Depression Can Threaten Recovery After a Heart Attack

When the flow of blood becomes blocked to part of the heart muscle, and the heart can’t get the oxygen it needs to function, everything stops.

Fortunately, a heart attack – the most common cause of death – doesn’t always kill. Quick treatment, such as an artery-opening stenting procedure or bypass surgery to improve blood flow, can limit damage. But a heart attack can still reduce the capacity of a person’s heart muscle to pump, knock a person off his or her feet and have a deep impact on an individual’s mental state.

Those who felt bulletproof before suddenly don’t anymore. “You no longer feel … invulnerable,” says Dr. Stephanie Coulter, a cardiologist and medical director of the Center for Women’s Heart and Vascular Health at the Texas Heart Institute in Houston. Practically speaking, experts say, a brush with death can spur a person to make long-overdue, needed lifestyle changes, from quitting smoking and exercising to eating a heart-healthy diet. Sometimes a pep talk is about all it takes, Coulter says, to lift a person’s spirits and to get back on track for recovery. For many, however, the same fateful concerns and mortal reckoning that can serve as a wake-up call are associated with a heavy darkness they just can’t shake.

“Depression rates are remarkably high after someone has had a heart attack. They range anywhere from 20 to 40 percent,” says Karina Davidson, a clinical psychologist and professor of medicine and psychiatry at Columbia University Medical Center in New York City. “We don’t know the exact reason for this. There has been some speculation that it’s just the shock and adjustment of having a very life-threatening disease. But, in fact, untreated, depression can last for many months or even years after a heart attack.” Davidson, who directs CUMC’s Center for Behavioral Cardiovascular Health, adds that inflammatory or neurohormonal changes that occur with a heart attack may also be part of the cascade that leads to depression.

Where nearly 7 percent of adults, in general, suffer from major depression in a 12-month period, according to the National Institute of Mental Health, 20 percent of heart attack survivors suffer from major depression. Though statistics vary, that represents a threefold increase, says Barry Jacobs,​ a clinical psychologist, director of behavioral sciences at the Crozer-Keystone Family Medicine Residency Program in Springfield, Pennsylvania, and an American Heart Association volunteer. Many more suffer from mild depression.

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Besides undermining quality of life, depression can severely inhibit recovery, including making it less likely patients will take prescribed medications or make difficult recommended lifestyle changes, like eating better. “Folks who are depressed – who may feel hopeless and helpless – have less initiative to really engage in activities that would help their recovery,” Jacobs says. “There are lots of people who eat high-carbohydrate foods in order to help themselves feel better, and when people are depressed, they’re more prone to do that. So that would certainly not aid their heart attack recovery.”

Just as women are more likely to die from heart disease and experience depression, as compared with men, they’re also more likely to become depressed after a heart attack, Coulter says. Not surprisingly, those who already had depression – an independent risk factor for cardiovascular health issues – are more likely to suffer from it post-heart attack.

“People who are depressed are at much higher risk of having another cardiac event, which could potentially kill them,” Jacobs says. Those diagnosed with major depression or who have symptoms indicating they have major depression after a heart attack – including that it impairs their ability to function – face almost twice the risk of having a future heart attack and are one and a half times more likely to die prematurely, Davidson says.

But while cardiologists typically inquire about other risk factors, they routinely fail to screen patients for depression after a heart attack. Previous research finds about 7 in 10 cardiologists failed to inquire about depression in more than half of their cardiac patients, even though depression is more common following cardiac events and procedures. “We really need to address this issue in a more systematic way,” says Coulter, who has done research on treating depression to reduce cardiac risk and improve outcomes.

Randomized controlled trial study data doesn’t yet exist to prove the working hypothesis that, since depression can worsen outcomes following a heart attack, treating depression will improve recovery. “It seems obvious on the face of it, but really you want to have trial data to support that,” Davidson says. Still, experts advise those who feel depression is affecting quality of life and undermining their ability to function as well as inhibiting recovery to seek treatment.

Medication and talk therapy – and frequently the combination – are generally the most effective treatment for depression post-heart attack, as in general, though experts say different people respond differently to treatment. Jacobs notes that primary care providers, who patients see most frequently for care, are most often the first to treat psychological issues, including depression; they can also refer patients to mental health professionals.

“People have a lot of fears about returning to cherished activities, including sex, after a heart attack,” says Jacobs, adding it’s helpful to talk through those fears. He thinks those struggling with depression can benefit from simpler forms of counseling, too, such as the education and encouragement offered in cardiac rehab. “Cardiac rehab to me is a very important psychological intervention, let alone a physical intervention for post-heart attack patients,” he says. Coulter agrees. “They’re exercising in rehab, and exercise has always been well-shown, in patients that are depressed, to improve outcomes,” she says. That’s in addition to rehab supporting lifestyle changes and doctors’ orders to bolster recovery after heart attack. “I’m really in favor of cardiac rehab. It’s underutilized big time,” Coulter says.

In the flourish to save a patient’s life, a person’s mental state may understandably not get the same attention as, say, a surgical intervention and other follow-up care during and immediately following a heart attack, Coulter says; but ultimately, she notes, a person’s psyche can make all the difference in how well that individual bounces back from that heart attack, which can so profoundly affect body and mind. “For many, it’s a life-defining event. So the advice would be, if your symptoms of melancholy or lack of interest or motivation are interfering in your functioning or if you’re fearful or having anxiety, then those really just need to be addressed.”
TAGS: health patients patient advice heart attacks heart surgery heart disease heart healthdepression

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