This is quite relevant to a large number of people since depression is quite prevalent in the general population. It is estimated that 5.8% of men and 9.5% of women will experience a depression e episode in a 12 month period. The lifetime incidence of depression has been estimated at more than 16% in the general population.

This research study was by Dr. An Pan  and four colleagues from the Harvard School of Public Health and Harvard Medical School. The research was a meta-analysis and a systematic review which meant that the authors studied research of many studies on this subject The ended up looking at 28 prospective cohort studies comprising 317,540 participants which reported 8478 stroke cases during a follow-up period ranging from 2-29 years.

Their scientific analysis of the data demonstrated that depression is associated with a significantly increased risk of developing stroke. They also found a positive association of depression with a fatal stroke.

The authors discussed a variety of mechanisms which depression may contribute to stroke. Depression has known neuroendocrine effects. For example t there is a dysregulation of HPA axis ( hypothalamic-pituitary-adrencortical axis which can cause high blood pressure. It has been shown that depression effects platelets and leads to  dysfunction which causes abnormalities in the clotting mechanism. There are also abnormalities in the immune and inflammation systems which could influence stroke risk..

Depression is associated with poor health behaviors such as smoking, physical inactivity, poor diet, lack of medication compliance and obesity, all of which may contribute to stroke.

Depression has already been associated with coronary heart disease, diabetes and hypertension. (See an earlier blog on depression and heart disease as well as another blog which raised the question whether people with depression should be taking aspirin to prevent heart attacks).

The data from the recent JAMA study also suggested that it is possible that antidepressant medication may be associated with stroke risk but this may be a false impression since medication use can be a marker of depression severity and many of the studies that the authors looked at lacked information on dose and duration of medication use.

There are some limitations of this study and the findings don’t prove 100% that depression causes stroke. I would imagine that it is conceivable that the genetic markers for stroke and depression could be located in close proximity leading to such impression of this effect. However even if there is no causative effect (  although I believe the research strongly suggest one ), the association of these conditions clearly calls out for great attention being paid to this association. There is an opportunity for doctors who see patients who are at a high risk for stroke to be referred for treatment of depression. Also patients who are being treated for depression should be encouraged to be seek medical attention and assistance in reducing all the other risk factors for stroke whenever possible.

Depression is a serious condition and is very treatable. Treatment works! Patients who have depression should be treated whether or not they are at a higher risk for stroke and other diseases.

Cardiologists usually  recommend that people who have a history of coronary artery disease or peripheral artery disease should take aspirin which has anti clotting qualities. This  is also often recommended for people who are in a high risk group for such conditions. In fact many doctors recommend that people who are in low risk group should take one baby aspirin per day as a preventative especially if they are in an age group where these conditions are more prevalent. Emergency first aid for a person who has the symptoms of a heart attack could be to take two regular aspirins while waiting for the ambulance or while on the way to the hospital.

If  people who have depression are more likely to develop coronary heart disease and more likely to have a heart attack should this group also be advised to take a baby aspirin as a preventative measure?

What Do We Know

In order to consider this question, let’s take a look at what we know about heart disease and depression.

Analysis of research data points to the fact that depression is an independent risk  factor for coronary artery disease  in both men and women  when other cardiovascular risk factors are controlled.

Patients with a history of recurrent depression have a four to five times increased mortality rate at 6 month follow-up after a heart attack than those without depression

Premorbid depression is associated with poor outcome in patients who had a post coronary artery bypass graft, this includes complications of congestive heart failure, and even death.

Depression after a heart attack was associated with increased risk of another heart attack and death.

Decreased serotonin associated with depression appears to cause changes in platelet stickiness, which leads to clotting and blocking of blood vessels.

