by Carolyn Thomas ♥ @HeartSisters
I can vividly remember those early days and weeks at home after surviving a heart attack, especially that cold creeping anxiety around how I “should” be feeling. I had just survived what many do not: what doctors still call the “widow maker” heart attack. (By the way, note the gender semantics there, please: doctors are not calling this the “widower maker”).
I was now resting comfortably, both of my darling kidlets had flown back home to be with their Mum, our home was filled with flowers, get-well cards and casseroles delivered by the daily line-up of concerned friends, family, neighbours and co-workers.
So why was I feeling so bleak inside, and even worse, now feeling guilty for all that bleakness?
Shouldn’t I be deliriously happy and thankful now because I was alive, because I was so lucky to live near world-class cardiac care, because I had such a strong social support network of family and friends around to fuss over me? Why was I so frighteningly tearful over every twinge I felt in my chest? Why was it becoming almost impossible to concentrate or to participate in conversations or to even drag my exhausted self out of bed every morning? Why had I simply stopped caring, day after day after day, about how I looked or how I smelled? Why was I no longer interested in, well . . . anything?
Ironically, being surrounded by so much love and attention actually made me feel even more broken: with all this caring, how dare I feel anything but a good patient’s appropriately cheerful dose of gratitude? Why couldn’t I just will myself to snap out of it?
It turns out, however, that what I was experiencing is actually remarkably common among heart patients.
When I was at Mayo Clinic, I was shocked to learn there that up to 65% of heart attack survivors experience depression, yet fewer than 10% are appropriately identified.
Before I was discharged from hospital, not one person in the CCU (the hospital’s intensive care unit for heart patients) had warned me of the reality of these mental health statistics. Not one doctor, not one nurse had said even one word to me about this common problem.
Unfortunately, many heart specialists may not have the time or the expertise to address depression, according to cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic:
“Cardiologists may not be comfortable with ‘touchy-feely’ stuff. They want to treat lipids and chest pain. And most are not trained to cope with mental health issues.”
The closest most cardiologists may come to identifying a bona fide mental health issue in their patients is through the common term “pump head”. In February 2001, The New England Journal of Medicine documented the frequency and persistence of mental deterioration following coronary artery bypass surgery – dubbed pump head. This deterioration includes symptoms like mental sluggishness, personality changes and memory problems – not surprisingly, also the symptoms of clinical depression.
But in his column called “Don’t Be So Sure It’s Pump Head” , cardiologist Dr. Richard Fogoros warns:
“It seems very likely that patients who actually have depression will be written off as having pump head. This would be a big mistake for two reasons. First, depression (unlike pump head) is treatable. Second, in cardiac patients, depression can be lethal if untreated. Thus, mistaking depression for pump head can be a fatal mistake.
“Cardiologists are not trying to cause harm when they fail to diagnose depression – they just don’t see it. They are focused, by their natures, on a completely different aspect of reality.
“The very nature of cardiologists is to embrace the concrete, the mechanistic, the object that can be analyzed, broken down into parts and assemblies, and held in the hand and examined, component by component.
“The heart, being essentially a sophisticated pump, is thus inherently attractive to the cardiologist, an object worthy of one’s entire career.”
Failing to take the known risk of depression seriously in these heart patients can have devastating consequences, as Dr. Fogoros warns. A 2007 study published in the European Journal of Cardiovascular Nursing on depression in women with coronary artery disease found that 74% of women diagnosed with post-cardiac event depression still had impaired physical and social functioning one year after their heart attack.* That impairment also meant that overall recovery, independence and quality of life was also impacted.
We know, for example, that those who suffer depression are far less likely to follow their doctors’ recommendations for a heart-healthy diet, exercise, prescribed cardiac medications or to quit smoking.
Depression in heart patients has “flown under the radar for far too long”, concluded the study author, Dr. Colleen Norris. She added that doctors must look for symptoms of depression in all patients who are undergoing treatment for heart problems, but particularly in women.
We also know that the age of a heart patient may be an important factor here. For example, Dr. Susmita Mallik of Emory University School of Medicine reported in the Archives of Internal Medicine that younger women diagnosed with heart disease before the age of 60 are three times more likely to become depressed than male heart patients. Dr. Mallik observed:
“Depression should not be considered a normal reaction after a heart attack. Both doctors and patients should be aware that depression is an important risk factor for adverse outcomes for cardiac event survivors.”
Cardiologists at Cleveland Clinic (widely considered the #1 heart institute in North America) describe temporary feelings of sadness as “common” following a cardiac event. They also warn that this sadness should gradually go away within a few weeks as people slowly resume normal routine and activities.
