When are cardiologists going to start talking about depression?

26 Nov

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, after all, 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 sorry ass 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 patients experience depression, yet fewer than 10% are appropriately identified.

The type of depression that occurs so frequently after a serious health crisis like a cardiac diagnosis 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’s typically temporary and treatable.   See also: 10 Non-Drug Ways to Treat Depression in Heart Patients

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 predicable problem.

It’s important for cardiologists to talk openly and early to their heart patients about this common companion of heart disease if they expect us to be able to follow basic instructions, quit smoking, exercise, take their new cardiac meds as prescribed, eat a heart-healthy diet, manage a healthy weight, or make other lifestyle improvements to stay healthy.

People who are depressed are often simply unable to follow any of those instructions.

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”The New England Journal of Medicine, for example, 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 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.(1)

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 simply hearing this diagnosis (“Your heart is failing!”)  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 labeling such people non-compliant because they aren’t following doctor’s orders or bouncing back the way they should?

But depression in heart patients has “flown under the radar for far too long”, concluded the nursing 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.(2) 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.”

Sometimes 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.

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.

© 2017 Carolyn Thomas Heart Sisters    www.myheartsisters
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1.  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
2.  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.

This post was originally published here in September 2013. I wrote much more about depression in heart patients in my new book,  A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, November 2017)

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See also:

 

25 Responses to “When are cardiologists going to start talking about depression?”

  1. Catnip Blog December 3, 2017 at 7:09 pm #

    Having been a psychotherapist for 30 years I never encountered a doctor, personally or professionally who asked about depression or anxiety much less treated it or suggested referrals. I did however know a physical therapist whose wife was a social worker and he was right on the mark on all his referrals to me. The medical profession on the whole (including many psychiatrists) is woefully uninformed when it comes to a holistic approach to people.

    I also wonder why doctors never address diet and exercise (which plays a huge part in our mental and physical well-being).

    Liked by 1 person

    • Carolyn Thomas December 3, 2017 at 9:53 pm #

      Thanks Judy-Judith! That’s a pretty sad declaration, isn’t it? – 30 years with no referrals from physicians!? My (now former) GP was like all of those docs who seemed to have no awareness of the importance of psychosocial support: I literally had to beg her for a talk therapy referral when I was desperate for help, post-MI. Her preferred solution instead was to prescribe (and then keep on tweaking the doses of) antidepressants.

      The average med school graduate has had virtually no training in nutrition or food science. Yet a growing number of doctors are increasingly vocal about lifestyle interventions like diet and exercise, particularly for heart patients. Mayo Clinic docs recommends the well-studied Mediterranean Diet, for example, and programs like Walk With a Doc – or Dr. James Beckerman’s Heart To Start that feature physician-led exercise right along with patients! So we live in hope!

      Liked by 1 person

  2. Andrew Harvard December 1, 2017 at 11:08 pm #

    Thank you for your blog and the enlightening articles you write.

    Liked by 1 person

  3. Mitral Valve Prolapse November 30, 2017 at 1:05 am #

    Depression is one of the toughest things that happen to me after being diagnosed with MVP. Luckily I have the support of my wife and the whole family to get through it.

    Liked by 1 person

    • Carolyn Thomas November 30, 2017 at 10:15 am #

      You are indeed lucky – not lucky to experience significant depression, but to have family support in order to get through it.

      Like

  4. Eve Hauser November 26, 2017 at 4:33 pm #

    Depression was never mentioned to me until weeks after my “widower maker”, when my GP and now ex-husband suggested that I might be depressed because I was sad and not bouncing back to my old type A personality. The answer then was an anti-depressant. Effective sure. But, talk therapy would have done better without any additional meds. I’m not against meds if you need it, but I never thought I did, or that they did very much for me.

    I wasn’t depressed, I thought, I was angry; “mad as hell, and not planning on taking it anymore” to quote the movie Network. In reality, I was depressed, frightened and guilty. Why did I live? Especially since I had done everything wrong; not listening to my body and seeking help right away. Actually my stubbornness made me wait 2 weeks to seek help and by then I nearly died from congestive heart failure. Who knows what my prognosis might have been if I had only called 911 that first night?