The connection between depression and heart disease can stand on its own. However depression also interacts with other known risk factors , making it more likely that people with depression will have a heart attack . Some of these interactions are as follows:

Smoking- There is often increased smoking with depression

Hypertension- Stress including depression can elevate blood pressure

Obesity- People with chronic depression often overeat

Diabetes- People with depression have an 2x increased chance to develop diabetes

Excessive Alcohol Use – Depression and excessive alcohol use reinforce each other

Family History of Premature Death from Heart Disease – Leads to depression & the     Nemesis Complex

I have discussed these factors in a previous blog

Logical Conclusion

It does appear that having depression increases the risk of having a heart attack whether it is directly or by interaction with other risk factors. Therefore it does seem logical that aspirin, as a preventive measure, should be advised when depression is diagnosed. Obviously the depression should be fully evaluated and treated. This may involve antidepressant, psychotherapy or both forms of treatment. Depression can completely disrupt a person’s life as well as that of their family and the people who are close to them. Depression can also lead to tragic suicidal behavior.

Before instituting any use of aspirin on a regular basis this plan should be discussed with your internist, family physician or cardiologist. There are some conditions such peptic ulcer disease or various bleeding disorders, which can be made worst by aspirin. There also may be drug interactions or synergies, which need to be avoided

The discussion and consideration of the use of aspirin as part of the treatment plan for depression could accomplish two important purposes. It might decrease the chance of these seriously medical conditions. It would also raise the awareness of the public about the far reaching effects of depression on physical health in addition to the well known  impact on mental health and the ability to function.

My Mood Monitor is the Test

In a recent journal article in the Annuals of Family Medicine there is a report of the My Mood Monitor (M-3) a self administered 27 item check list that was tested on a sample of consecutive patients who were seeking primary care at the academic family medicine clinic at the University of North Carolina.  Those completing the M-3 were then contacted by a research assistant and asked to take the much longer 15 minutes Mini International Psychiatric Interview (MINI) by telephone in order to validate the results of the M3. The MINI is a well established test that has been validated against the Structured Clinical Interview for DSM  (SCID) which can take up to hour or even more time to administer by a trained person which is more or less the gold standard for research tools using the current psychiatric categories. In this particular study the MINI test results administered by phone were discussed with a psychiatrist before final scoring. If the M-3 is validated against the MINI and the MINI is validated against the SCID, they believe they have test which will be an accurate screening test.

Each of the 27 questions of the M-3  is answered by a check mark in a column which offers the responses:  Not at All, Rarely, Sometimes, Often , Most of the Time. Since just having a bunch of symptoms doesn’t necessarily mean that a person is having diagnosable condition or a serious problem, there were four questions, which assessed if there was a functional impairment. If there were no functional impairments of the person’s life style AND if the suicide question was negative, no further scoring was done and therefore no condition was identified

The test was not set up to pick up psychosis, dementia, marital, sexual or personality problems unless they would show up with significant anxiety or depression, which could very well be the case.

Results

Participants and Completers- 723 people, which were 54 % of the patients approached to participate, agreed to be in the study. 99% of this group also completed the MINI follow-up test.

Diagnosis According to the MINI Test- According to the MINI test, 22% of the people had a depressive disorder (16 % had a major depressive disorder, while 6% had bipolar disorder and 9.3%  had bipolar spectrum illness), 28.1% had an anxiety disorder and 6.3% had PTSD. Overall, 35% of the study participants met MINI criteria for at least one psychiatric diagnosis. 12.1 % had co-morbidity for anxiety and depression.

How Well Did the Brief M-3 Test Do? First of all 349 people (53%) were eliminated from being scored because they did not have a functional impairment. Of the 298 patients who were then scored using the M-3 (meaning that they had a functional impairment according to M-3), 62.4% met the criteria being used for a psychiatric diagnosis. Without going into detailed statistical analysis, it was found that the M3 showed a 95% confidence level for diagnosing depression and anxiety as well as PTSD with a sensitivity and specificity of about 80%. Most screening tools don’t integrate screening for bipolar and PTSD while screening for other anxiety and mood disorders, which is an added bonus. Overall, that is pretty darned good for a waiting room brief screening tool.

Added Benefits of the M-3

Additional questions about the process yielded information that 70 % of the participants reported talking to their clinician  about mood or feelings. 70% said they did so for at least one minute (certainly better than not at all). 63% of all participants reported that the M-3 helped them talk to their doctors about their mood or feelings. Among participants assigned a MINI diagnosis, 75% stated that the M-3 facilitated talking to their clinician about mood or feelings. 83 % of clinicians reviewed the checklist in 30 or fewer seconds. None found the M-3 too complicated and 80% thought it was helpful in reviewing participants’ emotional health.

