Brought to you by the Depression Is Real Coalition, The Down &
Up Show is dedicated to the reality of depression. Each week our
hosts will talk with some of the world's top experts on depression,
as well as people who have been impacted by this illness. The reality
of depression is that it is a debilitating and potentially deadly
medical condition that affects more than 15 million Americans every
year. The other reality of depression is that there is hope.
Down & Up Show #37: Heart Disease and Depression
DR. REEF KARIM:
Okay. Welcome to the Down and Up Show on Depression is Real.org,
I'm your host for today's show, Dr. Reef Karim, psychiatrist, addiction
specialist and relationship (unint.). Dr. Mary Whooley will be speaking
with us today. Dr. Whooley's an associate professor of medicine,
epidemiology and bio-statistics at the University of California
San Francisco.
She's also a staff physician at the VA Medical Center in San Francisco.
Now Dr. Whooley has co-authored several publications on heart disease
including depression and cardiovascular disease, healing the broken-hearted
and depressive symptoms and health-related quality of life.
"The Heart and Soul Study" published in the "Journal of the American
Medical Association". It's great to speak with you today Dr. Whooley.
DR. MARY WHOOLEY:
My pleasure.
DR. REEF KARIM:
Alright, so we always hear the term co-morbidity which you know
a lot of people don't know when discussing depression and other
diseases. Can you tell us what co-morbidity means, as it relates
specifically to heart disease and depression?
DR. MARY WHOOLEY:
Co-morbidity simply means having two different illnesses at the
same time and when it relates to heart disease and depression, co-morbid
means that depression is present in the setting of heart disease
or that heart disease is present in the setting of depression.
DR. REEF KARIM:
Well how frequency how frequent is depression present in in a
person with heart disease?
DR. MARY WHOOLEY:
It's present in at least one of five persons with heart disease
and possibly higher, depending on the sample.
DR. REEF KARIM:
So about 20 percent, you know, a lot of people don't seem to to
realize that if you if you have a problem with heart disease, that
there is this co-morbidity with depression and it actually impacts
your ability to heal from your medical problem.
DR. MARY WHOOLEY:
Well that's exactly right.
DR. REEF KARIM:
Yeah, so often do you see that?
DR. MARY WHOOLEY:
Well uh in our in our clinics we see the link between depression
and heart disease all the time. Many people, well many people in
general, have depression first of all and then in the heart disease
population it's even more common.
And then in the patients who have depression, they are also more
likely to develop cardiac disease or to develop recurrent cardiovascular
events once they've had their first diagnosis.
DR. REEF KARIM:
In in my practice in working at UCLA I see quite a bit of of the
co-morbidity of heart disease and depression. How does this compare
to the co-morbidities of depression and other physical diseases?
DR. MARY WHOOLEY:
That's a great question. My sense is that and I don't know the
answer in terms of the scientific data, but my sense is it's probably
pretty similar, that patients with medical illnesses tend to be
more likely to have depression and that that is probably true for
chronic obstructive pulmonary disease and kidney dysfunction and
other chronic illnesses like rheumatoid arthritis or degenerative
joint disease.
DR. REEF KARIM:
Now a lot of those that you mention are more chronic diseases. Right
they they last
DR. MARY WHOOLEY:
Yes.
DR. REEF KARIM:
for awhile and there's treatment but there's chronicity [sic]
and there's kind of waxing and waning of those symptoms, that kind
of come and go.
DR. MARY WHOOLEY:
Yes.
DR. REEF KARIM:
You would think that if somebody had a chronic disease that you
never know if it was going to pop up or of it was going to be a
problem, that that would create this kind of mental mental health,
you know, obstacle to to knowing that you have this chronic problem.
Do you do you feel that heart disease specifically because there's
some chronicity to it that's one of the reasons there's a co-morbidity
to depression?
DR. MARY WHOOLEY:
Well that's an entirely possible I don't think we really understand
fully why patients with depression I'm sorry, patients with heart
disease have higher risk of depression then patients without heart
disease. It may very well be something to do with having a chronic
illness and not knowing when it's going to flair up, feeling the
stress of having a diagnosis that is a very serious one.
Or or feeling that consequences, you know, the physical consequences
of actually having the chronic disease that may affect your physiology
and your brain.
DR. REEF KARIM:
Why does heart disease so often co-occur with depression? Is it
is it surely the chronicity or is it something say has anybody
done any research on specifically heart disease?
