Depression, Anxiety, Stress, and Spirituality in Cardiovascular Disease



Depression, Anxiety, Stress, and Spirituality in Cardiovascular Disease


Mimi Guarneri, MD, FACC

Shyamia Stone, ND, MPH



Introduction

The human heart is notoriously understood as the life-giving organ of the body. With each contraction, it sends blood and nourishment to every organ and every cell of the body. As medical professionals, we are taught about the structure and function of the heart, its capacity for disease, and its centrality to life. However, across medical and cultural traditions, the heart is given many connotations outside of its cardiovascular functions. The heart is seen as the seat of the soul, of love, pain, and general emotion. Colloquialisms such as “follow your heart” and “brokenhearted” call to mind reminiscences of intuition and emotion, evoking memories and feelings in those who hear these phrases.

It is easy for medical professionals to discount the emotional connotations of the heart as mutually exclusive concepts or social folklore, but this interconnectedness of heart, body, mind, and soul has been described by medical practitioners for hundreds of years. Traditional Chinese Medicine (TCM) discusses a connection between diseases of the heart and excess stimulation; however, it is known in TCM that all emotions affect the heart, including sadness, grief, worry, fear, pensiveness, and anger.1 Ancient Grecian physicians saw cardiovascular disease (CVD) as a manifestation of emotion and psychological disorder, and in 1937 there was a scientific correlation noted between CVD outcomes and psychological pathology, noting an increase in cardiovascular-related deaths in those with depression.2,3

Medical knowledge and literature have illustrated many structural, biochemical, and genetic etiological mechanisms of CVD. Although these are important, it is necessary to look past each of these segregated components at the whole person when attempting to paint a complete picture of underlying risk factors and comorbidities. An individual’s biology does not exist in isolation of his or her surroundings, but rather within an internal and external milieu. From a public health perspective, it is possible to see the numerous ways that environment and lifestyle factors play a role in health outcomes. We see components such as toxic exposures,4,5 nutrition, and exercise6,7 as impacting physiology and being linked to CVD risk, although an often-overlooked part of one’s environment is external stressors and internal responses, along with other mental emotional states.

Although the connections between mind and body can be seen anecdotally, we also now know that mental-emotional and psychological states contribute to physiology through very real neurotransmitter and biochemical pathways that impact pathology and/or resilience. Depression and anxiety are emotional and physiological results of various types of stress that span from the biochemical to environmental.


Purpose of the Chapter

This chapter will outline what is known about depression, anxiety, and stress as pathological states and their connection with CVD. We will then present integrative medicine treatments including conventional therapies, nutrition, lifestyle, herbal, and mind-body mechanisms. It will show the ways in which it is imperative to address depression, anxiety, stress, and CVD both symptomatically and through identifying the root cause on the levels of mind, body, and spirit.


Depression

Depression in its broadest reach may be understood as a state of being that spans from a fleeting emotional experience or mood to that of a more long-term pathological state. People often experience depressed mood as feelings of sadness, despair, emptiness, or discouragement with associated rumination and fixation on the past. When sadness is experienced as an emotion, it is important that it is acknowledged as a
normal part of the human experience, allowed to be expressed and not suppressed. However, if this state continues and is accompanied by other features, it is possible for depression to cross over into a state of pathology.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), depression as a disorder may be classified as Disruptive Mood Dysregulation Disorder, Major Depressive Disorder, Persistent Depressive Disorder (Dysthymia), or Depressive Disorder Due to Another Medical Condition.8 The most commonly studied clinical diagnosis of depression related to CVD is Major Depressive Disorder (MDD). Although the DSM-58 is the gold standard in diagnosis of depressive disorders and is utilized extensively by mental health professionals, depression is often identified in medical offices through a variety of self-report measures (Table 33.1). These instruments provide information about the severity of depressive symptoms based on the frequency, severity, and impact on quality of life. Each of these measures simplify DSM criteria for self-report format and provide an estimated guideline of level of depression that may include categories such as normal/not depressed, mild, borderline, moderate, or severe depression.9,10,11,12 A measure specifically for cardiac patients has been developed that also assesses specific presentations of depression that may occur after a cardiovascular incident, including concern about health and recovery, feeling as if one is changed after their incident, fear or dread of impending health issues or dying, and loss of independence or function.13

