Many patients with cardiac disease also suffer from depression
When people used to ask Jang Jaswal, 61, what he did for a living, he would tell them he spent a lot of time in the hospital. “Are you a doctor?” they’d ask. “No,” he’d say, “I’m a patient.”
From 1989 to 2014, Jaswal experienced a major heart attack or cardiac event every two to three years. In 2000, he had two strokes and a triple bypass surgery, followed by additional blocked arteries in 2005, 2007, 2008, 2009 and 2010. In 2012, there were 16 times that he was admitted to the hospital for a period of three days or more.
He became so depressed during this time that he discussed funeral arrangements with his daughter. “I was really, really low in 2013, and I thought I was going to die,” he says.
Depression is common in cardiac patients. About 15 to 20 percent of patients with coronary artery disease have a major depressive disorder, and another 31 to 45 percent suffer from clinically significant depression, according to the medical journal Depression and Anxiety.
Patients might feel depressed related to uncertainty about their future, ability to fulfill their work or family roles, doubt about their physical capabilities and guilt about habits that might have put them at risk for a heart attack.
Not only is depression more common in cardiac patients than in the general population, but depression is also a risk factor for further cardiac disease and death, says Konstantinos Kostas, PhD, a psychologist with AMITA Health.
Depression after a heart attack can impact patients’ physical functioning, quality of life, healthcare follow-up and chance of rehospitalization, Kostas says. Research shows that patients who have had a heart attack and who are depressed have a 240 percent increased risk of mortality.
Cognitive behavioral therapy and medication can help.
Jaswal was referred to a psychologist in 2000 and eventually received a diagnosis for depression and bipolar disorder. “[A psychiatrist] prescribed antidepressants, such as Prozac, and I took those until about 2005, and then we started weaning me off them,” he says. He continues to see a psychologist, which he says has been one of the keys to his recovery.
The most commonly prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft) and fluoxetine (Prozac), says Gregory Teas, MD, chief medical officer at Alexian Brothers Behavioral Health Hospital. They can be used safely by patients who have had a myocardial infarction (MI), commonly called a heart attack.
“These drugs have been repeatedly shown to be safe and to be positive in post-MI depression,” Teas says. “But other forms of treatment such as cognitive behavioral therapy would also be very reasonable approaches to people who are initially diagnosed.”
Most heart patients with depression, however, are not being properly diagnosed and referred, Teas says. Often the depression is mistaken for something else. “When patients have symptoms of depression, their personal physician or cardiologist will think it’s secondary to their heart limitations or see it more as an adjustment disorder and may not refer them for treatment or initiate treatment for depression.”
About 15 to 20 percent of patients with coronary artery disease have a major depressive disorder, and another 31 to 45 percent suffer from clinically significant depression.”
Not only are patients with cardiovascular issues at risk for depression, but the vast majority don’t know it and many of their doctors are unaware of it as well.
A nationwide survey of cardiologists published in Cardiology in Review revealed that 49 percent were unaware that depression was a risk factor for coronary artery disease problems. Seventy-one percent of cardiologists failed to inquire about depression in over half of their patients.
A diagnosis of anxiety disorder or depression might be missed because the symptoms are similar to heart symptoms. For example, fatigue and insomnia are common with both conditions. Panic attacks can also cause symptoms that mimic heart issues.
Screening for depression after a cardiac event is important. Kostas recommends screening when a patient is hospitalized, when they are discharged and three, six and 12 months later. Clinicians use Patient Health Questionnaire-9 (PHQ-9) to screen for depression.
“I think it’s important that the PHQ-9 is administered at annual physical exams,” Kostas says. “When you go for an annual physical, your doctor should be screening for depression.”
Recognizing and treating depression is key, though all the monitoring in the world still might not be enough to help someone, as was Jaswal’s experience. For him, a heart transplant proved the turning point.
“Ever since my transplant — even from the very next day when I came back to my senses — I was feeling better. It was like there was energy flowing through my body. Before that, all the time I felt like life was slipping out of my body,” he says.
Today, Jaswal is an ambassador for the American Heart Association, offering support and guidance for those experiencing the very things he felt for nearly 25 years. “I feel like I have a second chance at life,” he says. Now he’s driven to help others receive that second chance as well.