Summary
The impact of psychological factors on somatic disorders – and vice versa – and the involvement of biological mechanisms in psychic disorders have generated considerable interest in recent years, notably thanks to cutting-edge investigation techniques (immunohistochemistry, functional imaging, genetics, etc.). In the field of psychosomatics, coronary heart disease (CHD) is a frequent co-morbidity of mental disorders, particularly mood disorders. Indeed, there is a bidirectional relationship between CHD and mood disorders, with a strong co-occurrence of the two diseases accompanied by a reciprocal worsening of the prognosis for the two conditions. Various epidemiological studies have shown that depression is a psychic risk factor for CHD and that CHD is present in almost 30% of patients with affective disorders. In this review of the literature, we tackle the crucial question of the diagnosis of depression during myocardial infarction. This clinical approach is essential given the underevaluation of this psychic problem. Then, various psychological, biological and genetic arguments are presented in support of the hypothesis that various aetiological mechanisms of the two disorders are partly shared. We finally deal with the treatment of depression in the context of CHD with its pharmacological and psychological specificities. In conclusion, this review reiterates the need for a multidisciplinary approach, which is necessary to understand, diagnose and then treat this frequent co-morbid condition of heart disease and depression.
Résumé
L’influence de facteurs psychologiques promoteurs d’affections somatiques ainsi que réciproquement l’implication de mécanismes biologiques dans les maladies psychiques suscitent actuellement un réel intérêt, notamment grâce aux techniques d’investigation performantes (immunohistochimie, imagerie fonctionnelle, génétique, etc.). Or dans le domaine de la psychosomatique, les maladies cardiovasculaires en general et les affections coronariennes plus particulièrement représentent une fréquente co-morbidité des troubles mentaux, notamment dans les troubles de l’humeur. En effet, coronaropathies et troubles de l’humeur entretiennent des relations bidirectionnelles avec une forte co-occurrence des deux pathologies accompagnée d’une aggravation mutuelle du pronostic des deux affections. Divers travaux épidémiologiques démontrent que la dépression constitue précisément, d’une part, un facteur de risque psychique de coronaropathie tandis que, d’autre part, les pathologies coronariennes s’accompagnent chez près de 30 % de sujets de troubles affectifs. À partir d’une récente revue de la littérature, les auteurs abordent la question cruciale du diagnostic de la dépression au décours d’un accident cardiaque, approche clinique essentielle du fait de la sous-évaluation de cette problématique psychique. Puis divers arguments psychologiques, biologiques et génétiques sont exposés, soutenant l’hypothèse de mécanismes étiologiques partiellement communs aux deux affections. Enfin les auteurs s’intéressent à l’aspect thérapeutique de la dépression dans un contexte de maladie coronarienne avec ses spécificités pharmacologiques et psychologiques. En conclusion cette revue rappelle la nécessaire collaboration transdisciplinaire nécessaire à la compréhension, au diagnostic, puis au traitement de la fréquente comorbidité cardiaque et dépressive.
Background
The supposed links between affections of the mind and the body have given rise to many questions and debates. The field of psychosomatics may shed light on the impact of psychic equilibrium on the psychodynamic and biological aspects of physical health. This discipline explores the measurable organic consequences of psychological factors in the aetiology. For example, the stress reaction experienced by a subject exposed to a stressful environment is a model of a psychosomatic phenomenon. This normal adaptive response to stress may sometimes become excessively intense or excessively long and trigger physiological modifications that are harmful for the body. In the field of somatic disease, could the fact of developing a depressive state, which is a major factor of stress, lead to physiopathological alterations at the origin of heart disorders? Today, although the precise nature of the links between depression and coronary heart disease (CHD) has not yet been clearly established, these links are being highlighted more and more frequently, first of all from an epidemiological point of view and then with regard to the aetiological and clinical aspects in patients with this worrying co-morbidity. In addition, for many years, the psychosomatic approach has led to better understanding of the bidirectional impact of emotional disorders on cardiac disease and vice versa. Different studies have underlined the impact of certain psychic dimensions in heart disease, in particular the importance of depression, which is frequently discovered in patients with coronary artery disease. Surprisingly, despite progress in theoretical knowledge on this issue, detecting an episode of depression in patients with a heart condition is not always easy for the clinician. We tackle here all of the epidemiological aspects of the links between depression and CHD; we also cover the clinical specificities of an episode of depression in patients with CHD and we present the principal aetiological mechanisms revealed to date, before dealing with the different management strategies for depression in patients with CHD.
