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More Than a Broken Heart

Network, Spring/Summer 2006

What may have been mere conjecture only a decade ago is now a well-established medical fact: heart disease and depression are inextricably linked. According to Dr. Brian Baker, associate professor of psychiatry at the University of Toronto and spokesperson for the Heart and Stroke Foundation, “Until the mid-90s, nobody realized that so many cardiac patients were getting depressed.”

The risk of depression among heart patients is “3 to 5 times what you’d expect,” says Dr. Baker, and people with depression don’t do as well recovering from a heart attack. “Since the mid-90s, cardiac specialists, rehab specialists, GPs and psychiatrists have become more aware that cardiac patients are at greater risk for developing depression.”

The fact is that over the next 20 years, heart disease and depression are expected to top the list as leading causes of disease burden worldwide. “They’re linked, definitely,” explains Dr. Baker. “If you already have heart disease, you are more likely to be depressed and you are less likely to do as well from a heart health perspective. That is, your survival and cardiac outcomes are worse. And that’s a really big problem.”

“We know that after a heart event — a bypass, heart attack, or even a diagnosis of heart disease — 1 out of 6 people will have a major depression and 1 out of 6 will have a minor depression. And both of these groups will have a worse outcome in terms of survival.”

“Now there’s evidence that people who are depressed earlier on are more likely to develop heart disease. Their risk ratio is only about 1.5 or 2 times, but it does increase their chances of getting coronary artery disease,” says Dr. Baker. “That’s an interesting new development.”

“The link between depression and heart disease is fairly complex and intertwined,” explains Dr. Jaan Reitav, psychologist with the Cardiac Rehabilitation and Secondary Prevention Program at the Toronto Rehabilitation Institute. “If you take people who’ve had chronic depression or anxiety through their early adult years, they do tend to be at more risk for heart disease and/or heart attack. So they are vulnerable and that’s important to understand.”

“In addition,” says Dr. Reitav, “depression is the kind of condition that often presents to the family doctor with a variety of physical symptoms — the so-called ‘masked depression.’”

When the doctor diagnoses the underlying depression, there’s the risk that all of the physical symptoms will be attributed to depression, and not taken as seriously. But in fact, Dr. Reitav continues, “these people are at risk for cardiovascular disease, and possibly having a heart attack down the road. So they need to be monitored closely for their mental health status as well as advised of their heart health risks.”

The combined challenge of depression and heart disease is a significant one.
As Dr. Reitav explains, “If the person with a history of depression does have a heart attack, the mountain they have to climb in order to be successful in their rehabilitation tends to be longer and steeper than someone without the depression.”

That climb to recovery is more difficult for a number of reasons. “First of all, depression as a syndrome can really sap your motivation,” says Dr. Reitav. “You may not feel like getting out of bed to do even the basics, let alone getting yourself out to the rehab program to participate in an active exercise program. In addition, you’re expected to do the exercises at home five times a week and keep a daily log of your activity. So you can imagine if you’re struggling with depression how difficult that would be. There’s a real risk that people will begin to fail at rehab because of their depression.”

Toronto Rehab’s Cardiac Rehabilitation program, one of the largest in North America, treats close to 1,600 people a year who are recovering from heart disease and/or surgery. The goals of the program are “to prevent and limit the physiological and psychological effects of cardiac illness, and to improve overall cardiovascular fitness and health.” These goals are achieved through individualized programs of exercise, education and lifestyle modification.

The evidence tells us that participation in a cardiac rehab program is beneficial to recovery and may reduce the risk of additional cardiac events.

Dr. Reitav adds, “It’s vital that where there is a previous history of depression or the person shows up with a mild or moderate depression, that they should be identified right away and additional treatment provided for the co-occurring depression. That’s very important. If you aren’t able to help the patient deal with it from day one, then the overall effectiveness of your rehab program is undermined and the patient may become discouraged and drop out.”

Identifying patients with low but persistent levels of depression can be challenging. The experience of having had a heart attack will itself prompt a normal response of shock, sadness and grief. Almost all heart patients feel down initially. The trick is to identify those who are struggling to recover, and who require closer, ongoing attention. Mild depression is an ongoing mood disorder that is not just contingent upon life events.

“Those with mild depression are those who don’t bounce back,” says Dr. Reitav. “Usually it’s your family and loved ones who gather round you and start helping you and cheering for you. This helps a lot in term of mobilizing your energies to get going and participate in the rehab. Those who have no family supports or are socially isolated are very much at risk and can become depressed in a mild but persistent way.”

“There are also lifestyle challenges to participating in the rehab program. People may arrive at the program with either good or bad health habits. If we take the worst case scenario, we may have someone who smokes, or who is obese, or who drinks beyond a social level, and all of these poor health habits compound the challenge of recovery.”

“Of course, depressed people are not immune to these health habits. There is even some evidence that teenagers who smoke may be resorting to cigarettes in order to manage their mood, and may go on to struggle with anxiety or depression as adults. So there is a further co-morbidity present in terms of proneness to smoking. Social isolation, smoking, and obesity are all factors that add to the challenge of recovery.”

Anger is another consideration for some heart patients. “Beyond the classic Type A personality, many of our depressed people will report feeling very irritable,” says Dr. Reitav. “They typically tend to describe feeling uncomfortable or awkward in social situations, as well as being quick tempered or easily annoyed. These too can be part of the clinical picture of depression.”

So what to do about the depression? Says Dr. Baker, “There’s increasing evidence that the best thing to do with a minor depression is send people to a rehab centre and get them to exercise. This type of depression can be monitored and treated if necessary, but if you have a major depression, there’s ample evidence that there are good treatments available. The SSRI medications [selective serotonin reuptake inhibitors, commonly prescribed for depression] are effective and safe for cardiac patients,” asserts Dr. Baker. “As for psychotherapies, we’re still trying to work out the best approaches for major depression in this population. Feeling supported is an important positive factor for those who are depressed.”

It is difficult to overemphasize the need to identify the risk for depression in the context of heart disease. As Dr. Reitav explains, “It’s not only that your cardiac patient may have another condition called depression alongside their heart condition. These two conditions interact, like a chemical reaction, and the negative impact from each on the person’s ability to successfully meet the challenge of a rehab program is compounded. It’s not just one plus one.”

“Depression impacts the heart condition negatively in many, many ways — motivation, behaviour, habits, self-esteem and focus. You must identify the mood problem quickly and start helping the patient to aggressively manage both. Otherwise, rehabilitation can be a daunting uphill struggle that the person does not feel ready, or equipped, to tackle.”

For more information

Heart and Stroke Foundation

Toronto Rehab