Depression and heart disease
Channel: York Cardiology
Date: 2020-07-13

Introduction
 
Mental health and physical health are very closely aligned. It is impossible to be physically healthy if you are not mentally and spiritually healthy. Unfortunately whilst most of modern day medicine focuses on numbers and physical health, a focus on mental health remains largely neglected.
 
 
Let's talk about depression.
 
Depression is highly prevalent in patients with cardiovascular disease and one in 5 patients with cardiovascular disease or heart failure is depressed.
 
This prevalence is at least 3 times greater than in the general population.
 
Patients who are depressed are more likely to have greater physical limitations and quality of life compared to patients who have equivalent objective markers of cardiac function but who are not depressed.
 
The presence of depression can also affect prognosis adversely Patients who have had a heart attack and who are depressed are twice as likely to have a future cardiac event. This is the same as the risk conferred by the presence of concomitant diabetes! In addition this increased risk is present regardless of whether the patient has had a confirmed clinical diagnosis of depression or even if it is that they report being depressed.
 
Whilst much of the research has focussed on patients who have already had a cardiac event, there is some research to suggest that depression is also associated with an increased risk of a first incident.
 
So what is the mechanism?
 
1) Depression is often linked with poor adherence to risk reducing behaviour such as diet, physical activity, smoking, and adherence to cardiac medications.
 
2) Depression is increasingly found to be associated with inflammation and there are 2 possibilities here - the first is that more depression is a by-product of increased inflammation in the body and secondly that depression is itself an inflammatory condition. 
 
3) There is some evidence that depression may also cause autonomic imbalances within the body and finally may also reduce coronary flow reserve which makes the heart muscle cells to be more susceptible to inflammation.
 
4) There is also some evidence that if you look at patients with blood pressure, the presence of depression can reduce the dip in blood pressure at night which is an excellent sign of good health and this may in turn put more stress on the blood vessels in the body.
 
 
The next question is what do you do about it. Are there any studies that show that addressing the depression can help improve quality of life and prognosis?
 
Well sort off:
 
There are many pharmacological and behavioural therapies which can help treat depression but it is still unclear as to which is the best way to treat depression in terms of improving prognosis. 
 
What we do know is that conventional treatment for depression seems to work  well for patients with heart disease as those without in terms of reducing depressive symptoms. 
 
In addition there have been some studies including a trial called MOSAIC which was published in the JAMA journal in june 2014 ( Huffman et al.) who found that once you identified depression and you delivered a medium term personalised intervention over the 24 weeks which consisted of both antidepressant medications (sertraline/citalopram or/and CBT/behavioural techniques), patients had a significantly improved mental health related quality of life, overall health related quality of life, and general functioning. 
 
 
So i think firstly it is important to understand the importance of mental and spiritual health as being exceptionally important components of overall health
 
Secondly it is important to actively understand that depression is common esp in patients with a known diagnosis of heart disease and can have adverse impact on both quality of life and prognosis
 
It is exceptionally important to look therefore for the presence of psychological distress, sadness and depression.Where it is identified it is important that we address it to the best of our abilities and in partnership with the patient because we may not only improve their quality of life but also possibly their overall prognosis.