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

~ Carolyn Thomas

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:

Published by Carolyn Thomas

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

  1. I am rereading a lot of posts because I have successfully fought with the right meds, a lifelong depression that took hold when I was in my 20s. After heart surgery with no one telling me that depression was a typical response, I felt very bad, physically and emotionally. My depression worsened and I attempted suicide, how ironic, 5 months after a successful heart surgery which left me with a completely open lifeline.

    My spouse expected me to heal faster. He was a problem too. But after so many years together, I was used to him. I coped. But I could not cope with the depression.

    So this is what happened, I fought with my husband, which is both hard to do with physical discomfort and emotional distress, gave up and went into the bathroom and swallowed a bunch of pills. I thought about it for about 5 minutes and then went and told my husband we needed to go to the emergency room.

    He took me. They kept me for 24 hours. They wanted to keep me longer. Nothing worse than sitting up all night with a night nurse who can’t talk to you because of limited English. Feeling foolish, wanting to go home. We met with a social worker the next day, who talked with my husband and me and decided I could go home. I had no idea I could just walk out at any time and I wish I had. That was pure misery and only thing it made me convinced of at that time was if I wanted to commit suicide, next time I wouldn’t fail. But primarily, not to ever do THAT again.

    It really bothers me that the cardiac doctors do so little to prepare you for the after-effects of their work. They do the job and then don’t care to talk about it. This is my experience. It took years to sort this out. I’m now on appropriate meds, I feel great. I was on antidepressants during menopause to help with the hot flashes and emotional ups and downs, but believe me when I say, the wrong meds don’t make things right!

    Meridee

    Like

    Reply

    1. Hello Meridee – this is such an important topic. The kind of post-cardiac depression you experienced is so common, yet largely ignored by the medical profession. Your own experience was so traumatic – you are indeed lucky to have survived all that.

      Dr. Sharonne Hayes (a cardiologist who is the founder of the Mayo Women’s Heart Clinic) once described her colleagues who ignore post-cardiac depression like this: “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.” I believe that observation is still true, sadly.

      Although there are many newer studies which remind cardiologists that they must start paying attention to this post-cardiac depression, many doctors still seem to behave as if once the cardiac procedures are complete and the patient is discharged from the hospital, they can simply move on to the next patient. This ignorance of the common experience of mental health issues (estimated by some researchers to affect as many as 40% of all heart patients) means that patients who are discharged from the hospital after a “successful’ cardiac procedure who subsequently develop symptoms of depression are unlikely to be able to take their new meds as directed, exercise, plan heart-healthy meals, cope with family/work responsibilities, or follow any other ‘doctor’s orders’ to improve their heart health.

      You had a higher risk of post-cardiac depression because you already had a history of depression. We now know that people with such a history are at higher risk of heart disease, and people diagnosed with heart disease are at higher risk of becoming depressed – it’s a double-edged sword!

      I’m glad you are finally on appropriate meds and feeling GREAT!

      Take care. . . ❤️

      Like

      Reply

  2. I went to another cardiologist for a second opinion after continued chest pain after PCI. The office paperwork actually asked if I was depressed. I thought to myself, “of course I am…but hell if I am going to tell you”.

    I just do not want to be labeled. I still feel that way, but I have a wonderful friend that listens to me and we do TFT. It always helps.

    Like

    Reply

    1. Hi Christine – I’m guessing (but not positive!) that you meant Thought Field Therapy (TFT) ? – so glad it is helping you.

      The stigma of depression, anxiety and other forms of mental health issues is pervasive (both internally within us and externally within our society). Your own reluctance to be ‘labeled’ is an interesting example. Few of us would feel reluctant to be labeled as having a broken ankle or a throat infection – it’s only with mental illness that we resist the ‘label’.

      My sincere hope is that one day, when we are suffering, we won’t feel reluctant to tell the truth to our healthcare professionals about what’s happening to us.

      Like

      Reply
  3. Pingback: 7Loop

  4. Oh my gosh! Best article to bring this to light.

    I was SUPER reluctant to admit I had anxiety/depression issues post MI at age 37. I had been a successful person in all facets of my life and believed I could control it if I just worked harder, tried harder.

    Only people I couldn’t fool were my docs, and I resisted and resisted until I finally could take it no longer and I picked up the phone, got a Rx and found a great (right for me) therapist.

    This is a big issue post-MI and if I had been able to accept my problem earlier, I could have saved myself a lot of trips to the ER and started to get healthy sooner.

    Five years later, off the depression/anxiety meds and doing great. Still, it is a tough time following an MI and I can only recommend that you try to surround yourself with supportive people as they are much needed.

    Like

    Reply

    1. I hear ya, Lisa!! I too was embarrassed and horrified that depression was happening to ME of all people! I think the fact that nobody had warned me while in the CCU that this might even be a remote possibility, never mind that it’s so pervasively common in MI survivors, made it 1,000 times worse than it should have been. I like Dr. Steve’s comment below- he recommends that all survivors: “be very depressed after a heart attack, sleep a lot, take it easy, don’t expect much of yourself, be lost for a while.” May sound goofy, but it’s far superior to being blind-sided and in denial as you and I both were. Thanks so much for your comment here.

      Like

      Reply

  5. This describes me perfectly. You really “get” the subject of post-heart attack depression in a way that few physicians do. Thanks so much for this.

    Like

    Reply

    1. Hi Rachelle – perhaps this is because until you’ve actually experienced this scenario personally, it can be very difficult to appreciate what others are going through. Knowing that such emotions are commonly experienced following a cardiac event can help us feel less isolated.
      Cheers,
      C.

      Like

      Reply

  6. Sandy

    There is a story that someone once asked Daniel Boone, the legendary American pioneer and frontiersman, if he had ever been lost. He is alleged to have replied, “Don’t reckon I was ever lost. But once I was confused for a couple of days.”

    Many people and many clinicians think depression is something that should be eradicated as soon as possible; They are uncomfortable around dark feelings and would prefer that we be as “normal” as possible as soon as possible.

    Depression is often adaptive and functional — after a deep wound, rest is needed. Depression essentially forces the person to rest, to take time to re-evaluate one’s life and the road that led to the heart attack, to use all available energy and resources for healing (both physically and psychologically).

    I personally recommend being very depressed after a heart attack, sleeping a lot, taking it easy, not expecting much of yourself, be lost for a while. Sadness is good too.

    Steve Parker

    Like

    Reply

    1. Hi Steve – I like the “sleeping, taking it easy” part if sadness were the only symptom. But not the uncontrollable weeping, lack of motivation, inability to make even the simplest decision or to function at all, anxiety that a second heart attack was imminent, endless rumination, plus that “foreshortened future” you talked about. That was a horrific experience to go through. Perhaps maybe if somebody had WARNED us in ICU before we were discharged…. ?

      cheers,
      C.

      Like

      Reply
  7. Pingback: Depression Therapy Guide

  8. I love this article. I have tried to explain to people that I’m not depressed, I’m just sad since my heart attack. Most people have even said to me that they don’t see depression in me at all.

    So can you be “sad” and not “depressed”?

    Like

    Reply

Your opinion matters. What do you think?