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 five months later, I was shocked to learn there that up to 65% of heart attack survivors experience depression, yet fewer than 10% are appropriately identified.
The type of depression that occurs so frequently after a serious health crisis like a heart attack is often known as “situational depression” or “stress response syndrome”. It’s what mental health professionals call an adjustment disorder that can strike within weeks following a traumatic life event as we struggle to make sense of something that makes no sense. The good news is that, unlike clinical depression, it typically tends to run its course over about a six-month period, and can often eventually fade even without treatment.
But before I was discharged from hospital after my heart attack, 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, not one janitor had said even one word to me about this very 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.
Depression is very common among those diagnosed with heart failure, affecting up to 40% of all such patients. As described at the 2015 European Society of Cardiology conference, depression as a direct result of hearing this diagnosis is associated with:
- loss of motivation
- loss of interest in everyday activities
- lower quality of life
- loss of confidence
- sleep disturbances
- change in appetite with corresponding weight change
So wouldn’t it just make sense for physicians to address these common depression symptoms instead of labelling such people “non-compliant“ because they aren’t following doctor’s orders, taking their meds, eating healthy, exercising every day or bouncing back the way they should?
As reported in Harvard Health, post-operative depression following any type of surgery under general anaesthesia is in fact not uncommon, most likely occurring well after the crisis of surgery has ended and the patient is back at home or even at work. Dr. Bernard Vaccaro of Brigham & Women’s Hospital in Boston explained:
“When we’re healthy, we tend to think of our bodies as intact.
“Major surgery can shatter that image, and with it the concept of self-sustaining health. The feelings of mortality, of loss, and of vulnerability can be profound, and recognizing depression in surgery’s aftermath becomes very important.”
But if signs of depression hit immediately after surgery, he warns that doctors suspect hidden complications, perhaps a problem with anesthesia, an infection, or some other underlying cause – especially in older patients whose post-op delirium symptoms can appear subdued – much like depression.
But depression in heart patients – whether they have experienced a surgical procedure or not – 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 classes, 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 after the class, 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), 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.”
Sadly, emerging information from cardiologists is still barely mentioning the common experience of such deeply wounding events.
When I was asked to review the book Your Personal Guide: Angioplasty by cardiologist Dr. Allen Jeremias, I was dismayed to find virtually nothing on mental health issues. Despite the fact that one of the book’s co-authors Dr. Susan Bartell is herself a psychologist, the psychosocial impact of being diagnosed with heart disease is virtually ignored here. How is that even possible?
In fact, I could find only one fleeting reference to this debilitating fallout common among so many heart patients, and that one reference is buried in a single paragraph in the “What About Sex?” section about halfway through the book.
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.
* 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?