Words of Caution

Anything that helps doctors become of aware of the patient’s emotional health has to be a good thing.

However, we must keep in mind that 46% of the people approached refused to participate in the study. That number is standard for research but any patient who refused to take a mental health screening test in a clinical practice should receive extra attention by the doctor.

53% people were not scored because even if they had positive symptoms, since they did not indicate that they had functional impairment or suicidal ideas. I hope that their physician would at least inquire about the symptoms, which were checked, and determine if the patient is having a problem and hasn’t yet come to the point of being impaired or is suicidal or perhaps just doesn’t want to readily acknowledge the severity of the problem.

The paper made a point that the M-3 had questions, which led to a distinction between major depression and bipolar depression. It was stated that the failure to do so can lead to the prescribing of antidepressants without a mood stabilizer, potentially destabilizing the illness and leading to the risk of hypomania, manic or mixed episodes. This is certainly true but I would hope that patients with first time bipolar disorder should ideally not be treated with mood stabilizers without psychiatric consultation. This condition can be difficult to manage and treatment is often not straightforward.

The diagnosis of any major depression may not only require medication, but also close monitoring, especially in the early phase of treatment. When there is the potential for suicidal ideation, an effective dosage of medication can increase the low energy of a depressed patient so they become more of suicidal risk than they were before starting medication.

Medications used for treating anxiety of course can be over used and create serious dependency issues.

Both anxiety and depression can be symptoms of underlying marital and other interpersonal problems as well personality disorders. PTSD once identified usually has complicated determinants and may not be easily treated by just medication.

The multidisciplinary team that put together the M-3 and the testing of it come from both Departments of Family Medicine and Psychiatry. As effective as these short diagnostic tools may be in identifying emotional problems for family physicians, they should be part a systematic approach to diagnosing and treating this condition. Family doctors need to spend more time with patients when these conditions are suspected, diagnosed and are being treated. It is also very important that physicians using the M-3 have a  collaborative relationship  with psychiatrists and other mental health professionals.

Recent Research of Studies of Antidepressant Medications

A recent study in the Journal of the American Medical Association reviewed six well-done research studies, which  looked at  double blind placebo of antidepressant treatment for at least six weeks  with adult outpatients who had  minor and major depression. The usually reliable Hamilton Depression Rating Scale ( HDRS ) was the instrument used for measuring depression.

Medication Works Best With Severe Depression

The researchers concluded that the  magnitude of benefit of antidepressant medication compared with placebo increases with the severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial. It is important to note that this information does not deny that many or probably most of the patients in these studies as they do, in doctors offices all the time, felt much better after taking antidepressant medication. The placebo effect of taking the medication and/or various forms of psychotherapy or general support caused improvement in people who also were taking antidepressants. Only in those patients with severe depression was the improvement clearly (or statistically) better than those were taking the placebo.

Considerations Whenever Depression is Diagnosed

The implications of this research should not be a surprise to most practicing psychiatrists. When treating depression, one must take into consideration many other factors in addition to the presence of depression symptoms.

Medical  Conditions

Is there an underlying medical condition, which might be causing the depression, or contributing to it?  If  there is such a condition, it is quite possible that any antidepressant treatment will have limited effects unless the underlying condition is addressed. While there might be some improvement above and beyond placebo effects with medication, the chances would be much better if attention were directed to the organic conditions. Even just the recognition that there is a medical cause will often help to alleviate the depression as the patient begins to understand the nature of their illness.

