’t know,” she says.
Marie P. of Ottawa, 64, is convinced that years of stress and depression contributed to her heart condition. She grew up in a difficult household, with a father and brother who were alcoholics. At 17, she married a man who became physically and verbally abusive during their 26-year marriage.
“My depression began in my marriage. I worried all the time,” says Marie, who began taking antidepressant medication before her heart condition was diagnosed in December 2006. “My anxiety got to the point that when I was leaving the house, I would go back three times to make sure everything was turned off.”
A happy second marriage turned Marie’s life around. But when a strange sensation in one arm led her to seek medical care, an angioplasty revealed 90 percent blockage in her left coronary artery. A stent was inserted to unblock the artery, and Marie received stress counseling as part of her cardiac rehabilitation.
“I learned how to relax,” she says. “They taught me how to say no, and that it’s okay to take 20 minutes a day just for you.”
Marie uses that time to listen to a relaxation tape.
Screening for depression
In response to mounting evidence that heart patients are at greater risk of depression than the general population, the American Heart Association (AHA) in 2008 recommended that cardiologists routinely screen patients for depression. The AHA also recommended that cardiologists and mental health professionals coordinate follow-up care for these patients.
This makes sense given that studies show that people who became depressed after a heart attack face a poorer prognosis than cardiac patients who don’t have depression. In a 2004 analysis of 22 studies conducted by Joost vanMelle,MD, PhD, and colleagues at the University Hospital Groningen in the Netherlands, patients who were depressed after their heart attacks had a two-fold increased risk of dying or suffering a new heart problem within two years after their heart attack. The review appeared in the journal Psychosomatic Medicine.
Tracy Stevens, a cardiologist who is a spokesperson for the AHA, takes a proactive approach, informing all her recovering heart patients that depression is common in the first year following a heart attack or stroke.
“They are surprised, and then relieved, that some of the emotions they are experiencing are normal, and that they are not alone,” says Stevens, medical director of Saint Luke’s Muriel I. Kauffman Women’s Heart Center in Kansas City, Missouri. “I tell them that if you ignored your depression, it would be like ignoring high blood pressure.”
It is crucial for health care providers to diagnose depression, says Alfred Bove, because untreated depression can lead to or exacerbate other serious health problems, including obesity and diabetes—both of which affect heart health.
“A lot of depressed people become obese because they use food to combat depression. Instead of just giving medicine for heart disease, it’s important to find the underlying cause,” he says. Dale B. of Clovis, California, wishes he had known about the heart disease-depression connection before undergoing mitral valve replacement surgery in 1994. Dale, an insurance adjuster and investigator, experienced significant depression and anxiety for about three months after his surgery. His symptoms included trouble concentrating and sleeping, and loss of appetite.
“I’d be lying in bed at night listening to my mechanical valve. Every time my heart missed a beat, it would scare me to death,” he says. When he told his internist how he was feeling, the doctor prescribed an antidepressant, which Dale still takes. He also began attending support group meetings at Mended Hearts, a national nonprofit organization affiliated with the American Heart Association that provides educational and peer support services for heart patients and their families.
Facing mortalty
Mary Whooley says it’s common for patients to feel reluctant about telling a primary care doctor that they feel depressed. “A lot of people feel embarrassed that they have it, or that they can just snap out of it, or that it’s their fault,” she says. “People need to recognize it’s an illness, just like diabetes.”
For Barbara F., 63, of Dayton, Ohio, admitting to depression seemed like a “sign of weakness.” Forman became clinically depressed for the first time in her life after undergoing bypass surgery in 2003. When she returned home from the hospital, the retired postal employee indulged in what she now refers to as a “pity party.”
“I thought 57 was too young for this to happen. I thought my life as I knew it before was over—that I’d be an invalid for the rest of my life,” she says. “I didn’t want to see anyone, I didn’t want to go anywhere. I slept a lot. Sometimes I was afraid to go to sleep—that I wouldn’t wake up. I thought about my own mortality more.”
A major cardiac event does indeed shake up your world, forcing you to come to terms with the fact you aren’t going to live forever, says Heather Tulloch. “You start processing life on a deeper level. You start to question your life goals and accomplishments, which can [lead to] depression.”
