Among the general population, depression and heart disease are two of the most disabling and widespread illnesses, and often occur simultaneously in the same individual.

Studies have shown that about one in five patients with coronary disease is found to have depression, and this figure is at least as prevalent in people who suffer from heart failure.

They also found that people recovering from a heart attack who have depression, have a lower chance of recovery and a higher risk of death than people without depression.

Depression is generally more common in women than in men, and in people over the age of 65 years than under.

These figures remain true in women and elderly with known heart disease.

Causality

It is thought to be a two-way relationship between heart disease and depression:

• A percentage of people with no history of mood disorder become depressed after a heart attack or after developing heart failure.

It is somewhat hard to prove though that cardiac disease directly leads to the development of a first-ever episode of depression.

That is because some people who have had previous bouts of depression may not have it formally diagnosed until they seek medical attention for their heart problems.

• People with depression but no previously detected heart disease seem to develop heart disease at a higher rate than the general population. The reasons are multiple.

In depressed heart-attack patients, decreased motivation to follow healthy habits can result in skipping medications, avoiding exercise and proper diet, and continuing smoking and drinking alcohol.

Individuals with depression can also experience changes in their nervous system and hormonal balance, which can make it more likely for a heart rhythm disturbance (called an arrhythmia) to occur.

If arrhythmia occurs on a recently damaged heart, it can have significant adverse consequences. In addition, people with depression may have uncommonly sticky platelets, the tiny cell fragments that cause blood to clot in coronary vessels and lead to a heart attack.

The challenges of recognising symptoms of depression

Heart disease and depression often carry overlapping symptoms such as fatigue, low energy, difficulty in sleeping and carrying on the daily rhythms of life.

So, it is not surprising that sometimes, symptoms of depression are thought by the patient, his/her family, and the treating physician(s) to be due to heart disease.

Psychological impact of a heart attack

It can psychologically affect:

• Attitude and mood

• Sense of certainty about the future

• Confidence about one’s ability to fulfil the roles of a productive employee, mother, father, daughter, son or spouse

• Feelings of guilt about previous habits that might have increased the person’s heart-disease risk

• Embarrassment and self-doubt over diminished physical capabilities.

Effect of a positive mentality on heart disease

Two terms are used when discussing the effect of a positive mental state on heart disease:

• Healthy adherer: several studies have examined how well or poorly people take their medicines. Those who take their medications as directed have a lower death rate than those who do not (poor adherers). Also, individuals with a positive attitude about taking meds tend to diligently follow proper diet and exercise.

• Self-efficacy: describes a person’s beliefs about their ability to do the right things in order to reach a desired outcome, or to influence events in their own life.

The self-confidence that our actions can have a positive effect on our health is very important in determining how motivated we are to engage in healthy behaviours.

Support

Most heart-attack survivors are able to return to the roles and responsibilities they had before their heart attack.

When uncertainty and anxiety become debilitating and interfere with the daily functions of life, then the process of rehabilitation and recovery after a heart attack may need to include psychological support, and perhaps medications for depression. Types of support include:

• Cardiac rehabilitation — primarily supervised forms of exercise.

— Nutrition planning and counselling — specifically developed for heart-attack recovery.

— Social support — according to studies, making an extra effort to re-engage and socialise with family and friends can help you return to the person you were before the heart attack.

— Referral, if needed, to a psychiatrist, psychologist, or psychiatric social worker.

•Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women’s Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients’ care recognition awards. The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician. You should never delay seeking medical advice, disregard medical advice or discontinue treatment because of any information in this article