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Mending Hearts

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Are we failing cardiac patients with depression?


By Avril Roberts


Autumn 2010, Volume 14 No 1

It wasn’t until his participation in a study about cardiac patients and depression ended that Warren Moquin discovered that he had been depressed for some time, possibly dating back years before his series of heart attacks. “The changes were subtle enough that I did not recognize it,” says Moquin. “I just thought it was a natural part of aging.”

On the advice of the researchers, Moquin sought help – seeing a psychiatrist and taking antidepressant medication – albeit reluctantly. “This idea that you’re crazy – nobody wants to admit to that,” says Moquin. But it was during the study that Moquin had begun to make a connection between his inner rage and previous episodes of chest constriction. “I realized that depression may have contributed to that,” he recalls.

Looking back five years later, Moquin views the researchers’ intervention as a lifesaver. “Without them identifying the problem and without their offer of help, I can’t say how long I would have lasted. I might not be here today.”

Mood problems such as depression and anxiety are surprisingly common in people with chronic health conditions. Canadian research has found that about 15 per cent of people hospitalized for cardiac problems experience major depression, which itself increases the risk of cardiac morbidity and mortality. Another 15 to 20 per cent have depressive symptoms. Research also shows that depression may actually increase the risk of heart disease in physically healthy people, particularly women.

Yet despite mounting evidence of a link between depression and heart disease, depression remains underdiagnosed in cardiac patients and is not effectively treated – if at all.

Researchers and clinicians cite various reasons for this oversight. It can be difficult to diagnose depression with co-morbid conditions, says Dr. François Lespérance, professor of psychiatry in the Faculty of Medicine at the University of Montreal. “Sleep problems and fatigue could be due to heart disease, and concentration difficulties may be due to vascular disease of the brain,” says Lespérance. “There could be several factors that blur the identification of symptoms and attribute them to the physical condition rather than depression.”

People may not seek help for depressive symptoms that they mistakenly attribute to heart disease. Some may be reluctant to take medication for depression in addition to their heart medications. Others lack access to proper professional care. “Patients with heart disease are seen by cardiologists or family doctors,” says Lespérance. “Access to psychiatrists who can advise patients or physicians to prescribe antidepressants may not be readily available.”

The obvious answer seems to be routine screening for depression. The American Heart Association issued a scientific advisory in 2008, recommending routine screening for depression in cardiac patients. General practitioners in the United Kingdom are required to screen heart disease (and diabetes) patients for depression. However, there is no similar requirement or call for screening in Canada.

“Based on international guidelines, we do recommend that cardiac patients be screened,” says Dr. Brian Baker, a spokesperson for the Heart and Stroke Foundation (HSF), but he acknowledges that the HSF has not issued a position statement about this. In fact, in the larger cardiology and psychiatric communities, the issue of screening generates much debate.

Baker, a psychiatrist whose practice focuses on people with cardiovascular disorders, says the complexity of treatment for depression in heart disease is a major problem. The older tricyclic antidepressants can be toxic to the heart. Two selective serotonin reuptake inhibitors (SSRIs) – sertraline (Zoloft) and citalopram (Celexa) – have been tested in cardiac patients and proven safe and effective, mainly for people with previous or recurrent moderate to severe depression. They seem to be less effective for first-time depression in people with heart disease and for people with mild to moderate depression.

As for psychotherapy, Baker cites a major study of cognitive-behavioural therapy with cardiac patients, which found that although there was some improvement in mood, CBT didn’t make any difference to survival.

For Dr. Brett Thombs, assistant professor of psychiatry at the Faculty of Medicine at McGill University, the problem with routine screening is basic. “It’s a question of evidence. There has never been a randomized controlled trial to establish whether or not there is a benefit,” he says. “As with any other intervention, we need a large, pragmatic, randomized controlled trial to show that the group that is screened has better mental health outcomes than the group that isn’t screened. Then we need to assess how big the benefits are compared to how much it will cost and what would be the potential harms to patients.”

