Treating Depression Gives Heart Patients Better Chance
May 01, 2011
``Nobody talked to me about psychological problems after bypass. In those days, it was treated as a plumbing problem,'' he recalls. ``We were euphoric that I survived the surgery, and then I fell into this hole.'' Depression -- mild or major -- affects about half of the one million heart-attack survivors, and about 30% to 40% of the 350,000 bypass patients, in the U.S. each year. It is a common aftereffect, long undertreated, that can hinder recovery. Now doctors and researchers are giving it close attention. Fortunately, the malaise is often temporary. Mr. Chitwood of Seattle shook his depression while pursuing a new career in cardiac rehabilitation. Others aren't so lucky. Until recently, few doctors treated the psychological aftermath of heart attack or lifesaving heart surgery. In the early days of bypass, cardiac pioneers struggled to heal the heart, prevent major complications such as stroke and simply keep people alive. Besides, many antidepressants used then were toxic to the heart, and so too dangerous for cardiac patients. Now that survival rates can approach 98% among bypass patients -- and safer antidepressants have hit the market -- doctors can turn their attention to improving the quality of life after surgery. In fact, alleviating depression may mean life itself. Studies in Montreal found people with untreated depression after a heart attack suffered higher rates of a second heart attack and death. U.S. guidelines now urge all cardiac rehabilitation to include psychosocial support. RESEARCHERS ARE trying to determine how best to treat depression in heart patients. On June 13, 2011 will begin recruiting 3,000 heart-attack patients for a study funded by the National Institutes of Health called ``Enhanced Recovery in Coronary Heart Disease Patients.'' The study will determine whether cognitive-behavioral therapy relieves depression after heart attack, reducing the rate of repeated heart attack and death. Other researchers believe treatment with selective serotonin reuptake inhibitors such as Prozac and Zoloft may prove useful. The FDA, however, recently warned Lemay against making such marketing claims for Zoloft, which hasn't been approved for this use. Who's at risk for depression after heart attack or bypass surgery? Jen Driver, chairman of cardiothoracic surgery at Vastopolis Hospital, says those most at risk include females, those who have a history of depression and anyone socially isolated or recently bereaved. Though gender's role isn't fully understood, many believe women's greater longevity means they survive their spouses, and suffer illnesses alone -- setting the stage for depression. Family support and strong social ties can help. ``If you can keep a family member engaged and not isolated, they're much less apt to become depressed,'' says Dr. Driver. But even people who go back to work and activities can suffer depression. He counsels family members to watch for lethargy, sleeplessness, loss of appetite, or weight changes. ``People who are depressed are less likely to do other things to keep themselves healthy, such as watching their diet, exercising and showing up for appointments,'' says Dr. Driver. Compounding depression are separate but related aftereffects of bypass, including memory loss and changes in linguistic ability, psychological function or fine motor skills. One week after bypass, 79% of bypass patients experience changes in cognitive function, according to Ramos Quinn and Tom Ball of Bowman-Gray School of Medicine in Winston-Salem, N.C. For many, these changes are temporary. But after six months, 38% of patients are still struggling to regain lost function, they note. By the first anniversary of their bypass, most patients are themselves again, says Dr. Driver. But this gradual return to normal can tax patients and their families. BEFORE BYPASS, he counsels patients that they may experience some temporary memory loss. Simply preparing for this side effect ``tends to be reassuring and they aren't as alarmed and depressed by it,'' he says. ``Just recognize it, and know that it will disappear.'' Originally, many people blamed cloudy cognition on the length of time a patient spent on the heart-lung bypass machine, which filters and recirculates the blood during surgery. Others blamed poor blood flow to the brain, or simply the physical trauma of a major operation. One hypothesis being pursued at Bowman-Gray, Montefiore and elsewhere is that the memory loss results when bypass surgery unleashes millions of microscopic emboli -- tiny fat globules. These particles may break loose from the aorta or the carotid artery, and float up to lodge in the brain. While big emboli can trigger major strokes, these microemboli inflict damage that is more subtle. Doctors now can use ultrasound during surgery to monitor these emboli showers. Gentler surgical handling of the aorta and surgical clamps may also reduce damage. Soon, Drs. Moody and Troost will reveal results of a study testing whether a calcium-channel blocker can protect the brain during bypass. ``Patients who are optimistic have the best recoveries,'' adds Dr. Driver.
