I’ve written quite a lot here about my own debilitating experience with depression following my heart attack.(1) I have since learned that post-heart attack depression is alarmingly common – and alarmingly under-diagnosed – among women survivors. Mayo Clinic cardiologists report that up to 65% of us experience significant symptoms of depression, yet fewer than 10% are appropriately identified.
NYU Women’s Heart Program cardiologist Dr. Nieca Goldberg says women under age 60 are particularly susceptible to depression because a heart attack is such a major psychological trauma, especially when it occurs at a younger age. Studies show, she adds, that depression is an important risk factor for adverse outcomes in cardiac event survivors:
“It’s a life-changing, stressful event. It’s a shocking experience. There are constant concerns among survivors about whether they are going to be able to return to their usual life.”
Unlike longterm clinical depression, post-heart attack depression is often called “situational” depression, or “stress response syndrome”, and what mental health professionals call adjustment disorder that can strike following a traumatic life event as we struggle to make sense of something that makes no sense.
There are antidepressant drugs available, of course, but this treatment option may not actually be the miracle cure that Big Pharma wants us and our physicians to believe it is.
Depression has gone from being what was described in the 1960s by leading medical experts as a self-limiting, episodic disorder showing spontaneous recovery without treatment after a few months to now being a more chronic, drug-managed illness.
Not coincidentally, this growth has paralleled that of the drug companies selling antidepressant meds. In 1955, for example, only one in 468 North Americans was diagnosed with a mental illness; by 2008 it was one in 76. And since 1987 – the year Prozac hit the market – the number of North Americans off work on disability benefits for mental health reasons has tripled.
Here’s a distressing example: a new study(2) reported this month by Dr. Ramin Mojtabai at the Johns Hopkins Bloomberg School of Public Health found:
“Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications.
“Much of this growth has been driven by a substantial increase in antidepressant prescriptions by non-psychiatrist providers without an accompanying psychiatric diagnosis and often for conditions such as tiredness, nonspecific pain, and headaches.
“Our analysis found that between 1996 and 2007, the proportion of visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5 percent to 72.7 percent. To the extent that antidepressants are being prescribed for uses not supported by clinical evidence, there may be a need to improve providers’ prescribing practices or revamp drug formularies.”
University of Connecticut researchers(3) examined 38 pharmaceutical company-funded studies involving over 3,000 depressed patients and found that those taking antidepressants did improve, but the improvement differences between the medicated and placebo-taking groups were actually “miniscule”.
And a 10-year Dutch study also found that 76% of depressed patients who did not take any antidepressant drugs recovered and never relapsed. Another five-year study of 9,500 Canadian patients in Alberta concluded that the drug-taking group were depressed on average for 19 weeks, but those who did not take antidepressants were depressed for only 11 weeks. And the World Health Organization has found that non-medicated patients with depression enjoyed better health than those who took antidepressants.
It’s important to keep in mind that most published research favouring the use of antidepressant drugs has been funded by the drug companies that manufacture those antidepressant drugs.
A 2003 study in The British Journal of Psychiatry, for example, found that the drug giant Pfizer paid medical ghostwriters to create more than half of all medical journal articles published about its antidepressant drug Zoloft. The other half were written by independent academic researchers. Guess which articles were more positive toward Zoloft? See also: Partners In Slime: Why Medical Ghostwriting Is So Alarming
Having said all this, it’s also important to mention here, however, that pharmaceuticals can indeed help treat debilitating symptoms of severe mental illness for some people. And many who could benefit from these meds may unfortunately consider taking antidepressants a sign of weakness. It is not, of course – any more than it’s weak for a diabetic to take insulin.
And remember that a person struggling with severe depression is not able to merely use willpower to control their moods, any more than a diabetic can use willpower to change their blood sugar levels.
But many patients report that a fear of being prescribed antidepressant drugs is the top reason for not telling their doctors that they are suffering depression symptoms. A study called Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care was published in the journal, Annals of Family Medicine.(4)
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.”
Besides drugs, what else could those of us living with depressive symptoms be doing for ourselves – with or without pharmaceutical help? Here are some non-drug options:
1. EXERCISE: This has been found to be among the most effective treatments for depression. A good 30-minute walk, swim or bike ride that raises your heart rate, for example, can also raise your serotonin level. Serotonin is a neurotransmitter (a chemical messenger in the brain that helps regulate sleep, mood and appetite). Selective serotonin reuptake inhibitors (SSRIs) are antidepressant medications that work on raising your serotonin level. But let’s aim to do it naturally with exercise – with no side effects. More is better when it comes to physical exercise, especially for women with heart disease.
