Indian Journal of PsychiatryIndian Journal of Psychiatry
Home | About us | Current Issue | Archives | Ahead of Print | Submission | Instructions | Subscribe | Advertise | Contact | Login 
    Users online: 2557 Small font sizeDefault font sizeIncrease font size Print this article Email this article Bookmark this page


    Advanced search

    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  

    Depression in Pa...
    Impact of Depres...
    Depression and t...
    Depression and C...
    Depression and I...
   Other Mechanisms
    Treatment of Dep...

 Article Access Statistics
    PDF Downloaded248    
    Comments [Add]    

Recommend this journal


 Table of Contents    
Year : 2011  |  Volume : 53  |  Issue : 3  |  Page : 192-194
"Blues" ain't good for the heart

Department of Psychiatry, St. John's Medical College and St. John's Research Institute, Bangalore, Karnataka, India

Click here for correspondence address and email

Date of Web Publication29-Oct-2011

How to cite this article:
Srinivasan K. "Blues" ain't good for the heart. Indian J Psychiatry 2011;53:192-4

How to cite this URL:
Srinivasan K. "Blues" ain't good for the heart. Indian J Psychiatry [serial online] 2011 [cited 2022 Dec 4];53:192-4. Available from:

Research in recent decades suggests that depression and coronary heart disease (CHD) have a bidirectional relationship. Depression, independent of other risk factors in an otherwise healthy person, doubles the risk of developing CHD. [1] Depression is seen in about 20% of the patients hospitalized with acute coronary syndromes either at admission or in the immediate period following recovery from CHD. [2]

   Depression in Patients with Coronary Heart Disease Top

Cross-sectional studies have reported that between 19 and 66% of the patients with myocardial infarction (MI) have depressive and anxiety symptoms, [3],[4] and a significant proportion of these patients (17-44%) are diagnosed with major depression. [5],[6],[7] In addition, major depression is also common following coronary bypass surgery [8] and in patients with unstable angina. [9] Thus, these studies suggest that the prevalence rate of depression among patients with CHD is far greater than the 12-month prevalence rate of 6.6% reported in the community. [10]

   Impact of Depression on Pre-Existing Coronary Heart Disease Top

Over the last two decades, evidence has accumulated for the adverse impact of depression in patients with CHD. In one of the earliest studies in this area, Frasure Smith et al.[11] in their study of depression and coronary heart disease in 222 patients post MI, those diagnosed with major depression on a modified version of the Diagnostic Interview Schedule had an adjusted hazard ratio of 3.44 (95% CI 2.25-4.63) for mortality over 6 months of follow-up compared with the controls. This was approximately equivalent to the risk engendered by clinical factors such as diminished left ventricular function and past history of MI. In a subsequent study, the same group of investigators followed-up this cohort over 18 months. [12] Although baseline depression still predicted mortality at 18 months, its impact mainly occurred in the first 6 months. Similar findings of high mortality in subjects with unstable angina and comorbid depression have been reported. [9] In addition, depression also has a negative impact on survival rates following coronary artery bypass graft (CABG). Two studies reported that the presence of depression at baseline prior to CABG was an independent predictor of cardiovascular mortality post-CABG. [13],[14] There is also a dose-response relationship between depression and death due to adverse cardiac events, [15] with increased baseline depression scores being associated with a higher risk of cardiac mortality. [16]

   Depression and the Risk of Development of Coronary Heart Disease Top

Several prospective studies have reported depression as a risk factor for the development of CHD, and this risk is independent of other cardiovascular risk factors. In a large prospective community-based study, patients with a history of dysphoria or depression had 4.5-times relative risk (RR) of having an acute MI compared with non-depressed subjects independent of other cardiovascular risk factors. [17] It was also noted in this study that the risk of developing CHD was linked to the severity of depression, with an RR of 4.5 for developing CHD in subjects with major depression as opposed to 2.1 for subjects with dysphoria. A metaanalysis of studies in this area reported an RR of 1.64 for the development of CHD in subjects with depression. [1]

   Pathophysiological Link between Depression and Coronary Heart Disease Top

Depression and lifestyle behavior

There exist several possible mechanisms that underlie the relationship between depression and CHD. Depression is associated with unhealthy lifestyle; depressed patients have a sedentary lifestyle, more likely to smoke and consume alcohol and are overweight/obese. [18],[19],[20] Depression is also associated with non-compliance to medical treatment. In a metaanalysis, DiMatteo et al.[21] reported that depression is linked to non-adherence to treatment recommendations, with an OR of 3.03 (95% CI 1.964-4.89); non-compliant patients are almost three-times more likely to die in the first year of follow-up post-MI compared with those considered compliant. [22] Similarly, depressed patients are less likely to participate in cardiac rehabilitation such as adopting an exercise program. [23] Exercise also has a positive impact on depression [24] and CHD.

