Depression is hard on the heart
		Women are especially at risk
		Catching depression early is key
		Positive thinking may help, too

1. Angina is a physical problem, but it can also take an emotional toll in the form of anxiety and depression.



2. Depression, anxiety, and stress may trigger angina pain by prompting the release of hormones that make the heart work harder.



3. Women are about twice as likely as men to be depressed, regardless of race, ethnicity or economic background.



4. Women with a history of angina are 57% more likely to suffer from depression than women without any history of heart disease.

Chronic angina can be a serious and debilitating heart condition marked by repeated and often unpredictable attacks of pain or discomfort. But physical symptoms aside, the emotional toll is a part of the condition as well—a burden that should not be ignored.

If you have angina, you may live in fear of the next painful attack, or feel depressed because angina has forced you to give up activities you enjoy, as well as a measure of your cherished independence. In time, anxiety and depression may become a part of your cycle of symptoms, along with the pain or discomfort in your chest that comes with an angina attack.

Depression is one of the most common mood disorders, and comes in different forms. People who have major depression, sometimes called clinical depression, have symptoms that may include intense sadness, feelings of guilt or worthlessness, fatigue, and excessive crying. These symptoms may last for at least two weeks, but often for many months or longer. Depression can range from mild to severe, and a person's ability to function in daily life may become impaired.

Depression can strike when major life changes occur, such as when a person suffers from a chronic illness or pain. People with heart trouble are particularly at risk for depression. Among patients with heart disease (including patients with chronic angina) who have never had a heart attack, roughly 20% are depressed—some of whom have clinical depression—according to the National Institute of Mental Health.¹

For patients with heart disease who have already had a heart attack, however, the prevalence of depression in its various forms jumps to as high as 65%.¹ Obviously, the problem is common—it is also alarming, and not always well understood or treated.

Depression is hard on the heart

Depression, anxiety, and stress not only impair a person's mental well-being; they may also trigger angina pain or discomfort. Stressful emotions can cause an increase of hormones in the nervous system that activate the "fight-or-flight" response, causing higher blood pressure and a faster heart rate that, in turn, increase the work of the heart. Blood flow—already slowed by narrowed arteries caused by coronary artery disease (CAD)—is decreased, which may then increase the risk of an angina attack. The more attacks a patient has, the more depressed he or she may become, which again may affect the arteries and heart. Patients may enter a vicious cycle of angina pain or discomfort and decreased well-being. In addition, their physical fitness level may decrease because they are participating in fewer physical activities.

On a practical level, depression may make patients with angina less motivated to comply with medical treatment and make healthy lifestyle changes, such as exercising and eating well. Not complying with a drug regimen can backfire, because medications work best when they are taken on a regular schedule that helps keep adequate levels of drugs in the blood. When a depressed person doesn't feel motivated to exercise, but instead turns to cigarettes, alcohol, or overeating to cope with emotional pain, he or she may be courting obesity, diabetes, and a risk of worsening heart disease.

Depression often goes hand-in-hand with anxiety, another emotion that can be harmful. In one study of heart attack survivors, anxiety was linked to higher rates of rehospitalization for cardiac problems and more frequent doctor's visits for heart symptoms.²

Women are especially at risk

Not only do women make up a large proportion of patients with angina, they are more prone to depression than men no matter what their health status. Some studies report that women develop depression at roughly twice the rate of men, regardless of racial, ethnic, or economic backgrounds.³

Women should be aware that depression and anger have been linked to heart-related health risks for their gender. In the Women's Ischemia Syndrome Evaluation (WISE) study,⁴ researchers studied 688 middle-aged women with chest pain. They found that those women with higher levels of depression, hostility, and anger were the most likely to be obese, to smoke, or to have unhealthy cholesterol levels—all recognized risk factors for CAD.

In one striking example, the women in this study with high scores for depression had a nearly three-fold risk of smoking, compared with women who had the lowest depression scores.⁴

In addition, the results of the Women's Health Initiative (WHI) showed that 15.8% of the almost 94,000 women who participated in the study had a depressed mood. Smoking and being overweight were also related to having depression. Women who didn't exercise regularly, had high blood pressure or diabetes, and who reported fair or poor health were more likely to be depressed. What's more, women with a history of angina had a 57% greater chance of having a depressed mood than women without any history of heart disease.⁵ Learn more in Women and Heart Disease.

Catching depression early is key

Fortunately, depression is treatable. The National Institute of Mental Health claims that 80% of depressed people can be treated effectively.⁶ Standard treatment involves antidepressant drugs, psychotherapy, or both. However, many cases go unrecognized and therefore, untreated.

