Healing an injured or poorly functioning heart requires attention to a patient's mental well-being as well as to his or her physical health -- so much so that in October, the American Heart Assn. recommended that doctors screen all heart patients for depression with a short questionnaire.
The American Psychiatric Assn. also endorsed this advisory, but some researchers think the blanket recommendation goes too far.
Dozens of studies have found depression occurring alongside heart disease. Whereas 4% to 10% of the general population reportedly suffers from depression, that number shoots to 15% to 40% in heart disease patients. But a survey found that about half of cardiologists don't address their patients' mental states.
"Depression is diagnosable, easily treatable and can make such a difference in the long-term outcome," says Dr. Carolyn Robinowitz, a psychiatrist in Washington, D.C. If doctors heed the new advisory, she says, "I think we will save a lot of lives."
Others say the science is incomplete. Studies have shown that depression can worsen heart disease, and treating depression improves, at least to some degree, a patient's mental well-being. But no research to date has proved that treating depression improves the patient's cardiovascular prognosis or life span.
Last week, a panel of experts in cardiovascular health and depression, writing in the Journal of the American Medical Assn., concluded there isn't enough evidence to support screening every heart patient for depression. As many as one-third of patients would say yes to some of the screener questions, says lead author Brett Thombs, a psychologist at McGill University in Montreal. Identifying so many people as potentially depressed could cause many to seek help (and medications) they don't need.
"It's hard to understand how this would be beneficial for patients," Thombs says. "We would advocate that clinicians be more aware of depression. . . . We're just not advocating that everyone be handed a questionnaire."
Effects of surgery
Erika Froelicher, a professor of nursing at UC San Francisco and co-author of the American Heart Assn. advisory, says the benefits of screening outweigh the risks. She says that even if depression treatment doesn't directly affect heart disease outcome, it could improve quality of life for many patients.
A heart attack or diagnosis naturally leads to sadness and sometimes depression. With bypass surgery, there may be a more direct link to altered mood. The body depends on a heart-lung machine during bypass surgery to pump blood, and the machine can cause inflammation and clots that alter the brain's steady blood supply and has been linked to cognitive deficits. Altered cognition could then lead to depression.
Depression, in turn, can endanger the heart. "One leads to the other and you get these vicious circles," says Willem Kop, a psychologist at the University of Maryland in Baltimore.
People who are depressed have extra stress hormones, their blood clots a bit faster and they show signs of inflammation. All can harm the heart. And depressed people often neglect physical activity and a healthful diet, and may not take medication regularly.
The new advisory offers cardiologists a simple, two-question screener they can use with their patients: Do you feel down, depressed or hopeless? Do you often find little pleasure in doing things? If a patient answers "yes" to either question, there are seven further questions that indicate the likelihood of depression.
Patients identified with possible depression may seek treatment from a cardiologist or primary care physician, a therapist or through a cardiac rehabilitation center.
Cognitive therapy and medication can help, studies show, and some antidepressants have proved safe for heart patients. Some people find support groups helpful, says Charles Emery, a psychologist at Ohio State University in Columbus. It's also important to manage stress, make time for enjoyable activities and get appropriate exercise, such as walking.
Dr. Roy Ziegelstein, a cardiologist with Johns Hopkins University in Baltimore, says heart specialists may lack the time or expertise to deal with depression. It "would require a more fundamental change in the scope of practice of cardiologists," he says.
One possibility, he says, is to make training in diagnosing and treating depression part of cardiology training programs. Or instead of practicing in clinics that focus only on heart health, cardiologists might work in facilities with other physicians who are skilled in dealing with depression.
Heart patients might also find help for depression at cardiac rehabilitation centers, where patients undergo an exercise regimen and learn about heart health. There are 2,600 such facilities in the U.S., but most patients never reach them. (More than 24 million adults have heart disease; 1.8 million are treated in rehabilitation centers each year.) Nearly all patients could benefit from cardiac rehab, Froelicher says. But many physicians don't make referrals unless asked, and some insurers won't pay.
Some doctors and nurses are talking about adding depression to the American Heart Assn.'s official list of risk factors for heart disease, along with high cholesterol and smoking. A more exhaustive analysis of the existing data would be required for depression to make the list.
"The purists might say, 'We would like to wait for more evidence that if you treat it, you can reverse the risk,' " says Dr. David Sheps, a cardiologist at Emory University in Atlanta. "The bottom line is, people who are clinically depressed need to be treated whether or not it has a beneficial effect on their heart disease."