The Mended Hearts, Inc.
Hearts of Jersey Chapter #179
Hearts of Jersey Chapter #179
February 2009
Sheila Turkell opened the meeting with the usual plea for more active participation in the work of Mended Hearts, noting also that Mended Hearts will soon have a new opportunity for patient visiting when Riverview begins doing angioplasties.
Our guest speaker for this meeting was Dr. Jacqueline Rondeau, a clinical neuropsychologist for the rehab center down the hall from the meeting room, working with people who have had strokes and other neurological problems as well as heart patients. Her topic was “Coping with Depression,” not just for people who have had cardiac procedures but for people who are depressed by, as Sheila put it, “a very frightening economy.”
After asking us what we would like to hear her talk about, she started by talking about efforts to improve outcomes after a heart attack. Depression - whatever else is happening - is an added risk factor against recovery and survival, and the more severe the depression, the greater the risk.
In the hospital, after heart attack, major depression is reported in about one out of six patients, and minor depression in one out of three. Studies vary, but generally one out of five experience clinical depression. One month after discharge, 35 to 60 percent of those who had clinical depression remain depressed, with major depression more likely to persist than minor depression.
Depressing statistic: 33 percent of those who have their very first depression after a heart attack die of a cardiovascular event - more than those who were depressed before the attack (22.6 percent) or did not get depression at all (21.5 percent). Maybe if you were depressed before you learned to cope with it. Emotional distress can show up three to six months after discharge, and it can persist after medical treatment ends.
Depression is cardiotoxic. It makes it harder to keep taking medications, exercising and eating healthy, and it lowers quality of life. But who wouldn’t be depressed? You’re facing mortality, facing loss, facing change. Sometimes that depression goes away, sometimes not.
Why does depression after MI increase the risk of heart failure? Explanations vary. Behavioral mechanisms include failure of the patient to comply with treatment and failure of the provider to offer treatment. Biological mechanisms include decreased heart rate variability and increased systemic inflammatory response - both of which are known risk factors.
The autonomic nervous system seems to be involved. It has two sides. The sympathetic nervous system arouses a “fight or flight” response to emergencies, which includes the “adrenaline rush” as well as increased heart rate and breathing rate, decreased digestive activity, and other changes that promote strenuous action. The parasympathetic nervous system promotes an opposite “rest and digest” state.
Experiments on rats show that MI (heart attack) activates the immune system and triggers an inflammatory response. It also affects the brain, deregulating the cingulate (prefrontal) cortex and affecting the limbic system, generating mood changes and arrhythmias. These changes increase coronary risk.
Putting this together: the anterior cingulate cortex (located above the ears, behind the eyes) is involved in regulating the activity of the autonomic system. It regulates blood pressure and heart rate, and it also affects rational functions like reward anticipation, decision making, empathy and emotion. So, when inflammatory responses after MI disturb the anterior cingulate cortex, you can get mood changes and cardiac arrhythmias.
Depression is not just sadness. It also includes fear and anxiety. Symptoms include feelings of hopelessness, guilt, worthlessness, pessimism, restlessness, agitation, difficulty concentrating and making decisions, insomnia or oversleeping, fatigue, and loss of interest in formerly pleasurable activities (including sex). If symptoms like these persist for two weeks or more you should see a physician or psychiatrist - you’re not crazy, but you need help.
Depression after MI can appear variously as fear, guilt, or acute stress. Here’s a simple screening test: in the past two weeks have you been bothered by (1) little interest or pleasure in doing things, or (2) feeling down, depressed or hopeless? There’s a longer test (which I won’t reprint here) if you answer yes to either of these.
Medications can help with depression. The older antidepressants disturbed the heart rhythm and should not be used by heart patients. The newer SSRIs may be safer and effective. They alleviate the symptoms of depression and they may short-circuit the cascade of symptoms that could cause a repeat heart attack.
Depression is part of your condition, not an added problem. Talk to your healthcare professional, ask about treatment, be active, confide in someone you trust. Build or rebuild a support network. Other strategies: Adopt a pet, learn relaxation techniques, try biofeedback, learn anger management.
You are not at fault and you are not alone. Get help .