Patients may also grieve for their former healthy self and fret about their ability to work in the future. Countering such feelings with accurate information is key, says Bove.
“Most people do recover from a heart attack, and return to a normal life, so education and encouragement is important.”
Two months after Barbara’s surgery, she picked up some literature about heart surgery she was given at the hospital. It made her realize that many of the feelings she’d been having —including fears about her future health —were normal. Like Dale, she turned to Mended Hearts for information and support from people who had been in her place. She also came to terms with needing antidepressants.
“The antidepressant medication has helped,” says Barbara. To other heart patients, she advises: “Don’t be afraid to talk to your doctor if you are feeling depressed.”
The mind-body connection
Untreated depression can hinder recovery in heart patients, as well as increase the risk of heart disease. The trouble is that the very nature of depression can erode your ability to take good care of yourself— specifically, to exercise, eat well and take heart medications regularly, studies show.
Yet the importance of exercise can’t be overstated. Regular cardiovascular exercise (at least four to five times a week) has not only been proven to reduce the symptoms of depression, but is one of the most important factors in lowering the risk of heart disease, according to Luc Djouss., MD, of the department of medicine at Brigham and Women’s Hospital in Boston.
But how do you begin an exercise regimen when your motivation and energy are at rock bottom? Whooley suggests taking small steps, such as starting with a 15- minute walk around the block.
“Any exercise is better than none,” she says. “You need to find a way to incorporate it into your daily life.”
Eating and drinking in moderation is also key to good health, says Djousse, the lead author of a study published in the July 2009 issue of JAMA which found a strong association between healthy behaviors and lower lifetime risk of heart failure.
Djousse. and his colleagues followed more than 20,000 men, all healthy at the start of the study, over a 25-year period. The lifetime risk of heart failure for those who practiced four or more healthy behaviors— exercised regularly, drank moderately, did not smoke, were not overweight and had a diet that included high-fiber cereal and fruits and vegetables—was 10 percent or less. Men who did not follow any of those healthy habits had a lifetime risk of 20 percent.
Since their heart procedures, both Barbara and Marie have adopted healthier lifestyles. Barbara walks daily, avoids fatty foods and soda, and eats more fruits and vegetables. She has lost 60 pounds, in part due to a gastric band placed around the upper portion of her stomach to reduce appetite.
Marie lost 50 pounds through lifestyle changes.
“I eat vegetables, I avoid soft drinks, I’ve cut down on my red meat and I water down my gravy,” she says. She has also eliminated salt from her diet. And she walks for 30 minutes every day—whether she feels like it or not.
“You don’t have to run or walk really fast,” she says. “It’s amazing how you feel when you come back from a walk— rejuvenated!”
Get moving
“Exercise really is the best medicine,” says Linn Goldberg, MD, co-author of The Healing Power of Exercise: Your Guide to Preventing and Treating Diabetes, Depression, Heart Disease, High Blood Pressure, Arthritis and More (John Wiley & Sons, 2002).
Regular exercise improves both mood and physical health, says Goldberg, professor of medicine and head of the Division of Health Promotion and Sports Medicine at Oregon Health & Science University. It increases “feel-good” endorphins, reduces anxiety through its effect on neurotransmitters, lowers blood pressure and improves cholesterol levels, among other benefits.
Here are Goldberg’s tips for making it easier to incorporate exercise into your life:
FIND WHAT SUITS YOU: Look for a physical activity you enjoy and one that fits readily into your schedule. You don’t have to jog or go to exercise class. Walk in the neighborhood or at a mall, garden, ride a stationary bike while you watch TV—whatever feels least like a chore.
PAIR UP: An exercise buddy can help you get motivated and stay committed.
START OUT SLOW: For someone who hasn’t been exercising at all, 15 to 20 minutes a day is a great start, says Goldberg. “Leave your house and walk 10 minutes one way, and then turn around and come back, so it doesn’t sound so challenging.” Add another minute to the workout each week. The goal is to build up to 35 to 40 minutes per workout.
STICK IT OUT: You’ll begin to feel the benefits of exercise after about six weeks. But beware the “three-month hump,” warns Goldberg. “This is when a lot of people quit. They start to find excuses: ‘I have other things I need to do, I don’t want to go out in the cold and dark.’”
Printed as “Straight to the heart”, Winter 2010
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