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Depression

Insights Into the Heart-Brain Connection: Psychocardiology

What can understanding the heart-brain connection mean for you?

Key points

  • The relationship between psychiatric disorders—particularly depression—and heart disease can be a two-way street.
  • The comorbidity of mental health problems and heart disease has been under-recognized and inadequately managed.
  • Both patients and clinicians can take steps to better manage the overlap between heart health and mental health.

If you’ve had a heart attack, you are likely aware of risk factors such as high blood pressure, high cholesterol, and diabetes. You may manage these risks by taking prescribed medications, quitting smoking, eating healthy foods, and getting active. However, you should also be aware of another risk factor that is just as important to manage: depression.

According to an article in the European Heart Journal, individuals with a history of cardiovascular disease are more likely to experience symptoms of depression than those without such a history. Conversely, the risk of developing cardiovascular disease increases by 65 percent in individuals with depression. This suggests that there is a deep, bi-directional connection between the heart and the brain.

Both cardiovascular disease and depression are serious medical conditions. And given that they often occur together in the same individual, it’s worth considering the implications for patients and clinicians.

Medicine and the Brain-Heart Connection

Clinicians are only beginning to understand the deep connection between the heart and the brain. We know, for example, that unmanaged external stressors can put extra strain on the heart. From a body mechanics perspective, heart attacks are caused by a buildup of plaque along the walls of your arteries and if that plaque suddenly releases, it can cause a blockage.

But also, stress can send our bodies into “fight-or-flight” mode, and then what happens? Our blood pressure increases, our brains release adrenaline, which triggers the release of another chemical, neuropeptide Y, and neuropeptide Y can cause the heart to spasm. All of this can precipitate a heart attack. So, it’s worth further studying the brain-heart connection.

Here is a brief summary of what we know about the connection between the brain and the heart:

1. The two-way connection between heart disease and depression.

As mentioned above, there is a bi-directional association between cardiovascular disease and major depressive disorder. In other words, a percentage of people with no history of depression become depressed after a heart attack. And people with depression, but no previously detected heart disease, are at higher risk for developing heart disease than the general population.

2. Broken heart syndrome.

“Broken heart syndrome is a temporary heart condition that is often brought on by stressful situations and extreme emotions,” according to the Mayo Clinic. Also known as stress cardiomyopathy or Takotsubo cardiomyopathy, broken heart syndrome includes symptoms such as sudden chest pain, which can mimic a heart attack.

However, unlike a heart attack, broken heart syndrome affects only part of the heart and temporarily disrupts your heart’s normal pumping function. The condition usually reverses itself in days or weeks. Also, it is more likely to affect women than men. For example, we see symptoms of broken heart syndrome in older women who lose their spouses.

3. Psychological factors account for about 30 percent of heart attacks and strokes.

Cardiologists and other clinicians have known for decades that smoking, hypertension, high cholesterol, and diabetes account for most cardiovascular disease. But it wasn’t until results from the Interheart Study (25,000 participants in 52 countries) were published in 2004 that researchers made the explicit link between cardiovascular disease and emotional stress. The study showed that psychological factors account for about 30 percent of heart attacks and strokes.

Beyond the effects of single, acutely stressful events, living with daily stress also increases the risk of heart attack and stroke. Stress hormones, which help us survive immediate threats to our lives, can also cause damage to our hearts when constantly released into our bloodstreams over long periods of time. In fact, psychiatrists and psychiatric nurse practitioners often treat conditions like anxiety with medications that slow down the heart rate and block the physical signs of anxiety (e.g. beta-blockers); these are also prescribed for patients with high blood pressure.

Additionally, mental stress increases inflammation of the brain and the heart muscle, which can also lead to further complications.

What Does This Mean for You?

Now that you are aware of the deep connection between the heart and the brain, let’s look at what patients and clinicians should do with this information.

For patients:

  • Be aware of the competing causes of your symptoms. One challenge here is that heart disease and depression often involve overlapping symptoms such as fatigue, low energy, and difficulty sleeping. Patients and cardiologists often attribute these symptoms to heart disease, when depression may be playing a key role.
  • Start a conversation with your clinician. Communication between patients and their medical care providers is vital. It’s important that patients and their advocates ask questions and insist on getting satisfactory answers. Starting the conversation can be as simple as asking, “Could depression be causing these symptoms?”
  • Realize that it is not uncommon for depression to occur after cardiac bypass surgery. If treating your heart issue leaves you with unresolved symptoms, it may be time to make an appointment with a psychiatrist, psychologist, or therapist. Remember, postoperative depression is associated with more complicated recoveries; therefore, unresolved depression can be just as dangerous as unresolved heart disease.

For clinicians:

  • Recognize the importance of treating heart patients for depression. The American Heart Association recommends that heart patients be routinely screened and treated for depression. Yet this rarely happens in a clinical setting. In one survey, less than 50 percent of cardiologists reported treating depression.
  • Talk to your patients about any personal obstacles to treatment. Depressed patients may experience decreased motivation to follow healthy habits such as taking prescribed medications, participating in daily exercise and healthy eating, and stopping smoking or abusing alcohol.
  • Partner with mental health professionals to treat patients. Cardiologists and other clinicians need to consider ways to treat the whole patient, rather than compartmentalizing treatment. When clinicians regularly consult with other experts outside of their area of specialty, patients receive better care for optimal patient outcomes.

The Bottom Line

The bottom line is that a heart attack can affect much more than a person’s heart. It can also affect:

  • Attitude and mood
  • Sense of certainty about the future
  • Confidence about one’s ability to adequately perform the roles of employee, mother, father, daughter, son, etc.
  • Feelings of guilt about past behaviors that may have increased a person’s heart attack risk
  • Embarrassment and doubt about diminished capacities

Depending on the problem, most who have had a heart condition can return to normal functioning following treatment, but when the above implications become debilitating, psychological or psychiatric help may be necessary to support heart patients. If you or someone you love has had heart issues, be on the lookout for any mental health changes that you may also want to address.

Understanding the brain-heart connection can lead to better health outcomes both for those who have had heart conditions and for those living with depression.

References

Bangalore, S., Shah, R., Pappadopulos, E., Deshpande, C. G., Shelbaya, A., Prieto, R., Stephens, J., & McIntyre, R. S. (2018). Cardiovascular hazards of insufficient treatment of depression among patients with known cardiovascular disease: a propensity score adjusted analysis. European heart journal. Quality of care & clinical outcomes, 4(4), 258–266. https://doi.org/10.1093/ehjqcco/qcy023

Ravven, S., Bader, C., Azar, A., & Rudolph, J. L. (2013). Depressive symptoms after CABG surgery: a meta-analysis. Harvard review of psychiatry, 21(2), 59–69. https://doi.org/10.1097/HRP.0b013e31828a3612

Yusuf, S., Hawken, S., Ounpuu, S., Dans, T., Avezum, A., Lanas, F., McQueen, M., Budaj, A., Pais, P., Varigos, J., Lisheng, L., & INTERHEART Study Investigators (2004). Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet (London, England), 364(9438), 937–952. https://doi.org/10.1016/S0140-6736(04)17018-9

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