Depression After Heart Attack
Why Should I Be Concerned About Depression After a Heart Attack?
Depression is 3 times more common in patients after a heart attack than in the general population, with 15% to 20% of heart attack victims qualifying for a diagnosis of major depressive disorder, and a far greater proportion experiencing increased levels of depressive symptoms. This comes as no surprise, given that major life stressors are known to contribute to the development of depression, and a heart attack certainly qualifies as such a stressor. Depression after a heart attack is bad not only because of the accompanying emotional distress and suffering; it also increases one’s risk of having another heart attack or dying over the ensuing months and years. Listed in Table 1 are several characteristics that have been found in depressed persons that could account for a poorer prognosis after a heart attack.
How Can I Tell if I’m Depressed?
On the basis of this extensive evidence that depression not only causes misery, but is also associated with a poorer prognosis after a heart attack, an American Heart Association Science Advisory panel recently recommended that patients who have had a heart attack be screened for depressive symptoms to identify those “who may require further assessment and treatment.”1 As shown in Table 2, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth E dition (DSM-IV) specifies depressed mood (feeling sad, “down,” unhappy, dissatisfied) and a marked reduction in interest or pleasure in activities that one usually enjoys as key indicators of major depressive disorder. Other symptoms include change in appetite or sleep habits, fatigue or loss of energy, feelings of worthlessness or excessive guilt, trouble concentrating, and recurrent thoughts of death or suicide. A diagnosis of major depressive disorder can only be made by a physician or other mental health professional, but if you have been experiencing several of the symptoms just outlined, it would be a good idea to seek evaluation for depression.
What Can Be Done to Reduce the Impact of Depression on My Mental and Physical Health?
There is some good news here. Depression is a treatable disorder, and there is extensive evidence from rigorously conducted clinical trials that both antidepressant medications and certain forms of psychotherapy are effective in reducing depression. Selective serotonin reuptake inhibitors (SSRIs; eg, sertraline, citalopram) are a type of antidepressant medication that has been found to be both effective in reducing depression and relatively safe to use in patients with coronary heart disease. Cognitive behavior therapy is a form of psychological treatment that has been found to be effective in treating depression; it teaches patients to evaluate their thoughts and feelings in distressing situations in ways that are less colored by their depressed mood and outlook.
Given that depression predicts a poorer prognosis after a heart attack and that SSRIs and cognitive behavior therapy reduce depression, it stands to reason that treating depressed heart attack victims with an SSRI, cognitive behavior therapy, or both would not only reduce their depressive symptoms, but also result in reduced heart disease–related morbidity and mortality. Although there are some studies that have found reduced morbidity and mortality in patients treated with an SSRI or cognitive behavior therapy after a heart attack, there are also studies that failed to demonstrate such a clinical benefit. This is not an unusual state of affairs in cardiology. In the late 1970s, there were several clinical trials that tested β-blockers as a means of improving prognosis after a heart attack. As with the treatment of depression, about half the trials showed a clinical benefit, but half did not, and it was not until a large randomized, controlled trial of β-blocker therapy was conducted that it became clear that treatment with a β-blocker after a heart attack results in a 23% to 28% reduction in morbidity/mortality.2 Similarly, a large randomized, controlled trial evaluating the impact of an SSRI, cognitive behavior therapy, and a combination of the 2 will be required to provide definitive documentation that treatments known to be effective in reducing depression also reduce morbidity and mortality in patients after a heart attack.
What Can I Do About the Depression I’m Experiencing After My Heart Attack?
Even though we cannot guarantee at this time a reduction in morbidity/mortality when depression is treated after a heart attack, we do know that effective treatment of depression will reduce suffering and improve your quality of life. So it is appropriate for your physician to have you evaluated for depression after a heart attack and to advise treatment if you are found to have clinically significant symptoms of depression. Your physician will also likely refer you to a cardiac rehabilitation program after your heart attack, and many aspects of this program will help reduce those symptoms. It has been shown, for example, that aerobic exercise in the setting of cardiac rehabilitation reduces symptoms of depression in addition to improving your cardiovascular fitness.1 It could also help if you approach the cardiac rehabilitation program with a positive, optimistic attitude that your active participation will help you cope more effectively with your heart disease. A growing body of research is showing that patients with such a positive, optimistic outlook not only have lower levels of depressive symptoms, but also may have reduced morbidity and mortality. By taking an active role in the process of recovery from your heart attack, you may also be not only adhering to a health-enhancing medical regimen, but also fostering the development of such a positive, optimistic outlook.
Here is a summary of some things you can do to reduce the impact of depression on your heart:
Don’t be surprised if you are experiencing some feelings of depression after your heart attack. It’s not unusual to feel depressed after such a major stressful life event; you have lots of company.
Welcome your assessment for depressive symptoms by the mental health professional your physician calls in to see you. After all, depression is a treatable disorder; treatment can reduce your suffering and improve your quality of life; and, even though we can’t be certain given the present state of knowledge, treatment could also increase the quantity of your life.
Be an active participant in your recovery: Take your prescribed medications as directed and be a regular attendee at your cardiac rehabilitation program, following the diet and exercise recommendations.
And finally, seek out the company of supportive friends and family whom you trust. Patients with heart disease who have a trusted confidant with whom they can share distressing thoughts and feelings have been found in prior research to have lower mortality rates.
Sources of Funding
Dr Williams is supported by National Heart, Lung, and Blood Institute grant P01HL36587; National Institute on Aging grant R01AG19605, with cofunding by National Institute of Environmental Health Sciences; and the Duke University Behavioral Medicine Research Center.
Dr Williams is a founder and major stockholder of Williams Life Skills, Inc, and holds US patent 7,371,522 on the use of the 5HTTLPR L allele as a genetic marker of increased risk of cardiovascular disease in persons exposed to chronic stress.
The information contained in this Circulation Cardiology Patient Page is not a substitute for medical advice, and the American Heart Association recommends consultation with your doctor or healthcare professional.
- © 2011 American Heart Association, Inc.
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