Sometimes, however, a depressed mood can be severe and accompanied by other symptoms (including withdrawal from activities, not responding when visiting with family and friends, increased negative thoughts and tearfulness – pretty well the textbook description of my own symptoms!) that persist every day for more than two weeks running. That’s when it’s time for heart patients to seek immediate help.
But I knew nothing about this kind of information at the time. When those unexpected feelings of depression struck following my heart attack, I felt horribly overwhelmed, frightened and confused – and certainly too ashamed to tell anybody in my family. They’d already gone through so much because of my cardiac event; I couldn’t put any more on their plates.
On the seventh week of our 7-week Heart To Heart patient education series, the guest speaker was the cardiac social worker at our local hospital, who talked openly about mental health issues common to those diagnosed with heart disease. I recall feeling a glimmer of relief that evening just to finally realize that I was not alone – but this was over two months past my hospital discharge.
Why, I asked her much later, isn’t this important topic right up front at the very beginning of their 7-week schedule of guest speakers addressing freshly diagnosed heart patients?
Might scare people off, she replied.
In effect, the stigma of a mental health diagnosis is so pervasive in our culture that not even our health care providers will warn us about what the statistics already clearly show.
And when I shared with my (otherwise wonderful!) cardiologist my own experience with debilitating depression (after I’d started seeing a therapist and was well on the mend), his reaction was to recheck my chart and observe:
“Well, of course, it could be the beta blockers you were taking.”
NO! I replied. It was because I had just had a frickety-frackin’ HEART ATTACK!
Dr. Stephen Parker (a cardiac psychologist and – more importantly – a heart attack survivor himself) describes what he calls the “swirling emotions” he experienced after surviving a heart attack:
“Relief at survival — disbelief and anger that it happened — grief for everything that has and will be lost — gratitude to those who helped — extreme vulnerability in a previously safe world — fear of what the future might bring.
“A heart attack is a deeply wounding event, and it is a wound that takes a long time to recover from, whatever the treatment.”
Doctors, next time you’re seeing a freshly-diagnosed heart patient for a follow-up appointment, please remember that we’re more than just a major organ that’s successfully undergone a procedure. It’s time to start paying attention to the real-life emotional, mental and psychological trauma embodied in the whole person sitting across from you.
© 2013 Carolyn Thomas Heart Sisters ♥ www.myheartsisters
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* Colleen M. Norris et al. “Depression Symptoms have a Greater Impact on the 1-Year Health-Related Quality of Life Outcomes of Women Post-Myocardial Infarction Compared to Men”. Eur J Cardiovasc Nurs June 2007 vol. 6 no. 2 92-98
** Susmita Mallik et al, “Depressive Symptoms After Acute Myocardial Infarction: Evidence for Highest Rates in Younger Women,” Archives of Internal Medicine 2006; 166: 876-883.
- The New Country Called Heart Disease
- Depressing News About Depression and Women’s Heart Disease
- “I’m Not Depressed!” – And Other Ways We Deny the Stigma of Mental Illness
- 10 Non-Drug Ways to Treat Depression in Heart Patients
- Depressed? Who, me? Myths and facts about depression after a heart attack
- A Heart Patient’s Positive Attitude: A “Crazy, Crazy Idea”?
- How To Be a “Good” Patient
- Is It Post-Heart Attack Depression – or Just Feeling Sad?
- When Grief Morphs Into Depression: Five Tips for Coping With Heart Disease
- How We Adapt after a Heart Attack May Depend on What We Believe The Diagnosis Means
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Q: Did you experience symptoms of depression after your cardiac event?
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My 40-year old husband biked his way through a heart attack involving 100% blockage of the LAD on Jan. 2. We’re both in this weird “how did this happen?” questioning stage, and we’re definitely both sad at what could have happened, the life we had that now has to change, and the thought of what is more likely to happen now that he’s experienced one heart attack.
I’m not sure exactly why I’m posting this as I have no real point. I can tell you that I find it incredibly difficult to fall asleep. I keep checking to make sure he’s breathing, as if he might expire quietly in the night as a result of said attack. And I’m deathly afraid of preparing a meal that’ll kill him because of the salt or bad fats.
Might I inquire if you have any good cookbooks to recommend? We’ve already ordered a big AHA cookbook. Best wishes to you. We’re still working our way through this.
Hi Christie – I’m so sorry to hear of your husband’s shocking experience. Welcome to the very exclusive club that nobody ever wanted to join.
Your feelings of “hyper-vigilance” around him are very common – they will wear off in time, but right now can feel overwhelming and exhausting. You might want to read “How To Cope When Your Hubby Is The Heart Patient” which also has some links to some really helpful recommended books for women in your shoes, as well as some good advice on “Self-Care for the Caregiver”. Good luck to you!