DR. MARY WHOOLEY:
Well there are a lot of great studies trying to understand why
depression is associated with an increased risk of heart disease
and there are many potential mechanisms that have been suggested.
Some are physiological like maybe depressed patients have elevated
stress hormone levels or elevated cortical adrenaline levels that
might damage their heart directly.
Or it maybe that patients with depression don't take care of themselves
as well. Maybe they don't eat as well and they don't exercise as
much and they don't take the medicines that they're supposed to.
And maybe those are the reasons that they are developing more heart
disease then they non-depressed patients.
DR. REEF KARIM:
So if that happens and they have changes in their cortical level
or you know not taking care of themselves, not doing what they're
supposed to do and they have untreated depression, what are some
of the consequences of that individual who has untreated depression
in a person with heart disease?
DR. MARY WHOOLEY:
Well depression is associated with a greater risk of having a second
myocardial infarction or from dying earlier from your heart disease
then someone who doesn't have depression. And so the consequences
I think are increasing recognized as being quite serious.
DR. REEF KARIM:
So basically, there's a higher change you will have a heart attack
if you've already had one, by being depressed as opposed to not
being depressed?
DR. MARY WHOOLEY:
That's exactly right.
DR. REEF KARIM:
Okay, well that's a scary thing. We definitely want to treat depression
impact better health physically in somebody as well as mentally.
DR. MARY WHOOLEY:
Well that's the good news is that it really is very easy to treat
and I think once we get the increased recognition and awareness
out there, we might really be able to you know change the course
of of disease for some of these people.
DR. REEF KARIM:
Yeah are are most heart patients aware of the psychiatric effects
of (unint.) conditions?
DR. MARY WHOOLEY:
I would say most are not aware that I think it's only recently
really come to the forefront of the media the association between
depression and heart disease has been known for a long time. Dr.
Nancy Frazier Smith published pioneering work well over 20 years
ago, demonstrating this link well.
And of course clinicians as far back as Osler (ph.) have noticed
diff you know different personalities in patients with heart disease.
DR. REEF KARIM:
And (unint.).
DR. MARY WHOOLEY:
Yes and then there was the whole Type A personality association
that was published in the ī60s and it became, I think the general
consensus now is that there are multiple forms of psychological
distress that impact the heart. And we're not quite clear why these
forms of psychological distress can cause the heart to get worse.
But but that's what the evidence is showing.
DR. REEF KARIM:
Yeah I remember I remember hearing about some of that, that data,
that Type A personality
DR. MARY WHOOLEY:
Yes.
DR. REEF KARIM:
(Unint.) around and you're really Type A and you're really intense
about everything, that you might have more psychological stress
and that might impact your heart and other aspects of your physical
health. Whatever became of that, did they do they is that a fact
or
DR. MARY WHOOLEY:
Well that's a great question. I think that there wasn't really
ever a super clear conclusion. My best sense of the evidence is
that overtime it was realized that there were different components
to the Type A personality. There was the time emergency component
that all of us are familiar with.
And then there's the hostility component of someone who just really
has a negative outlook on others and on life. And it was found in
subsequent work that it was really the hostility piece of the Type
A personality that seems to be the bad actor and that patients with
hostility were more likely to develop cardiac disease and to die
of cardiovascular events then those without hostility.
So I would say that the Type A personality has faded out in favor
of just focusing on hostility.
DR. REEF KARIM:
So if you're really (unint.) and you want to get stuff right away,
you're okay. But if you're really hostile about getting that stuff
done, then that's a (unint.).
DR. MARY WHOOLEY:
Well that might be one way to put it.
DR. REEF KARIM:
Okay, do cardiologists often evaluate the mental health status of
their patients, especially when prescribing treatment therapies
because I mean you and I both know that a lot of the times we have
kind of territories as doctors. There's the psychiatrist and their
territories.
There's the psychologist and their territories, but obviously when
we're dealing with co-morbidities, we're all working together in
an integrated, you know, treatment program. So how often do cardiologists
really look at the mental health status of their patient?
DR. MARY WHOOLEY:
Well I think there are a few who always consider it and probably
the majority don't consider it and you know they they at the
moment they don't really have compelling reason to be concerned
about psychological problems in their patients because we don't
have any evidence that having cardiologists treat those psychological
ailments improves their heart disease.
And I think the cardiologists feel like they're dealing with the
heart and the primary care doctor should deal with the brain and
it's not that the depression or the psychiatric co-morbidity is
not important, but it's just that they aren't completely convinced
that it's important for the heart.
