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Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease, affecting approximately 280 million people.¹ The connection between cardiovascular disease and depression is well established,¹ but our understanding about the bidirectional nature of that relationship, namely how mental health disorders like anxiety may impact cardiovascular risk, is in the early stages.²

To summarize what is known about the association of cardiovascular disease with depression, one group of researchers from Harvard Medical School stated that depression in cardiac disease is common, persistent, underrecognized, and deadly.³ Patients with coronary artery disease, heart failure, atrial fibrillation, and implanted cardiac defibrillators are all at greatly increased risk of depression compared to healthy individuals.³

Some evidence suggests that depression precedes cardiovascular events for many patients. For instance:

• In one study, major depression preceded acute coronary syndrome by more than 30 days in 53% of patients.⁴
• In another study, nearly 50% of patients had thoughts that life was not worth living two weeks before hospitalization for a cardiac condition.⁵
• A meta-analysis concluded that whether pre- or post-cardiac event, depression is prevalent among coronary heart disease patients and is “hazardous.”⁶

One decade-long study on all-cause mortality and cardiovascular mortality examined more than 3,400 middle-aged men.⁷ The results indicated that the presence of depressed mood and exhaustion is a middle-ranking risk factor for all-cause and CVD mortality, comparable to hypercholesterolemia and obesity.⁷ A 2018 study of 1,075 women found a significant prevalence of untreated and undertreated depressive symptoms among women with, or at high risk of developing, cardiovascular disease.⁷ These studies highlight the need to widen the lens for cardiometabolic assessment.

Depression and anxiety may also significantly impact the course of illness and efficacy of treatment after a cardiac event. For instance, analyses have revealed that patients with comorbid depression after myocardial infarction have a threefold increased risk of death.¹

We know that mental health issues are extremely common across the population. More than 42% of people surveyed by the US Census Bureau in December 2020 reported symptoms of anxiety or depression, an increase from just 11% the previous year.⁹ Data from other surveys suggest that the picture is similar worldwide.⁹ Patients with coronary artery disease or heart failure are roughly three times more likely than the general public to have comorbid depression.¹⁰ For patients at risk of cardiovascular and cardiometabolic conditions, depression and exhaustion are vital risk factors to consider for public health in general.¹¹

Special Population: Aging Adults

Statistically, older adults are more likely than those under 60 years of age to have depression and seek treatment from primary care providers.^12-13 Depression may be especially common in long-term care settings, with a prevalence of 29%¹² compared with 19% in the general population.¹⁴ Furthermore, the likelihood of depression increases with each comorbid condition.¹² Despite this frequency, at least one meta-analysis concluded that primary care providers are less successful at diagnosing depression in older populations.¹⁵

Researchers report that perceptions of time pressure or of more difficult patients both tend to reduce the likelihood of physicians screening for depression in this population.¹³ In a primary care setting, both physician and patient may be more likely to focus on physical complaints than mental health. However, given the importance of depression as a mediating factor for cardiovascular health, functional medicine teaches that such screening remains extremely important. For aging patients, who are more likely to have multiple symptoms and/or diagnoses, pre-visit screening tools may aid assessment.

Conclusion

For those with cardiometabolic and cardiovascular diagnoses, therapeutic lifestyle change in the areas of diet, exercise, stress management, and sleep are common and effective.¹⁶ Depression can greatly interfere with the ability to conduct normal life and may influence an individual’s quality of life.¹⁷ To be sure, there is room to improve in the detection and treatment of comorbid depression, and doing so could help to improve outcomes as well as increase patients’ adaptability and resilience to adhere to needed lifestyle changes.

