Within the mental health care community, the “mind-body connection” is often viewed as a clear indicator of optimal mental and physical health. Mental health conditions like depression are not only associated with increased suffering and loss of functioning, but depressed people are more at-risk for potentially fatal health problems, especially those with coronary heart disease (CHD). In theory, treating a patient’s depression should improve mood and heart health. Yet research suggests the opposite: treating depression in individuals with co-morbid CHD does not automatically reduce the risk of future cardiac events. American Heart Month is a good time to consider the best ways to treat CHD patients’ depression without unintended negative consequences.
People with CHD are twice as likely to become depressed as individuals in the general population. Worse, if you have CHD and are depressed, you are more likely to experience a future cardiac event than if you were not depressed.
Depression is associated with reduced heart rate variability, platelet aggregation and increased sympathetic nervous system activity, all of which increase risks for patients with cardiac disease. Further, depressed individuals often have reduced energy and lower motivation, which interferes with activities like exercise, buying and preparing healthy foods, and attending medical appointments, all of which are critical for restoring heart health.
Clearly, depression is bad for patients struggling with co-morbid CHD, but studies show treating depression, while it can improve mood, does not decrease the risks of CHD. These results are consistent regardless of the type of depression treatment, whether psychotherapy or anti-depressant medication.
It turns out, while no one wants to be depressed, there are actually aspects of depression that can be helpful in managing disease. Many people do not make healthy behavioral changes after a cardiac event, but depressed individuals are more likely to detect and take seriously physical symptoms that may require care. There are a few reasons for this.
For one thing, people with depression are self-focused. This can have a good effect, increasing the ability to detect signs of stress, such as increased heart rate or chest pain.
Because depressed people are given to rumination—going over and over the same ideas in their heads—they may more accurately assess the risk associated with these symptoms. This could be because rumination can actually result in more analytical thought, which would yield more accurate risk assessment. For example, depressed individuals are more likely to base estimates of cancer risk on actual medical feedback.
Because of this “depressive realism,” depressed individuals are more likely to recognize that medical conditions like heart attacks are chronic—meaning they can happen again. While emotionally painful, this belief is crucial for optimal disease management. Less depressed people are less likely to adhere to a medical regimen because they view negative health conditions as transient rather than permanent.
Thus depression presents a paradox: depressed people are more likely to recognize the importance of physical symptoms, but they may be unable to act on that perception. So treating depression in individuals with co-morbid CHD can increase the energy and motivation to act, but it also may inadvertently reduce the perception of the need for action. As a result, while therapy for depression and cardiac rehabilitation can be synergistic, in some ways these treatments can actually be at odds.
So what can be done? Leaving depression untreated is not the answer. Overall, treatment of depression does not worsen cardiac health, and it reduces suffering and improves overall functioning. But more can be done to optimize outcomes so that both mental and heart health improve.
On an individual level, the key is for people to recognize that CHD is both chronic and controllable. As people improve their mood and have more energy to engage in disease management, they must not lose sight of the serious and chronic nature of CHD. They must pay attention to their symptoms and diligently follow through with disease management behaviors like diet, exercise and taking medication.
The recognition that CHD requires ongoing care can be scary. It’s particularly difficult for people recovering from depression—why think of something upsetting just as we’re feeling better? One way to manage this is by focusing on specific functional goals. For example, thinking of being alive for one’s children as they get older may make it easier for a person to consider engaging in disease management behaviors; it may even make those behaviors more enjoyable. Exercising might seem unnecessary for a person who’s feeling good, but doing it for one’s children connects it to a higher purpose, which gives more satisfaction.
This approach not only improves CHD management, it helps to continue to draw people out of depression as well. Behaviors like exercise are useful in managing both depression and CHD. Further, sustained work towards an achievable goal is a core behavioral activation skill with demonstrated efficacy in managing depression.
There are also systemic issues in the health care delivery system that can help:
First, integrating mental and physical healthcare is key. A unified setting for care can highlight when an improved mood results in less motivation for disease management, providing more opportunity to remedy the situation.
Second, it is critical that mental health care professionals receive training in the physical ramifications of mental health treatment. Psychologists and other practitioners must understand how treating depression can impact physical health, especially in patients with CHD.
Third, much more research is needed to show the correlation between physical and mental health and integrated treatments, before we automatically accept the idea that depression is bad for physical health.
If we are to truly improve the mental and physical health of our patients, we must begin by understanding the fundamental paradox, that being happy does not automatically also mean being healthy. We have to fight depression, while recognizing the ramifications this can have for patients’ physical health, and putting safeguards in place to keep both mind and body strong.
Dr. Mike Friedman is a clinical psychologist in Manhattan and a member of EHE International’s Medical Advisory Board. Follow Dr. Friedman onTwitter @DrMikeFriedman and EHE @EHEintl.