2. TALK THERAPY: I found my own weekly visits to a therapist tough at first, but profoundly helpful in adjusting to the “new normal” of living with heart disease. Therapists can include psychologists, psychiatrists, social workers, or other mental health professionals. The two most commonly-used talk therapies for depression are cognitive-behavioral therapy (CBT) and interpersonal therapy. CBT focuses on identifying how negative thought patterns may be affecting how you feel. Interpersonal therapy focuses on how you relate to others. Both types of therapy can be effective in treating depression by helping people at risk for recurring depression avoid spiraling down into a full episode of depression.
Talk therapy, however, costs more than medication, at least in the short term, and may not be covered by insurance plans. But as one researcher observed:
“In the long run, talk therapy may well be worth it. People who take antidepressant meds may end up taking these drugs for many years. But with talk therapy, patients often go for only a few months to a year.”
3. WATCH YOUR COMFORT HABITS: Mindless consumption of coffee, alcohol, sugar, and recreational drugs can aggravate mood disorders. Sugary foods, for example, are absorbed quickly into the bloodstream. This may cause an initial surge of energy that soon wears off as the body increases its insulin production, leaving you feeling tired and low. And Dr. Daniel Hall-Flavin of Mayo Clinic believes that even modest amounts of caffeine can disturb your moods. He says if you are particularly sensitive to caffeine, you may find that consuming coffee, soft drinks or other caffeine sources disrupts your sleep, which in turn can affect your overall mental and physical health. See also: Mindless Eating: 8 Reasons Women Eat When We’re Not Even Hungry
Mayo Clinic experts also have this specific warning about drugs and alcohol:
“Stop drinking or using drugs. Many people with depression drink too much alcohol or use illegal drugs, which then worsens depression. If you can’t stop drinking alcohol or using drugs on your own, talk to your doctor or mental health provider. Depression treatment may be unsuccessful until you address your substance use.”
4. DIETARY SUPPLEMENTS: Although early research on the beneficial effects of omega-3 fatty acids on mood disorders is encouraging, more studies are needed. But omega-3 has very few side effects, along with claimed cardiovascular and other health benefits, so may be worth a try. These healthy fats are found in cold-water fish like salmon, flax seed, walnuts, and fish oil or flax oil supplements. For mild – but only mild- cases of depression, St. John’s Wort may rival antidepressant drugs, with generally few side effects, but it can interact with other drugs. As with all supplements, consult your doctor first. SAMe (pronounced “sammy”) is a synthetic form of a chemical that occurs naturally in the body (S-adenosylmethionine). This supplement is used in Europe as a prescription drug to treat depression. Remember, however, that dietary supplements are products of a completely unregulated industry whose claims do not even have to be based on evidence-based science. Always check credible resources like Mayo Clinic’s evaluation of drugs and supplements.
5. SUNLIGHT: Some people, particularly females over age 20, are vulnerable to a type of depression that follows a seasonal pattern. For them, the shortening days of late autumn are the beginning of a type of clinical depression that can last until spring. This is called Seasonal Affective Disorder or SAD. Research shows that neurotransmitters may be disturbed in SAD. Try spending more time outdoors during the day and by arranging your environment so that you receive maximum sunlight. Keep curtains open during the day. Move furniture so that you sit near a window. Build physical activity into your lifestyle before SAD symptoms take hold. If you exercise indoors, position yourself near a window. Make a habit of taking a daily noon-hour walk. Sunny winter vacation can temporarily relieve SAD symptoms, although symptoms usually recur after return home. Try to resist the carbohydrate and sleep cravings that come with SAD. And many people with SAD respond well to exposure to “light therapy” that involves sitting beside a specially designed bright fluorescent light box for several minutes day. Bu consult your health care professional before beginning light therapy.
6. REGULAR HUMAN CONTACT: Many people feel depressed because they are isolated, and they’re isolated because they feel so depressed. This is a tough dilemma when the only thing you really feel like doing is pulling the covers up over your head, all day, every day. When my (former) perky therapist suggested brightly that I should just sign up for a really interesting course at the university to help me “snap out of” my depressive state, I looked at her with utter dismay. I felt unable to motivate myself to wash my hair. How would I manage signing up for (never mind actually attending) a “really interesting” night school class?
But we are social animals. Counting on our close friends and family for regular companionship – even if just a short outdoor walk – can actually help to lift our spirits and get us through one day at a time. The Canadian Mental Health Association recommends:
“Support from family, friends and self-help groups can make a big difference.”
