Depression and Heart Conditions

Depression is common in heart patients. Most studies show 2 out of 3 patients will experience depression. Does depression cause heart disease or does heart disease cause depression? Probably both. We all have ups and downs, however when one finds them overwhelming and debilitating it is time to get help. According to the National Institute for Mental Health the following are the symptoms of depression:

Signs and symptoms include:

  • Persistent sad, anxious, or “empty” feelings
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness
  • Irritability, restlessness
  • Loss of interest in activities or hobbies once pleasurable, including sex
  • Fatigue and decreased energy
  • Difficulty concentrating, remembering details, and making decisions
  • Insomnia, early-morning wakefulness, or excessive sleeping
  • Overeating, or appetite loss
  • Thoughts of suicide, suicide attempts
  • Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

One of the best things a person who is suffering from depression can do is to get daily exercise. Yet it is one of the hardest things to do when depressed. I would encourage patients to at a minimum schedule themselves 10 minutes per day of exercise. I know it is a very short duration, but it is a starting point. We build from there.  If you are a significant other of someone you suspect is depressed, don’t nag them to exercise, rather help them to engage in it. Offer to go for a walk, or go to the gym together.

For many suffering from depression winter can be especially difficult. The holidays may trigger episodes, a change in healthy eating habits to the holiday party foods, a change in exercise habits due to weather changes, getting out and socializing less due to weather, loss of loved ones,  and seasonal effective disorder can all be a catalyst for symptoms to worsen. If you note this contact your healthcare practitioner, consider counseling, increasing exercise, getting sunlight every day, and/or medications. It is important because if depression isn’t treated often heart disease worsens.

Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy



Heart disease patients who have anxiety have twice the risk of dying from any cause compared to those without anxiety, according to new research in the Journal of the American Heart Association.

Patients with both anxiety and depression have triple the risk of dying, researchers said.

Many studies have linked depression to an increased risk of death in heart disease patients. However, anxiety hasn’t received as much attention. Studies show that depression is about three times more common in heart attack patients. The American Heart Association recommends that heart patients be screened for depression and treated if necessary.

Depressed heart disease patients often also have anxiety, suggesting it may underlie the risk previously attributed solely to depression. It’s now time for anxiety to be considered as important as depression, and for it to be examined carefully.”

In the study, 934 heart disease patients, average age 62, completed a questionnaire measuring their level of anxiety and depression immediately before or after a cardiac catheterization procedure at Duke University Medical Center. Patients had anxiety if they scored 8 or higher on a scale composed of seven common characteristics of anxiety, with each item rated from 0 to 3 (range of possible scores: 0-21). Depression was measured using a similar scale composed of seven symptoms of depression.

Researchers, after accounting for age, congestive heart failure, kidney disease and other factors that affect death risk, found that 90 of the 934 patients experienced anxiety only, 65 experienced depression only and 99 suffered anxiety and depression. Among 133 patients who died during three years of follow-up, 55 had anxiety, depression or both. The majority of deaths (93 of 133) were heart-related.

Researchers measured anxiety and depression during cardiac catheterization because levels better reflected how patients normally handle stressful situations. Anxiety and depression each influence risk of death in unique ways. Anxiety, for example, increases activity of the sympathetic (adrenaline-producing) nervous system that controls blood pressure.

People who worry a lot are more likely to have difficulty sleeping and to develop high blood pressure. The link between depression and mortality is more related to behavioral risk factors. Depression results in lack of adherence to medical advice and treatments, along with behaviors like smoking and being sedentary.

Future studies should test strategies to manage anxiety alone and with depression in heart disease patients.

Anxiety reducing medications combined with stress management could improve outcome for patients with just anxiety, whereas patients with anxiety and depression may need a stronger intervention involving more frequent outpatient monitoring and incentives to improve adherence.

Slowly getting there, comments from our cardiac health innovators?

10 thoughts on “Depression and Heart Conditions

  1. Pingback: Depression and Heart Conditions | heart diseases an heart conditions |

  2. Thanks so much for reminding your readers that depression and heart disease are very closely linked. As you say, we get it from both ends: studies have shown that people who experience depression are at higher risk for heart disease, and those of us living with heart disease are at higher risk for depression. As if that’s not depressing enough, untreated depression in heart patients significantly increases our risk of poor outcomes as survivors.

    As Alaska cardiac psychologist Dr. Stephen Parker (a heart attack survivor himself) likes to say: “A heart attack is a deeply wounding event.” Yet, as Mayo Clinic cardiologists say, fewer than 10% of heart patients suffering depression are appropriately identified. This has got to change! When I confided to my (otherwise wonderful) cardiologist about my own debilitating experience with depression, he merely checked my chart and said “Of course, it could be the beta blockers you’re on . . . ” If I’d had the energy, I would have thrown something at his head and screamed: “NO! It’s because I’ve just had a frickety-frackin’ HEART ATTACK!”

