Harvard Heart Letter

Treat depression, help the heart

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Depression in people with heart disease is common — and treatable.

Learn the warning signs: Depression is often unrecognized in people with heart disease.

It's a two-way street: heart disease triples a person's risk of depression, and people who already suffer from depression are at greatly increased risk of heart disease. Untreated depression makes it more likely that a person will die of heart disease, yet it's often overlooked.

"Depression in people with heart disease is common and under-recognized. It really is a major problem," says Dr. Jeffery C. Huffman, associate professor of psychiatry at Harvard-affiliated Massachusetts General Hospital and the lead author of a recent overview of research into the connection between depression and heart disease.

Fortunately, depression is just as treatable in people with heart disease as it is in the general population. But it doesn't go away all by itself. Getting treatment means learning the warning signs and, if they appear, finding out from your doctor what they mean.

Recognizing depression

You aren't suffering from depression if you have the blues once in a while, or if you feel sad for the time it takes you to get over a heart attack or to adjust to a new diagnosis of coronary artery disease.

"A person who has a major heart event has ups and downs of energy and mood," Dr. Huffman says. "But those who feel mostly bad for most of the day for weeks or months, who lose the ability to enjoy life, these are the people we are talking about."

The kinds of depression that interact with heart disease include both the long-term type, whose symptoms do not always interfere with normal function, and major depressive disorder (MDD), in which these symptoms are disabling.

Both are all-too-common among people with heart disease:

  • 31% to 45% of people with coronary artery disease have symptoms of depression, and 15% to 21% suffer MDD.

  • 36% of people with heart failure suffer depressive symptoms, and 20% have MDD.

  • 11% to 28% of people with an implantable cardioverter-defibrillator (ICD) have
    either depressive symptoms or MDD.

  • 30% to 40% of people who get a coronary bypass have depressive symptoms, and some 15% have MDD.

Some people are particularly likely to suffer depression when they develop heart disease: those with a previous history of depression, younger people, and women. Some evidence also suggests that people who have received ICD shocks are at higher risk of depression.

Depression may be accompanied by other psychiatric disorders. High anxiety is particularly common. Those who have undergone bypass surgery or ICD implantation often experience post-traumatic stress disorder as well as depression.

How caretakers can help

One of the insidious aspects of depression is that people who experience it may not recognize their need for help. Moreover, they may resist assistance even when it's offered.

Dr. Huffman advises spouses and caretakers to start small when they notice depressive symptoms in a person with heart disease.

"There is this push to say, 'Hey, get out and get some exercise. Come on, let's go out with friends; let's go out to a movie.' But you have to find a nice balance between not letting the person remain stuck, and taking cues to how much pushing they can handle," he says.

Go slow. Try to get the person to walk around the block one day, and maybe go talk to a doctor some other day about depression.

"Often, a significant other or caregiver has to walk a fine line between overwhelming the person—making them feel they can't do any of those things—and not helping them at all," Dr. Huffman says. "Don't do too much. But do something."

Warning signs of depression

Depression is common in people with heart disease. Here are some warning signs:

  • loss of interest in activities previously enjoyed

  • lack of energy

  • loss of appetite (or unusual, persistent craving for food)

  • difficulty sleeping

  • out-of-proportion feelings of guilt about one's medical condition

  • feelings of worthlessness or loss of self- esteem

  • ?irritability throughout the day

  • excessive fatigue

  • ?loss of interest in sex

Treating depression

There are a number of good treatments for depression, and having heart disease does not make treatment more difficult. Treatments include:

  • Antidepressants. Most are safe to take with most heart medications. Sertraline (Zoloft) has been studied extensively in people with heart conditions, Dr. Huffman says, and like other antidepressants in its class, it's been shown to be both safe and effective.

  • Psychotherapy. Several kinds of therapy are effective. "There are no side effects from psychotherapy, it can be individualized, and people can be taught new skills to battle depression—not just now, but in the future," Dr. Huffman says.

  • Exercise. A Duke study found an exercise program was as effective as an antidepressant in relieving symptoms of depression. "This is a double benefit for heart disease patients, because exercise not only treats depression but also treats heart disease," Dr. Huffman says.

  • Cardiac rehabilitation. Cardiac rehab programs offer a lot more than exercise. "There is a social support aspect," Dr. Huffman says. "You see a lot of people in the same boat you're in. This means less of the isolation that can lead to depression.

"The more and different approaches you can take, the better," Dr. Huffman says.