Feel heartsick?
You may literally be, without knowing it.
Researchers have long known that depression can increase the risk of heart disease and stroke. Now, mounting research suggests that treating it could, in turn, reduce cardiovascular risk.
One recent study analyzing more than 5,300 patients with moderate to severe depression found those who took antidepressants alone had a 53 percent lower risk of dying, developing coronary artery disease or having a stroke than those who didn’t take antidepressants or statins. “It didn’t surprise me … that the risk was cut in half,” says the study’s lead author Heidi May, a cardiovascular epidemiologist at Intermountain Medical Center Heart Institute in Salt Lake City, Utah. “Studies have shown over and over and over that depression is an independent risk factor [for heart disease].”
May presented the study’s results in March at the American College of Cardiology’s annual scientific session in San Diego. Among those findings, patients with moderate to severe depression who took antidepressants alone appeared to fare better than those taking statins alone or in combination with antidepressants. “Overall, I think it reinforces the importance of treating and screening for depression,” she says.
Neither May, nor others familiar with her research, expect antidepressants to overtake statins in preventing heart attacks and other cardiovascular events in the general population. She says the difference in effect between antidepressants alone and antidepressants in combination was small, and she didn’t think the cholesterol-lowering medications had a negative effect in patients taking an antidepressant.
Rather, for those who struggle with depression, experts say research indicates it should be considered a focal point in the screening and treatment process, which could reduce cardiovascular risk.
Treating the Depression First
“If someone’s depressed, I would certainly focus on treating the depression first,” says Dr. Robert Kim, a cardiologist at New York-Presbyterian University Hospital of Columbia and Cornell in New York City. “I would probably not automatically think they’ve got to be on a statin, too.”
At present, May points out and Kim concedes, screening for depression often takes a back seat to measuring for traditional risk factors, such as high blood pressure or cholesterol. This, despite the fact about 1 in 10 Americans suffers from depression, and it’s associated with a higher risk for heart disease.
“I would say we’re probably still not doing a good enough job with screening for depression and we should be,” Kim says. “It clearly has consequences and we clearly can make a difference.”
As a caveat, Kim points out that while the relative risk reduction achieved in May’s study was 53 percent, the absolute risk reduction was 2 percent. Namely, 2 percent of patients who took an antidepressant suffered a cardiovascular event during the three-year study period — a reduction of 2 percentage points from 4 percent of patients who didn’t take an antidepressant and suffered an event.
“Not to take away the significant benefit there is, but we’re not taking people who would have 100 percent chance of dying and saving 50 percent of them, in other words,” he says. Still, while Kim says the findings should precipitate a nuanced discussion between patient and provider about the best course of action for the individual, he emphasizes that for someone who is depressed, treatment remains the most prudent course of action.
Mental Health Improvement Can Lead to Heart-Healthy Lifestyle Changes
Among other benefits, experts say, treating mental health concerns, such as depression, empowers patients to take on pesky bad habits such as not exercising regularly or eating poorly, or failing to adhere to medical advice. May speculates that the impact of taking antidepressants measured in the study she led likely stems, in large part, from how treating the disease can lead to behavioral changes.
Kim adds that given how depression can thwart one’s best efforts to make positive lifestyle changes, it does little good to advise such changes without first addressing the underlying mental health condition. “You actually need to treat the depression so that they’ll engage in those other things that will improve their health,” he says.
The American Heart Association currently recommends clinicians screen cardiovascular patients — a person recovering from a heart attack or stroke, say — for depression. There’s no recommendation at present to screen for depression as a means to prevent a first cardiovascular event, however.
May advises patients (or family members who suspect a loved one might suffer from depression) to discuss these concerns with their doctor. She adds that they should request to take a standardized questionnaire, a screening tool for depression, which can help with the assessment.
Treatment options don’t begin or end with a pill, either.
A study published last year found older depressed patients treated with antidepressants and/or psychotherapy as part of a collaborative care model suffered fewer heart attacks or strokes during the eight-year study than those who received standard care from a primary care provider. Standard care often included prescribing antidepressants, but Stewart says these providers did not receive input from a mental health professional to ensure recommended guidelines for treatment were closely followed. The collaborative care model involved a mental health professional providing input to a primary care provider. Patients studied showed no signs of heart disease at the study’s outset, and patient preference and responsiveness to treatment dictated the course of treatment.
“I think that the data suggest a collaborative care model might be a good fit,” says study author Jesse Stewart, an associate professor of psychology at Indiana University-Purdue University Indianapolis whose research focuses on the relationship between depression and cardiovascular disease.
He published his findings in the January 2014 issue of Psychosomatic Medicine.
A ‘Whole New Tool’ to Prevent Heart Attacks and Stroke
Stewart says historically, treatment of depression, as it relates to cardiovascular risk, has focused on patients who already had a heart attack, stroke or another cardiovascular event. In addition, he says studies on older classes of antidepressants failed to prove patients who took them had a lower cardiovascular risk. However, newer antidepressants, such as selective serotonin reuptake inhibitors, or SSRIs, he says, have yielded more promising results.
“Our unique take on things is that perhaps what needs to be done is that depression needs to be treated earlier in the natural history of cardiovascular disease — before the onset of a heart attack or stroke,” Stewart says.
He’s pursuing additional research aimed at proving a causal relationship between treating depression and lowering one’s risk for cardiovascular disease. If successful, he hopes that would give credence to treating depression as part of a holistic approach to prevention.
That would mean doing a mental health assessment alongside other standardized measures taken today, such as blood pressure and cholesterol levels. “This could provide physicians and primary care providers with a whole new tool for managing the cardiovascular risk of their patients,” he says.
In addition to thwarting positive lifestyle choices, depression is known to contribute to inflammation in the body that can play a role in heart disease. Besides treating the depression itself, Stewart says antidepressants, in particular SSRIs, have direct effects on platelet activation. Platelet buildup can contribute to atherosclerosis, the progressive hardening of the arteries that can lead to heart attack, stroke and even death.
“So antidepressants could be exerting a cardioprotective effect by improving depression and then also by directly decreasing platelet activation in your bloodstream.”
Stewart doesn’t think there’s enough evidence to recommend prescribing antidepressants to people who aren’t depressed solely to prevent cardiovascular disease. But he hopes future research showing treatment of depression lowers heart disease risk will provide added motivation to patients and doctors to make sure those who are depressed get the help they need.
Stewart is also seeking to modernize the collaborative care intervention by examining the use of computerized cognitive behavioral treatments; CBT focuses on changing patterns of thinking that negatively affect how a person feels or behaves. Stewart says early results show promise for computerized CBT, which he thinks could fit well into the primary care setting. Additionally, with funding from the National Institutes of Health, he has begun research this year to evaluate whether treating depression in HIV patients lowers their cardiovascular risk.
“Cardiovascular disease is the leading cause of death among HIV-affected adults,” Stewart says. He notes that HIV patients are now living longer because of the effectiveness of antiretroviral therapy, but suffering cardiac events earlier than the rest of the population. “So there have been calls to develop novel treatments for cardiovascular disease among HIV-infected adults and we’re now testing the depression treatment approach.”
He says the research is being done by IUPUI, in collaboration with Indianapolis-based infectious disease specialist Dr. Samir Gupta, at the Indiana University School of Medicine.
Stewart hopes, with all his research, that if it establishes a causal link between addressing depression and lowering heart disease risk, it will improve the quality of depression treatment in the primary care setting. Says Stewart: “You will be improving mental health along with preventing the No. 1 killer of Americans: cardiovascular disease.”
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Head and the Heart: How Treating Depression Can Lower Cardiovascular Risk originally appeared on usnews.com
