Abstract
Depression and heart disease affect millions of people worldwide. Studies have shown that depression is a significant risk factor for new heart disease and that it increases morbidity and mortality in established heart disease. Many hypothesized and studied mechanisms have linked depression and heart disease, including serotonergic pathway and platelet dysfunction, inflammation, autonomic nervous system and hypothalamic-pituitary-adrenal axis imbalance, and psychosocial factors. Although the treatment of depression in cardiac patients has been shown to be safe and modestly efficacious, it has yet to translate into reduced cardiovascular morbidity and mortality. Understanding the impact and mechanisms behind the association of depression and heart disease may allow for the development of treatments aimed at altering the devastating consequences caused by these comorbid illnesses.
Similar content being viewed by others
Abbreviations
- AF-CHF:
-
Atrial Fibrillation and Congestive Heart Failure
- CREATE:
-
Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy
- ENRICHD:
-
Enhancing Recovery in Coronary Heart Disease Patients
- ESCAPE:
-
Epidemiological Study of Acute Coronary Syndromes and the Pathophysiology of Emotions
- M-HART:
-
Montreal Heart Attack Readjustment Trial
- MIND-IT:
-
Myocardial Infarction and Depression–Intervention Trial
- OPTIMIZE-HF:
-
Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure
- SADHART:
-
Sertraline Antidepressant Heart Attack Randomized Trial
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
World Health Organization: Cardiovascular disease: prevention and control. Available at http://www.who.int/dietphysicalactivity/publications/facts/cvd/en/. Accessed March 2, 2010.
Jiang W, Krishnan RR, O’Connor CM: Depression and heart disease: evidence of a link, and its therapeutic implications. CNS Drugs 2002, 16:111–127.
Pozuelo L, Tesar G, Zhang J, et al.: Depression and heart disease: what do we know, and where are we headed? Cleve Clin J Med 2009, 76:59–70. This is a great review of the literature on the association between depression and heart disease. It cites important epidemiologic and clinical studies on this subject.
Rudisch B, Nemeroff CB: Epidemiology of comorbid coronary artery disease and depression. Biol Psychiatry 2003, 54:227–240.
Ladwig KH, Kieser M, Konig J, et al.: Affective disorders and survival after acute myocardial infarction. Results from the post-infarction late potential study. Eur Heart J 1991, 12:959–964.
Koenig HG: Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry 1998, 20:29–43.
Barth J, Schumacher M, Herrmann-Lingen C: Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis. Psychosom Med 2004, 66:802–813.
Carney RM, Freedland KE, Steinmeyer B, et al.: Depression and five year survival following acute myocardial infarction: a prospective study. J Affect Disord 2008, 109:133–138.
Frasure-Smith N, Lesperance F: Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiatry 2008, 65:62–71.
Frasure-Smith N, Lesperance F: Reflections on depression as a cardiac risk factor. Psychosom Med 2005, 67(Suppl 1):S19–S25.
Weeke A, Juel K, Vaeth M: Cardiovascular death and manic-depressive psychosis. J Affect Disord 1987, 13:287–292.
Van der Kooy K, van Hout H, Marwijk H, et al.: Depression and the risk for cardiovascular diseases: systematic review and meta analysis. Int J Geriatr Psychiatry 2007, 22:613–626. This systematic review and meta-analysis reviews the available literature on depression and its risk for poor cardiovascular outcomes, and also calculates such risk.
Surtees PG, Wainwright NW, Luben RN, et al.: Depression and ischemic heart disease mortality: evidence from the EPIC-Norfolk United Kingdom prospective cohort study. Am J Psychiatry 2008, 165:515–523.
Scherrer JF, Virgo KS, Zeringue A, et al.: Depression increases risk of incident myocardial infarction among Veterans Administration patients with rheumatoid arthritis. Gen Hosp Psychiatry 2009, 31:353–359.
Wellenius GA, Mukamal KJ, Kulshreshtha A, et al.: Depressive symptoms and the risk of atherosclerotic progression among patients with coronary artery bypass grafts. Circulation 2008, 117:2313–2319.
Lichtman JH, Bigger JT Jr, Blumenthal JA, et al.: Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation 2008, 118:1768–1775.
Carney RM, Freedland KE, Steinmeyer B, et al.: History of depression and survival after acute myocardial infarction. Psychosom Med 2009, 71:253–259. This article describes a study evaluating mortality after an MI in ENRICHD participants, particularly comparing the effect of first-episode depression versus recurrent episode of depression. This study found that both predicted shorter survival compared with nondepressed participants, with initial depression episodes being most predictive.
Parker GB, Hilton TM, Walsh WF, et al.: Timing is everything: the onset of depression and acute coronary syndrome outcome. Biol Psychiatry 2008, 64:660–666. (Published erratum appears in Biol Psychiatry 2009, 65:449.)