DR. REEF KARIM:
So so what are the treatment options for someone with both heart
disease (unint.)?
DR. MARY WHOOLEY:
That's a great question, there are several treatment options that
are have proven to be safe and effective. And one of those is what
we call talk therapy, cognitive behavioral therapy, where patients
go in and talk about their problems with their doctor and they come
up with behavioral strategies to change the way they think about
about things.
And then the other as you of course know are are medications
and patients with depression are are safely treated with Searchalene
(ph.), with Setalapran (ph.), those are both selective serotonin
reuptake inhibitors. And we have good data from from studies to
show that those two medications are safe in depressed patients.
If the side effects of those are intolerable or if they're not
effective for someone with depression another option is to use
Uproprion (ph.) which is Dopamine (ph.) Dopamine metabolism medication
and that can also be very effective for treating depression.
DR. REEF KARIM:
Alright, so as long as it doesn't increase blood pressure or put
more compromise on the heart, it's a good thing?
DR. MARY WHOOLEY:
Well that's exactly right and that's why the tricyclic (ph.) anti-depressants
for example are not really recommended in patients with heart disease
cause they can be associated with an at risk of arrhythmias and
other cardiac problems.
DR. REEF KARIM:
Yeah, that's a good point. So can treating depression reduce cardiac
(unint.)?
DR. MARY WHOOLEY:
Well that's the big question we do not know the answer and there
has been a large trial that I'm sure you're familiar with called
the enriched trial, enhancing, recovery in coronary heart disease.
And it randomly assigned almost just over 3000 patients with myocardial
infarction and depression or low social support to a cognitive behavioral
intervention versus a usual care.
And in that study they found no difference in cardiovascular outcomes
the patients who had been assigned to the cognitive behavioral therapy.
And there's been a lot of kind of you know looking backwards and
saying, well what could we have done differently in that study and
did it really prove that there's nothing that there's not a benefit?
Or it was just that the study was designed in a way that didn't
show the benefit? And that's a big open question and I think that
my my own sense from my own patients of course is that treating
depression helps with everything. It helps their quality of life
and it helps their physical problems.
But we do not yet have evidence from randomized trials that that
is the case.
DR. REEF KARIM:
It's really surprising, you know? You would think I mean in anybody's
functionality, if you're depressed, you're not as functional as
(unint.) be otherwise and we we know about the data with with
stroke and there's data with heart disease and and other physical
ailments.
So you would think it would make sense that if you treat depression,
there's going to be less of a chance of having physical as well
as mental health compromise. But it sounds like we don't exactly
have data yet (unint.).
DR. MARY WHOOLEY:
Well that's exactly right and I think that one of the issues is
that depression is such a heterogeneous condition, it's really
you know one person's depression can be quite different from another
person's depression. And on a biochemical level, we really have
very little knowledge of what what's going on.
And so it maybe that there are certain patients who would have
a great benefit and others with perhaps transient depression who
might just get better on their own. But we don't have a great way
of figuring out (a) what exactly is causing depression and (b)
which ones are going to best respond to our treatment.
DR. REEF KARIM:
So what do you think can be done to raise awareness about the effect
depression has on people with other chronic diseases like heart
disease?
DR. MARY WHOOLEY:
Well I think the the media can do a great service to the public
and shows like this and your focus on the Depression is Real Coalition
can really help to bring this to the forefront of of the public's
mind and once it's kind of like Al Gore doing his movie on the
global warming.
You know once the word gets out and it starts to spread, it people
can more and more aware and more and more accepting. I think the
other thing that needs to happen is that people need to get over
the stigma of depression. A lot of patient feels that somehow
it's a flaw to be depressed and that they should snap out of it.
And that there's really, it's a character defect rather then a
physical illness. And I think the more that we move beyond that
and treat depression just like any other chronic illness like diabetes
the better it'll be for our patients.
DR. REEF KARIM:
Do you have any closing thoughts or anything you'd like to add?
DR. MARY WHOOLEY:
I think I'd just like to encourage all patients who maybe depressed
to you know get get some help, talk to your provider, see where
in fact you might benefit from therapy.
DR. REEF KARIM:
Yeah I I agree. Okay so thank you for speaking with us today
DR. MARY WHOOLEY:
My pleasure.
DR. REEF KARIM:
Great, so listeners please visit www.heartsandsoulstudy.net, www.heartsandsoulstudy.net
for more information on Dr. Whooley's research into the relationship
between mind and the heart. Join us next for another segment of
the Down and Up Show on Depression is Real.org.