The list of medical conditions, which can cause depression,  is quite long. Some examples which are far from inclusive are as follows:

1. Thyroid condition particularly hypothyroidism
2. Other endocrine abnormalities such as parathyroid disease and even diabetes
3. Various forms of epilepsy
4. Brain trauma or vascular insufficiency to the brain including stroke
5. Brain Tumor can often first be manifested as depression
6. Infectious processes particularly those that can effect the brain such as Lyme Disease or Syphilis
7. Parkinson’s Disease and other degenerative diseases such as Alzheimer’s; Disease or Huntington’s Disease
8. Cancer of Pancreas is known to first show itself as depression but so can other cancers
9. More exotic diseases such Wilson’s Disease, Huntington’s Disease or even Pellagra, a rare vitamin deficiency

Bipolar Disorders

Of special  importance are Bipolar Disorders where the  depressive phase can be indistinguishable from a severe depression other than by a  history of a manic phase. Antidepressants if used in these conditions may actually make things worst by precipitating   a manic phase whereas mood stabilizers can bring about great improvement.

Schizophrenia

While Schizophrenia is usually relatively easy to diagnose, there can be a depressive component to this disorder. At times if the underlying schizophrenia is not recognized, the use of antidepressants alone will most likely not be effective . These patients usually require an antipsychotic medication to put the condition into remission.

Obsessive-Compulsive Conditions and Phobias

Obsessive-Compulsive conditions and severe Phobias may respond to antidepressant but specific classes of these medications have been shown to be most effective. Thus if these conditions are not recognized, the wrong medication may be chosen. In addition these disorders usually require additional forms of specialized psychotherapy.

Dependency & Addictions

The failure to recognize alcoholism and drug dependency and to just direct treatment towards the depressive symptoms with antidepressant medication is doomed to failure. Since such conditions can ultimately be fatal such an omission is quite serious. Other dependency conditions such as compulsive gambling , sexual addiction, and even eating disorders while perhaps not technically classified in this category are similar in that specialized treatment is absolutely required . Antidepressants may also be helpful but by themselves will not significantly improve these conditions.

Character Disorders, Interpersonal,  Psychodynamic Issues & PTSD

People with these conditions can appear in a psychiatrist or other mental health professional’s office or they can even be recruited into a drug study. If they have depressive symptoms they may be put on antidepressant medications. They may have some improvement  because they have a dual diagnosis with a depressive condition or because of placebo effect. However,  if the underlying condition is not addressed with a meaningful psychotherapy, which is effective for them, the depression will most likely reoccur. In a large percentage of these patients the use of antidepressant may very well be judged to be ineffective. As in all the above conditions unless both diagnoses are addressed it is most likely that the antidepressant will fall short of significantly helping the patient.  On the other hand sometimes in many of  these conditions and those mentioned above, if a serious  depressive component is recognized and treated, the patient will become more able to relate and engage in treatment of the co-existing conditions.

Grieving

I left this condition for last because the manifestation of it  can often resemble major depression with insomnia, poor appetite, and diminished interest in the world, severe depressed mood. Obviously, the history of the loss as well as other specific characteristics distinguish grieving. In most cases it is time limited. Sometimes supportive therapy or even specialized groups are helpful. If these symptoms become incapacitating, or if there is a history of previous depression a trial of antidepressants may be used.

Dual Diagnosis

As was mentioned above, there can be two conditions present at once and one of these may be a major depression which requires antidepressant medication as well as treatment of the other conditions. Therefore, when treating any psychiatric problem a careful history should always explore for previous signs of depression as well as family history of it.

Suicidal Thoughts

The other special condition that should always be considered during diagnosis and treatment of any patient where there is a depressive component is the possibility of suicidal ideation. Obviously, this is a serious and difficult condition to detect and manage and I won’t go into detail here other than to emphasize it should always be in the mind of the treating psychiatrist or mental health professional involved in treatment.

Split Treatment

Any discussion about the treatment of depression with medication should mention split treatment which mostly occurs when  another mental health professional is treating the patient with some form of psychotherapy and a psychiatrist is  prescribing the medication. In view of all the other complicated and interacting factors mentioned above including the manifestations of suicidal ideation  there must be very good communication between both professionals if there is this type of a treatment arrangement. Some of my colleagues are not comfortable in sharing such treatment. I have found that if you have a good working relationship with the other professional such a treatment plan can work effectively. Similarly at times a psychiatrist is a consultant to another physician or another mental health professional will work with non psychiatric physician. In the future I shall try to examine various potential pitfalls and advantages of split treatment .