Glassman AH, Bigger JT Jr, Gaffney M: Psychiatric characteristics associated with long-term mortality among 361 patients having an acute coronary syndrome and major depression: seven-year follow-up of SADHART participants. Arch Gen Psychiatry 2009, 66:1022–1029. This excellent article describes findings from a 7-year follow-up of SADHART participants. It highlights characteristics of depression, such as its severity and lack of improvement, that predict greater cardiovascular mortality.
Carney RM, Freedland KE: Treatment-resistant depression and mortality after acute coronary syndrome. Am J Psychiatry 2009, 166:410–417. This review focuses on the particularly high risks that treatment-resistant depression places on cardiovascular morbidity and mortality. It reviews relevant studies and considers possible explanations for this relationship.
Huffman JC, Smith FA, Blais MA, et al.: Pre-existing major depression predicts in-hospital cardiac complications after acute myocardial infarction. Psychosomatics 2008, 49:309–316.
York KM, Hassan M, Sheps DS: Psychobiology of depression/distress in congestive heart failure. Heart Fail Rev 2009, 14:35–50. This is an excellent, detailed, and comprehensive review of mechanisms linking depression and congestive heart disease, including autonomic nervous system dysfunction, inflammation and HPA axis activation, platelet dysfunction, and the relationship between mental stress and ischemia.
Parissis JT, Fountoulaki K, Paraskevaidis I, Kremastinos D: Depression in chronic heart failure: novel pathophysiological mechanisms and therapeutic approaches. Expert Opin Investig Drugs 2005, 14:567–577.
Frasure-Smith N, Lespérance F, Habra M, et al.: Elevated depression symptoms predict long-term cardiovascular mortality in patients with atrial fibrillation and heart failure. Circulation 2009, 120:134–140. This is a substudy of nearly 1000 patients from the AF-CHF trial, which evaluated and found that depression predicts long-term cardiovascular mortality in patients with heart failure and AF receiving optimal medical care.
Albert NM, Fonarow GC, Abraham WT, et al.: Depression and clinical outcomes in heart failure: an OPTIMIZE-HF analysis. Am J Med 2009, 122:366–373. This is a good article summarizing results from a large, prospective, observational study of almost 50,000 heart failure patients from 259 hospitals. It describes how depression in this population unfavorably affects rates of cardiac interventions, length of hospital stay, and post–hospital stay mortality.
Lange HW, Herrmann-Lingen C: Depressive symptoms predict recurrence of atrial fibrillation after cardioversion. J Psychosom Res 2007, 63:509–513.
Ziegelstein RC, Parakh K, Sakhuja A, Bhat U: Platelet function in patients with major depression. Intern Med J 2009, 39:38–43. This is a great review on the pathophysiologic link between depression and cardiac illness via platelet activation mechanisms.
Wulsin LR, Musselman D, Otte C, et al.: Depression and whole blood serotonin in patients with coronary heart disease from the Heart and Soul Study. Psychosom Med 2009, 71:260–265.
Parissis JT, Fountoulaki K, Filippatos G, et al.: Depression in coronary artery disease: novel pathophysiologic mechanisms and therapeutic implications. Int J Cardiol 2007, 116:153–160. This review details current knowledge about depression as a risk factor in patients with coronary artery disease, the implied pathophysiologic pathways, and the effects of antidepressant therapy on CVD outcomes.
van Zyl LT, Lespérance F, Frasure-Smith N, et al.: Platelet and endothelial activity in comorbid major depression and coronary artery disease patients treated with citalopram: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy Trial (CREATE) biomarker sub-study. J Thromb Thrombolysis 2009, 27:48–56.
Frasure-Smith N, Lespérance F, Irwin MR, et al.: Depression, C-reactive protein and two-year major adverse cardiac events in men after acute coronary syndromes. Biol Psychiatry 2007, 62:302–308.
Pizzi C, Mancini S, Angeloni L, et al.: Effects of selective serotonin reuptake inhibitor therapy on endothelial function and inflammatory markers in patients with coronary heart disease. Clin Pharmacol Ther 2009, 86:527–532.
Carney RM, Freedland KE, Veith RC: Depression, the autonomic nervous system, and coronary heart disease. Psychosom Med 2005, 67(Suppl 1):S29–S33.
de Jonge P, Mangano D, Whooley MA: Differential association of cognitive and somatic depressive symptoms with heart rate variability in patients with stable coronary heart disease: findings from the Heart and Soul study. Psychosom Med 2007, 69:735–739.
Carney RM, Steinmeyer B, Freedland KE, et al.: Nighttime heart rate and survival in depressed patients post acute myocardial infarction. Psychosom Med 2008, 70:757–763.
Lesperance F, Frasure-Smith N: Depression and heart disease. Cleve Clin J Med 2007, 74(Suppl 1):S63–S66.
Ali S, Garg SK, Cohen BE, et al.: Association between omega-3 fatty acids and depressive symptoms among patients with established coronary artery disease: data from the Heart and Soul study. Psychother Psychosom 2009, 78:125–127.
Carney RM, Freedland KE, Rubin EH, et al.: Omega-3 augmentation of sertraline in treatment of depression in patients with coronary heart disease: a randomized controlled trial. JAMA 2009, 302:1651–1657.