   Depression and Cardiac Autonomic Regulation Top

Patients with depression are known to have decreased heart rate variability (HRV). [25],[26] HRV (beat-to-beat alterations in heart rate) is a dynamic measure of cardiac autonomic regulation. In one of the earliest studies, Kleiger et al.[27] showed that decreased HRV was independently associated with an increased risk for mortality in post-MI patients. Numerous studies have since confirmed this association between decreased HRV, especially the vagal component and mortality, in high-risk populations as well as those living in the community. Low-HRV has been observed in patients with depression and in depressed patients with CHD compared with non-depressed subjects. [28],[29],[30] In addition, many medications used in the treatment of depression adversely impact HRV. [31],[32]

   Depression and Inflammatory Processes Top

Pro-inflammatory cytokines such as tissue necrosis factor (TNF), interleukin-1 (IL-1) and IL-6 have been implicated in the etiopathogenesis of CHD. [33] Elevated levels of pro-inflammatory markers have also been reported in patients with major depression, [34] raising the possibility that inflammatory processes may be involved in both the onset of depression and CHD.

   Other Mechanisms Top

A variety of other mechanisms have been proposed that underlie the association between depression and risk of CHD. These include elevated endothelin levels in patients with depression, which has been linked to a higher risk of plaque rupture, [35] a greater risk of diabetes and insulin resistance in depression, [36],[37] elevated platelet reactivity [38] and altered coronary reserve flow impacting microvascular circulation in depression. [39]

   Treatment of Depression in Patients with Coronary Heart Disease Top

While treatment of depression in patients with CHD offers the potential of improving quality of life and cardiac outcomes, only few studies have empirically studied the efficacy of treatment of depression in patients with CHD. The SADHART study examined the safety and efficacy of sertraline in patients with major depressive disorder and a recent MI or unstable angina. [40] The findings showed a modest decrease in depressive symptoms in patients with sertraline versus placebo, but the study lacked statistical power to examine the impact of treatment of depression on clinical end points. In another study, ENRICHD investigators examined the impact of psychosocial intervention on outcomes in patients with depression and CHD. [41] Results from this randomized trial using cognitive behavior therapy in post-MI patients with depression showed that there was a small decrease in the depressive symptoms but no clear effect on survival. In a more recent randomized trial of antidepressants (Citalopram) and interpersonal therapy (IPT) compared with routine clinical management in 284 patients with major depressive disorder (MDD) and CHD, there was no significant difference between IPT and clinical management; however, citalopram was superior to placebo in reducing the hamilton depression rating scale (HAM-D) scores and demonstrated better remission rates (35.9% vs 22.5%). [42] However, this study did not examine the effects of treatment of depression on cardiac clinical outcomes. A recent randomized trial incorporating the concept of enhanced depressive care for patients with persistent depression in 237 post-acute coronary syndrome patients showed a significant reduction in depressive symptoms and modest improvement in cardiac prognosis. [43]

There is robust evidence for an association between depression and CHD from both epidemiological and clinical studies. In addition, depression confers a poor outcome in patients with a recent MI and in patients with unstable angina. While the pathophysiological basis for this link still remains uncertain, various studies in the recent decade have suggested several possible mechanisms. Treatment studies indicate safety of antidepressants such as sertraline and citalopram in the treatment of depression in patients with CHD, but more studies are needed to demonstrate the impact of treatment of depression on hard cardiac clinical end points. There is preliminary indication from efficacy studies that medication is perhaps more effective than psychosocial interventions, and is in line with recent observations that somatic symptoms but not cognitive symptoms of depression are associated with an increased risk of 12-month all-cause mortality. [44] A recent randomized study that is examining the effects of exercise and antidepressant therapy on depression and cardiac outcomes (UPBEAT trial) has the potential to open new avenues for treatment intervention. [45] More comprehensive studies are also needed to understand the interactions between depression and other risk factors for CHD that will enable development of more focused intervention.

