Depression can strike anyone. However, research over the past two
decades has shown that people with heart disease are more likely to
suffer from depression than otherwise healthy people, and conversely,
that people with depression are at greater risk for developing heart
disease.1
Furthermore, people with heart disease who are depressed have an
increased risk of death after a heart attack compared to those who are
not depressed.2
Depression may make it harder to take the medications needed and to
carry out the treatment for heart disease. Treatment for depression
helps people manage both diseases, thus enhancing survival and quality
of life.
Heart disease affects an estimated 12.2 million American women and
men and is the leading cause of death in the U.S.3
While about 1 in 20 American adults experiences major depression in a
given year, the number goes to about 1 in 3 for people who have survived
a heart attack.4,5
Depression and anxiety disorders may affect heart rhythms, increase
blood pressure, and alter blood clotting. They can also lead to elevated
insulin and cholesterol levels. These risk factors, with obesity, form a
group of signs and symptoms that often serve as both a predictor of and
a response to heart disease. Furthermore, depression or anxiety may
result in chronically elevated levels of stress hormones, such as
cortisol and adrenaline. As high levels of stress hormones are signaling
a "fight or flight" reaction, the body's metabolism is
diverted away from the type of tissue repair needed in heart disease.
Despite the enormous advances in brain research in the past 20 years,
depression often goes undiagnosed and untreated. Persons with heart
disease, their families and friends, and even their physicians and
cardiologists (physicians specializing in heart disease treatment) may
misinterpret depression's warning signs, mistaking them for inevitable
accompaniments to heart disease. Symptoms of depression may overlap with
those of heart disease and other physical illnesses. However, skilled
health professionals will recognize the symptoms of depression and
inquire about their duration and severity, diagnose the disorder, and
suggest appropriate treatment.
Depression is a serious medical condition that affects thoughts,
feelings, and the ability to function in everyday life. Depression can
occur at any age. NIMH-sponsored studies estimate that almost 10 percent
of American adults, or about 19 million people age 18 and older,
experience some form of depression every year.4
Although available therapies alleviate symptoms in over 80 percent of
those treated, less than half of people with depression get the help
they need.4,6
Depression results from abnormal functioning of the brain. The causes
of depression are currently a matter of intense research. An interaction
between genetic predisposition and life history appear to determine a
person's level of risk. Episodes of depression may then be triggered by
stress, difficult life events, side effects of medications, or other
environmental factors. Whatever its origins, depression can limit the
energy needed to keep focused on treatment for other disorders, such as
heart disease.
Heart disease includes two conditions called angina pectoris and
acute myocardial infarction ("heart attack"). Like any muscle,
the heart needs a constant supply of oxygen and nutrients that are
carried to it by the blood in the coronary arteries. When the coronary
arteries become narrowed or clogged and cannot supply enough blood to
the heart, the result is coronary heart disease. If not enough
oxygen-carrying blood reaches the heart, the heart may respond with pain
called angina. The pain is usually felt in the chest or sometimes in the
left arm and shoulder. (However, the same inadequate blood supply may
cause no symptoms, a condition called silent angina.) When the blood
supply is cut off completely, the result is a heart attack. The part of
the heart that does not receive oxygen begins to die, and some of the
heart muscle may be permanently damaged.
Chest pain (angina) or shortness of breath may be the earliest signs
of heart disease. A person may feel heaviness, tightness, pain, burning,
pressure, or squeezing, usually behind the breastbone but sometimes also
in the arms, neck, or jaws. These signs usually bring the person to a
doctor for the first time. Nevertheless, some people have heart attacks
without ever having any of these symptoms.
Risk factors for heart disease other than depression include high
levels of cholesterol (a fat-like substance) in the blood, high blood
pressure, and smoking. On the average, each of these doubles the chance
of developing heart disease. Obesity and physical inactivity are other
factors that can lead to heart disease. Regular exercise, good
nutrition, and smoking cessation are key to controlling the risk factors
for heart disease.
Heart disease is treated in a number of ways, depending on how
serious it is. For many people, heart disease is managed with lifestyle
changes and medications, including beta-blockers, calcium-channel
blockers, nitrates, and other classes of drugs. Others with severe heart
disease may need surgery. In any case, once heart disease develops, it
requires lifelong management.
Effective treatment for depression is extremely important, as the
combination of depression and heart disease is associated with increased
sickness and death. Prescription antidepressant medications,
particularly the selective serotonin reuptake inhibitors, are generally
well-tolerated and safe for people with heart disease. There are,
however, possible interactions among certain medications and side
effects that require careful monitoring. Therefore, people being treated
for heart disease who develop depression, as well as people in treatment
for depression who subsequently develop heart disease, should make sure
to tell any physician they visit about the full range of medications
they are taking.