    It’s also important to remember that although exercise is indeed one of the most effective forms of therapy for depression (in heart patients and others!) the tragic reality (as I discovered personally to my horror) is that depressed people are severely limited in motivating themselves to brush their teeth or get dressed or put one foot in front of the other, never mind go to the gym. I wrote more on this at “The New Country Called Heart Disease”

    • Carolyn,
      Yes I didn’t even get to discussing the depression linked with beta blockade, or due to multiple health conditions. You are correct exercise is really impossible to address if the clinical depression is severe. In cardiac rehabilitation the use of a screening to such as the PHQ -9 is used to identify if depression improving or being addressed. I was part of a team that presented this to AACVPR via a poster presentation in 2010.

      The impact of Cardiac Rehabilitation on depression scores using the PHQ-9.

      Purpose: The purpose of this study was to determine the impact of cardiac rehabilitation (CR) on depression scores as measured by the PHQ-9.
      Significance: Approximately 9.5% of all adults in the United States suffer from depression. Approximately 15 to 20% of patients with heart disease also have depression. Heart disease patients who also have depression are at a higher risk of mortality compared to heart disease patients who are not depressed. Patients who have heart disease and depression have 3 times the mortality risk of healthy, age-matched controls.

      Background: The Montana Outcomes Project started in 2006 and includes over 125 programs representing 15 states. The intent of the project was to create a standardized outcomes program the CR programs could utilize and submit their de-identified outcomes data to a centralized location for analysis and feedback. The feedback would provide benchmarking information that programs could use to compare their individual data and identify areas to focus quality improvement efforts.
      Methods: Participants were given the PHQ-9 depression screening questionnaire upon entrance to and upon completion of phase II CR.

      Conclusions: Data was collected on 1838 patients with both pre and post test scores between July and September 2010. Mean pre-PHQ-9 score: 5.12 std. dev (4.7); range 0-29. Mean post-PHQ-9 score: 2.82; std. dev. (3.6); range (0-26). P-value <0.01. The results of this study indicate that PHQ-9 depression scores dropped significantly after completion on of CR. Scores were decreased from 5 indicating physicians use clinical judgment for treatment of depression to 2 which indicates no treatment needed. This suggests that CR patients who are suffering from clinically depressive symptoms prior to enrolling are not suffering from these symptoms after completing CR.
      Implications: The PHQ-9 depression screening tool can be an effective measure of depression in heart disease patients.

      The PHQ-9 is a free tool and available to all CR programs. CR programs should screen for depression on all patients entering phase II.

    • It would be interesting in your team’s study to parse the results to see if the decrease in PHQ-9 scores were attributable to the exercise component of CR, or the psychosocial support, or eating better, or the passage of time, or ? ? ? What’s your take on this?

    • PS By the way, I wasn’t even taking beta blockers when my cardiologist made that comment about my being depressed!

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  4. Yes it would be very interesting to break the data down further. I believe a depression response following a health scare is normal and yes over time it will improve for many. The exercise component would attribute to improvement as well as improves self image, confidence, regular endorphin release, improved ADL’s due to improved strength, prolonged independence. The psychosocial support is huge as well, as what better group therapy than cardiac rehabilitation, a one to one counseling session with staff and regular group support from fellow patients who understand best the ups and downs of the disease process. It would be difficult to pick which part helps the most. Then again there are people who absolutely require medication as exercise nutrition and support cannot touch the chemical responses going on within the body.

    I do believe the healthcare provider needs to consider the body as a whole, not just their specialty. What good is a beta blocker if it causes that person to be depressed and impair their daily life, or a statin that causes them to be extremely sore or forgetful, or increases depression. The problem here is the algorhythm of performance measures in which hospitals and physicians are rated, it becomes a cook book approach, with diagnosis x they must be discharged on x, y and z or provide the appropriate documentation to support alternate care plan or they will be tagged and rated poorly.

    The time constraints also do not allow for a strong relationship to form between patient and doctor to be able to discuss the little things. Think about the cardiology visit post heart problems, it usually occurs 3 months and one year following the event. The side effects at 3 months are still becoming apparent and after a year, many have accepted this is their life. The primary care won’t discuss or change because this steps on the toes of cardiology. Medicine is a complex twisted world that is so hard to navigate. I wish every person had a health advocate who could help them through the process.

  5. “The side effects at 3 months are still becoming apparent and after a year, many have accepted this is their life.” BINGO! You are so right. When I was at Mayo Clinic, cardiologists there frankly described themselves as “mechanics”: very, very good at this one particular body part, but apparently unaware that this body part is surrounded by a entire whole body. I’d like to think this is changing, but my blog readers and audience members continue to tell me otherwise. Sigh…..

    • Don’t give up. I believe social media such as our blogs are the beginning for patients to get honest discussion without sales, support, education that they don’t get in our current health care systems. It is from the consumer end, and not preaching the same information in the same way…do this or else…they discuss what is good and what is bad about the current line of thinking, or practices. Now we provide what works and what doesn’t, the barriers, and the support through our blogs. This will continue to grow as the population we serve is more tech savy.

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