Is Depression a Form of Heart Disease?

Depression hurts, and not only in the ways people expect. Alongside the emotional flatness and the sense of being broken, a lot of people living with it describe real physical pain. Aching joints, sore muscles, headaches, an unsettled stomach: all of it shows up. Chest pain, though, is the symptom that comes up most often. Nobody can say with certainty why this happens. What researchers and clinicians do agree on is that depression interferes with neural communication, and when that signaling breaks down the body sometimes responds in strange, physical ways.

So stress, sorrow, and despair can genuinely hurt the chest. Can grief actually damage a heart? Yes.

The condition has a clinical name, stress-induced cardiomyopathy, often called broken heart syndrome. It is real, and it tends to strike after a profound loss, whether from a death or the end of a relationship. Healthy people can develop it, and on its own it is not evidence of a depressive disorder. The longer-term picture is different. Chronic stress and sadness, the kind that slides into depression, have been tied to heart disease. A sudden loss does not cause heart disease by itself, but when clinical depression sits alongside existing heart problems, the combination can turn deadly.

A panel of twelve psychiatric scholars recently urged the American Heart Association to recognize depression as a major risk factor for heart disease. Their more pointed finding: in someone who already has heart disease, depression raises the odds of a heart attack and of dying. The people at greatest risk of a cardiac event, one that might end in surgery or death, are women under 55 who carry moderate to severe depression. That group faces roughly double the risk.

Part of the difficulty is that depression rarely travels alone. It is a comorbid condition, showing up beside all sorts of other illnesses. Which one drives the other is still murky. Some symptoms of depression, fatigue and apathy among them, can erode a person's general health. Those same symptoms can blind someone to the warning signs of something serious going wrong in their body. And serious illness, with all the fear and strain it brings, can tip a person into depression in the first place.

Whatever the direction of cause and effect, depression opens the door to a stack of physical troubles: diabetes, obesity, poor eating, a life spent sitting still, substance abuse. Those are many of the same conditions that lead to heart disease. Beyond behavior, the body's chemical response to depression plays a part. Overproduction of cortisol, the stress hormone, and of pro-inflammatory cytokines, part of the immune response, can inflame the heart tissue itself, weakening its structure.

Anxiety adds another layer. Most people who have both heart disease and depression are dealing with anxiety too. Anxiety by itself doubles a person's risk of dying. Stack it on top of depression and that risk roughly triples. Why does the jump get so steep? Lana Watkins, Ph.D., associate professor in Psychiatry and Behavioral Sciences at Duke University Medical Center in Durham, North Carolina, points out that depression and anxiety carry different risk profiles, and together they compound the danger. Depression is at its core a behavioral disorder; neglecting your health drags other consequences along with it. Anxiety does something more direct, triggering adrenaline that pushes blood pressure up. Keep that constant worry running alongside a sedentary life and the outcome can be grim.

What about treatment? Watkins suggests that anti-anxiety medication paired with stress management might be enough for someone whose only problem is anxiety, while patients carrying both anxiety and depression likely need something stronger. Depression, unfortunately, does not yield easily. Existing therapies affect people inconsistently, and only about half of those who get treated reach remission.

Robert M. Carney, Ph.D., professor of psychiatry at Washington University School of Medicine in St. Louis, sat on the panel that made the recommendation. He is uneasy about how little evidence exists connecting the treatment of depression to any protection against heart disease, heart attack, or death. So far no study has shown that treating depression actually shields the heart. 'We believe better depression treatments may improve survival,' Carney says, before adding the caveat: 'More research will be needed, though, before we can say treating depression can improve heart health or survival in patients with heart disease.'

That leaves an open question about where this goes next. Leaving depression alone makes for a diminished life regardless of the heart. Treatments that do help include cognitive behavioral therapy, often just called talk therapy; selective serotonin reuptake inhibitors such as Zoloft and Prozac; and serotonin and norepinephrine reuptake inhibitors like Effexor and Cymbalta. When depression lifts, people are often able to pick up healthier habits, better food, more movement, giving up tobacco. Those changes can lower the risk of heart disease and death, and they tend to ease the depression too.

Melissa Lavery, M.S.