Heart health can suffer from matters of the mind

More research is needed to understand the multiple mechanisms involved in the relationship between mood disorders and heart disease

by Jadranka Bacic

University of Montreal psychiatrist Dr. François Lespérance has been working to get to the heart of the connection between depression and coronary artery disease for almost 15 years.

Studies have reported prevalence rates of major depression to be between 17 and 27 per cent in hospitalized patients with cardiac illness. And these patients are four times more likely to die in the next six months after a heart attack.

Dr. Lespérance’s interest in heart disease runs deep. His father, a radiologist, had dedicated much of his professional life to the treatment of cardiac illness, but the younger Dr. Lespérance wanted to combine his interest in the mind and body.

“I wanted to reconcile the division in medicine where the brain got split off from the rest of the body," he bluntly explains. “The connection between depression and cardiovascular disease seemed a good place to start."

Epidemiology shows a clear association between heart disease and depression, but is this relationship one of cause or coincidence. The associate professor and chief of psychiatry at the Centre hospitalier universitaire de Montréal (CHUM) says it is both.

Years of research with McGill’s Dr. Nancy Frasure-Smith has shown him that people with heart disease also have depression; and that depression can predict the development of cardiovascular disease in healthy people as well as increased mortality in patients who have had heart attacks.

“Stress and emotion can change the brain in many ways, which can also affect the cardiovascular system," says Dr. Lespérance. “Stress can increase the inflammatory markers for cardiovascular disease and an increased heart rate can have an effect on the risk of arrhythmias. Data also suggests that a heart attack can affect mood."

There are also genetic and behavioural risk factors for depression and cardiac disease such as physical inactivity and poor diet, he explains.

Many researchers and cardiologists are still searching for definitive studies to prove causation and show that treating depression can reduce cardiovascular mortality, but Dr. Lespérance says the cause, effect and coincidence connection between depression and heart disease should come as no surprise since multiple pathways are involved.

“We know that depression and heart disease are associated so we need to think about treatment that would benefit the mood and the cardiovascular system at the same time. We need to take a comprehensive approach and treat the depressed patient globally—not only the depression, but also the risk factors predicting a cardiovascular event."

The search for better treatment options for the depressed cardiac patient led Dr. Lespérance to chair the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy Trial.

The 12-week study was designed to evaluate the short-term effectiveness and tolerability of two depression treatments in 284 patients with coronary artery disease. The multi-site study conducted from May 2002 to March 2006 separated participants into two groups to simultaneously evaluate the benefit of an antidepressant (citalopram) against a placebo, and interpersonal psychotherapy against clinical management.

“We found citalopram to be superior to placebo in alleviating symptoms of depression in patients with coronary artery disease, but even more intriguing was that we found no evidence that interpersonal psychotherapy worked better than clinical management," recalls Dr. Lespérance. “One might assume that spending more time on interpersonal issues would help the patient with feelings of depression, but in fact those randomized to clinical management alone improved more on average than patients randomized to clinical management plus interpersonal psychotherapy."

Dr. Lespérance thinks it is time to rethink the psychotherapeutic approach to patients with comorbid medical conditions and depression to focus less on interpersonal issues and more on helping depressed patients control their cardiovascular risk factors.

He and his longtime research partner Dr. Frasure-Smith are now making waves with a new study that is the first to demonstrate a connection between cardiac illness and generalized anxiety disorder.

Published in the January edition of the Archives of General Psychiatry, it shows that people with stabilized heart disease were still at risk for repeated heart problems if they suffered from anxiety or depression.

They interviewed 804 patients with stable coronary artery disease and found that patients with one or both of these mental illnesses had a 26 per cent chance of a repeated cardiac event in the next two years. This is double the risk found in patients who were free of depression and/or anxiety.

“We’ve known for a long time now that depression was a risk factor, but now we have evidence that anxiety has just as much an impact on the heart as depression," says Dr. Lespérance. “We don’t have a clear picture as to why both types of mental disorders put people at risk for cardiac events, but the findings are very interesting. Anxiety and depression may share mechanisms, but there also may be some important distinctions that could point to more effective interventions tailored to the comorbid condition."

After 15 years of research in the area of depression and heart disease, Dr. Lespérance thinks there is still work to be done in figuring at how to best serve the health care needs of depressed patients with comorbid cardiac problems.

“I believe it is important to treat depression, but not at the expense of increasing the risk of cardiac illness," he says. “This can be challenging because you’re chasing two goals at the same time which may not always be compatible."

Dr. Lespérance says more research is needed to gain a better understanding of the multiple mechanisms involved in the relationship between mood disorders and heart disease.

“We need to develop treatment strategies aimed at improving both the mood disorder and cardiac condition at the same time," he says. “It has to be treatment that is multi-staged and can last through the acute phases of both conditions and prevent the potential for relapse."

“The long-term investment is important because the recurrence of depressive symptoms and the risk of another cardiac event can happen if the patient doesn’t make healthy changes."

© Copyright 2008. Canadian Psychiatry Aujourd’hui. All rights reserved.

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