Harvard Heart Letter

Different shades of gray for post-heart attack depression

Depression that develops for the very first time during recuperation from a heart attack affects recovery more than depression that started before the attack.

Recovering from a heart attack is tough enough without facing the fog of depression. Yet that's exactly what happens to nearly half of heart attack survivors. Depression is a painful, isolating, joyless state of mind that interferes with recovery and dulls life. It may even make it shorter "" people with post-heart attack depression are two to three times more likely to have another heart attack or to die prematurely compared with survivors who don't have depression.

Like a dreary artist's palette, the term depression covers everything from the light grays of mild depression to the dark blacks of a serious, life-threatening mental illness. It isn't just the severity of the condition that varies from person to person. Depression after a heart attack isn't a one-size-fits-all classification. Different variations have different effects on the heart and recovery. Developing depression for the very first time during recovery from a heart attack appears to be more cardiotoxic than depression that started before the attack.

Dutch researchers interviewed 468 heart attack survivors three months after their attacks and again at 12 months, asked them to fill out several standard mood and personality questionnaires, and followed their health for 30 months. Among the volunteers who developed depression for the very first time after their heart attacks, 33% died of cardiovascular disease or had a heart attack, stroke, or other cardiovascular event during this time. That was far higher than among those who didn't develop depression (21.5%) or who were depressed before their attacks (22.6%). The results were published in the Journal of the American College of Cardiology.

What's the difference?

Depression arises for various reasons, ranging from personal setbacks to chemical imbalances in the brain. In some people, depression and heart disease may bloom from the same twisted vine "" a genetic vulnerability that can trigger both conditions, such as hyperactive inflammation or an imbalance of serotonin, a neurotransmitter that also affects blood vessels.

Depression that first appears after a heart attack could be different from classic depression. It may represent fear of dying, grief over the loss of health, or trouble adjusting to the traumatic and life-changing experience of a heart attack. Fear, grief, and post-traumatic stress look a lot like depression but don't necessarily respond to the same treatment strategies.

Do antidepressants help heart attack survivors?

Treating depression after a heart attack has long vexed doctors. Early efforts using older antidepressants weren't a success since the drugs sometimes disturbed the heart's rhythm and further endangered an already weakened heart. Testing of newer antidepressants of the type known as selective serotonin reuptake inhibitors, such as fluoxetine (generic, Prozac), sertraline (generic, Zoloft), and others, has gone slowly.

Two small studies, completed in 2002 and 2003, suggested that heart attack survivors can safely take sertraline, and that the drug alleviates symptoms of depression and may prevent a repeat heart attack or early heart-related death. Canadian researchers have just added a third study.

The researchers recruited 248 men and women with depression who had recently survived a heart attack or had artery-opening angioplasty. Depression improved more in those who took citalopram (generic, Celexa, Lexapro) for 12 weeks than in those who took a placebo. Drug therapy also worked better than talk therapy.

So far, clinical trials testing the safety and effectiveness of antidepressants for heart attack survivors have included under 1,000 people and lasted for a few months at best. That's too few people and too little time to paint an accurate picture of the safety and effectiveness of these drugs. That said, the repercussions of depression are serious enough to warrant antidepressant therapy if needed.

Individual approach

From a health perspective, depression gets in the way of taking medications that protect the heart and blood vessels. It drains the resolve to exercise or adopt a more healthful diet. It generates feelings of helplessness and isolates people from those who can help.

Breaking out of depression can be tough to do on your own. It often takes the efforts of a family member, friend, or doctor to help you recognize the problem and tackle it.

The standard approach to depression includes talk therapy and medication. Selective serotonin reuptake inhibitors such as citalopram (generic, Celexa, Lexapro) or sertraline (generic, Zoloft) may help both depression and heart disease.

Depression that first appears after a heart attack may respond to these approaches as well. If not, ask your doctor for a referral to a therapist who can help you sort out your thoughts and feelings and possibly hit on a more specific therapy that can help you ease out from under depression.

Some physicians look on depression that appears after a heart attack as an understandable reaction to a stressful event that will go away as you get better. It is usually much more than that. Regardless of its origin, recognizing the signs of depression, realizing they aren't just in your mind, and getting help will be good for your heart, your health, and your life.