In the last two columns we have looked at the relationship between mental health and one’s physical health.  One area of research that really helps illustrate this relationship is what we know about the links between depression and heart disease.

I had a close friend who was a very successful small business owner.  He was quite active, loved to travel and took up painting landscapes.  He shared his self-doubt and frustrations from time to time as friends do.  He admitted to occasional bouts of low mood which he attributed to long hours and stress of his work.  He tended to shrug off concerns that he might be depressed and never sought treatment.

Then John had a heart attack.  From a medical standpoint, he did well after hospitalization and his doctors were reassuring.  What John had not expected was the profound change he experienced over the weeks and months to follow. He lacked energy and found himself napping a great deal.  “All to be expected and it will get better,” he thought.  His doctors again reassured him.  But he found himself gloomy and often irritable with his family.  And while he had painted daily before the heart attack, he now lost all interest and the thought of picking up his brushes seemed burdensome.

While transient poor energy and depressed mood are normal following a heart attack, the continued presence of these symptoms is cause for concern. Is this just the physiological effects of a heart attack or could it be a more specific complication of depression following a heart attack? How do we understand John’s symptoms?  Is he having a psychological reaction to a serious medical event, experiencing the loss of who he was, or are his symptoms a factor of biology related to his heart and recovery?  Or perhaps a combination of these possibilities?

Here’s a bit of what research can tell us.  Depression is a serious complicating factor associated with heart disease.  Depression increases both the risk of having a heart attack and how well patients recover after having a cardiac event.  It is estimated that one in six patients who have a heart attack suffer from depression.  In one study, those with persistent depression after recovery had a 17% risk of death within six months after the heart attack versus 3% risk in patients without depression.  Depression was second only to congestive heart failure as a predictor of death within two years of a heart attack.  These findings have made the presence of clinical depression after a heart attack one of the most important predictors of outcome following a heart attack.

We also know that the treatment of depression with both medications and psychotherapy does appear to make a difference in terms of depression and quality of life for heart attack patients identified as depressed.  However it is not clear that the treatment of depression in this group of patients makes a difference in overall cardiac health and survival.  The one large study looking at antidepressant medications for this group of patients showed the incidence of severe cardiac events (death, second heart attack, congestive heart failure, stroke and recurrent chest pain) was numerically lower among patients receiving an antidepressant than those receiving a placebo.  However, it was not certain if this difference was of significance in actual clinical care.  It does appear that the newer antidepressant medications, such as selective serotonin re-uptake inhibitors (SSRIs), appear to be both effective and safe in the treatment of depression and safe for cardiac patients.  Psychotherapy and counseling may be helpful in terms of offering support, increasing the use of resources, and helping develop realistic expectation of both medications and therapy that can possibly make the difference and contribute to overall well being.

By Michael A. Keys, MD

Dr. Keys is a geriatric psychiatrist, Director of the Senior Health Program at the Lindner Center of HOPE, Mason, Ohio and Adjunct Associate Clinical Professor of Psychiatry at the University of Cincinnati College of Medicine.