Conclusion

I believe the antidepressant medications that we have today to treat patients with depressive condition can be extremely effective. I know that they have saved many people’s lives and relieved an untold amount of suffering. If used indiscriminately and not properly monitored they can be dangerous and also allow conditions that require other treatment to go undiagnosed.

I welcome your comments on any aspect of this subject whether you are a mental health professional, a patient or anyone  interested in this subject.

If an American soldier is wounded and then dies or is killed immediately in Iraq or Afghanistan,  the President of the United States and The Secretary of Defense write a condolence letter to the family. However, if an American soldier is wounded physically and /or psychologically during his action in Iraq or Afghanistan and then commits suicide there is no letter of condolence written to his or her family by the President and the Secretary of Defense.

There are now more suicides among our combat troops than all those killed by enemy fire in Iraq and Afghanistan together according to a recent CNN Report on this topic. There have been 354 suicides thus far in the year 2009 which is more than the 335 total of combat deaths which occurred in Iraq and Afghanistan combined . While most of the suicides don’t occur until the soldiers have returned to the states at least one third have taken place in Iraq and Afghanistan. The US Army and the National Institute of Mental Health are partnering to assess risk and resilience in service members in an epidemiologic study of mental health, psychological resilience, suicide risk, suicide-related behaviors, and suicide deaths. While this is quite important, it does not address the failure of our leaders to knowledge the sacrifice of those psychologically injured soldiers who commit  suicide. This is a serious defect in our moral fabric.

While Presidents since Lincoln have been writing letters of condolence to families, there is apparently unwritten policy that this does not include families of soldiers who have committed suicide. It is easy to imagine how hurtful that must be to a family who is burying a son or daughter who came back from war with psychological problems and then committed suicide or perhaps killed themselves while still overseas. The New York Times recently wrote a story about one such family. After Gregg and Janet Keesling’s son, Chancellor, killed himself in Iraq in June, the family received a folded flag, a letter from the Army praising their son, a 21-gun salute at his burial and financial death benefits, but not a letter of condolence from President Obama.

A spokesperson for President Obama said that the policy in regard to who should receive a letter of condolence is currently undergoing a review.

What is Going on Here?

I heard one report state that many soldiers would feel that their comrades combat death would be somehow demeaned if the families of soldiers who suicided were given an equal letter of condolence. Another view is that treating suicide the same as other war deaths might encourage mentally frail soldiers to take their lives by making the act seem honorable. These ideas may be influencing the thinking of some our military leaders and perhaps the President. I hope not.

If this is the case it is misguided thinking which resurrects the stigmatization of mental illness. These conditions are not something that anyone chooses to have. This includes depression, post traumatic stress disorder and traumatic brain injury all of which can be secondary to combat experiences. Soldiers cannot will themselves to avoid these conditions anymore than a soldier can avoid a bullet aimed at their head or an explosive device that goes off under their vehicle.  While training and good support can reduce the odds somewhat but once you are in a combat zone you are vulnerable to injury. I also know of no evidence that people on the verge of suicide would be driven to do it because their family would get a letter of condolence.

There is a famous cartoon which shows a therapist giving a patient a large slap in the face while saying “Snap out of it”  and the title of the cartoon is “One Session Therapy”. If there is humor in this, it is because some people have the phantasy that it is that easy to put aside psychological injury. Anyone with knowledge about mental illness and clinical experience knows that it is not true.

A soldier who suffers to the point of  ending his or her own life, has to be recognized as someone who has suffered as much as anyone can imagine.

As far as the idea that some deaths deserve a letter of condolence and some don’t, consider this. If a soldier in Iraq is working in the kitchen and the stove catches fire leading to his demise, would this death be any less deserving of a letter of condolence than a soldier who was caught in an enemy ambush? Would the loss be any less deserving of the latter soldier if it turned out that he made a foolish tactical error leading to his being killed as compared to someone who was brave enough to fall on a grenade to save others lives? Of course not. Similarly, would you compare a soldier who faced many horrific combat situations and developed PTSD with another soldier who became severely depressed shortly after his  plane just  touched down in the combat zone if both ended up having intolerable suicidal feelings which led to their death? Would one family be deserving of a letter of condolence and another not? I don’t believe that we judge some soldiers deaths as being more worthy than others.