The fact that a measure has been created for patients who have cardiac concerns shows that the presentation of depression may vary between patients and comorbidities. It is important to recognize symptoms of depression in patients even if they do not fit the criteria for diagnosis of MDD. It is not necessary for a patient to have MDD to be at risk for depressive symptoms contributing to CVD, as depressive symptoms in themselves have been correlated with adverse cardiac outcomes.14,15








Table 33.1 SCREENING MEASURES FOR DEPRESSION AND ANXIETY
























Depression


Patient Health Questionnaire (PHQ-9)9



Beck Depression Inventory (BDI)11



Hospital Anxiety Depression Scale (HADS)



Center for Epidemiologic Studies Depression Scale-10 (CES-10)10



Cardiac Depression Scale13


Anxiety


Generalized Anxiety Disorder (GAD-7) questionnaire31


Depression and Anxiety


Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS)32


From an etiological standpoint, studies have determined that patients with depression have twice the risk of developing new-onset CVD.16 Depression is also correlated with greater mortality in patients with a history of acute myocardial infarction (MI), with depressed patients having three times increased incidence of mortality post-MI than patients who are not depressed.16 These outcomes are not related only to the presence or absence of depression, as the 5-year mortality rate has been correlated with the severity of depression.17 Interestingly, MDD is noted as the second leading cause of disability in America, behind ischemic heart disease, which ranks number one,18 although arguably, these could be varying manifestations of related disease processes, which will be discussed in the pathophysiology section.

As depression exists on a continuum from normal emotion to pathology, with variations in clinical presentation, the etiology of depression is still being discovered with potential for differing mechanisms at work in each of the presenting criteria.19 Perhaps the most comprehensive integrative view is the biopsychosocial model of depression, which shows a multifactorial etiology including genetics,19 biochemistry, cognition, personality traits, environmental factors, trauma,20 and social interactions.21 Pathophysiological features of depression can include structural and functional brain changes as witnessed through neuroimaging studies,22,23 specifically showing reduction of dopamine network responses in the brain.22 Overall, MDD is thought to be due to deficiencies of dopamine, serotonin, and/or norepinephrine, which may occur concurrently or may lead into one another.24


Anxiety


Overlap Between Anxiety and Depression

When discussing anxiety and depression, it is difficult to draw a clear line where one ends and the other begins. There is a high level of comorbidity between depression and anxiety, even in their clinical forms of MDD and Generalized Anxiety Disorder (GAD). In fact, it has been hypothesized that MDD and GAD may be different presentations of the same disorder.25 Comorbidity rates between MDD and GAD range from 40% to 98%, with 67% of individuals with GAD reporting MDD at some point in their lives and 20% of individuals with MDD reporting GAD in the past.26 A common component between the disorders is that of general distress, yet uniquely differentiating components are that of excessive worry in GAD and anhedonia in MDD.26 In addition to common features, there also appears to be shared etiological factors, including similar genetics,27 and the trait of neuroticism that predisposes for both depression and anxiety.26 Appearance of comorbidity may also be due to overlap in the diagnostic criteria for disorders such as MDD and GAD.28 Regardless, both depression and anxiety have been shown to be correlated with CVD.



Defining Anxiety

As with depression, anxiety exists on a spectrum from that of a mental-emotional state, or a trait, to that of a psychological disorder.29 A state of anxiety is fleeting and is experienced as a momentary fear of a potential threat.30 This heightened emotional state can be a healthy part of the human experience, leading to motivation and vigilance when situationally necessary. Anxiety can also be in response to a positive event, manifesting as the stimulation of excitement. An individual with trait anxiety is predisposed to experience an anxious state of fear and/or apprehension about distant and potential threats as opposed to real ones.30 When this experience transcends into inappropriate situations and adopts a state of chronicity, anxiety can become a psychological disorder with an impact on daily functioning.

Anxiety Disorders as outlined in the DSM-5 include Separation Anxiety Disorder, Phobias, Social Anxiety Disorder, Panic Disorder, Agoraphobia, and Generalized Anxiety Disorder. The two disorders that have been the most extensively studied in conjunction with CVD are GAD and Panic Disorder (PD).8

Trait forms of anxiety may be screened in a clinical setting through use of self-report measures, which has primarily consisted of the Generalized Anxiety Disorder (GAD-7) questionnaire.31 However, recently, a combined measure called the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) has been created to combine PHQ-9 and GAD-7 into one measure.32 Although the PHQ-ADS is still in its initial validation phase, it shows promise as an initial screening tool because of the overlap between anxiety and depression.

