First Glance

Ans. Management of anxiety and depression has shown to increase ejection fraction, pre and after load which are the determinants of cardiac functions. Rapid return to work due to increased motivation which was otherwise decreased because of depression. There is also increased use of leading health services. Increased social support and help from spouse will speeden recovery.

Q. What are the steps involved in the management of this co-morbidity?

Ans. The steps involved in the management of anxiety and depression along with cardiovascular diseases are two pronged, one involving the treatment of anxiety and depression which becomes very essential and two in treating cardiovascular diseases. The management of anxiety and depression along with cardiovascular diseases therefore involves :

a) Pharmacotherapy

• Using antidepressants like dothiepin for effective control of anxiety and depression and relevant medicines to treat the cardiovascular diseases.

b) Decrease in anxiety using

• relaxation, cognitive and behaviour therapy
• psychological support system to deal with problems at work, sexual life, physical complaints and mortality.

c) Morale boosting is necessary and promotion of independent action.

d) Counselling regarding medication and dietary factors.

e) Gradually making him encounter the causatory factors for anxiety and depression.

f) Sociological factors modification - overcrowding, frequent confrontation, severe threat, transition or changed tradition, crying, unemployment and socioeconomic status in general.

g) Newer factors being tried are meditation, progressive muscle relaxation, thermal bio feedback and stress management.

h) Under severe depression ECT can be tried as a mode of therapy.
The conditions where ECT can be used include :

• elderly with cachexia secondary to depression
• major depressive feature with cardiac complaints
• depression with psychosis

Q. How can compliance with treatment be increased?

Ans. Patient compliance is very important especially in chronic conditions like cardiovascular diseases. Patient compliance for treatment can get hampered if depression and anxiety are not taken care of.

In addition to that there are certain factors that can influence the compliance with treatment. They include :

• rapport should be established between the doctor and patient to build conviction
• education of the patient
• good choice of medication after considering side effects, efficacy, co-morbidity, drug interactions, dosage schedule and cost
• make the patient aware of the necessity and benefit of the treatment.

Denial of illness affects the diagnosis as well as treatment. This must be corrected and patient must be made to develop insight.

Q. What are cardiac side effects of antidepressant drugs and which are the cardiovascular drugs that produce depressive features?

Ans. The cardiac side effects of antidepressant drugs are :

• Conduction abnormalities like ectopic
• PR,QRS & QT interval increased
• T wave abnormalities with decrease in amplitude
• Decrease conduction time at bundle of His
• Bradycardia and atrial fibrillation especially with fluoxetine
• Orthostatic hypotension (fall of BP on standing)
• Cardiac contractility affected if antidepressants are used with class la antiarrhythmic
• Increase in heart rate by 3-15/min

The cardiac drugs that produce depressive features are B-blockers, Methyl dopa, Ca channel blockers, Digitalis, Procainamide, Disopyramide.

Thus, "every affection of the mind that is attended with either pain, pleasure hope or fear is the cause of agitation whose influence extends to the heart."