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Link Between Depression and Heart Disease
Hostility, Social Interaction & Depression
Can Depression Harm the Heart
Depressed Heart Patients Go Untreated

Examination of the Link Between Depression and Heart Disease:

Over the years, evidence has been mounting that depressed people are more likely to suffer from heart disease and that many people with heart disease are depressed. Researchers are now trying to determine which comes first: does depression cause heart disease or does having heart disease cause depression, and, how can the link between these two diseases be broken?

Approximately one out of every six people in the general population will have a "clinical" episode of major depression sometime in their lives-- In patients with heart disease, approximately half will suffer from major depression at some point in their lives. Additional studies augment this theory. Research led by Dr. Nancy Frasure-Smith of the Montreal Institute of Health followed over 200 heart attack patients and found that those who suffered from depression were four times as likely to die within six months of their heart attacks as those patients who were not depressed. The researchers found that depression was just as good a predictor of looming death as previous heart attacks and poor heart functioning.

Dr. Robert M. Carney, a professor of medical psychology at Washington University in St. Louis, found that patients who had just been diagnosed with heart disease and were also depressed were twice as likely as non-depressed new heart patients to suffer from a heart attack or require bypass surgery within 12 months of their diagnosis.

Doctors are also concerned that many depressed heart patients are either not treated at all for their depression, misdiagnosed when they do seek treatment, or treated incorrectly, such as being prescribed sedatives, which makes depression worse.

More recent research seems to indicate that depression leads to heart disease. In a study led by Dr. William W. Eaton of the Johns Hopkins School of Hygiene and Public Health in Baltimore, researchers followed approximately 1,500 "healthy" (no evidence of heart disease) people over a 14 year period from 1981 to 1995. During this 14 year period, researchers found that those subjects who were depressed suffered from heart attacks at a rate that was four times higher than that of subjects who did not suffer from depression.

Further research into biochemical changes caused by depression may lead to the answers. Evidently, people who suffer from depression have hearts that beat faster, even when sleeping. In addition, several other biochemical reactions occur in depressed people: their heart rhythms do not regulate well to modifications in activities, they have a greater tendency toward high blood pressure and their blood clots more easily. All of these factors result in more stress on the blood vessels and the heart. While depressed patients say they are sad and lethargic, their stress hormones are paradoxically working overtime. Researchers believe that this oversecretion of stress hormones (particularly cortisol) causes a depressed person to be in a constant state of arousal and anxiety, and causes them to ignore other important stimuli such as the need to eat, sleep, and have sex. In addition, this hypersensitive state can last for weeks, months, and even years. Increased cortisol production in depressed patients can intensify arrhythmia as well as cause decreases in secretion of growth hormones which has the result of shifting cholesterol production from the good (HDL) which protects blood vessels, to the bad (LDL). Cortisol can also cause abdominal fat to amass which increases the risk of heart attack.

In addition, Dr. Richard Veith, a professor of psychiatry and behavioral science at the University of Washington in Seattle, has found that depressed patients have norepinephrine levels in the blood that are 30% higher than in non-depressed patients. This stress hormone causes the heart rate to accelerate and raises blood pressure.

On the positive side, all drugs that are used to treat depression also control the overabundance of cortisol secretion. However, scientists note that currently there are no direct studies which prove that intervention helps to reduce the risk of death and heart attack. The National Heart, Lung and Blood Institute is commencing such a study which will involve 3,000 heart attack patients throughout the United States. HeartInfo will report on this study's findings, when they become available.

SOURCE: The New York Times, January 14, 1997.

Editorial Comment: The interest in depression and heart disease is increasing, as it is recognized that many people with heart disease are depressed but also that depression may be a risk factor for a first or second heart attack. Physicians need to recognize and treat depression more actively. If you are depressed, bring it to the attention of your doctor--it may be a good thing for your heart to talk about it!