Yes, we do give out special medals and recognition  for unusual acts of bravery but these in no way diminish the sacrifice that others have made.

They Are All Heroes

All of the soldiers that we have discussed above would have volunteered to serve in the military and today everyone knows that this most likely could mean exposure to combat. For this they deserve our thanks and when they and their families have made the supreme sacrifice they deserve at least a letter of condolence.

Action to Fix This Situation

What can we do to see that the families of soldiers who have suicided be given the same letter of condolence as families of other soldiers who have died in the military?

We can a write a letter to the President of the United States, Secretary of Defense and our Congressperson and US Senator. Those of you who are mental health professionals should clearly state this in such correspondence and explain how you feel about this situation especially based on your understanding of mental illness. The email address to write to the President is :       president@whitehouse.gov       There is every indication your email would be read by his staff and a sample of them are often shown to the President.  If many of the readers of this blog were to write him a note it is bound to make an impression as this issue is under consideration by the President at present. If you would like some tips on how to write to the President I found this brief article .

We should also ask our professional organizations if they have not done so already to weigh in on this matter. I am writing a letter to my colleague Dr. Alan Schatzberg, President of the American Psychiatric Association (APA), requesting him to consider asking the Board of Trustees to pass such a resolution if this has already not been done. This last November I finished my term as Past Speaker of the Assembly of the American Psychiatric Association and left the Assembly. So while I cannot sponsor such a resolution myself anymore,  I will ask my former colleagues there to also consider doing so . Both the Board of Trustees and the Assembly must approve position statements in the APA. I would hope that once this organization takes it on they will be able enlist the support of our colleagues in the American Medical Association as well as other professional groups.

By all indications President Obama is a compassionate person and I believe that once he has the facts and has heard from the public including mental health professionals, he will do the right thing.

I welcome your comments on this issue.

New York Times Front Page Article About Depression and Suicide in the Military Goes too Far by Publishing Confidential Mental Health Records

After Combat, Victims of an Inner War by Erica Goode was an outstanding front page description of depression and suicide in the military in the NY Times on Sunday August 2, 2009. It focused on the background and circumstances of the suicide of Sgt. Jacob Blaylock who was one of four soldiers of a 175 person military unit who ended their own lives. It used his case history to humanize the complicated issues involved in screening for mental health problems and providing treatment for military personnel who need it. Ms Goode gathered information from many sources including friends, families, fellow soldiers, and records of military service as well as treatment records in the veterans health system. However, I question whether this article, as written, should have been published as it has obviously included publication of confidential mental health records.

The article states that veterans agency records obtained by the New York Times reported that Sergeant Blaylock was hospitalized for depression during a previous tour of duty. It quotes from mental health records from a veterans affairs medical center that he had told an intake counselor that he was experiencing ” sleep problems”, “excessive worry and anxiety,” “recurrent thoughts of death ” and other symptoms. It states that he answered” yes” to all four screening questions for post-traumatic stress disorder” and goes on to describe the content of what appears to have been a therapy session. There are other examples in the article of how the patient responded to being evaluated for suicidal ideation as well as a description of the psychotropic medications which were prescribed for him. Ironically, this is followed by a statement from a spokeswoman for the veterans agency noting that it could not legally comment on specific cases without family authorizations which would seem to indicate that the surviving family did not provide the medical records which they may have obtained. Even if they had, this would be a questionable journalistic approach.

The New York Times owes the mental health community and the public at large an explanation as to the ethical standards that it uses

The delineation of the difficulty in predicting suicidal behavior, the need for more research and continued development of screening and treatment programs can be a worthy outcome of the publication of this article. On the other hand the exposing of confidential medical records may very well make potential patients of the military and veterans system hesitate to seek care as the word gets out that their records can end up in the hands of the press. I believe that the New York Times owes the mental health community and the public at large an explanation as to the ethical standards that it uses in situations such as this one.

