Women's Heart Advisor April 2013 Issue

How Heart Disease Affects Your Risks of Anxiety, Depression

Why women face such high risks and what you can do to gain control.

Stress and depression often go hand in hand, and for a woman with heart disease this combination is often an unavoidable reality. It’s estimated that 15 to 20 percent of American women have depression, with women being twice as likely to be depressed than men. And when depression is added to cardiovascular disease, there is a stronger likelihood of a worse cardiovascular outcome.

While it isn’t exactly clear what happens in the brain when people become depressed, the link between heart disease’s impact on anxiety and depression is evident. Depression is two times more common in patients after a heart attack compared to the general population, and it’s crucial to detect it. Left untreated, depression affects a patient’s quality of life and adherence to wellness behaviors such as diet, exercise and medication compliance, according to Cleveland Clinic psychiatrist Leo Pozuelo, MD.

“Up to 15 percent of patients with cardiovascular disease and up to 20 percent of patients who have undergone coronary artery bypass graft (CABG) surgery experience major depression,” explains Dr. Pozuelo. “Increased levels of depression, even mild depression, increase the risk of recurrent cardiovascular events and death by up to two and a half times. For women with heart disease, it’s important that they are aware of their risk of developing depression and the many ways their condition can be improved.”

Value of Screening
Long gone are the days when the existence of anxiety and depression is overlooked. As the most common mental disorders, depression and anxiety often coexist and can be extremely disabling. Because of this, an American Heart Association Science Advisory panel recently recommended that patients who have had a heart attack be screened for depressive symptoms to identify those “who may require further assessment and treatment.” Additional support of this directive came from recent research that shows controlling depression in patients with heart failure improves health status, social functioning and quality of life, according to results published in the journal Circulation: Heart Failure (October 2012).

A primary method for getting a good snapshot of a patient’s mental health is the PHQ-4 Patient Health Questionnaire. A powerful tool used to assist clinicians with diagnosing depression and monitoring treatment response, the PHQ-4 can help track a patients overall depression severity as well as the specific symptoms that are improving or not with treatment. “By using this tool as part of the first line of treatment for a patient’s overall medical condition, we can have a conversation with them about their possible mental health needs to begin the best treatment plan,” explains Dr. Pozuelo.

By using the PHQ-4 clinicians are able to piece together a patient’s overall cardiovascular and mental health puzzle. With a focus on a collaborative care model, women with heart disease who battle depression are managed with multiple modes of treatment that encompass the whole picture of their condition.

“We know that using a straight pharmacologic treatment approach in lieu of behavioral therapy is not beneficial,” Dr Pozuelo says. “Instead, we integrate an overall care coordination approach that speaks to each of their needs.”

And the most important of these factors to help boost mental health is participating in cardiac rehabilitation, stresses Dr. Pozuelo. While exercise has been known to lift the spirits, new research has amped its impact by finding that patients with chronic heart failure had modest reductions in symptoms of depression after 12 months of participating in exercise training, compared with usual care, according to a study published in JAMA (August 2012).

“If there’s one recommendation I can make for those with heart disease and depression is to make sure they follow through with cardiac rehab,” Dr. Pozuelo says.

Cardiac Rehab
As the primary caregiver and multi-tasking manager of all things, a woman attacked by heart disease tends to still put others before her needs following treatment. But, this overriding need to care for others often leads to neglect of important opportunities that cardiac rehab can provide for not only physical rehabilitation, but also the mental boost a woman needs, according to Gordon Blackburn, PhD, program director of cardiac rehabilitation and prevention at Cleveland Clinic.

“It’s been proven that participation in cardiac rehab can lead to a 47 percent reduction in mortality. Yet, there is a very low percentage of women with heart disease who utilize it along with their follow-up care,” says Dr. Blackburn.  “Nationwide, less than 15 percent of eligible patients participate in cardiac rehab programs after a heart attack.”

A medically directed exercise and lifestyle modification program, cardiac rehabilitation helps patients recover as fully as possible following any type of cardiac event, such as a heart attack, bypass, coronary stenting or valve surgery. The goals of cardiac rehab are to optimize the quality and quantity of a patient’s life by improving their overall heart health, preventing their condition from worsening and helping them make the best lifestyle changes to reduce the risk of future cardiovascular problems.

While cardiac rehabilitation begins in the hospital, with preliminary education, after discharge from the hospital, a second phase begins. “In the second phase, patients meet with the Cardiac Rehab Team’s physicians, exercise specialists, registered nurses and dietitians. This team helps tailor a personalized plan to decrease the risks of not only a recurrent cardiovascular event, but also treat any signs of depression and anxiety,” explains Dr. Blackburn.

Typically, cardiac rehab involves 36 sessions over 12 weeks, but the frequency and duration of the program is tailored to each patient’s needs and lifestyle. While patients gain significant benefits during the first two phases of rehab, some choose to continue throughout phases three and four for ongoing care.

“Participating in cardiac rehab offers a peer-support group that helps them recognize and manage their anxiety and depression. Instead of facing their fears in isolation, they are educated on heart disease, heart-healthy lifestyles and medical management issues that they may need to optimize their recovery process,” says Dr. Blackburn. “It’s a complete package of ongoing care that ensures their medical care and their mental health as well.”