    I have my reasons why I didn’t, all of which depress me even further. Being told repeatedly that “once they knew I wasn’t going to die, they began to develop a plan to treat me”. I couldn’t have stents, or even a By-pass, the damage was too far gone.

    It’s 7 years later and I made major changes in my life included divorcing the ex, went to grad school, began to own my recovery and changed my career focus. Now I am a Licensed Social Worker, looking to work in the health care field to help others cope and thrive with their critical illness diagnosis and care.

    I’m trying to convince my Cardiologist group that they need to hire me as their first Social Worker to counsel, educate and coordinate care for their patients. Who better than someone who has “worn the hospital gown” as they have to understand what they are going through best?

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 5:10 pm #

      Hello Eve – I wish more patients would really hear it when people who know them (in your case, your GP and husband) tell them straight out that they’ve noticed a significant change in affect. Many of us paste on a brave little smiley-face and try to push through, but when others start noticing, it’s time to call for help. Good luck in landing that social work job, Eve.

      Like

  5. speak766 November 26, 2017 at 3:03 pm #

    Wow, it’s terrible that doctors don’t discuss the mental health consequences of such a traumatic event. The mental health effects are just as important as the attack, and being prepared for it and developing a support system is key. Thank you for sharing this. Wish you all the best –
    speak766

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 4:06 pm #

      I agree, it is terrible. Instead, I suspect that many doctors are feeling frustrated and annoyed by their “non-compliant” patients who are too ill and too depressed to take their meds, plan healthy meals, lose weight, exercise, quit smoking, or follow basic instructions – instead of talking to each heart patient about how common post-diagnosis depression can be and to ‘let me know if you have either physical or emotional symptoms that are distressing you.’

      Liked by 1 person

  6. Meghan November 26, 2017 at 1:55 pm #

    Great article, but I just wanted to stress that women aren’t the only ones who get depressed following a cardiac episode. I run a cardiac support group and we’ve seen several men who came to talk and just didn’t know what to do with their feelings. At least women will generally try to talk about their feelings, but men often have nowhere to go to admit they are depressed!

    I love the idea of having counseling be part of cardiac rehab. In our program we can take appointments as needed for nutrition or diabetic advice as well as the exercise. But I’ll bet they never thought of mental health counseling.

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 3:05 pm #

      Hi Meghan – you are absolutely correct! Male heart patients can and do indeed suffer depression following a cardiac event. The stigma of mental health issues can be at odds with that tough strong veneer that many men in our society feel expected to maintain. Some cardiac rehab programs (the best ones!) do include a built-in psychosocial support component every week. My own, like lots of exercise-based programs, focused 95% of the time on exercise only; the psychosocial support we got was incidental (like chatting with our fellow classmates in the parking lot after class). Not exactly “counseling”… Best of luck in your cardiac support group!

      Like

  7. Robin Vetia Hodges-Petruchyk November 26, 2017 at 12:36 pm #

    Hi Carolyn,
    To that undertaking I have been blessed with having a very good cardiologist. He and his nursing staff and all others check and question you regarding depression and mood swings.

    I on the other hand feel that patients in part are responsible for part of their not being diagnosed with depression. Finding out that you’ve had a heart attack is a major stressor for most and your cardiologist will approach you with care. A year and a half out from my cardiac event, I questioned my cardiologist about my stopping using Plavix and he was stunned.

    In talking to him I found that the worst possible response we can give is “okay”. My doctor then questioned me as to just what I understood about the heart and what I needed to deal with. He told me that the first thing patients do to make doctors back away from a discussion is answer okay. He said they have been taught to back away and not cause further stress to the patient. My doctor and I came up with an understanding that I need all information as to what is happening to my heart. As a patient you need to stand up to your doctors and let them know that you need information or help. Patients having trouble with depression or mood swings need to let their doctors know and not blow them off.