CHD and depression: epidemiology of a co-morbidity
The significant prevalence of depression in cardiovascular disease in general and coronary artery disease in particular is a frequent phenomenon . Several studies ( Table 1 ) have shown a rather high incidence of episodes of depression, characterized by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria, ranging from 15% to 30% in the aftermath of a coronary event. These figures need to be compared with the mean annual prevalence of episodes of depression in the population at large, which is about 7%.
| Published studies | Number of subjects | Mean age (years) | Symptoms of depression (%) | Depression characterized by DSM IV-TR criteria (%) |
|---|---|---|---|---|
| Myers et al., 2012 | 632 | 52 | 27.8 | NA |
| Davidson et al., 2010 | 453 | 25–93 | 24.0 | 17.0 |
| Ziegelstein et al., 2000 | 204 | 60 | 17.2 | 15.2 |
| Frasure-Smith et al., 1995 | 222 | 60 | 30.6 | 16.0 |
In a bidirectional manner, depression is an independent risk factor of cardiovascular co-morbidity . Compared with the population at large, people with characterized depression frequently develop cardiovascular disease due to psychological, behavioural and biological mechanisms. The multicentre INTERHEART study reported the impact of psychic disease on coronary artery disease and the importance of psychosocial stress (a notion that includes depression), which puts it in third place in the league table of risk factors (with an odds ratio of 2.67) for developing cardiovascular disease , after the apolipoprotein B/apolipoprotein A1 ratio and smoking but in front of diabetes, arterial hypertension and abdominal obesity. Intense and chronic stress lead to anxiety or depression disorders. Consequently, a certain number of patients with heart disease had experienced mood disorders beforehand, whereas others developed heart disease and the episode of depression occurred during the evolution of their disorder; these epidemiological aspects thus justify specific attention.
In addition, major depression worsens the cardiovascular prognosis, particularly for coronary artery disease, by significantly increasing the risk of recurrent coronary artery disease. The relative risk of death in depressed patients during the 18 months following the cardiac event is twice that in non-depressed patients . Recent studies have also shown the harmful nature of depression after myocardial infarction in terms of rehospitalization and of greater difficulty in stopping smoking or getting access to cardiac rehabilitation, which is particularly beneficial in this context .
All of these epidemiological aspects underline the frequent co-occurrence of depression and heart disease and clinicians should investigate the presence of depression in patients with heart disease.
Depression in CHD patients: specific clinical aspects
The diagnosis of an episode of characterized depression in the context of CHD remains a complex question, requiring a specific approach from the clinician, who often focuses on the somatic environment and does not spontaneously consider a psychiatric approach. Given the sometimes sudden onset of a cardiovascular event, the normal psychological reaction to disease requires the patient to adapt, which leads to a certain physiological depression in mood, the time to come to terms with the possible loss related to the disease and the sometimes very much changed future prospects for life. Usually, the potential problems due to adaptation should resolve in a few weeks with no amplification of thymic phenomena. In certain cases, patients fail to recover their normal mood to such a degree that authentic depression progressively develops. The diagnosis will be relatively easy if this state of characterized depression takes on a classical clinical presentation, combining over several weeks the three key elements of sadness, ideomotor slowing and somatic signs (modification in sleep and appetite, the existence of various functional disorders). Nonetheless, the clinical picture is often incomplete: first of all, the patient is particularly preoccupied by the somatic aspects of the heart condition and cannot think about a psychic problem that he was probably unaware of; and then the symptoms of depression develop insidiously, in an almost masked form, essentially appearing as extreme fatigue, which makes it difficult to return to the previous state . It therefore seems important to adopt a dimensional analysis of the depression by seeking the circadian component, with increased sadness in the morning, the absence of vitality or simply asthenia, accompanied by a substantial improvement in these symptoms at the end of the day. Indeed, these semiological circadian variations may be the only signs that suggest a diagnosis of depression. In the same way, particular attention should be paid to sleep with regard to both quality and quantity, as depression is almost systematically accompanied by sleep disorders: insomnia in 80% of cases and hypersomnia more rarely. Although depression is sometimes difficult to identify, cardiologists and general practitioners must be encouraged to seek expert advice in cases of doubt about the diagnosis. Clinicians must really bear in mind the potential severity of this co-morbid association, as it very seriously worsens the prognosis in terms of suicide. A recent study showed that women in particular showed a significantly greater risk of suicide in depression associated with coronary artery disease . In order to optimize screening for affective disorders, certain cardiology or cardiac rehabilitation units routinely use standard self-questionnaires, such as the Hospital Anxiety and Depression scale , which give an overall idea of the severity of the anxiodepressive episodes sometimes found in patients with heart disease; obviously, these questionnaires do not replace the clinical interview and are not standardized automatic providers of psychiatric diagnoses but they do reveal certain emotional disorders and may confirm a clinical impression or simply facilitate discussions between the doctor and the patient on this very sensitive issue of depression in the wake of a cardiac event. As the epidemiological and clinical reality of depression during a cardiac event is now accepted, the nature of the aetiological links between depression and CHD needs to be considered from a psychological, behavioural and even biological point of view.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
