Heart attack patients more depressed but get less antidepressants
Heart attack patients are more depressed but are less often prescribed antidepressants than people who have not had a heart attack, according to research presented today at EuroHeartCare 2016 by Dr Barbro Kjellström, a researcher at the Karolinska Institute in Stockholm, Sweden.1
"Stress related disorders such as depression and exhaustion are increasingly common and have been the main reason for long-term sick leave in Sweden for more than a decade," said Dr Kjellström. "We know that stress and depression are big risk factors for heart attack and we confirmed this connection in our study. But what was new and astonishing was that heart attack patients less often receive treatment for depression."
The research presented today was a substudy of the PAROKRANK study which found that periodontitis increased the risk of having a first myocardial infarction by 30%.2 The study included 805 patients under 75 years of age who had experienced a first myocardial infarction and 805 people without a myocardial infarction (the control group) matched for age, gender and where they lived.
Detailed information was collected on stress, depression and exhaustion using well established, validated questionnaires.3 Study participants were asked to grade the level of stress they felt at home and at work and about their economical situation. They were also asked about stressful events during the past year and their feeling of control in life, both at work and at home.
The study participants were 62 years old on average and 81% were men. The researchers found that 14% of patients had symptoms of depression compared to just 7% of controls. Symptoms of depression or exhaustion were associated with a doubled risk of heart attack. When the researchers looked at types of stress, they found that more patients than controls had experienced stress at home (18% compared to 11%) and at work (42% versus 32%). Even moderate levels of stress at home were associated with a doubled heart attack risk.
Dr Kjellström said: "Patients who had a heart attack had more stress both at work and at home but interestingly there was no difference between the two groups as regards to financial stress. Patients also reported that they had less control of their work situation. In addition, those who had a heart attack were more likely to be divorced whereas people in the control group more often lived with a partner."
She continued: "When asked 'Were you angry during the last 24 hours?' many more patients said yes compared to controls. It appears that stress in life can also trigger feelings of anger in patients who have had a heart attack."
Just 16% of heart attack patients with depression received antidepressants compared to 42% of controls with depression. Dr Kjellström said: "Our results suggest that heart attack patients are undertreated with antidepressants. When we looked at the participants in the study who had experienced depression we saw that more than twice as many controls as patients were prescribed antidepressant medication. We did not ask about cognitive therapies but it's unlikely that the large gap in treatment was filled in this way."
She continued: "It appears that patients who had a heart attack did not seek help for their depression, or if they did, their symptoms were not accurately recognised and managed. An important take home message is for clinicians to ask patients 'How do you feel?' and listen to the reply, rather than zoning out because they are stressed themselves."
"There is no treatment for stress," added Dr Kjellström. "If you have enough stress you might get exhaustion which, if not treated, can result in depression. This is an escalating scale. Prevention of stress, exhaustion and depression is the optimal goal and we should remember that these are risk factors for many other diseases than heart attack."
Dr Kjellström concluded: "People today have stresses that did not exist before which may explain some of our findings. We're always connected - people check their phones constantly during the day and even in the middle of the night. We don't switch off and relax. The effects of this on our health need to be investigated further."
2. Rydén L, Buhlin K, Ekstrand E, de Faire U, Gustafsson A, Holmer J, Kjellström B, Lindahl B, Norhammar A, Nygren Å, Näsman P, Rathnayake N,Svenungsson E, Klinge B. Periodontitis increases the risk of a first myocardial infarction: a report from the PAROKRANK study. Circulation. 2016;133(6):576-583.
3. Information on perceived stress at home and at work, control of life, and symptoms of depression was collected using the Montgomery Asberg Depression Scale (MADRS). The Karolinska Exhaustion Disorder Scale (KEDS) was used to collect data on exhaustion. A MADRS score of 13 or greater and a KEDS score of 19 or more indicated clinically relevant symptoms of depression and exhaustion.