    In short my doctors were new to me and needed to find the best way to deal with me, that meant my speaking up. Until that point my doctor didn’t know that I fully understood everything he was saying. I told him the moment that I have questions about my condition or any procedure, I will ask questions. I found that the doctors are as afraid of approaching us as patients as we may be afraid of our new found heart conditions.
    Take care,
    Robin

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 2:35 pm #

      Hi Robin – being “blessed with a very good cardiologist” is THE BEST! I too have been similarly blessed. I agree that it’s important for all patients to be open and honest with their physicians at all times, and to bring up issues that are concerning them. The trouble with mental health issues is the stigma and shame that so often accompanies conditions like depression or anxiety which can make it feel far more difficult to mention compared to a new pain symptom, for example. Personally, I have not yet encountered any physicians so far who were “afraid of approaching us” patients. Most that I know are interested in finding out what’s going on – even if, as in mental health issues, they are not trained to offer solutions.

      Like

      • Robin Vetia Hodges-Petruchyk November 26, 2017 at 7:33 pm #

        Hi Carolyn,
        I’m not talking about saying what is happening in terms of pushing a patient that is withdrawing. Here everyone questions you from the nurse through the doctors. Telling you that depression is the fastest way to throw yourself back into another heart attack. They even give you a written questionnaire. I wish all medical care was the same world wide.
        Robin

        Like

  8. Carol Dameron November 26, 2017 at 9:20 am #

    Oh how I wish that I could have seen what was happening to me on the first day after my heart attack! Although I read and researched my condition, I couldn’t see it in myself. Depression was present but pushed back because of my bullheaded strength to overcome whatever came my way.

    For me, it was knowing that it could happen that would have helped me deal with what did happen. When my cardiologist told me I wasn’t getting well fast enough… I got angry which caused me to start a rehab program for myself and allowed me to find my inner strength. Still, had I known that the pain in my chest happens sometimes in stent patients and feeling badly could be attributed to some side effects of my medications, I wouldn’t have felt so inadequate in my ability to cope with my new normal.

    It is a question of honesty in talking to patients that should be a priority for communication. Doctors aren’t Gods who can meet every person’s needs but should be competent enough to suggest the possibility that modern medicine is not a cure for all that ails us… the aim should be to help the patient cope with whatever is happening through common sense and medicine.

    I am doing much better with my cardiologist because he has acknowledged that I have a problem that can be managed but not cured and I am a major part of what it takes to manage it. When I was ready to hear how my circumstances were changing my life and how other women with heart disease were coping, I truly understood the picture your articles painted for me.

    It is encouragement that can only be internalized when you are ready for it but should be consumed until that happens. I appreciate your mission to help those of us waiting to find that spark that launches normalcy in a life that has found a new path. Thank you for continuing the task Carolyn! Keep on writing… I believe I can hear you now!

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 2:24 pm #

      You raise such an important point, Carol! We need to be *ready* to let reality sink in sometimes, and for some of us (me included) that can take a long time. I often wish that somebody, anybody before I was discharged home had taken just a few moments to tell me that post-cardiac depressions is common, but temporary and treatable. Just matter-of-fact like that. A simple statement could have prevented me from believing I was losing my mind. Thanks so much for your comment!

      Like

  9. Carol Harris November 26, 2017 at 7:48 am #

    After reading your wonderful article, I felt better myself. I have had atrial fibrillation and Ventricular Tacchardia and although my ablation cured the AFib I find that I am on alert for the least little odd beat or Heart Rate still.

    I am thinking and feeling that matters of heart health no matter what they may be can cause depression and I also know severe anxiety at times. I am not sure I ever have relaxed even during massage! Thanks for sharing, now I know that I am not as alone as I feel most of the time.

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 8:27 am #

      Hello Carol – you’ve hit the nail on the head. No wonder life-altering medical conditions like heart disease cause serious mental health problems. I hope you’ll make an appointment to see a counselor, therapist, pastor for talk therapy to help you relax during your next masssage!

      Like

  10. Dr. Anne Stohrer November 26, 2017 at 7:40 am #

    I experienced a deep depression with anxiety after my bypass surgery in 2011, and was blown off by every professional I met. Because I am a doctor and must be perfect according to our culture, I got a lot of “pull up your socks” and “stiff upper lip” from my doctors and from my now ex-husband as well.