Thombs suggests that cardiac patients with depression would be better served by good clinical interviewing and good clinical care from well-trained front-line health care providers. “Speaking with patients about how well they are doing and difficulties they are having with the things they need to do to take care of their disease will lead the conversation to depression where it is appropriate,” he says. Thombs also sees a need to educate patients “so they know what depression is, how to recognize it and destigmatize it.”

Lespérance echoes some of Baker’s and Thombs’ concerns: “You don’t screen if you don’t have the resources to properly evaluate patients and treat them,” he says. Lespérance favours an interdisciplinary care approach that addresses depression in the broader context of cardiovascular risk management, such as medication compliance and proper exercise and nutrition. “Screening for depression in cardiac patients could be perceived negatively, but if you include the management of emotion, including anxiety and depression, in a more comprehensive cardiac rehabilitation program, then patients will see themselves as being treated more globally.”

Fast facts about depression and heart disease
  • Unmanaged stress can lead to high blood pressure, arterial damage, irregular heart rhythms, faster blood clotting and weaker immune systems.
  • During recovery from cardiac surgery, depression can intensify pain, worsen fatigue and sluggishness, or cause a person to withdraw into social isolation.
  • Patients with heart failure and depression have an increased risk of being readmitted to hospital, and also have an increased mortality risk.
  • Patients with heart disease and depression have worse medication adherence than patients with heart disease who do not have depression.
  • Negative lifestyle habits associated with depression – e.g., smoking, lack of exercise, poor diet, lack of social support – interfere with treatment for heart disease.

Source: Cleveland Clinic

Self-management: Getting to the heart of the matter

In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Guided or supported self-management is a promising approach to care that partners patients with their health care providers.

Dr. Dan Bilsker, a psychologist and consultant with the Centre for Applied Research in Mental Health and Addiction in Vancouver, British Columbia, is a strong proponent of supported self-management. Co-author of the self-care workbook Positive Coping with Health Conditions, Bilsker trains family physicians to deliver supported self-management to adult patients with mild to moderate depression and chronic physical illness. “Research shows that if you give someone a self-management tool, it can be meaningful, but if you add support, you double the impact,” says Bilsker. Self-management is also affordable and easy to disseminate, and it is an effective use of existing networks of community and medical support.

The Bounce Back: Reclaim Your Health program, led by the Canadian Mental Health Association – B.C. division (CMHA-BC), showcases British Columbia as one of the first jurisdictions in the world to take an integrated approach to addressing chronic health conditions that are accompanied by mental health issues, using a self-management approach.

Targeting people with mild to moderate depression and chronic illness, Bounce Back provides psychoeducation and guided self-help through two interventions: a DVD provides practical tips on managing mood, healthy living, building confidence and problem solving; patients also have access to one-on-one telephone coaching by community-based coaches trained and supervised by psychologists. The coaches guide participants through a workbook based on cognitive-behavioural therapy.

“Many people who are depressed do not feel very motivated or organized,” says Lynn Spence, associate executive director and director of provincial programs at CMHA-BC. “Coaching helps people identify what might be getting in the way of making changes and supports them to develop plans to introduce new behaviours into their lives to better manage their mood.”

Access to the program is via physicians’ offices throughout B.C. Other health care professionals such as nurse practitioners and mental health clinicians can make referrals, but they must be endorsed by a family doctor. Spence says it makes sense to place the family doctor at the heart of the service delivery system because “the first place people go with issues of depression is primary care.” It also serves as a safeguard in case a person needs more help with depression than Bounce Back can provide in the typical three to five sessions over four to eight weeks.

Since Bounce Back launched two years ago, 38,000 DVDs have been distributed to physicians’ offices, and there have been more than 7,000 referrals. Feedback has been positive: “The more tools we have, the better we can respond,” said one doctor. “It is very difficult for patients to get mental health services, so Bounce Back is a critical option.”