7. CHALLENGE YOUR THINKING: A book I recommend that can be almost-shockingly helpful with this option is Feeling Good: The New Mood Therapy by Dr. David Burns, who observes:
“Intense negative thinking always accompanies a depressive episode. The negative thoughts that flood your mind are what may keep you lethargic. One of the most destructive aspects of depression is the way it paralyzes your willpower. In its mildest form, you may simply procrastinate about doing a few odious chores. As your lack of motivation intensifies, virtually any activity appears so difficult that you become overwhelmed by the urge to do nothing. Because you accomplish very little, you feel worse and worse.
“If you don’t recognize the emotional prison in which you are trapped, this situation can go on for weeks, months, or even years. Your inactivity will be all the more frustrating if you once took pride in the energy you had for life. Your do-nothingism can also affect your family and friends, who, like yourself, cannot understand your behaviour.
8. GOOD NUTRITION: According to Dr. Fernando Gómez-Pinilla, a UCLA professor of neurosurgery and physiological science:
“Food is like a pharmaceutical compound that affects the brain.”
Foods high in folic acid, for example, include spinach, orange juice and yeast. Adequate levels of folic acid, says Dr. Gómez-Pinilla, are essential for brain function, and folate deficiency can lead to depression or cognitive impairment. The U.K. Mental Health Foundation also recommends including protein at every meal to ensure a continuous supply of the amino acid tryptophan to the brain – such as meat, fish, eggs, milk, cheese, nuts, beans, or legumes. Eat regular meals throughout the day to maintain blood sugar levels. Make sure you eat at least three meals each day. Missing meals, especially breakfast, leads to low blood sugar and this can cause low mood, irritability and fatigue. And not drinking enough fluids every day has significant implications for mental health. The early effects of even mild dehydration can affect our feelings and behaviour. See also: De-junk Your Kitchen to Start Heart-Smart Eating
9. YOGA: Yoga is another form of non-drug treatment for mild to moderate depression that may help. Yoga focuses on deep breathing and a series of stretches and careful movements. Researchers at the Walter Reed Army Medical Center in Washington, D.C., are now offering a yogic method of deep relaxation to combat veterans returning from Iraq and Afghanistan. Dr. Kristie Gore at Walter Reed says the military hopes that yoga-based treatments will be more acceptable to the soldiers and less stigmatizing than traditional psychotherapy. People who do yoga regularly say it can help to balance the mind and body, and helps restore a sense of well-being.
10. MINDFULNESS MEDITATION: A U.K. study published in the Journal of Consulting and Clinical Psychology found that a group-based mindfulness-based meditation practice was as good as or better than treatment with anti-depressants like Prozac in longterm prevention of a relapse of serious depression. Mindfulness meditation helped the study participants learn to focus on the present moment, rather than dwelling on the past or worrying about the future. This cost-effective non-drug therapy was also more effective in enhancing quality of life and better physical well-being for depressed patients. For others, meditation may be as simple as listening to soothing music, breathing deeply and totally relaxing the body, muscle by muscle, with a process called systematic relaxation, which allows both the body and the mind to relax.
PLEASE NOTE: If these options have been tried and there is no change in a month, get a full evaluation by your health care provider. Depression can be devastating for heart patients, and it does not make you a better person to endure needless suffering.
Mental health professionals at Mayo Clinic also stress the connection between mind and body that has been studied for centuries. Some mind-body techniques they recommend to address depression symptoms include:
- guided imagery meditation
- massage therapy
They add that although the signs and symptoms of depression are the same for both men and women, women tend to experience depression twice as often as men do. This is true in most countries around the world.
Since hypothyroidism can also cause depression in women, this medical problem should also be be ruled out by a physician.
Also, women are more likely to experience the symptoms of atypical depression (sleeping excessively, eating more – especially carbohydrates, and gaining weight).
NOTE FROM CAROLYN: I wrote more about situational depression associated with heart disease Chapter 6 of my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher Johns Hopkins University Press (and use their code HTWN to save 20% off the list price when you order).
(1) See also:
- When are cardiologists going to start talking about depression?
- The New Country Called Heart Disease
- Depressed? Who, Me? Myths and Facts about Depression Following a Heart Attack
- “I’m Not Depressed!” – and Other Ways We Deny the Stigma of Mental Illness After a Heart Attack
- Should You Take Antidepressants – And If So, Which One?
- Is it Post-Heart Attack Depression – or Just Feeling Sad?
- 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?
- 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
(2) Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Affairs, August 2011, vol. 30 no. 8 1434-1442
(3) Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac But Hearing Placebo: A Meta-analysis of Antidepressant Medication. Prevention and Treatment, 1 (Article 0002a)
(4) Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care. Annals of Family Medicine 9:439-446 (2011)