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REVIEW ARTICLE
Correlation between depression and cardiovascular diseases and its
effect on clinical outcomes
Vaghela Bhavesh 1*, Kamothi Ketal 1, Shah Darshit 2, Rathod Jignasa 3
1
Research coordinator, 2Director, CliniApps Pvt. Ltd, Ahmadabad
3
Pharmacist, Rajasthan Hospitals, Ahmedabad

ABSTRACT
Depression is commonly present in patients with coronary heart disease (CHD) and is independently associated with
increased cardiovascular morbidity and mortality. The physiological mechanisms accounting for this association are
unclear. Hypothalamic–pituitary–adrenal dysregulation, diminished heart rate variability, altered blood platelet function
and noncompliance with medical treatments have been proposed as mechanisms underlying depression and
cardiovascular disease. Such approaches may hold promise for advancing our understanding of the interaction between
this mood disorder and CAD.
Key words: Depression, Coronary heart disease

* Corresponding Author
-----------------------------------
Mr. Bhavesh Vaghela
e- mail: bhaveshvaghela10@gmail.com

INTRODUCTION
Cardiovascular diseases are the class of diseases that involve the heart or blood vessels (arteries and veins).
While the term technically refers to any disease that affects the cardiovascular system, it is usually used to
refer to those related to atherosclerosis (arterial disease). Cardiovascular disease (CVD) is the leading cause of
death for people in industrialized countries. Each year, heart disease kills more Americans than cancer. In
recent years, cardiovascular risk in women has been increasing and has killed more women than breast cancer.
1
Depression is a psychological disorder that affects a person's mood changes, physical functions and social
interactions. According to WHO, Depression is a common mental disorder that presents with depressed mood,
loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and
poor concentration. These problems can become chronic or recurrent and lead to substantial impairments in an
individual's ability to take care of his or her everyday responsibilities. At its worst, depression can lead to
suicide, a tragic fatality associated with the loss of about 850 000 lives every year.2–3
Depression Associations with Cardiovascular Diseases
Depression and heart disease are very common and often coexist: the prevalence of depression in various
heart conditions ranges from 15% to 20%. The World Health Survey4 showed that depression worsens health
more than angina, arthritis, asthma, or diabetes. Furthermore, patients with severe mental illness have a higher
risk of dying from heart disease and stroke.5 It is well established that hospitalized patients with CHD,
including post-MI patients, patients with congestive heart failure, those recovering from attacks of unstable
angina, and patients undergoing coronary bypass surgery or angioplasty, show higher prevalence of elevated
depressive symptoms (30% to 50%).6 In the Heart and Soul Study7, 1,019 patients with stable CHD were
assessed using the Patient Health Questionnaire to determine depression. A comparison was made on a new
cardiovascular event (myocardial infarction, stroke, transient ischemic attack, or congestive heart failure) or
death (mean follow-up duration 6.1 ± 2.0 years) on the basis of cognitive and somatic sum scores and for
patients with or without each of those specific depressive symptoms. A total of 399 events occurred (MI, heart
failure, stroke, transient ischemic attack, or death) during an average of 6.1 ± 2.0 years of follow-up. This
study concluded that somatic symptom was associated with 14% greater risk for events (hazard ratio [HR]:
1.14; 95% confidence interval [CI]: 1.05 to 1.24; p = 0.002). In contrast, cognitive symptoms (HR: 1.08; 95%
CI: 0.99 to 1.17; p = 0.09) were not significantly associated with cardiovascular events. In Figure 1, the HRs
and 95% CIs of specific depressive symptoms with CV events are visualized in a forest plot.

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Figure 1. Association between specific depressive symptoms and CV events.

*HR = hazard ratio, CV = cardiovascular


In Nurses’ Health Study8, 63,469 women without prior CHD/Stroke in 1992 were enrolled. Depressive
symptoms were assessed in 1992, 1996, and 2000 with the Mental Health Index (MHI-5) questionnaire.
Among enrolled women, 4,994 women (7.9 % of the total) had an MHI-5 score < 53, which has been shown
to be predictive of clinical depression. The study end points included incident cases of Sudden cardiac death
(HR: 1.51for MHI-5 score <53; 95% CI: 0.89-2.56; p= 0.01) and CHD mortality (HR: 1.49 for MHI-5 score
<53; 95% CI: 1.11-2.00; p=0.007) that occurred after return of the 1992 questionnaire and before June 1,
2004. These results are statistically significant. This study concluded that symptoms of depression are
associated with higher risks of cardiac events.
Insights from COACH study9, in which analysis of a potential interaction between depression at baseline and
the effect of DMP (Disease management program) in Heart failure patients was done. In this study, of the 958
patients, 377(39%) reported depressive symptoms assessed by CES-D (Centre for epidemiological studies
depression scale) at baseline. During 18 months of follow-up, Patients were randomly assigned to DMPs. At
the end of the study, a total of 39% of the 581 non-depressed patients were hospitalized for HF or died within
follow-up period. Of 377 depressed patients, a total of 41% were hospitalized for HF or died within the
follow-up. Interaction between depression and DMPs in HF discuss in Figure-2. Heidi T. May et al10 found
that depression after CAD is associated with heart failure. They enrolled 13,708 patients without a diagnosis
of HF and depression at the time of CAD diagnosis. Patients were followed until a subsequent hospitalization,
where they received a clinical diagnosis of HF, or until death. Average length of follow-up was 5.6 ± 3.6
years for all the study patients. At the end of the study, A total of 1,377 (10%) of 13,708 patients had a post
CAD depression diagnosis. The incidence of HF among those without a post-CAD depression was 3.6 per 100
compared with 16.4 per 100 for those with a post- CAD depression diagnosis.

