“I’m not depressed!” – and other ways we deny the stigma of mental illness after a heart attack

by Carolyn Thomas  ♥ @HeartSisters

“This is the most thorough review article I have seen on psychological interventions after heart events,” writes cardiac psychologist Dr. Stephen Parker* about a U.K. study on heart patients. And he should know. Dr. Steve is also a heart attack survivor himself who has explored his own profound experiences with the depression and anxiety that commonly accompany any cardiac event.

The study, reported in the British Journal of Cardiology in July 2010, followed over 400 London heart patients for two years – of whom at least half showed symptoms of anxiety or depression when first interviewed.  But the study authors described their participants in this way:

“Many of these heart patients were reluctant to accept a diagnosis of anxiety or depression and expressed reservations to the clinical psychologist by rejecting the term ‘depression’ for describing their problems, or by expressing negative views about attending a mental health service for treatment.”

In fact, these ‘negative views’ associated with the stigma of having mental health problems were so strong that all psychological interventions studied were provided to heart patients as part of a scheduled Cardiac Rehabilitation program at St. Thomas’s Hospital in London – instead of at a mental health facility.  

Experts at the world-famous Mayo Clinic would not be surprised by this reported stigma surrounding mental illness. They explain:

“Based on stereotypes, stigma is a negative judgment based on a personal trait – in this case, having a mental health condition.

“It was once a common perception that having a mental illness was due to some kind of personal weakness. We now know that mental health disorders have a biological basis and can be treated like any other health condition.

“Even so, we still have a long way to go to overcome the many misconceptions, fears and biases people have about mental health, and the stigma these attitudes create.”

Another recent study called Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care was published in the journal, Annals of Family Medicine. A research team led by Dr. Robert A. Bell of the University of California Davis found that the most frequent reason patients gave for not telling their family doctor about their depression symptoms was the concern that the physician would recommend antidepressant drugs.**

“Reported reasons for nondisclosure of depression varied based on whether the patient had a history of depression. For example, respondents with no depression history were more likely to believe that depression falls outside the purview of primary care, and were more likely to fret about being referred to a psychiatrist.”

In addition, other barriers to admitting to feeling depressed included:

• being female, Hispanic, of low socioeconomic status
• beliefs about depression (depression is stigmatizing and should be under one’s control)
• symptom severity
• absence of a family history of depression

Meanwhile, back at the London study, what kinds of psychological difficulties were observed in the heart patients?  Although varying widely in severity, complexity and duration, all symptoms stemmed from adjusting to living with cardiac problems, including:

• concerns about the significance and impact of symptoms
• adherence to or side effects from treatments
• shock, disbelief and denial about having a cardiac problem
• coping and engaging in everyday activities
• modifying behavioural risk factors for coronary heart disease
• changes in their relationships and interactions with other people
• catastrophic interpretations about the impact of cardiac disease on their lives and prospects for the future
• the re-emergence or intensification of other psychological difficulties.

Here’s Dr. Stephen Parker’s take on the study results:

“Surprisingly, the interventions for anxiety and depression were not very successful.

“I would suggest that they are using the wrong strategies (cognitive-behavioral therapy, for example) and perhaps inexperienced therapists. I think a supportive strategy is probably more effective, as would be education in anxiety-reduction and strategies for the management of depression.

“One of the interesting findings was that it was more effective to have psychological interventions two months after the cardiac event rather than immediately afterwards.

“I think the depression and anxiety following a heart attack are a bit different than the depression and anxiety that most therapists encounter, and both are going to be more resistant to treat because there are damned good reasons to feel anxious and depressed.

“A heart attack is a deeply wounding event, and it is wound that takes a long time to recover from, whatever the treatment.”

The key messages reported by the London researchers were:

• Depression and anxiety are commonly experienced by cardiac patients and are associated with reduced quality of life and increased mortality.
• The evidence for the effectiveness of medical and psychological treatments for depression has been mixed.
• A stepped-care model of psychological care was both accessible and acceptable to cardiac patients.
• Offering a range of psychological treatments might be an effective way of meeting psychological needs of heart patients

And the key message according to heart attack survivor Dr. Steve is:

“Who the hell wouldn’t get depressed and anxious after a heart attack?”

Here are some disturbing facts about depression in general. We know that women are twice as likely to develop depression compared to their male counterparts.

This higher overall risk, according to Dr. Nasreen Khatri of Toronto’s Baycrest Hospital, is likely due to a combination of factors, including:

• biological ones like the effects on the brain of hormonal changes during pregnancy
• social factors like the multiple roles women tend to play in modern society
• psychological ones like different coping styles

Dr. Khatri adds that many middle-aged women today are also caring for both their own children and elderly parents, thus increasing stress levels which in turn can lead to depression. And depression itself appears to make women two times more susceptible to Alzheimer’s disease than our male counterparts – for reasons that are not yet entirely clear.

What may not be well known is that seven out of 10 new cases are women – ironically, explains Dr. Khatri, the people who more often than not take on the major responsibility for caring for dementia sufferers.

It may not be all bleak, however. When the former Globe and Mail reporter Jan Wong wrote about her own journey with debilitating depression in the memoir Out of the Blue, she described the life lessons that depression had taught her:

“The big life lessons are that you can have clinical depression and you can get over it. It’s completely treatable. It has an end.

“Second life lesson: you’ll probably be stronger when you come out of it than you were before.

“The third life lesson is you’ll probably be happier because you leave it behind and you will find a new life.

“The fourth lesson: that family matters. Everything else is extra.”

Visit Dr. Stephen Parker’s website HeartCurrents, his Emotions of the Wounded Heart project, or the full article about the London study from the British Journal of Cardiology.

** Annals of Family Medicine 9:439-446 (2011) doi: 10.1370/afm.1277

See also:

• When are Cardiologists Going To Start Talking About Depression?
• 10 Non-Drug Ways to Treat Depression in Heart Patients
• The New Country Called Heart Disease
• Post-Traumatic Stress Disorder: Not Just For Soldiers Anymore
• Women Heart Attack Survivors May Be as Psychologically Traumatized as Victims of Violence
• Why Aren’t Women Heart Attack Survivors Showing Up for Cardiac Rehab?
• Depressed? Who, me? Myths and Facts about Depression Following a Heart Attack
• Handling the Homecoming Blues
• How That Ache May Signal Depression
• Women’s Heart Pain May Be Both Physical and Emotional
• Depressing News about Women’s Heart Disease and Depression