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Hostility, Social Isolation, & Depression

For both men and women, says Prevention advisor, Redford Williams, MD, Professor of Psychiatry and Director of the Behavioral Medicine Research Center at Duke in Durham, NC, the latest studies link three psychosocial risk factors to a higher risk and worse prognosis for heart disease--hostility, social isolation, and depression. As Dr. Williams explains, men are more likely to have hostility and less likely to have social support. Women tend to have more social support and less hostility -- but they're twice as likely to experience depression. Could depression be one factor explaining why heart disease kills as many women as men? Nancy Frasure-Smith, Ph.D., associate professor of psychiatry and nursing at Montreal University, tracked 613 men and 283 women who'd had heart attacks. "We found that people who were depressed -- men or women -- were three to four times more likely to die of cardiac causes. That makes depression as dangerous to the heart as traditional risk factors like high blood pressure or smoking."

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Can depression harm the heart?

Dr. Ziegelstein, who did a similar study of depression and mortality in more than 200 male and female heart attack patients, offers some theories. "We found that patients who were depressed had lower adherence to a risk-reduction program," says Dr. Ziegelstein. "Depressed people often lose interest in helping themselves." Another possible explanation, says Dr. Ziegelstein, is a link between the heart and the brain. "The damaging processes may be tied to the level of serotonin in the brain, which may make them more apt to develop a fatal rhythm abnormality." Whatever the cause, our experts agreed, research suggests pervasive sadness after a heart attack should be addressed and treated promptly. "A lot of people think that very mild depression after a heart attack is perfectly normal and will go away by itself," says Dr. Ziegelstein. "And in many instances, they're correct. But if it doesn't, it should be cause for concern."

In particular, alarms should go off if the depression is very deep or lasts longer than a month. "Even milder forms of sadness that go on for longer than a month after a heart attack need attention," says Dr. Ziegelstein. He notes that, in some cases, mild depression could be a reaction to medication, and the patient may need the doctor to make an adjustment. (Never stop taking heart medication without consulting your physician.) Or it may be that the person needs additional psychological and emotional help. It's critical to raise the issue with your doctor. "And if the doctor doesn't respond," says Dr. Ziegelstein, " get a new doctor or ask for a referral to a psychiatrist or a psychologist."
By Cathy Perlmutter with Laura Goldstein

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Most Depressed Heart Failure Patients Go Untreated

Doctor's Guide February 16, 1998
Major depression is common among patients who have been hospitalized with congestive heart failure (CHF), but most older depressed patients receive neither antidepressants nor psychotherapy.

Harold G. Koenig, MD, of Duke University Medical Center, reports in the February issue of the journal, General Hospital Psychiatry, that only 44 percent of depressed CHF patients age 60 or older received any treatment for depression, either during hospitalization or during the year after being discharged. "Those with major depression - despite a worse diagnosis - were not more likely to receive treatment than those with minor depression," he writes. "This relatively low rate of treatment for depression is cause for concern given its long duration, impact on service use and effects on the quality of life." He reported that depressed patients were no more likely than nondepressed patients to see mental health specialists either before hospitalization or after being discharged.

Koenig's study, based on records of 542 patients aged 60 and over screened for depression upon admission to Duke University Medical Center, found 58 percent of those admitted for CHF were depressed. Among the 342 cases that qualified as cases or controls for his study he studied 107 CHF patients, 36.5 percent of whom had major depression - significantly higher than the 25.5 percent depression rate among non-CHF patients. "(CHF) patients often remained depressed for a prolonged period," Koenig reported, "and over 40 percent failed to remit during the year following discharge.... The only factor that predicted faster time to remission was social support.... Physical health factors did not affect speed of remission, once situational and social factors were controlled." He noted that for each point of increase on a social support index the speed of remission of depression increased by 16 percent.

Among other findings: During the three months before admission to the hospital, depressed patients averaged two to three times more medical visits than those without depression; even after controlling for the severity of their physical illness, they still saw physicians more often, "suggesting that the depression itself might have contributed to the increased frequency." Between three and nine months after discharge, patients with major depression were readmitted to the hospital twice as often as nondepressed patients - 55 percent compared to 28 percent between three and six months, 41 percent compared to 18 percent between six and nine months.

The study was funded by the National Institute of Mental Health and an NIH, NIA Claude D. Pepper Older Americans Independence Centers grant. This news story was printed from *Doctor's Guide to the Internet* located at

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Last Modified on Oct. 8, 2001

We would like to thank Jon from Jonsplace for the use of his Heartman graphic.