Depression affects about 20% of Americans in their lifetime, and is one of the leading causes of disability. The rates of depression are even higher in those with cardiovascular disease (CVD). Depression affects 38% of patients undergoing coronary artery bypass graft surgery, and the risk of depression is three times as high in patients who have experienced a heart attack compared with the general population. Depression also makes it much more likely that CVD patients will be readmitted to the hospital and report heart-related symptoms.
Yet much of the time, symptoms of depression in those with CVD go unrecognized. And as we all know, if we don't identify a problem it's very difficult to find a solution.
Depression makes adherence to healthy behaviors less likely
Depression matters to cardiologists because patients with both depression and CVD have increased mortality rates, and significant reductions in their quality of life. Depression can often stem from feeling increased stress and lack of control regarding a chronic health condition like heart disease. In other cases, depression may already exist, and continue or worsen in response to CVD.
By affecting mood, sleep, and energy, among other things, depression can greatly impact a person's ability to optimally manage their CVD. For example, depression makes it less likely that someone will take their medications as prescribed. And depression can make it very difficult to adhere to lifestyle recommendations such as eating a healthy diet or getting regular exercise.
The brain-heart connection
In addition to affecting behaviors, depression is also associated with physiologic mechanisms that help to explain the poor prognosis in patients with CVD. These mechanisms highlight the connection between the brain and the heart.
For example, depression can cause autonomic dysfunction, which negatively impacts resting heart rate, heart rate variability, and blood pressure. Depression can affect underlying inflammation, leading to elevated levels of potentially harmful circulating inflammatory molecules. Depression can also worsen insulin resistance, leading to further inflammation and diabetes. And depression can affect platelet reactivity, making blood stickier and, in turn, making a recurrent or new heart attack more likely.
Screening for depression
In April 2019, the Journal of the American College of Cardiology published a review in which they discussed a practical approach to the screening and management of depression in patients with CVD.
The review is a practical resource for cardiologists, which can help with early identification and improved management of patients with depression and CVD. By implementing screening practices, doctors can start a conversation about symptoms and their impact on health outcomes.
A multidisciplinary approach to symptom assessment is likely most effective, and involves the patient, the cardiologist, and the primary care physician (PCP). In some cases, mental health professionals, pharmacists, and care coordinators might also be involved.
The American College of Cardiology recommends that screening take place at routine office appointments with both cardiologists and PCPs. Screening questions you may be asked include:
- Have you had little interest or pleasure in doing things over the past two weeks?
- Have you felt down, depressed, or hopeless in the past two weeks?
Your doctors are looking for symptoms of a depressed mood, diminished pleasure in activities, low self-esteem, sleep disturbances, changes in appetite, loss of energy, and difficulty with concentration.
If your cardiologist or PCP does not ask you about symptoms of depression, you should feel comfortable volunteering this information.
Path to treatment
Thankfully, multiple proven treatment options exist for depression, and doctors and patients should discuss a personalized treatment plan. Exercise is an effective antidepressant therapy for those with mild or moderate depression. Exercise has been shown in multiple studies to have a significant impact on depression and cardiovascular outcomes.
With my cardiology patients who are experiencing depression, I typically recommend participating in an organized exercise program. If patients have had a recent heart attack they are eligible to enroll in a cardiac rehabilitation program. For all other patients, I recommend joining a program at their local gym.
Cognitive behavioral therapy (CBT) is another great nondrug way to treat depression. CBT is a form of therapy designed to change ingrained patterns of negative thoughts or behaviors. Medications can also be used, either alone or in combination with exercise and CBT.