If you're a patient with chronic angina, or a caregiver, be on the lookout for these warning signs of depression.³ If any should appear, be sure to consult your doctor:

• Despair; persistent feelings of sadness, emptiness, worthlessness; excessive crying; inappropriate guilt; recurring thoughts of suicide or death



• Apathy: loss of interest in activities, including sex



• Trouble concentrating; difficulty making decisions; restlessness



• Fatigue: loss of energy, constantly feeling tired



• Sleep or eating problems: changes in weight or appetite, changes in sleep patterns or early-morning waking



• Poor hygiene or sloppy appearance



• Persistent physical symptoms such as headaches, digestive problems, or chronic pain

For patients with heart disease, treating depression before a major event such as a heart attack occurs seems to be best. One study, supported by the National Heart, Lung, and Blood Institute (NHLBI), shows that treating depression after a heart attack may help a person feel better and be less socially isolated, but does not seem to lower the risk of a second heart attack.

In the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study,⁷ scientists studied 2,481 men and women who had a recent heart attack and who also reported they had depression, little social support, or both. The subjects were randomly placed into two groups: a "treatment" group that received psychological counseling, group therapy, and—in cases of major depression—prescription antidepressants, and another group that received standard medical care without these therapies.

After six months, patients in the treatment group reported less depression and better social connection than did their counterparts who received standard care. However, the same group did not fare better with heart disease. After three years, 24.4% of the treatment group either died or had a second heart attack, compared with 24.2% of the patients who got standard care.

Again, earlier treatment of depression may have made a difference. Researchers in the ENRICHD study noted, "We may find out that the timing of the treatment should be changed. Treating depression and social support during the medically vulnerable period right after a heart attack may not be the best time to prevent deaths and heart attacks. We may need to intervene earlier—and treat heart disease patients who are depressed before they have a heart attack."⁷ Other researchers have stated that depression linked with heart attacks and unstable angina should be "treated because it is a serious illness that is both painful to patients and impedes their medical care."⁸

Positive thinking may help, too

Another study suggests that optimism helps protect against heart disease. In a report recently published in Psychosomatic Medicine,⁹ researchers at the Harvard School of Public Health and the Department of Veteran Affairs found a connection between optimism in older men and a dramatically lowered risk of heart disease, even after accounting for other variables such as smoking and alcohol intake.

In the 10-year study of 1,306 men, 162 subjects developed heart disease. Among these, 77 were identified as pessimists, while 34 were optimists. "Most of the evidence for the notion that 'thinking positively' is good for your health has been anecdotal," said one researcher. "This study provides some of the first hard medical evidence for this idea in the arena of heart disease."¹⁰

If you have symptoms of depression, talk to your doctor or seek a mental health professional. Roughly two of three people who suffer from depression don't get appropriate treatment, often because they fail to ask for help. But depression is highly treatable, so get help as soon as you can.

Together, you and your doctor, and perhaps a counselor or support group, can work together to speed up your emotional recovery.

	The Seattle Angina Questionnaire's primary goal is to objectively measure: Click here.

Sources

1. National Institute of Mental Health. Co-Occurrence of Depression with Medical, Psychiatric, and Substance Abuse Disorders. 2004. http://www.nmha.org/infoctr/factsheets/28.cfm. Accessed June 3, 2004.
   
   
2. Strik, J.J., Denollet, J., et al. "Comparing Symptoms of Depression and Anxiety as Predictors of Cardiac Events and Increased Health Care Consumption After Myocardial Infarction." J Am Coll Cardiol. 2003;42:1801-7. PubMed
   
   
3. National Institute of Mental Health. Depression: What Every Woman Should Know, 2000. http://www.nimh.nih.gov/publicat/depwomenknows.cfm. Accessed June 17, 2004.
   
   
4. Rutledge, T, et al. "Psychosocial Variables Are Associated with Atherosclerosis Risk Factors Among Women with Chest Pain: the WISE [Women's Ischemia Syndrome Evaluation] Study." Psychosom Med 2001;63:282-288. PubMed
   
   
5. Wassertheil-Smoller, S., Shumaker, S., et al. "Depression and Cardiovascular Sequelae in Postmenopausal Women: the Women's Health Initiative (WHI). Arch Intern Med 2004;164:289-98. PubMed
   
   
6. National Institute of Mental Health. Depression and Heart Disease. 2002. http://www.nimh.nih.gov/publicat/depheart.cfm. Accessed June 17, 2004.
   
   
7. National Heart, Lung, and Blood Institute, National Institutes of Health. Study Finds No Reduction in Deaths or Heart Attacks in Heart Disease Patients Treated for Depression and Low Social Support. November 12, 2001. http://www.nhlbi.nih.gov/new/press/01-11-13.htm. Accessed June 3, 2004.
   
   
8. Glassman AH, O'Connor CM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002;288:701-709. PubMed
   
   
9. Kubzansky, Laura D., et al. "Is the Glass Half Empty or Half Full? A Prospective Study of Optimism and Coronary Heart Disease in the Normative Aging Study." Psychosom Med 2001;63:910-916. 2004;164:289-98. PubMed
   
   
10. Harvard School of Public Health. Press Release: Research suggests optimistic attitude can reduce risk of heart disease in older men. November 21, 2001. http://www.hsph.harvard.edu/press/releases/
    press11212001.html. Accessed June 18, 2004.