Indian Write-Ups

A sudden throttling pain ran through Mr. Verma’s chest at midnight. He woke up to find himself in a pool of sweat and a heaviness and extreme discomfort in his chest, suffocation and palpitations.

He was rushed to the ICU & treated for acute myocardial infarction.

After discharge Mr. Verma continued to have symptoms of ischemic heart disease such as chest pain and raised B. P. He could not return to his job. He had insomnia, loss of appetite, decreased interest and reduced energy.

Finally he consulted a psychiatrist and was started on antidepressant medication. Within a month he was back at his job and his cardiac symptoms had also improved considerably.

Cardiovascular disease frequently co-exists with psychiatric disorders. Of all parts of the body the heart holds a place of special distinction in common thinking as the seat of emotion, effort and even of life itself.

Prevalence of depression in patients of cardiovascular disease is at least 20%.

DEPRESSION AS A CAUSE OF CARDIOVASCULAR DISEASE

There is overwhelming evidence from community based studies that there is a 1.5-2 fold increase in mortality among patients with depression and this excess is primarily from cardiovascular deaths. Various reasons cited for this include:

• Increased smoking in depressed people
• Fluctuation of blood pressure
• Obesity due to decreased physical ctivity
• Increased serum cholesterol because of lipid release from deposits during stress produced as a result of depression
• Increased atherogenesis (increased fatty deposits in blood vessels)
• Increased platelet aggregation

Thus a 65% increase in risk of ischemic disease is associated with depression.

DEPRESSION AS A CONSEQUENCE OF CARDIOVASCULAR DISEASE

Following cardiovascular diseases like acute myocardial infarction, many patients are forced to be dependent on others. They contribute less to the support of their families. Sexual function may be adversely affected.

Smoking, alcohol use, failure to exercise and non-compliance with medication or diet have contributed to development of illness and may result in feelings of guilt.

The issues of progression of disease, recurrence and death are universally present for heart disease patients and may be met with reactions such as denial, anxiety and depression.

EFFECTS OF DEPRESSION ON THE OUTCOME OF CARDIOVASCULAR DISEASE

It has been proved beyond doubt that the presence of depression after myocardial infarction increases the risk of mortality to almost 4:1 at 6 months follow-up. The patients at greatest risk of mortality are those with combination of significant premature ventricular cardiovascular disease (PVCs) and depression. There might be an arrhythmic relationship between depression and sudden death.

Other Consequences

• Inadequate response to therapy due to poor patient compliance to cardiac treatment and rehabilitation regimens. Also there may be problems in doctor-patient relationship. All these lead to persistence of cardiovascular symptoms and prolonged treatment.
• Poor quality of life and increased disability
• Decreased level of functioning. The patients cannot resume their previous jobs.
• Adjustment disorders with family members
• Restricted social life.

DIAGNOSTIC CRITERIA

Diagnosis of co-morbid depression with cardiovascular disease is difficult because many of the symptoms overlap both the diseases. However clinicians are urged to aggressively and proactively identify depressive symptoms whether they appear from cardiovascular disease or not. The various symptoms include:

• Insomnia - usually waking in the morning at least 2 hours before the usual time
• Feeling of apprehension and tension
• Loss of interest and enjoyment
• Decreased energy causing tiredness and decrease in activity
• Decreased attention and concentration
• Ideas of guilt and worthlessness
• Decreased self-esteem
• Somatic symptoms such as backache, headache, dizziness, GI distress.

The clinician can pay attention to the following to help the diagnosis:

• Prior history of depressive episode in the patient
• Positive family history of depression
• Female gender
• Time of onset of depressive symptoms (prior to onset of medical illness)
• Duration of current depressive episode (>2 weeks) and pervasive throughout the day

It is far better to over diagnose depression than to under diagnose since if depression is present, regardless of etiology, it requires proactive diagnosis and treatment.

MANAGEMENT

The aggressive management of depression is extremely essential to improve the outcome of co-morbid cardiovascular disease.

1.PHARMACOTHERAPY - ANTIDEPRESSANTS

• Dothiepin is an effective antidepressant in cardiovascular disease.
• Selective serotonin re-uptake inhibitors (SSRI) such as fluoxetine (20-60 mg/d), paroxetine, sertraline have been found to have the safest cardiovascular profile. They are well tolerated in patients with stable heart disease & left ventricular dysfunction.
• Amongst the tricyclic anti-depressants, nortryptiline is safer than others. However it may have certain cardiac side-effects.
• Nefazodone also has no reported cardiac effects.

2.PSYCHOTHERAPY

• Establish rapport between the doctor and the patient
• Education of the patient regarding medication and dietary factors.
• Morale boosting of the patient
• Psychological support system to deal with problems at work, sexual life, physical complaints and mortality
• Relaxation, Cognitive and Behavior therapy, Stress Management