Reblogged this on Ember Branch and commented:
Take care of your second life.
When my father had a heart attack and then quadruple bypass surgery his heart surgeon (one of the best) did not care about his mental health. It wasn’t “his job” and that was made very clear.
It’s like that in today’s medical care too. My Internist always refers me to “Specialists”; she stays within the narrow confines of her sinus infections and strep throat. The cardiologist and the cardiac surgeon viewed my dad as a number even though it was many years ago and it was a very risky procedure. When my father got severely depressed, he went to see a psychiatrist. I don’t think it ever occurred to him to broach his heart team.
I think your Dad’s experience is not unusual! It’s an example of how fragmented each specialty can become (not involved in the “whole” person at all). Our family doctors can serve as the traffic cop here, but – given the known poor outcomes of depressed heart patients – cardiologists MUST be both aware of and pro-active in asking their patients about mental health issues.
The question determining whether we are depressed or not seems to be “Do you feel suicidal?”
I did not so I was pronounced “not depressed” after my first heart attack. Thankfully my PCP took some time to give me a little questionnaire that asks more than that one question and discovered that I was most likely depressed. (Sadly a condition my spouse does not acknowledge as being real.)
I began trying several medications without any good results until we hit on Lexapro 10mg and the results were amazing. Plus my PCP assured me this depression was common after a heart attack.
My Cardiologist, to this day even after my second recent heart attack, has never asked me a thing about depression. My spouse to this day does not know I take Lexapro for “mood”.
After this second attack my gynecologist discussed depression with me and supported my suggestion that I would increase my Lexapro dose to 15 mg. When I asked my Cardiologist what he thought about that, he simply responded “Whatever you think helps.”
Hi Annie – sadly, your cardiologist’s response is all too common. Mental health issues are under-appreciated (not only by docs, but often by our family members, as in your case). Before my own experience with depression post-heart attack, I didn’t “get” it either. Not at all.
I too share many of the other women’s experiences of depression after my heart attack.
Though I tried to keep it to myself, thinking it would just go away in time, it really never did. Then, seven months after my heart attack, my husband died suddenly, so of course my depression became major.
Thankfully, with the aid of medication, exercising, eating healthy, and support from friends and family has lessened my depression, but it never has completely healed me.
Sometimes the depression is more painful than having a heart attack. I do feel that depression should be addressed to heart patients before discharge, and also would recommend it to the cardiac rehab nurses to address in their rehab classes.
“Sometimes the depression is more painful than having a heart attack”. Most people who haven’t experienced depression after a cardiac event might find this statement hard to understand. True for me, too, Sherrie. Thank you for taking the time to share your experience here, and my condolences to you on the sudden loss of your husband.
I think depression and anxiety are under treated. I have taken Wellbutrin and celexa for years with great results.
Don’t tolerate your symptoms another day. See your primary care provider for assessment. Take care of all aspects of your life. It will make a big difference. Exercise, eat well, sleep 7 hours. Have supportive relationships. Don’t get overtired. Pay attention to your thoughts, they influence your mood and behavior. Be mindful of your blessings.
Good advice, Wanda – I particularly appreciated “Don’t tolerate your symptoms another day!” Being reluctant to seek professional help just makes the status quo seem more normalized – not good for heart patients.
There is so much food for discussion here, but I will keep my reply as brief as possible. You are, as usual, 1,000% right. But there is more. Depression is anger or sadness turned inward, layered with different forms of the self protection called denial.
Whether it is an “actual” heart attack, or just daily chest pain that is recurrent and constant, treated or untreated, depression is a virtual given. I don’t know anybody who goes through this who isn’t profoundly distressed.
Ultimately, this type of experience is a mortality threat, just as cancer is. All doctors have to do is take the playbook on cancer depression, and apply that to heart issues.
But yes, there are differences. Those with heart issues may not be able to exercise, no matter how good it is for you. There may or may not be “a cure”. Life may not return to normal. But the center of this experience is that it is a deeply wounding mortality crisis.
By definition, one’s body experience and one’s mortality awareness are now deeply linked, and it becomes a constant companion, because we are watchful for “signs” that things are not right with our heart. And, they aren’t ~ it is the new normal.
We have written volumes about midlife crisis, mortality crises because we know it is psychologically unsettling. Aside from other daily living issues, any questions must be opened up and addressed that lie at the core of the distress: How do I feel about mortality? Am I ready for it? Do I believe/not believe in God? Why have these bad things happened to good people (me!)? And more, yet….
