Stress, anxiety and depression and its impact on Heart Disease

Written with: Leo Pozuelo, MD

Department of Psychiatry and Psychology

It is common for you to feel sad or depressed after a heart attack, cardiac surgery or procedure, recent hospitalization, or new diagnosis of heart disease. These emotions may be the result of not knowing what to expect or not being able to do simple tasks without becoming overly tired.

Temporary feelings of sadness are normal, and should gradually go away within a few weeks, as you get back to your normal routine and activities.

Sometimes, however, a depressed mood can prevent you from leading a normal life. When a depressed mood is severe and accompanied by other symptoms that persist every day for 2 or more weeks, treatment is necessary to help you cope and recover.

What is the role of depression in patients with cardiovascular disease?

Up to 15 percent of patients with cardiovascular disease and up to 20 percent of patients who have undergone coronary artery bypass graft (CABG) surgery experience major depression.¹

Studies have shown that mental stress has a negative effect on a person’s heart health. In particular:

  • Unmanaged stress can lead to high blood pressure, arterial damage, irregular heart rhythms and a weakened immune system.
  • Patients with depression have been shown to have increased platelet reactivity, decreased heart variability and increased proinflammatory markers (such as C-reactive protein or CRP), which are all risk factors for cardiovascular disease.
  • For people with heart disease, depression can increase the risk of an adverse cardiac event such as a heart attack or blood clots. For people who do not have heart disease, depression can also increase the risk of a heart attack and development of coronary artery disease.
  • In one landmark study, the continued presence of depression after recovery increased the risk of death (mortality) to 17 percent within 6 months after a heart attack (versus 3 percent mortality in heart attack patients who didn’t have depression).²
  • During recovery from cardiac surgery, depression can intensify pain, worsen fatigue and sluggishness, or cause a person to withdraw into social isolation. Patients who have had CABG and have untreated depression after surgery also have increased morbidity and mortality.
  • Patients with heart failure and depression have an increased risk of being readmitted to the hospital, and also have an increased mortality risk.
  • Early research findings have indicated there may be genetic factors that increase a patient’s risk of depression and risk of recurrent cardiac events after a heart attack.³
  • Patients with heart disease and depression also perceive a poorer health status, as manifested by Quality of Life (QoL) studies. Furthermore, heart disease patients with depression have worse treadmill exercise and medication adherence than that of patients with heart disease who do not have depression.⁴⁻⁵⁻⁶
  • Negative lifestyle habits associated with depression – such as smoking, excessive alcohol consumption, lack of exercise, poor diet and lack of social support – interfere with the treatment for heart disease.
  • Depression has been proven to be a such a risk factor in cardiac disease that the American Heart Association (AHA) has recommended that all cardiac patients be screened for depression using simple screening questions and an easy-to-administer survey called the Patient Health Questionnaire (PHQ-2).⁷

How do I know when to seek help?

If you’re recovering from heart surgery, a heart attack, or another heart condition, temporary feelings of sadness and a depressed mood are common for the first few weeks.

However, treatment is necessary when depression is severe and accompanied by other symptoms (including withdrawal from activities, not responding when visiting with family and friends, increased negative thoughts and tearfulness).

Without treatment, depression can become worse. For heart patients, depression can contribute to an increased risk of heart attack and coronary disease. Talk to your health care provide who can diagnose and start depression treatment with safe antidepressants. Your health care provider also can refer you to a mental health specialist who can provide other appropriate treatment when necessary.

When depression is negatively affecting your life — such as causing increased difficulties with relationships or performance at work or at home, it is important for you to get help to prevent things from getting worse.

More specific reasons to seek help include:

  • Your negative feelings, such as low mood or lack of experiencing pleasure, persist daily for 2 weeks or more.
  • You find it increasingly difficult to participate in your recovery from heart disease. It is not uncommon for patients participating in cardiac rehabilitation to experience emotional difficulties during their physical recovery. A lack of mental drive or motivation, as well as a lack of confidence may indicate that depression has settled in.
  • You have significant difficulty with your daily routine, social activities and/or work.
  • You don’t have anyone in whom you can confide. If you don’t have anyone to share your thoughts with, it’s hard to know if what you’re thinking makes sense. Depression also has a tendency to make people more withdrawn and isolated, making it harder to receive social support during difficult times.
  • You have suicidal thoughts or feelings. Suicide is an irreversible solution to problems and causes permanent harm not only to yourself, but also to family members and friends. If you are having thoughts of suicide, call your physician or local 24-hour suicide hotline right away, or go to the nearest emergency room for help.

Depressive disorders result from a mix of factors

  • A person’s family history, physical health, state of mind and environment.
  • High levels of stress, life transitions, loss and many other factors.
  • Imbalances in the chemicals that the body uses to control mood.

Last reviewed by a Cleveland Clinic medical professional on 04/29/2019.

References

  1. Reference: Jiang W, Davidson JRT. Antidepressant therapy in patients with ischemic heart disease. American Heart Journal, November 2005. 150(5):871-881.
  2. Reference: Frasure-Smith N, et al. Depression following myocardial infarction: Impact on 6-month survival. JAMA, October 20, 1993. 270(15):1819-1825.
  3. Reference: Nakatani D, et al. Influence of serotonin transporter gene polymorphism on depressive symptoms and new cardiac events after acute myocardial infarction. American Heart Journal, October 2005. 150(4):652-658.
  4. Ruo B, et al. Depressive symptoms and health-related quality of life: the Heart and Soul Study. JAMA, July 9, 2003. 290(2):215-221.
  5. Gehi AK, et al. Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: the Heart and Soul Study. Archives of Internal Medicine, November 2005. 165(2):2508-2513.
  6. Gehi AK, et al. Relation of self-reported angina pectoris to inducible myocardial ischemia in patients with known coronary artery disease: the Heart and Soul Study. The American Journal of Cardiology, September 15, 2003. 92(6):705-707.
  7. Litchman JH, et al. Depression and coronary heart disease: Recommendations for screening, referral and treatment. A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation, Oct 21 2008. 118(17):1768-1775.
  8. Blumenthal JA, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine 2007. 69(7):587-596.
  9. Lesperance F, et al. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: The Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA, 2007. 297(4):367-379.
  10. Frasure-Smith N., et al. Design and rationale for a randomized, controlled trial of interpersonal psychotherapy and citalopram for depression in coronary artery disease (CREATE). Psychosomatic Medicine, 2006. 68:87-93.
  11. Glassman AH, et al. Onset of major depression associated with acute coronary syndromes: relationship of onset, major depressive disorder history, and episode severity to sertraline benefit. Archives of General Psychiatry, 2006. 63(3):283-288.
  12. Glassman AH, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA, 2002. 288(6):701-709.
  13. Writing Committee for the ENRICHD Investigators. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Disease patients (ENRICHD) randomized trial. JAMA, 2003. 289(23):3106-3116.

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