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Posted: October 14, 2008

Depression Tied to Heart Disease; Patients Should Be Screened, Treated

 Depression is about three times more common in heart attack patients than in the general population, and heart patients should be screened for depression on a routine basis and treated if necessary, according to a recommendation from the American Heart Association.

The AHA recommendation is the association’s first scientific statement on depression and coronary heart disease. It was endorsed by the American Psychiatric Association and published in the medical journal Circulation.

The recommendations include:

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• early and repeated screening for depression in heart patients;
• the use of two questions to screen heart patients, and if depression is suspected ask seven other questions;
• coordinated follow-up for both heart disease and depressive symptoms in patients who have both conditions.

“The statement was prompted by the growing body of evidence that shows a link between depression in cardiac patients and a poorer long-term outlook,” said Erika Froelicher, R.N., M.A., M.P.H., Ph.D., a professor at the University of California San Francisco, School of Nursing and Medicine and co-chair of the recommending group.

The Circulation article quoted Dale Briggs, who experienced depression after his heart valve surgery, as welcoming the recommendation. “I think it’s long overdue. It is unfortunate that some patients aren’t warned of the possibility of some depression after surgery,” he said. 

Briggs is the volunteer executive vice president of Mended Hearts, Inc., a national non-profit organization affiliated with the AHA, offering resources and support for heart surgery patients. He shares his experience with new cardiac patients during hospital visits, one of the main patient-to-patient support services offered by Mended Hearts. 

“Since my surgery, I’ve visited about 1,000 patients. During a visit, I always let patients know that this may happen, and encourage them to talk to their doctor about getting treatment,” he said. “I’ve had a number of people call me through the years and thank me for warning them about the possibility of depression.”

Experts say depressed cardiac patients have at least twice the risk of second events in the one to two years after a heart attack. Furthermore, studies have shown that more severe depression is associated with earlier and more severe second cardiac events, Froelicher said.

For example, one study found that 15% to 20% of hospitalized heart attack patients met the clinical measurement criteria for major depression. An even greater proportion showed more depressive symptoms than usual in the population, though not sufficient to meet these criteria. The study also found that some subgroups of patients, such as young women with heart disease, seem particularly vulnerable to depression.

“Studies show that depression is about three times more common in patients following a heart attack than in the general community,” said Judith H. Lichtman, Ph.D., M.P.H., writing co-chair of the statement and associate professor of epidemiology at Yale University School of Medicine in New Haven, Connecticut. “Because there has been no routine screening for depression in heart patients, we think there is a large group of people who could benefit from appropriate treatment.”

Although depression was mentioned in earlier AHA scientific statements, this is the first to specifically target the condition. Lichtman said more research is needed to determine why depression is associated with poorer outcomes.

Recent studies indicate that depressed patients are less likely to take their medicines as directed, improve their diets, exercise and attend cardiac rehabilitation sessions, all of which could contribute to a worse outcome, Lichtman said.

It’s also possible that biological changes associated with depression such as reduced heart rate variability and increases in blood factors that encourage clot formation could increase risk, the statement said. 

Other recommendations in the AHA statement include:

• Patients who have depressive symptoms should be evaluated by a professional qualified in diagnosing and managing depression, and should be screened for other psychiatric disorders, such as anxiety.
• Treatment options include cognitive behavioral therapy, physical activity, cardiac rehabilitation, antidepressant drugs or combinations of those treatments.
• Selective serotonin reuptake inhibitor (SSRI) treatment soon after a heart attack is considered safe, relatively inexpensive and may be effective for treating depression.
• Routine screening for depression in coronary heart disease patients should be done in multiple settings, including the hospital, physician’s office, clinic and cardiac rehabilitation center, to avoid missing the opportunity to effectively treat depression in cardiac patients and improve physical health outcomes.
• Coordination of care between health providers is essential for patients with combined medical and psychiatric diagnoses.

“Depression and heart disease seem to be very much intertwined,” Lichtman said. “You can’t treat the heart in isolation from the patient’s mental health.”

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