In 1937, during the thick of the Great Depression, a doctor from the New York State Department of Mental Hygiene made a curious observation: patients with depression died more often than their healthy peers. What was the main cause of death in these patients with so-called “involutional melancholia”? Heart disease.
As investigators have pulled back the curtain of history from the comfortable couch of twenty-first century lives, we see just how great the effects of depression still are on the health of those with—and without—heart disease.
A study published twenty-five years ago followed a group of people with known coronary artery disease for a year. For that small group of patients, the best predictor of future cardiac events (such as a heart attack or bypass surgery) was whether or not they had major depressive disorder. The effects of metal health on the heart for this group were as strong as the impact of smoking or the drag of depressed systolic function on the heart. Rather than being an isolated island of melancholy in a time of general prosperity, these data from this study in the 1980’s would prove to be a bellwether of bad news leading into the new millennium.
Twin studies in the 1990’s out of Canada looked at over two hundred mostly male patients with a diagnosis of myocardial infarction and followed them for six months. In that short interval, investigators found that depression was a significant and independent predictor of death for this group. As earlier studies had suggested, the effect of depression on the heart was as strong for these patients at the effect of a previous heart attack. When that same group of patients was reviewed 18-months after their initial MI [Frasure-Smith et al. 1995], the death rate from cardiac causes seemed to cluster around those who were depressed. Interestingly, the follow up study shed some light on why this might be. Those who died had a higher rate of arrhythmias.
Be still my beating heart.
Such data can make one swoon knowing that one in three patients who have had a heart attack will experience depression in the first year afterwards. But what about the rest of those hardy hearts? Surely those who exercise and eat right are inoculated against the ravages of depression on an otherwise healthy heart. Unfortunately, data from the turn of the twenty-first century gives us pause from such reassurances.
Examining the health records of over 5000 women and over 2800 men in the United States who did not have heart disease at the study’s outset, scientists found an increased risk of coronary heart disease in both groups if they experienced depression. When other health-related factors were accounted for, the diagnosis of depression increased the chance of heart problems like a cigarette for the soul. The previously healthy men in this group actually had an increased risk of cardiac death once diagnosed with depression.
Such a barrage of depressing data can leave one rudderless and unsure of where to turn for help. But don’t despair. Hope is on the horizon.
In the cleverly named MIND-IT trial published in 2007, investigators at hospitals across the Netherlands studied 2177 patients diagnosed with depression in the first year after a heart attack. These doctors asked a simple question: can treating depression offer a lifeline to those in need? After six months in the study, the data shouted an unequivocal “Yes!” Compared to placebo pills, patients taking an effective antidepressant medication (in this trial mirtazapine, but previous trials have offered supporting data for sertraline, citalopram, and fluoxetine) had documented improvement with their depressive symptoms. Another reassuring, and perhaps unexpected, finding was that the study medication seemed to have stronger anti-depressive effects in patients with heart disease compared to their healthy (but depressed) peers. This data underscored that while patients cannot choose whether they suffer depression after a heart attack, they can benefit from proven therapies to help them recover. Medicines, of course, but also therapies such as exercise that help the head and the heart.
Heart attacks make people feel bad. Depression can complicate that recovery, stealing one’s energy, slowing one’s rehab, and worsening one’s quality of life. But patient’s don’t have to suffer this alone. Talking to a doctor about common symptoms of sadness after a heart attack can help patients turn their back on this Great Depression and face forward on the road to recovery.