I sent my above comments to the NY Times as a letter to the editor and as an inquiry to the public editor who solicits concerns about the paper’s journalistic integrity. As of this date I have not received any acknowledgment or reply.

This blog however gives me the opportunity to raise this issue with my colleagues in the mental health profession and all interested parties. Even in the pursuit of a worthwhile goal of improving mental health services and preventing future suicides, was it necessary to obtain confidential medical records of this nature and display it on the front page of one of the leading newspaper in the country? Could not the same effect have been achieved by printing the interviews with the various parties and conveying the dramatic and sad story without resorting to this last step? If there are no journalistic standards or ethics in this regard, does this mean that any medical records that a reporter can get his or her hands on are fair game for publication if the reporter and the editor feel the story is worthwhile? Or is up to their judgment as to what part of the record can be published? If this becomes the standard of our leading newspapers, I hope that this will not erode the confidence and trust that is necessary for psychiatric patients to have in the professionals who care for them and in the hospitals where it sometimes becomes necessary for them to be admitted.

I welcome your comments on this subject.

DEPRESSION MUST BE CONSIDERED A RISK FACTOR FOR HEART DISEASE

In the May 27^th 2009 issue of the Journal of the American Medical Association on the Patient Page eight risk factors for heart disease are listed. They are as follows:

• Smoking
• High Blood Pressure
  
• A high level of low-density lipoprotein (LDL; bad cholesterol) especially when associated with a low level of high-density lipoprotein (HDL; good cholesterol)
• High levels of triglycerides (another form of fat found in the bloodstream that can contribute to heart disease)
• Diabetes

• Overweight (body mass index [BMI] greater than 25) or obesity (BMI greater than 30)

• Excessive alcohol use

• Family history of premature death (before age 65) from heart disease.

In my opinion a crucial risk factor was omitted and an opportunity was missed to educate the public about an important approach to limiting heart d isease and maybe even preventing death from this killer. There is ample evidence based research for listing depression as a risk factor for heart disease.

POSSIBLE MECHANISMS

Depression  and Blood Clotting

There is also a pretty good idea as to the physiological mechanisms which connect depression and heart disease. For example, when the platelets in the body are activated a thrombus or clot is formed which can lead to a coronary artery heart blockage and hence a heart attack. Studies have compared this clotting phenomenon in a healthy population without heart disease using both a depressed and a non-depressed group. There was an increase in the clotting activity of the depressed over the non-depressed group.

Depression  and Heart Variability

Another mechanism concerns the HRV or heart rate variability .When the heart is stressed physically or emotionally it has the ability to speed up and slow down depending on the degree of stress. This can be monitored by a 24 hour/day device which can be worn by a person who can keep track of their events. After a heart attack if there is a decreased HRV meaning the heart has lost some ability to respond to stress that has been shown to predict potentially fatal heart rhythms. There is also evidence that has shown depressed mood, whether one has cardiac disease or not, is associated with reduced HRV.

Depression and the Inflammatory Process

In addition, depression has been shown to be characterized by an increase in markers of the inflammatory process, particularly substances known as Interleukin -6 and C-reactive protein (CRP). Both of these factors have also been implicated in bringing about Coronary Artery Disease. However, depressed individuals even without heart disease have elevated levels of these substances. Depression leads to the body producing increased cortisol (the stress hormone) which may produce these inflammatory markers. However most recent research published this month  suggests that there is a genetic link to the production of CRP which may not be connected to heart disease, making these connections less significant.

DEPRESSION AND DEATH FROM HEART DISEASE

Pre-existing depression prior to the development of heart disease is associated with a poor outcome in patients who subsequently develop heart disease and need a coronary artery bypass graft. Not only are such people more likely to die but they are more likely to have prolonged pain and are less likely to return routine activities. There are similar findings in people who have had congestive heart failure. In addition, if there were two people in the intensive care unit after a heart attack with the same degree of damage and one was depressed and the other was not , the depressed person would have a four times greater chance of dying in the next six months than the non depressed patient.

