Provided by the National Institute of Mental Health
Symptoms of Depression
Persistent sad, anxious, or "empty" mood
Feelings of hopelessness, pessimism
Feelings of guilt, worthlessness, helplessness
Loss of interest or pleasure in hobbies and activities that were once enjoyed,
including sex
Decreased energy, fatigue, being "slowed down"
Difficulty concentrating, remembering, making decisions
Insomnia, early-morning awakening, or oversleeping
Appetite and/or weight changes
Thoughts of death or suicide, or suicide attempts
Restlessness, irritability
If five or more of these symptoms are present every day for at least two weeks
and interfere with routine daily activities such as work, self-care, and
childcare or social life, seek an evaluation for depression.
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Introduction
Depression can strike anyone. However, research over the past two decades has
shown that people with heart disease are more likely to suffer from depression
than otherwise healthy people, and conversely, that people with depression are
at greater risk for developing heart disease.1 Furthermore, people with heart
disease who are depressed have an increased risk of death after a heart attack
compared to those who are not depressed.2 Depression may make it harder to take
the medications needed and to carry out the treatment for heart disease.
Treatment for depression helps people manage both diseases, thus enhancing
survival and quality of life.
Heart disease affects an estimated 12.2 million American women and men and is
the leading cause of death in the U.S.3 While about 1 in 20 American adults
experiences major depression in a given year, the number goes to about one in
three for people who have survived a heart attack.4,5
Depression and anxiety disorders may affect heart rhythms, increase blood
pressure, and alter blood clotting. They can also lead to elevated insulin and
cholesterol levels. These risk factors, with obesity, form a group of signs and
symptoms that often serve as both a predictor of and a response to heart
disease. Furthermore, depression or anxiety may result in chronically elevated
levels of stress hormones, such as cortisol and adrenaline. As high levels of
stress hormones are signaling a "fight or flight" reaction, the body's
metabolism is diverted away from the type of tissue repair needed in heart
disease.
Despite the enormous advances in brain research in the past 20 years, depression
often goes undiagnosed and untreated. Persons with heart disease, their families
and friends, and even their physicians and cardiologists (physicians
specializing in heart disease treatment) may misinterpret depression's warning
signs, mistaking them for inevitable accompaniments to heart disease. Symptoms
of depression may overlap with those of heart disease and other physical
illnesses. However, skilled health professionals will recognize the symptoms of
depression and inquire about their duration and severity, diagnose the disorder,
and suggest appropriate treatment.
Depression Facts
Depression is a serious medical condition that affects thoughts, feelings, and
the ability to function in everyday life. Depression can occur at any age. NIMH-sponsored
studies estimate that almost 10 percent of American adults, or about 19 million
people age 18 and older, experience some form of depression every year.4
Although available therapies alleviate symptoms in over 80 percent of those
treated, less than half of people with depression get the help they need.4,6
Depression results from abnormal functioning of the brain. The causes of
depression are currently a matter of intense research. An interaction between
genetic predisposition and life history appear to determine a person's level of
risk. Episodes of depression may then be triggered by stress, difficult life
events, side effects of medications, or other environmental factors. Whatever
its origins, depression can limit the energy needed to keep focused on treatment
for other disorders, such as heart disease.
Heart Disease Facts
Heart disease includes two conditions called angina pectoris and acute
myocardial infarction ("heart attack"). Like any muscle, the heart needs a
constant supply of oxygen and nutrients that are carried to it by the blood in
the coronary arteries. When the coronary arteries become narrowed or clogged and
cannot supply enough blood to the heart, the result is coronary heart disease.
If not enough oxygen-carrying blood reaches the heart, the heart may respond
with pain called angina. The pain is usually felt in the chest or sometimes in
the left arm and shoulder. (However, the same inadequate blood supply may cause
no symptoms, a condition called silent angina.) When the blood supply is cut off
completely, the result is a heart attack. The part of the heart that does not
receive oxygen begins to die, and some of the heart muscle may be permanently
damaged.
Chest pain (angina) or shortness of breath may be the earliest signs of heart
disease. A person may feel heaviness, tightness, pain, burning, pressure, or
squeezing, usually behind the breastbone but sometimes also in the arms, neck,
or jaws. These signs usually bring the person to a doctor for the first time.
Nevertheless, some people have heart attacks without ever having any of these
symptoms.
Risk factors for heart disease other than depression include high levels of
cholesterol (a fat-like substance) in the blood, high blood pressure, and
smoking. On the average, each of these doubles the chance of developing heart
disease. Obesity and physical inactivity are other factors that can lead to
heart disease. Regular exercise, good nutrition, and smoking cessation are key
to controlling the risk factors for heart disease.