    I believe that counseling should be required in every cardiac rehab program (I know, I know, less women are referred and attend, but it is a first step).

    Well done, Carolyn.

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 8:25 am #

      Hello Dr. Anne – I suspect that the stigma of mental health issues is more keenly felt among medical professionals than it is in patients! So you end up suffering in silence and shame. Awful… I agree – psychosocial counseling should be routinely part of every cardiac rehab program.

      Like

  11. Chris Weigand November 26, 2017 at 7:38 am #

    I am now 10 months following a widowmaker heart attack… yes, I am diabetic, type 2, with no complications and thought I was safe because it is under control, what a shock !!

    I live in an area of great hospitals and doctors, which saved my life… Following my heart attack, I had several setbacks due to severe reactions to medications which kept me from getting better as soon as I should have… Thank goodness for the visiting nurses that gave me several really good suggestions and calling doctors and getting the help I needed. Now mind you, these started the day after my release. I found myself back at my primary care getting inhalation therapy, x-rays, and blood work… I was in pain and couldn’t breathe from the medications.

    Fast forward three weeks…I am now off 3 of the 5 new medications and feeling better. My cardiac doctors are confounded because they want me on these drugs!! They suggest other drugs to add so I can take their drugs, really!! I say no thanks, it’s no way to live…

    In the meantime, my husband has several setbacks to his health, being a heart patient of 25 years with heart failure during my crisis. So I became the caregiver as usual too soon after my heart attack…

    Is it any wonder I was depressed ? I had to ask my primary for help to cope with the stress and was embarassed that I had to ask for the first time in my life. She was wonderful and helped me a lot…

    I feel guilty because the cardiac doctors are not happy with my choice of drugs but I am getting better all the time with no other setbacks..the tests show very little damage, thank goodness! All tests show great numbers and I am back to baseline health in spite of the hard times. No one can say the reason for the blood clot that almost killed me, only that I am diabetic so I wonder if it will happen again…but the real point is that all the docs ignored my mental health, so I struggled more than I should have. I never want to go it alone again…

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 8:22 am #

      Thanks for sharing your comments, Chris. Being both a patient and the caregiver for your heart patient/husband is an overwhelming scenario! Thank goodness your primary doc did not ignore your depression symptoms. Best of luck to you…

      Like

  12. Brenda Whitley November 26, 2017 at 6:32 am #

    I have just had such a depression and this report has prompted me to comment. My old doctor retired almost 2 years ago and I had to go to a new practice. Having asked among my family and friends I thankfully joined my present doctor’s practice. He is everything I needed, a listener, kind, knowledgeable and most of all very up to date with treatments.

    When I began to feel down I spoke to him and he put me on a short term tablet to help me but told me it was very addictive and he wouldn’t leave me on too long, this happened and gradually was weaned off it when I was finished, approximately 5 months. It did help along with good friends who pulled me out of the house for little danders of walks, ha,ha, light lunches and an odd hot whiskey.

    My cardiologist or my previous doctor never mentioned depression once to me in the 5 years since I had my heart attack and 4 different stents. So Carolyn well done for that welcome written report. It sounded so like myself that I had to let you know how it resonates with me.

    I am doing well at the moment, still breathless but no pain, taking my meds and enjoying life. On a long waiting list to see my cardiologist for checkup but with things as they are here in UK will not hold my breath or should I rephrase that ha,ha for a speedy appointment.

    I keep telling my friends and my lovely doctor about your website. Thank you.

    Liked by 1 person

    • Carolyn Thomas November 26, 2017 at 6:43 am #

      Thanks for your comment, Brenda. I’m guessing that getting pulled out of the house (what depressed heart patients least want to do at the time!) by your good friends helped you manage and overcome your depression. Isolation can be a dangerous ‘slippery slope’ – it’s too exhausting to socialize, so we gradually stop seeing others and living life. You are lucky to have both a lovely doctor and lovely friends.

      Like

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