Figure -2: Interactions (p values) Between Depression and DMPs in HF and Hazard Ratios for
Depressed (n=377) and Nondepressed Patients (n=581).

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Hamer et al11 found psychological distress as a risk factor for cardiovascular events. They performed
prospective study on 6,576 healthy male and women (ages 50.9 ± 13.1 years). Baseline assessment was
demographics, height, weight, and health behaviors. Measurement of psychological distress was done by 12-
item version of General Health Questionnaire (GHQ-12). The questionnaire comprises 12 questions about
level of happiness, experience of depressive and anxiety symptoms, and sleep disturbance over the last 4
weeks. The main outcome was fatal and non-fatal cardiovascular events. There were a total of 223 incident
CVD events (63 fatal) over an average of 7.2 years of follow-up. Psychological distressed participants (GHQ-
12 ≥ 4) were at a higher relative risk of CVD events during follow-up. The results of study are as Table 1 and
Table 2.
Table 1. Descriptive Characteristics of Participants (n=6,576) at Baseline by Psychological Distress 10-11

Variable No Distress GHQ-12 <4 Distressed GHQ-12 ≥ 4 p Value


(n = 5,618) (n = 958)
Men, % 46.4 36.2 < 0.001
Smokers, % 27.2 43.1 < 0.001
Alcohol, U/week
Men 16.8 ± 20.6 20.6 ± 29.1 0.02
Women 5.9 ± 8.1 7.6 ± 13.6 0.004
Hypertension, % 15.6 21.6 < 0.001
C-reactive protein, mg/l 3.29 ± 6.21 4.73 ± 9.10 < 0.001
± Standard deviation

Table 2. The Extent to Which Behavioral and Pathophysiological Risk Factors Explain the Association
Between Psychological Distress and CVD Events (Total n = 6,576)10-11

No Distress Distressed
Model
GHQ-12 <4 GHQ-12 >4 p Value
Cases/N Cases/N
183/5,618 40/958
Age- and sex-adjusted HR (95% CI) 1.00 1.54 (1.09–2.18) 0.013
Model 1 HR (95% CI) 1.00 1.32 (0.93–1.87) 0.116
Model 2 HR (95% CI) 1.00 1.20 (0.84–1.70) 0.317
Model 3 HR (95% CI) 1.00 1.19 (0.84–1.69) 0.328
Model 4 HR (95% CI) 1.00 1.12 (0.79–1.59) 0.533
Model 5 HR (95% CI) 1.00 1.09 (0.77–1.56) 0.614

Model 1 was adjusted for age, sex, and cigarette smoking.


Model 2 was adjusted for age, sex, cigarette smoking, and physical activity.
Model 3 was adjusted for age, sex, cigarette smoking, physical activity, and alcohol intake.
Model 4 was adjusted for age, sex, cigarette smoking, physical activity, alcohol intake, and hypertension.
Model 5 was adjusted for age, sex, cigarette smoking, physical activity, alcohol intake, hypertension, and
CRP.

Among 4,041 patients with major depression in the STAR*D (Sequenced Treatment Alternatives to Relieve
Depression) study, 14.3% had comorbid cardiac disease.12
Three separate publications 13-15 found that depressed individuals are more than 1.6 times as likely to develop
CHD compared with individuals without depression. Lichtman et al.16 found that depression is important and
prevalent in patients with CHD.
The inter heart study17-18 gathered data about attributable risk in the development of myocardial infarction
(MI) in 52 countries in a case-control fashion. Psychosocial factors including stress, low generalized locus of
control (ie, the perceived inability to control one’s life), and depression accounted for 32.5% of the
attributable risk for an MI. This would mean that they account for slightly less attributable risk than that of
lifetime smoking but more than that of hypertension and obesity. A 2007 study from Sweden19 prospectively

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followed patients who were hospitalized for depression. The odds ratio of developing an acute MI was 2.9,
and the risk persisted for decades after the initial hospitalization.
A meta-analysis by Van der Kooy et al20 of 28 epidemiologic studies with nearly 80,000 patients showed
depression to be an independent risk factor for cardiovascular disease. Depression can also exacerbate the
classic risk factors for coronary disease, such as smoking, diabetes, obesity, and physical inactivity. 21
A prospective United Kingdom cohort study of people initially free of heart disease revealed major depression
to be associated with a higher rate of death from ischemia. 22 Lespérance et al23 found that in MI patients, the
higher the Beck Depression Inventory score at the time of hospital admission, the higher the 5-year death rate.
Using meta-analysis, Barth et al24 found the risk of dying in the first 2 years after initial assessment to be
twice as high in depressed cardiac patients as in nondepressed cardiac patients (odds ratio 2.24).
Van Melle et al25 reviewed 22 studies and found that in the 2 years after an MI, depressed patients had a 2 to
2.5 times higher risk of dying of a cardiac cause than did nondepressed patients. Medical illnesses can
predispose a patient to develop depression. Specifically, compared with healthy people, cardiac patients
appear to be at greater risk of developing depression for many years after the initial medical diagnosis is
made.26 Katon et al27 reviewed 31 studies involving 16,922 patients, that assessed the impact of depression
and anxiety in chronic medical illnesses such as heart disease, diabetes, pulmonary disease, and arthritis. After
the severity of the medical disorder was controlled for, patients with depression and anxiety reported a higher
number of medical symptoms.
CONCLUSION
We concluded that there is a strong correlation between depression and cardiovascular diseases, and
depression results into worst clinical outcomes among the patients. Increased knowledge about the
relationship between depression and cardiovascular disease opens the possibility for attenuating the influence
of depression on cardiovascular diseases as well as reducing mortality rates among depressed cardiac patients.

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