November 16th, 2011
AHA Lessons on Emotions and Heart Disease: Depressing Data but Hopeful Trends
Several Cardiology Fellows who are attending AHA.11 this week are blogging together on CardioExchange. The Fellows include Revathi Balakrishnan, Eiman Jahangir, John Ryan (moderator), and Amit Shah. Read the previous post here. Check back often to learn about the biggest buzz in Orlando.
The many studies and sessions devoted to depression and heart disease at AHA — especially the session Depression and Cardiac Disease (where I also presented) — gave renewed focus and drive to this researcher into the psychosocial factors of cardiovascular disease.
The studies collectively support the role of depression in heart disease, but many questions remain, particularly regarding the direction of causality. Does heart disease cause depression, or does depression cause heart disease? Or does a third factor, such as inflammation, cause both? If so, what drives the inflammation?
Several points during the session were salient:
- Persistent depression is associated with a 100% increased relative risk of incident ischemic heart disease (IHD) in the general population
- Inflammation and other traditional risk factors such as obesity and serum cholesterol are associated with depression, thereby suggesting mechanisms by which IHD risk may be increased.
- Temporally, inflammation may precede development of depression in a peri-operative setting. Other work has supported the role of inflammation in the etiology of depression.
- Medication nonadherence and depression are related, and they have additive effects on heart disease outcomes.
The scientific community has been stumped by negative studies such as ENRICHD that call into question the importance of depression as a modifiable CVD risk factor. Nonetheless, more studies are needed, and depression treatment is always warranted, given that depression itself is debilitating, regardless of whether heart disease is comorbid.
I hope that with the trends toward increasing attention to this topic, as seen at AHA, more screening of depression in CHD patients will occur, and more clinical trials will try to find better strategies for treating it. The potential benefits that could be reaped are enormous: better quality of life, cost savings from reduced hospitalizations, and improved survival. Nonetheless, with the national shortage of primary care doctors and psychiatrists, as well as rising copays, many challenges face us.
What do other people think? Should cardiologists screen for depression, anxiety, etc., in their patients, and if they screen positive, what’s the next best step? Is there even time for this consuming task in a 15-minute clinical visit?