RELATIONSHIP BETWEEN DEPRESSION AND OTHER RISK FACTORS

The connection between depression and heart disease can stand on its own. However, even if you just look at the risk factors listed at the beginning of this piece which were given in the JAMA article mentioned above, we will find a linkage to many psychological factors including depression. In addition, depression is usually co-morbid meaning it co-exists with most other psychological symptoms. Depression also can limit a persons ability to cooperate with treatment, especially with diet and exercise which are often a major component of the recommendations which are made to the person with cardiac risk factors. I will briefly review some of the connections to these risk factors.

Smoking - Often engaged in during times of distress including depression. May become part of an obsessive behavior pattern. Leads to addiction to nicotine. Failure to succeed in cessation often leads to depression which causes a vicious cycle

High Blood Pressure- Psychological stress such as severe anxiety, but also depression, can cause elevated blood pressure especially in individuals predisposed to hypertension.

Diet Related Factors (Inability to control proper levels of various types of cholesterol and triglycerides as well as objective obesity)- People with depression often overeat, although individuals with severe depression often have diminished appetite. Obesity can complicate the treatment of hypertension and diabetes.

Diabetes – The issues of diet are intertwined with diabetes and thus with depression. In one study of 6000 people with varying degrees of depression but no diabetes at the start of the study, it was found that 6 % developed diabetes over the next 20 years. Those with high degrees of depression were more than 2 times more likely to develop diabetes. That group was also more likely to be less active, more likely to smoke and more likely to be obese.

Excessive Alcohol Use- Depression and excessive alcohol reinforce each other in many ways. The pain of depression can lead to self medication with alcohol in an attempt to relieve such feelings. Alcohol is a depressant to the central nervous system which can intensify pre-existing depressive tendencies. In addition the despair and difficulty in breaking alcoholic dependency can precipitate severe depression.

( image from: link to freedigitalimages.com )

Family History of Premature Death (before age 65) from heart disease-When a person knows that they have a family history which makes them more likely to have a serious illness such as heart disease at a young age, they often feel as though they are a “walking time bomb”. As they come closer to the age of the expected illness, despair and depression may very well become prominent. George Engel described the Nemesis Complex in this regard related to the dates of heart attacks of his father and then his identical twin

As depression brings about any of the above risk behaviors or exacerbates them, so is the individual more likely develop heart disease and symptoms.

PREVENTION OF HEART DISEASE BY TREATMENT OF DEPRESSION

Good health care would dictate behavior to eliminate any risk factor for heart disease and if possible do whatever you can to modify it. Since I contend that depression is one of these risk factors, treatment of depression is indicated when it exists or when there are precursors of depression such as major emotional conflicts. The type of treatment would obviously depend on the individual and might be psychopharmacology, some form of psychotherapy or a combination of these forms of treatment. In the days when tri-cyclic antidepressants (such as Elavil and others) were essentially the main form of psychopharmacology for depression there was the added problem that these medications had significant cardiac side effects. That is not the case with most of the medications used today for depression. In fact there has been some evidence that treatment with the SSRI (Prozac, Zoloft and others) type of medications will normalize the platelet and Heart Rate Variability problems discussed above There is a great deal of experience in treatment of depression in people with existing heart disease without deleterious effects. One of the research projects which demonstrated this is the SADHEART Study. There continues to be ongoing interest and research in this area.

Psychotherapy and medication may also be helpful in treating the other risk factors mentioned which could lead to diminished heart disease.

Finally, remember that depression is a condition that not only is a risk factor for heart disease and other medical illnesses but it is widespread and can be a devastating illness itself. The lifetime prevalence of depression in the general US population is 17.1 %. It is even higher in women (21%). According to the National Institute of Mental Health a suicide occurred every 18 minutes in the United States in the year 2000. It is estimated that at least 90% of completed suicides have diagnosable mental illness, usually a mood disorder. Treatment for depression does work and it can be life saving in more ways than one.

Related Links- Dr. Blumenfield interviews Dr. Lawrence Wulsin about Heart Disease & Depression on “Shrink Pod”