EPIDEMIOLOGY (Depression & Coronary Heart Disease)
- Depression has repeatedly been found to predict:
- Early-onset CHD.
- Post-MI mortality (1.5-5.07 times risk), esp. severe and chronic types.
- e.g. (HAM-Depression) scale score in first 2 weeks post CHD event predict 7 years mortality risk.
- Increased CHD symptoms (chest pain, fatigue).
- Noncompliance on exercise/medication/smoking.
Glassman AH, et al, Psychiatric characteristics associated with long-term mortality among 361 patients having an acute coronary syndrome and major depression: seven-year follow-up of SADHART participants, Arch Gen Psychiatry, Sep 2009
Keteyian SJ. Cardiovascular symptoms in coronary-artery disease patients are strongly correlated with emotional distress. Psychosomatics, 2008
Pathophysiology (Depression & CHD)
-
STRESS
- HYPOTHALAMUS
- ↓ CRH
- ANTERIOR PITUITARY
- ↓ ACTH
- ADRENAL GLANDS
- CORTISOL
- CATECHOLAMINES
- HYPOTHALAMUS
-
IMMUNE SYSTEM
- Increased secretion of cytokines
- (FNT-α, IL-1, IL-6)
- Increased secretion of cytokines
-
HEART
- Myocardial ischemia
- ↓ Of the heart rate variability
- Ventricular arrhythmias
-
ALTERATION OF THE REGULATION OF THE CENTRAL NERVOUS SYSTEM
Fig. 1 - Relation between major depression and cardiovascular disease
Negative and Positive Associations of Psychological Health and Cardiovascular Risk and Health and Potential Biologically Plausible Mechanisms of How Improved Psychological Health Can Lead to Decreased Cardiovascular Risk.
Negative Psychological Health
- Stress
- Negative outlook
- Anxiety
- Anger and hostility
- Depression
Reported Associated Behavioral and Biological Detrimental Processes
- Smoking initiation
- Physical inactivity
- Poor eating and overeating
- Weight gain
- Medication noncompliance
- Activation of the hypothalamic-pituitary-adrenal axis
- Dysregulation of the autonomic nervous system
- Inflammation
- Hypercoagulability
- Increased arterial stiffness
- Endothelial dysfunction
- Inducible myocardial ischemia
Changes in Behavioral, Psychosocial, and Biological Processes
- Smoking cessation
- Increased medication adherence
- Increased physical activity
- Effective emotion regulation
- Flexible stress management
- Positive social relationships
- Decreased inflammation
- Lower LDL, VLDL
- Lower BP
Positive Psychological Health
- Happiness
- Positive affect
- Emotional vitality
- Optimism
- Sense of purpose
- Gratitude
- Psychological well-being
- Mindfulness
Reported Associated Behavioral and Biological Beneficial Processes
- Smoking cessation
- Increased physical activity
- Heart-healthy eating
- Weight loss
- Increased medication adherence
- Preventive screening
- Blood pressure reduction
- Better glucose control
Glenn N. Levine. Circulation, © 2021 American Heart Association, Inc.
Post-Stroke Depression
- After stroke, 25 to 40% of patients meet criteria for Depression.
- Studies in the 80’s and 90’s demonstrated that post-stroke depression (PSD) was associated with left frontal brain lesions, worse physical and cognitive recovery, and increased mortality.
- These depressions were shown to be treatable with antidepressants and successful treatment led to both improved recovery and survival.
- There have now been RCTs showing PSD may be treated and prevented effectively with citalopram, nortriptyline, reboxetine, etc.
Post-Stroke Depression
- Later, antidepressants (ADs) shown to improve physical and cognitive recovery over 1 year independent of depression.
- Over 7 years, antidepressants shown to decrease mortality by 50% even among non-depressed patients …How?
- Inflammatory proteins are released both by stroke and depression and can have long lasting negative effects on brain function.
- ADs have been shown to decrease these:
- Inflammatory proteins
- Neurogenesis
- Synaptogenesis
- Improved recovery and decreased mortality following stroke.
- However, patients who take both NSAIDs & ADs should be monitored for intracranial hemorrhage.