Nakatani D, Sato H, Sakata Y, et al.: Influence of serotonin transporter gene polymorphism on depressive symptoms and new cardiac events after acute myocardial infarction. Am Heart J 2005, 150:652–658.
McCaffery JM, Duan QL, Frasure-Smith N, et al.: Genetic predictors of depressive symptoms in cardiac patients. Am J Med Genet B Neuropsychiatr Genet 2009, 150B:381–388.
Joynt KE, Whellan DJ, O’Connor CM: Depression and cardiovascular disease: mechanisms of interaction. Biol Psychiatry 2003, 54:248–261.
Gehi AK, Ali S, Na B, Whooley MA: Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: the Heart and Soul study. Arch Intern Med 2007, 167:1798–1803.
Whooley MA, de Jonge P, Vittinghoff E, et al.: Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. JAMA 2008, 300:2379–2388. This article describes an interesting study of Heart and Soul study patients demonstrating how the relationship between depression and coronary artery disease is largely mediated by behavioral factors such as physical inactivity.
Vogelzangs N, Kritchevsky SB, Beekman AT, et al.: Depressive symptoms and change in abdominal obesity in older persons. Arch Gen Psychiatry 2008, 65:1386–1393.
Dickens C, McGowan L, Percival C, et al.: Negative illness perceptions are associated with new-onset depression following myocardial infarction. Gen Hosp Psychiatry 2008, 30:414–420.
Stafford L, Berk M, Jackson HJ: Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease. Gen Hosp Psychiatry 2007, 29:417–424.
Thombs BD, Ziegelstein RC, Whooley MA: Optimizing detection of major depression among patients with coronary artery disease using the Patient Health Questionnaire: data from the Heart and Soul study. J Gen Intern Med 2008, 23:2014–2017.
Davidson KW, Kupfer DJ, Bigger JT, et al.: Assessment and treatment of depression in patients with cardiovascular disease: National Heart, Lung, and Blood Institute Working Group Report. Psychosom Med 2006, 68:645–650.
Shapiro PA: Depression in coronary artery disease: does treatment help? Cleve Clin J Med 2008, 75(Suppl 2):S5–S9.
Glassman AH, O’Connor CM, Califf RM, et al.: Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002, 288:701–709. (Published erratum appears in JAMA 2002, 288:1720.)
Glassman AH, Bigger JT, Gaffney M, et al.: Onset of major depression associated with acute coronary syndromes: relationship of onset, major depressive disorder history, and episode severity to sertraline benefit. Arch Gen Psychiatry 2006, 63:283–288.
Berkman LF, Blumenthal J, Burg M, et al.: Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized trial. JAMA 2003, 289:3106–3116.
Taylor CB, Youngblood ME, Catellier D, et al.: Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction. Arch Gen Psychiatry 2005, 62:792–798.
van Melle JP, de Jonge P, Honig A, et al.: Effects of antidepressant treatment following myocardial infarction. Br J Psychiatry 2007, 190:460–466.
Lesperance F, Frasure-Smith N, Koszycki D, et al.: Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA 2007, 297:367–379. (Published erratum appears in JAMA 2007, 298:40). This article describes results of the CREATE trial, a two-by-two factorial design study evaluating the efficacy of citalopram and/or IPT for treatment of depression in patients with coronary artery disease. It demonstrated efficacy for citalopram but lack of such for IPT.
Rigotti NA, Thorndike AN, Regan S, et al.: Bupropion for smokers hospitalized with acute cardiovascular disease. Am J Med 2006, 119:1080–1087.
Halperin D, Reber G: Influence of antidepressants on hemostasis. Dialogues Clin Neurosci 2007, 9:47–59.
Cohen HW, Gibson G, Alderman MH: Excess risk of myocardial infarction in patients treated with antidepressant medications: association with use of tricyclic agents. Am J Med 2000, 108:2–8.
Honig A, Kuyper AM, Schene AH, et al.: Treatment of post-myocardial infarction depressive disorder: a randomized, placebo-controlled trial with mirtazapine. Psychosom Med 2007, 69:606–613.
Thombs BD, de Jonge P, Coyne JC, et al.: Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA 2008, 300:2161–2171. This is a great article providing a systematic review evaluating the benefits of depression screening in patients with cardiac disease by assessing the accuracy of depression screening tools and the effect of depression treatment on depression and cardiovascular morbidity and mortality.
Milani RV, Lavie CJ: Impact of cardiac rehabilitation on depression and its associated mortality. Am J Med, 2007, 120:799–806.
Katon WJ: Approaches to improving mental health outcomes in primary care. Paper presented at the 56th Annual Meeting of the Academy of Psychosomatic Medicine. Las Vegas, NV; November 11–14, 2009.
Disclosure
No potential conflicts of interest relevant to this article were reported.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sher, Y., Lolak, S. & Maldonado, J.R. The Impact of Depression in Heart Disease. Curr Psychiatry Rep 12, 255–264 (2010). https://doi.org/10.1007/s11920-010-0116-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11920-010-0116-8