It takes a deep therapist to recognize and travel on mortality journey with the respect it deserves. I used a therapy called EMDR, which was a good choice for me. It takes a deep therapist to accompany their patient on this very personal journey. The visit to this foreign and sometimes very feared place may pave the way back to living life with new and deeper eyes, new and unpredictable terms and renewed enthusiasm.
* The film, The Way, highly recommended as a metaphorical experience ~ Buon Camino, pilgrims.
Oh, Mary. You have raised many interesting points here. Thanks for reminding all of us that mental health problems are associated with many cardiac issues – not just heart attack. Many patients living with heart failure, or with an implanted device like an ICD, or with serious arrhythmia diagnoses, or with a number of other cardiac conditions also report depression and anxiety. It’s the HEART we are talking about here, that is why! Even the most benign symptom can lurch us into an “Is this something? Is it nothing? Should I call 911?” frozen panic. Thanks also for your helpful recommendations to address this issue.
Yes Yes Yes! I have had multiple conversations with providers since my quadruple bypass, and none of them has been willing to acknowledge the huge emotional toll of a cardiac event and the barbaric invasion of the body that is cardiac surgery. And when I have queried about support groups, I have been uniformly told that they don’t pay so they aren’t run. Or the current culture doesn’t support them. Or nobody wants to run them. Etc.
When I was lying in my bed the first day out of intensive care, the cardiothoracic surgery fellow asked me how I was. I told him that I had just spent the worst night of my life. He tsked and said, “Oh, we’ll pull your Foley and your chest tube, that should make things better” and breezed out of the room. Little wonder I was in tears after that.
I could go on and on. This is a really important topic that needs to be addressed by cardiothoracic services everywhere.
Hooo boy, your story of your first day out of the CCU is maddeningly common – and tragically representative of the inability/unwillingness of some health care professionals to address the psychosocial impact of a cardiac event. Thanks a lot, Dr. Anne.
Hi Carolyn,
I really enjoy your essays. In November I had open-heart surgery to replace my mitral valve and repair my tricuspid valve. I’ve had quite painful, debilitating depression since about three weeks post-op.
Also, because I chose the mechanical valve due to being 42 years old, I am and will be on coumadin for the rest of my life. It’s affected my menstrual cycle quite a bit, and I am afraid of having dental work done, cutting myself et cetera, not to mention the weekly blood tests, and I had better never go without health insurance! This wasn’t discussed with me before the surgery or after. Really, I wish I had done more research pre-op.
I’ve heard that the heart-lung machine and the anesthesia together somehow cause the post-op depression; of course I don’t know the exact cause, I just know that I am depressed. If it doesn’t go away soon with the positive lifestyle changes I’ve made, I’m definitely going to see a mental health professional. I talked with my cardiac surgeon (very nice man) and he didn’t quite know what to say.
Apologies for the length, I just wanted to mention that post open-heart surgery is a possibility as well. I even read a New York Times article about this by googling “open heart surgery depression.”
Thanks Carolyn!
Rachel, thank you for telling your story to us here. Please do not wait to see if your depression goes away: call today for an appointment to see a mental health professional. If nothing else, the very act of talking to a trained therapist who knows better than to tell you he doesn’t “quite know what to say” should feel better. Meanwhile, for some practical help, read “10 Non-Drug Ways To Treat Depression in Heart Patients”.
Earlier studies have looked at depression in patients who suffered a heart attack or underwent open heart surgery as you did, but recent research also suggests serious depression is common in other heart patients, too. For example, a Danish study last March examined what effect depression might have on mortality in patients who had coronary stents implanted and found that patients who are depressed after stenting had significantly worse prognoses compared to patients who were not depressed. The heart-lung machine’s “pump head” is not the only culprit!
Wow, you just described me to a tee. After three years my depression is no better. I still feel the same today as the moment my cardiologist said, “you had a heart attack”.
I push myself everyday to keep going for my family but deep down inside I could care less about anything. I just want someone to understand how I feel instead of thinking I should be Miss Happy Happy and still do the things I use to do before the heart attack.
Physically I am not the same person and don’t think I ever will be. Everyday life details are not important to me anymore. I see myself stepping further and further behind and no one understands. Even the nurses at rehab, which I have been to three times, don’t understand it. They don’t think depression is a part of it at all.
I feel like I’m standing in the middle of a foggy field and no one can see me. I pray everyday I don’t have another heart attack because I will give up completely. I’m going to copy and send this article to my cardiologist, family doctor, rehab nurses, and director of my hospital and see if it opens any eyes.
Thank you for writing this and letting these people know where I am at in my life.
Thanks so much for taking the time to share your own experience, Sandy. It’s so important that our doctors (and rehab nurses, and hospital administrators!) learn what it can actually be like for so many of us. Good luck to you.