Specific types of psychotherapy, or "talk" therapy, also
can relieve depression. Ongoing research is investigating whether these
treatments also reduce the associated risk of a second heart attack.
Preventive interventions based on cognitive-behavior theories of
depression also merit attention as approaches for avoiding adverse
outcomes associated with both disorders. These interventions may help
promote adherence and behavior change that may increase the impact of
available pharmacological and behavioral approaches to both diseases.
Exercise is another potential pathway to reducing both depression and
risk of heart disease. A recent study found that participation in an
exercise training program was comparable to treatment with an
antidepressant medication (a selective serotonin reuptake inhibitor) for
improving depressive symptoms in older adults diagnosed with major
depression.7
Exercise, of course, is a major protective factor against heart disease
as well.
Use of herbal supplements of any kind should be discussed with a
physician before they are tried. Recently, scientists have discovered
that St.
John's wort, an herbal remedy sold over-the-counter and promoted as
a treatment for mild depression, can have harmful interactions with some
other medications. (See the alert on the NIMH Web site:
http://www.nimh.nih.gov/events/stjohnwort.cfm.)
Treatment for depression in the context of heart disease should be
managed by a mental health professional—for example, a psychiatrist,
psychologist, or clinical social worker—who is in close communication
with the physician providing the heart disease treatment. This is
especially important when antidepressant medication is needed or
prescribed, so that potentially harmful drug interactions can be
avoided. In some cases, a mental health professional that specializes in
treating individuals with depression and co-occurring physical illnesses
such as heart disease may be available.
While there are many different treatments for depression, they must
be carefully chosen by a trained professional based on the circumstances
of the person and family. Recovery from depression takes time.
Medications for depression can take several weeks to work and may need
to be combined with ongoing psychotherapy. Not everyone responds to
treatment in the same way. Prescriptions and dosing may need to be
adjusted. No matter how advanced the heart disease, however, the person
does not have to suffer from depression. Treatment can be effective.
Other mental disorders, such as bipolar
disorder (manic-depressive illness) and anxiety
disorders, may occur in people with heart disease, and they too can
be effectively treated. For more information about these and other
mental illnesses, contact NIMH.
Remember, depression is a treatable disorder of the brain. Depression
can be treated in addition to whatever other illnesses a person might
have, including heart disease. If you think you may be depressed or know
someone who is, don't lose hope. Seek help for depression.
National Institute of Mental Health (NIMH)
Office of Communications
Information Resources and Inquiries Branch
6001 Executive Blvd., Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
TTY: 301-443-8431
Fax: 301-443-4279
Mental Health FAX 4U: 301-443-5158
E-mail: nimhinfo@nih.gov
Web site: http://www.nimh.nih.gov
National Heart, Lung, and Blood Institute
(NHLBI)
Information Center
P.O. Box 30105
Bethesda, MD 20824-0105
Phone: 301-592-8573
Heart Health Toll-Free Information Line:
1-800-575-WELL
E-mail: NHLBIinfo@rover.nhlbi.nih.gov
Web site: http://www.nhlbi.nih.gov
1Nemeroff CB,
Musselman DL, Evans DL. Depression and cardiac disease. Depression
and Anxiety, 1998; 8(Suppl 1): 71-9.
2Frasure-Smith
N, Lesperance F, Talajic M. Depression and 18-month prognosis after
myocardial infarction. Circulation, 1995; 91(4): 999-1005.
3Morbidity
and mortality: 2000 chart book on cardiovascular, lung, and blood
diseases. National Heart, Lung, and Blood Institute, 2000.
http://www.nhlbi.nih.gov/resources/docs/00chtbk.pdf
4Regier DA,
Narrow WE, Rae DS, et al. The de facto mental and addictive disorders
service system. Epidemiologic Catchment Area prospective 1-year
prevalence rates of disorders and services. Archives of General
Psychiatry, 1993; 50(2): 85-94.
5Lesperance F,
Frasure-Smith N, Talajic M. Major depression before and after myocardial
infarction: its nature and consequences. Psychosomatic Medicine,
1996; 58(2): 99-110.
6National
Advisory Mental Health Council. Health care reform for Americans with
severe mental illnesses. American Journal of Psychiatry, 1993;
150(10): 1447-65.
7Blumenthal JA,
Babyak MA, Moore KA, et al. Effects of exercise training on older
patients with major depression. Archives of Internal Medicine,
1999; 159(19): 2349-56.
All material in this brochure is in the public domain and may
be reproduced or copied without permission from the Institute. Citation
of the National Institute of Mental Health as the source is appreciated.