Heart disease is treated in a number of ways, depending on how serious it is.
For many people, heart disease is managed with lifestyle changes and
medications, including beta-blockers, calcium-channel blockers, nitrates, and
other classes of drugs. Others with severe heart disease may need surgery. In
any case, once heart disease develops, it requires lifelong management.
Get Treatment for Depression
Effective treatment for depression is extremely important, as the combination of
depression and heart disease is associated with increased sickness and death.
Prescription antidepressant medications, particularly the selective serotonin
reuptake inhibitors, are generally well-tolerated and safe for people with heart
disease. There are, however, possible interactions among certain medications and
side effects that require careful monitoring. Therefore, people being treated
for heart disease who develop depression, as well as people in treatment for
depression who subsequently develop heart disease, should make sure to tell any
physician they visit about the full range of medications they are taking.
Specific types of psychotherapy, or "talk" therapy, also can relieve depression.
Ongoing research is investigating whether these treatments also reduce the
associated risk of a second heart attack. Preventive interventions based on
cognitive-behavior theories of depression also merit attention as approaches for
avoiding adverse outcomes associated with both disorders. These interventions
may help promote adherence and behavior change that may increase the impact of
available pharmacological and behavioral approaches to both diseases.
Exercise is another potential pathway to reducing both depression and risk of
heart disease. A recent study found that participation in an exercise training
program was comparable to treatment with an antidepressant medication (a
selective serotonin reuptake inhibitor) for improving depressive symptoms in
older adults diagnosed with major depression.7 Exercise, of course, is a major
protective factor against heart disease as well.
Use of herbal supplements of any kind should be discussed with a physician
before they are tried. Recently, for example, scientists have discovered that
St. John's wort, an herbal remedy sold over-the-counter and promoted as a
treatment for mild depression, can have harmful interactions with some other
medications.
Treatment for depression in the context of heart disease should be managed by a
mental health professional—for example, a psychiatrist, psychologist, or
clinical social worker—who is in close communication with the physician
providing the heart disease treatment. This is especially important when
antidepressant medication is needed or prescribed, so that potentially harmful
drug interactions can be avoided. In some cases, a mental health professional
that specializes in treating individuals with depression and co-occurring
physical illnesses such as heart disease may be available.
While there are many different treatments for depression, they must be carefully
chosen by a trained professional based on the circumstances of the person and
family. Recovery from depression takes time. Medications for depression can take
several weeks to work and may need to be combined with ongoing psychotherapy.
Not everyone responds to treatment in the same way. Prescriptions and dosing may
need to be adjusted. No matter how advanced the heart disease, however, the
person does not have to suffer from depression. Treatment can be effective.
Other mental disorders, such as bipolar disorder (manic-depressive illness) and
anxiety disorders, may occur in people with heart disease, and they too can be
effectively treated. For more information about these and other mental
illnesses, contact NIMH.
Remember, depression is a treatable disorder of the brain. Depression can be
treated in addition to whatever other illnesses a person might have, including
heart disease. If you think you may be depressed or know someone who is, don't
lose hope. Seek help for depression.
For more information about depression and research on mental disorders
Please visit the following links for more information about organizations that
focus on depression and other illnesses and research on mental disorders.
References
1Nemeroff CB, Musselman DL, Evans DL. Depression and cardiac disease. Depression
and Anxiety, 1998; 8(Suppl 1): 71-9.
2Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis
after myocardial infarction. Circulation, 1995; 91(4): 999-1005.
3Morbidity and mortality: 2000 chart book on cardiovascular, lung, and blood
diseases. National Heart, Lung, and Blood Institute, 2000. http://www.nhlbi.nih.gov/resources/docs/00chtbk.pdf
4Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive
disorders service system. Epidemiologic Catchment Area prospective 1-year
prevalence rates of disorders and services. Archives of General Psychiatry,
1993; 50(2): 85-94.
5Lesperance F, Frasure-Smith N, Talajic M. Major depression before and after
myocardial infarction: its nature and consequences. Psychosomatic Medicine,
1996; 58(2): 99-110.
6National Advisory Mental Health Council. Health care reform for Americans with
severe mental illnesses. American Journal of Psychiatry, 1993; 150(10): 1447-65.
7Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on
older patients with major depression. Archives of Internal Medicine, 1999;
159(19): 2349-56.
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All material in this brochure is in the public domain and may be reproduced or
copied without permission from the Institute. Citation of the National Institute
of Mental Health as the source is appreciated.
NIH Publication No. 02-5004
Department of Health and Human Services
Public Health Service
National Institutes of Health
National Institute of Mental Health
May 2002
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