IFM’s Cardiometabolic Advanced Practice Module (APM) helps clinicians understand the physiology underlying cardiometabolic syndrome and cardiovascular disease, new approaches to effective assessments and treatments, and how to integrate these lifesaving tools into practice. Learn more:

Clinical Pearls on Cardiometabolic Treatment

Lifestyle Interventions to Modify Cardiovascular Disease Risk

The Right Food Plan for Cardiometabolic Patients

References

1. World Health Organization. Depression. Published September 13, 2021. Accessed October 21, 2021. https://www.who.int/news-room/fact-sheets/detail/depression
2. Karlsen HR, Matejschek F, Saksvik-Lehouiller I, Langvik E. Anxiety as a risk factor for cardiovascular disease independent of depression: a narrative review of current status and conflicting findings. Health Psychol Open. 2021;8(1):2055102920987462. doi:10.1177/2055102920987462
3. Huffman JC, Celano CM, Beach SR, Motiwala SR, Januzzi JL. Depression and cardiac disease: epidemiology, mechanisms, and diagnosis. Cardiovasc Psychiatry Neurol. 2013;2013:695925. doi:10.1155/2013/695925
4. Glassman AH, Bigger JT, Gaffney M, Shapiro PA, Swenson JR. Onset of major depression associated with acute coronary syndromes: relationship of onset, major depressive disorder history, and episode severity to sertraline benefit. Arch Gen Psychiatry. 2006;63(3):283-288. doi:10.1001/archpsyc.63.3.283
5. Huffman JC, Mastromauro CA, Sowden GL, Wittmann C, Rodman R, Januzzi JL. A collaborative care depression management program for cardiac inpatients: depression characteristics and in-hospital outcomes. Psychosomatics. 2011;52(1):26-33. doi:10.1016/j.psym.2010.11.021
6. Leung YW, Flora DB, Gravely S, Irvine J, Carney RM, Grace SL. The impact of premorbid and postmorbid depression onset on mortality and cardiac morbidity among patients with coronary heart disease: meta-analysis. Psychosom Med. 2012;74(8):786-801. doi:10.1097/PSY.0b013e31826ddbed
7. Ladwig K-H, Baumert J, Marten-Mittag B, et al. Room for depressed and exhausted mood as a risk predictor for all-cause and cardiovascular mortality beyond the contribution of the classical somatic risk factors in men. Atherosclerosis. 2017;257:224-231. doi:10.1016/j.atherosclerosis.2016.12.003
8. Bhardwaj M, Price J, Landry M, Harvey P, Hensel JM. Association between severity of depression and cardiac risk factors among women referred to a cardiac rehabilitation and prevention clinic. J Cardiopulm Rehabil Prev. 2018;38(5):291-296. doi:10.1097/hcr.0000000000000311
9. Abbott A. COVID’s mental-health toll: how scientists are tracking a surge in depression. Nature. 2021;590(7845):194-195. doi:10.1038/d41586-021-00175-z
10.  Cohen BE, Edmondson D, Kronish IM. State of the art review: depression, stress, anxiety, and cardiovascular disease. Am J Hypertens. 2015;28(11):1295-1302. doi:10.1093/ajh/hpv047
11.  Catalina-Romero C, Calvo-Bonacho E. Depression and cardiovascular disease: time for clinical trials. Atherosclerosis. 2017;257:250-252. doi:10.1016/j.atherosclerosis.2017.01.004
12.  Hall CA, Reynolds-III CF. Late-life depression in the primary care setting: challenges, collaborative care, and prevention. Maturitas. 2014;79(2):147-152. doi:10.1016/j.maturitas.2014.05.026
13.  Seitz D, Purandare N, Conn D. Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. Int Psychogeriatr. 2010;22(7):1025-1039. doi:10.1017/S1041610210000608
14.  Van Damme A, Declercq T, Lemey L, Tandt H, Petrovic M. Late-life depression: issues for the general practitioner. Int J Gen Med. 2018;11:113-120. doi:10.2147/IJGM.S154876
15.  Mitchell AJ, Rao S, Vaze A. Do primary care physicians have particular difficulty identifying late-life depression? A meta-analysis stratified by age. Psychother Psychosom. 2010;79(5):285-294. doi:10.1159/000318295
16.  Eliasson A, Kashani M, Vernalis M. Results of a prospective cardiovascular disease prevention program. Prev Med Rep. 2021;22:101344. doi:10.1016/j.pmedr.2021.101344
17.  Mei S, Quin Z, Yang Y, et al. Influence of life satisfaction on quality of life: mediating roles of depression and anxiety among cardiovascular disease patients. Clin Nurs Res. 2021;30(2):215-224. doi:10.1177/1054773820947984