Depression and Heart Disease
By Emily York-Crowe, Ph.D. and James A. Blumenthal, Ph.D.
Edited by Dr. Alan Kronhaus, Health and Wellness Editor

Depression is a common problem and an insidious disorder, especially among women. It can express itself in a wide range of physical symptoms, and increases the risk for drug and alcohol abuse, absenteeism from work, lost productivity, and marital distress. It is associated with a variety of physical health problems, including coronary heart disease.

Coronary heart disease is the leading cause of death for adults in the United States. In 2002, heart disease was responsible for 29% of all U.S. deaths, with women accounting for over half of those deaths. Most people are familiar with the traditional risk factors for heart disease: cigarette smoking, high cholesterol, diabetes, and high blood pressure, but few are aware that psychosocial factors, such as depression, also play a major role in the heart disease. This article will summarize the recent evidence that depression is a risk factor for heart disease, discuss potential treatments for depression, and describe a new research study currently being conducted by investigators at Duke University and the University of North Carolina at Chapel Hill.

What is Depression?
Common symptoms of depression include the following:
• Depressed mood, sad mood, or irritable mood most of the day;
• Reduced interest or pleasure in all, or almost all activities;
• Significant weight loss when not dieting, or decrease in appetite;
• Insomnia or hypersomnia (not sleeping enough or sleeping too much);
• Restlessness or agitation, or significant slowing down that is observable by others;
• Fatigue or loss of energy;
• Feelings of worthlessness or excessive or inappropriate guilt;
• Difficulty concentrating or thinking, or indecisiveness;
• Recurrent thoughts of death, recurrent thoughts of suicide.

All of these symptoms are not necessary for depression to be present, and sometimes these symptoms can be due to a medical condition, or can be better accounted for by bereavement. Depression is diagnosed when a person is feeling depressed, sad or irritable, loses interest in activities, has some of the other symptoms listed above for two weeks or longer, and experiences significant distress as a result.

Depression and Heart Disease
Research conducted in the United States and elsewhere has shown that depression is associated with an increased risk for cardiac events in healthy people. Some evidence suggests that the impact of clinical depression may even be comparable to traditional risk factors, such as smoking, diabetes, and high cholesterol.
Depression is also an important risk factor for patients who already have a heart condition. For example, it was shown in one study to increase the risk of death in patients hospitalized with a heart attack compared to similar patients who were not depressed. In addition, a study at Duke University found that elevated depression also increased the risk of death among patients who underwent coronary bypass surgery, or patients with heart failure.

Treating Depression
Treating depression is important not only because depression adversely affects peoples’ quality of life, but also because depression is associated with an increased risk for poor health outcomes, especially among people with heart disease. There are a number of effective treatments available, but depression remains inadequately treated particularly in older adults.

Antidepressant Medication: Antidepressant medication is the most commonly used treatment for depression in the United States. Antidepressant medication has been particularly effective in reducing symptoms of depression and restoring overall functioning. Research has found selective serotonin reuptake inhibitors (SSRIs) to be safe and effective, particularly for cardiac patients. Although the mechanisms of action are not fully understood, SSRIs such as Paxil and Zoloft appear to work by restoring a chemical balance of serotonin in the brain. While many patients improve with anti-depressant medications, there is controversy about how much of the therapeutic benefit results from the drug, and how much may be related to patient expectations and the so-called “placebo effect”. Despite the success of anti-depressant medication in most people with depression, medication fails to fully reduce depressive symptoms or is associated with unwanted side effects in a significant number. Adverse effects may be relatively more common or more problematic in older cardiac patients. Thus, there continues to be a need to identify alternative approaches for treating depression, particularly in cardiac patients.

Psychotherapy: Research has shown that certain types of psychotherapy can as also be effective in treating depression, particularly when provided by experienced therapists. Some studies have shown that psychotherapy may be as effective as antidepressant medication even in patients with moderate to severe depression.

Botanical, dietary and energy-based treatments: A variety of botanical, dietary and energy-based approaches have been studied including St. John’s Wort, S-adenosylmethionine (SAMe), omega 3 Fatty Acids, Chromium picolinate, and acupuncture. Evidence was strongest for St. John’s wort as being superior to placebo, although recent evidence cast some doubt over the value of St. John’s Wort over placebo pills. Overall, it does not suggest a significant contribution to treating depression for any of these “alternatives.”

Exercise: Extensive research has shown that exercise reduces the risk of fatal and non-fatal cardiac events. An increasing number of studies have also shown beneficial effects of exercise on psychological functioning, including improvements in mood and cognitive performance that may be as powerful in some patients as the effect of antidepressant medication.

Treating Depression in Cardiac Patients: To date, few studies have examined the effects of treating depression in cardiac patients with exercise or antidepressant medication. A large scale epidemiologic study found that heart patients who exercised had a 50% lower risk of dying compared to their sedentary counterparts, but what is needed is a randomized trial of exercise in heart patients.

UPBEAT is a new research study at Duke University Medical Center that aims to compare the effects of exercise and antidepressant medication relative to a placebo on depression and on the physical signs associated with the risk of death among heart patients who exhibit elevated depressive symptoms. In this study, 200 heart patients will be randomly (i.e., by chance) assigned to one of three treatment conditions: supervised exercise at one of our participating exercise facilities in Durham, Chapel Hill, Raleigh, or Henderson, NC.; medication (Zoloft); or a placebo pill for 4 months of treatment.

In order to qualify for UPBEAT, patients must: (a) have experienced a heart attack, had coronary angioplasty, stenting, or bypass surgery, or had an abnormal cardiac catheterization, (b) be 35 years or older, (c) be experiencing symptoms of depression; (d) NOT currently taking antidepressant medication, exercising regularly, or in psychotherapy, and (e) be willing to be randomly assigned to one of the three treatment groups. In addition to receiving free treatment, patients will be compensated for their time.

If you would like to participate or have any questions, please contact Dr. Sharon Rogers, UPBEAT Study Coordinator at (919) 681-3903.

Dr. Kronhaus is a recognized expert in the medical field and the owner of Doctors Making Housecalls, 919.932.5700, www.doctorsmakinghousecalls.com

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