HARVARD GAZETTE ARCHIVES

(Staff iIlustration Georgia Bellas/Harvard News Office)

Depression is more likely to break your heart than smoking or eating fatty food.

"Recurrence of cardiovascular events, including heart attacks, strokes, cardiac arrest, severe chest pain and other problems is more closely linked to depression than to high cholesterol, smoking, high blood pressure, or diabetes," according to a Harvard Medical School publication.

An article printed in the February issue of Harvard Mental Health Letter points out that patients who are depressed at the time of hospitalization for heart conditions "are two to four times more likely than average to die or to suffer further cardiovascular events during the following year."

And, just as sad, "about 50 percent of patients hospitalized with coronary heart disease have some depressive symptoms, and up to 20 percent develop major depression."

Depressed people who also are anxious add to their problems. According to one recent study, whereas depression doubles the risk of heart problems recurring, anxiety triples that risk.

It's not unusual for depressed people to suffer from anxiety. The two go together like pretzels and beer, so well that scientists have given it a new name - the Type D (for distressed) personality. Such people are chronically gloomy, worried, pessimistic, and lack self-assurance. The Harvard article mentions research in Belgium that found that "over a 10-year-period, patients in a cardiac rehabilitation program were three times as likely to die or have a second heart attack if they had this kind of personality."

Nonstop emergencies

Why does this happen? The Harvard publication notes that your mind and mood can push you into a chronic state of emergency readiness. Such people are ready to fight or run even when there's nothing to fight about or run from. In real emergencies, stress hormones rise, blood vessels constrict, your heart speeds up, appetite slackens, and it's harder to fall asleep. Inflammatory chemicals increase in the blood, which becomes stickier in anticipation of wounds that will need healing. When the scare ends, this red alert shuts down - unless you are seriously depressed or anxious.

Then, stress hormones stay jacked up. Inflammation may damage the lining of your arteries. Blood vessels become less flexible. The heart responds more sluggishly to internal signals telling it to slow down as the body's demands change.

It's hard to figure out exactly what happens. As the article notes, "cause and effect are difficult to disentangle in the relationship between depression and heart disease." Vicious cycles arise. Depression damages the heart and blood vessels, and that causes further depression.

Isolation makes things worse. One study concluded that men who survive heart attacks and live alone have twice the average death rate. Another study found that people who did not talk to their doctors and rarely contacted friends or family were more likely to die in the nine years after a heart attack, regardless of their physical condition.

It's not so much living alone, or the size of your social circle, as the absence of relatives and friends to provide solace, advice, and help, according to the article.

Help on the way

Studies have demonstrated and continue to demonstrate that the best treatments for the blues include antidepressant drugs and visits with a psychotherapist. Heading the list of promising drugs are the so-called selective serotonin reuptake inhibitors (SSRI), such as Celexa, Paxil, Prozac, and Zoloft. They work by combating the feeling that life is one continuous emergency, packed with things that make you gloomy and give you cause for worry.

The Medical School health letter points out that these SSRIs are less likely to produce serious side effects than other types of antidepressants, and they don't disturb heart rhythms. However, they do interfere with the clotting capacity of blood, raising the risk of bleeding.

Two large national studies found in favor of SSRIs. One, which goes by the acronym SADHART (Sertaline AntiDepressant Heart Attack Randomized Trial), showed that heart patients taking Zoloft for six months suffered fewer deaths, heart attacks, and heart failures than those who took a dummy pill. The most improvement occurred in people who were depressed before a heart attack.

The other acronymous research effort, called Enhancing Recovery in Coronary Heart Disease (ENRICHD), tested 2,500 people who recently survived heart attacks. Half of them received normal care for their heart condition; half got group and individual psychotherapy. Those in the latter group who did not respond sometimes had an antidepressant added to their treatment.

The idea was to determine who came out better. After an average of three years, it became clear that it was those who received the combination of psychotherapy and medication. Of these people, 42 percent - close to half - were less likely to die or suffer from another heart attack, stroke, or other cardiovascular problem.

Psychotherapy alone hasn't been shown yet to be as effective.

Research so far finds that talk therapy lifts depression and anxiety but doesn't reduce risk of death or more attacks and strokes in heart patients. But talk therapy along with follow-up care that helps people keep up their morale and urges them to take better care of themselves shows some evidence of cutting down the damage depression does to the heart.

Many questions remain, the article notes. For example: Which patients are at the most risk for depression deep enough to raise their chances of deterioration and death? Do depressed people get worse treatment after a cardiovascular event? If so, why?

Until such questions are answered, one conclusion becomes clear. Doctors who see heart patients, say the experts, "should be better prepared to ask their patients about stress, low mood, and isolation." If the doctor does not do this, then patients who feel down and out should let the doctor know.