The etiology of anxiety appears to be multifactorial including inheritance, biological processes, and environmental risk factors. Some individuals with anxiety show genetic predisposition for dysregulation of serotonin33 and glutamic acid decarboxylase.34 Disturbances of neurotransmitters norepinephrine, serotonin, and gamma aminobutyric acid (GABA) have also been associated with GAD.22 Although there are widely varying experiences of anxiety that are reflected in the spectrum of state, trait, or disorder, functional magnetic resonance imaging data have shown similar neurological networks in the brain that are activated across all forms of anxiety.30 Areas of activation correspond with heightened amygdala responses and overall greater emotional responsiveness.35 Additional environmental risk factors associated with development of GAD include a greater incidence of trauma throughout life and adverse childhood events.36

Clinical presentation of anxiety may appear through emotional complaints that can be assessed through the above-mentioned DSM-5 criteria or GAD-7 assessment. However, anxiety may also present as physical symptoms such as sleep disturbance, fatigue, difficulty relaxing, muscle tension (especially in the neck, shoulders, and back), and recurrent headaches.37 It is important as a practitioner to keep anxiety in the differential diagnosis when these physical symptoms present.


Stress

Psychological stress is defined as a perceived tension or worry that impacts an individual’s behaviors and ability to traverse life events.38 In many ways, depression and anxiety are both manifestations of chronic stress and occur either as a result of the interplay of stress with the above-mentioned etiological factors or lead to a physiological state that simulates chronic stress in the body.38


Stressors

The term “stress” has also been used to describe stressors themselves, those things that one encounters that incite a stressful response. Humans exist in a context of a complex interplay of factors including internal environment, social environment, and physical environment. Stressors may exist in any of these arenas, thereby increasing the strain put on the body’s systems to come back to a point of balance, which has been termed “allostasis.”39 The concept of allostasis illustrates the way in which the body has an active regulatory process to maintain physiological balance and adapt to changing needs utilizing physiological responses such as hormones, temperature changes, and blood pressure.40 Therefore, it is possible to see that stressors have a direct impact on physiology through the body’s mechanisms to perceive these events, react, and then compensate in attempt to preserve balance. There are times when balance is unable to be achieved, and this is referred to as “allostatic load,” a state wherein the normal balancing processes are overtaxed or fail to act, leading to a lack of adaptation and dysregulation of the physiological systems that are in flux in response to stressors.41 These systems include the autonomic nervous system, hypothalamic-pituitary-adrenal (HPA) axis, sympathetic nervous system, and immune system.41

Stressors may be acute or chronic and may vary between individuals based on their perceptions of what is and is not stress. Acute stressors are encountered on a daily basis in small doses, such as having to complete tasks of daily living. They may also come in response to unexpected life changes in health, family, home, or livelihood. Acute stressors can negatively impact individuals, although chronic stressors appear to have a greater cumulative burden on the body’s ability to allostatically adjust. Chronic stressors have been shown to include low social support, low socioeconomic status, occupational stress, marital or relationship stress, and caregiver strain.15




Prevention and Screening

In patients with known CVD, it is important to perform screenings for emotional disorders of depression, anxiety, and chronic stress. It is possible to utilize the self-report screening measures mentioned previously (Table 33.1) or work in collaboration with a mental health professional to determine patient risk. Although these measures may provide information regarding a patient’s emotional state, they can be impersonal, and owing to the stigma of mental health concerns, patients are not always forthcoming in this format. It is important to develop a positive relationship with the patient to facilitate trust and openness, while allowing the practitioner to attend to underlying emotional concerns.

Conversely, there is controversy regarding whether all patients with CVD should be screened for depression and anxiety, owing to potential for overdiagnosis and overtreatment in a clinical setting. It is debatable whether psychotherapy and pharmacotherapy for depression and anxiety help to mitigate CVD risk, and overtreatment may result in adverse cardiovascular side effects.70,71 It is therefore important to aim for prevention through integrative therapies, which are described in detail later.

Because the connections between depression, anxiety, chronic stress, and CVD are multidimensional and multidirectional, there are many treatment approaches that can be taken. We will begin by discussing the conventional mitigation of comorbid mental health disorders and CVD and then expand to discuss less invasive, integrative modalities to target the underlying factors that lead to these states.


Feb 27, 2020 | Posted by in CARDIOLOGY | Comments Off on Depression, Anxiety, Stress, and Spirituality in Cardiovascular Disease

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