A heart attack, like any other brush with death, can unleash intense waves of emotion. Many survivors feel scared and nervous, even though they're grateful to be alive. And unfortunately, many also slip into depression. Though feeling bleak may seem like a perfectly natural reaction to heart trouble, depression shouldn't be taken lightly. Left untreated, the condition can sap a heart patient's strength and even hasten death. Those who have recently suffered a heart attack should know that overcoming depression can be the key to recovery.
How common is depression after a heart attack?
Very common. The days and weeks immediately following a heart attack can be rocky. Major depression strikes about 20 percent of all people recovering from an attack, and another 20 percent suffer mild depression. The depression may fade over time, but the relief often turns out to be temporary. In any given year, one out of three long-term survivors of heart attack will slip into depression.
How dangerous is depression?
Severe depression can interfere with daily tasks just as surely as severe heart disease, sometimes to an even greater degree. And for heart patients, depression can even be deadly. Patients with major depression are three to four times as likely as other patients to die within six months of a heart attack. They are also more likely to suffer future heart attacks or return to the hospital for heart trouble.
Why are depression and heart disease such a dangerous mix? Part of the explanation lies in the body's reaction to stress. Depression can trigger the release of adrenaline and other "stress" hormones that have the potential to increase the heart rate, boost blood pressure, damage the inner lining of the heart muscle, and disrupt the heart's rhythm. The hormones can also speed the buildup of fatty plaques in the arteries, setting the stage for another heart attack.
On a more basic level, depression can simply sap a person's will to fight heart disease. A study reported in the Archives of Internal Medicine found that severely depressed heart patients were less likely than nondepressed patients to exercise regularly, give up smoking, eat a low-fat diet, or generally follow their doctor's advice.
How can I protect myself from depression?
First, be aware that clinical depression is not a normal part of recovery. Second, remember that cardiologists and primary care doctors may not realize their patients are depressed. To best protect yourself or a loved one from the burden of depression, you'll have to watch for the signs yourself. According to the National Institute of Mental Health, you should suspect depression if a person has five or more of the following symptoms for at least two weeks:
- frequent feelings of sadness or emptiness
- loss of interest in pleasurable activities
- strange eating or sleeping patterns
- excessive crying
- thoughts of suicide and death
- difficulty concentrating or remembering
- feelings of worthlessness or helplessness
- unexplained aches and pains that don't respond to treatment
If you think you or a loved one may be suffering from depression, seek help right away from a family doctor or a mental health specialist. You may also want to join a support group for heart attack survivors, such as Mended Hearts, which is sponsored by the American Heart Association.
Are antidepressants safe for heart patients?
There's still much uncertainty about the safe use of antidepressants in patients with coronary artery disease. Tricyclic antidepressants, such as Elavil (amitriptyline), cause irregular, slow, or rapid heartbeat and other cardiac conduction disturbances, as well as a sudden drop in blood pressure and dizziness upon rising; these problems can be especially difficult to manage in patients with heart disease. The drugs' ability to ease irregular heartbeats were once thought to benefit patients with frequent premature contractions of the ventricle (which they may experience as "skipping a heart beat.") Studies have shown, however, that class I antiarrhythmic drugs increase mortality rates in patients who've previously had a heart attack. This finding raises the concern that the same effect could occur with tricyclic antidepressants.
Medications that depress serotonin levels such as Prozac (fluoxetine) represent a promising alternative to tricyclic drugs for the treatment of depression accompanying heart disease, although experts say further evaluation is needed. In patients without cardiovascular disease, these antidepressants rarely cause problems in blood flow or cardiac conduction, although symptoms of bradycardia (slow heartbeat) have been reported. In patients with stable heart disease, including patients with prior heart attacks and subsequent harm to the left ventricle, recent studies have shown that selective serotonin reuptake inhibitors (SSRIs) such as Prozac caused few adverse events. They resulted in a clinically insignificant slowdown in heartbeat, and they didn't damage the function of the left ventricle. These drugs have been associated with occasional bleeding problems, however.
Besides seeing a doctor, what else may help me recover from depression?
You can do your part to overcome depression by getting regular exercise. Daily walks and a good exercise program, under your doctor's supervision, will improve your mood, boost your energy, and give you new strength to fight your disease. Of course, exercise will also strengthen your heart. And if you're battling depression and heart disease at the same time, you and your heart will need all of the strength you can get.
National Institute of Mental Health. Depression can break your heart.
National Institute of Mental Health. Co-occurence of depression with heart disease.
Ziegelstein RC et al. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Archives of Internal Medicine; 160: 1818-1823
Januzzi JL et al. The influence of anxiety and depression on outcomes of patients with coronary artery disease. Archives of Internal Medicine. 160: 1913-1920
National Institute for Mental Health. Breaking Ground, Breaking Through: The Strategic Plan for Mood Disorders Research. http://www.nimh.nih.gov/about/strategic-planning-reports/breaking-ground-breaking-through--the-strategic-plan-for-mood-disorders-research.pdf