   References Top

1.Wulsin LR, Singal BM. Do depressive symptoms increase the risk for the onset of coronary disease? A systematic quantitative review. Psychosom Med 2003;65: 201-10.  Back to cited text no. 1
2.Bigger JT, Glassman AH. The American heart association science advisory on depression and coronary heart disease. An exploration of the issues raised. Cleve Clin J Med 2010;77 Suppl 3:S12-9.  Back to cited text no. 2
3.Forrester AW, Lipsey JR, Teitelbaum ML, DePaulo JR, Andrzejewski PL. Depression following MI. Int Psychiatry Med 1992;22:33-46.  Back to cited text no. 3
4.Schleifer SJ, Macai-Hinson MM, Coyle DA, Slater WR, Kahn M, Gorlin R, et al. The nature and course of depression following MI. Arch Inter Med 1989;149:1785-9.  Back to cited text no. 4
5.Freedland KE, Carney RM, Lustman PJ, Rich MW, Jaffe AS. Major depression in coronary artery disease patients with Vs. without a prior history of depression. Psychosom Med 1992;4:416-21.  Back to cited text no. 5
6.Carney RM, Rich MW, Tevelde MA, Saini J, Clark K, Jaffe AS. Major depressive disorder in coronary artery disease. Am J Cardiol 1987;60:1273-5.  Back to cited text no. 6
7.Hance M, Carney RM, Freedland KE, Skala J. Depression in patients with coronary artery disease. A 12 month follow up. Gen Hosp Psychiatry 1996;18:61-5.  Back to cited text no. 7
8.McKhann GM, Borowicz LM, Goldsborough MA, Enger C, Selnes OA. Depression and cognitive decline after coronary artery bypass grafting. Lancet 1997;349:1282-4.  Back to cited text no. 8
9.Lesperance F, Frasure-Smith N, Juneau M, Theroux P. Depression and 1-year prognosis in unstable angina. Arch Intern Med 2000;160:1354-60.  Back to cited text no. 9
10. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-105.  Back to cited text no. 10
11.Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993;270:1819-25.  Back to cited text no. 11
12.Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-months prognosis after myocardial infarction. Circulation 1995;91:999-1005.  Back to cited text no. 12
13.Blumenthal JA, Lett HS, Babyak MA, White W, Smith PK, Mark DB,et al. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet 2003;362:604-9.  Back to cited text no. 13
14.Burg MM, Benedetto MC, Soufer R. Depressive symptoms and mortality two years after coronary artery bypass graft surgery (CABG) in men. Psychosom Med 2003;65:508-10.  Back to cited text no. 14
15.McConnell S, Jacka FN, Williams J, Dodd S, Berk M. The relationship between depression and cardiovascular disease. Int J Psychiatry Clin Pract 2005;9:157-67.   Back to cited text no. 15
16.Barefoot JC, Helms MJ, Mark DB, Blumenthal JA, Claiff RM, Haney TL,et al. Depression and long-term mortality risk in patients with coronary artery disease. Am J Cardiol 1996;78:613-7.   Back to cited text no. 16
17.Pratt LA, Ford DE, Crum RM, Armenian HK, Gallo JJ, Eaton WW. Depression, psychotropic medication, and risk of myocardial infarction: prospective data from the Baltimore ECA follow up. Circulation 1996;94:3123-9.  Back to cited text no. 17
18.Bonnet F, Irving K, Terra JL, Nony P, Berthezene F, Moulin P. Anxiety and depression are associated with unhealthy life style in patients at risk of cardiovascular diseases. Atherosclerosis 2005;178:339-44.  Back to cited text no. 18
19.Glassman AH, Helzer JE, Covey LS, Cottler LB, Stetner F, Tipp JE, et al. Smoking, smoking cessation and major depression. JAMA 1990;264:1546-9.  Back to cited text no. 19
20.Greenberg I, Perna F, Kaplan M, Sullivan MA. Behavioral and psychological factors in the assessment and treatment of obese surgery patients. Obes Res 2005;13:244-9.  Back to cited text no. 20
21.DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for non-compliance with medical treatment: Meta analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160:2101-7.   Back to cited text no. 21
22.Gallagher EJ, Viscoli CM, Horwitz RI. The relationship of treatment adherence to the risk of death after myocardial infarction in women. JAMA 1993;270:742-4.  Back to cited text no. 22
23.Guiry E, Conroy RM, Hickey N, Mulcahy R. Psychological response to an acute coronary event and its effect on subsequent rehabilitation and lifestyle change. Clin Cardiol 1987;10:256-60.  Back to cited text no. 23
24.Craft LL, Landers DM. The effects of exercise on clinical depression and depression resulting from mental illness: A meta-regression analysis. J Sport Exerc Psychol 1998;20:339-57.  Back to cited text no. 24
25.Carney RM, Saunders RD, Freedland KE, Stein P, Rich MW, Jaffe AS. Association of depression with reduced heart rate variability in coronary artery disease. Am J Cardiol 1995;76:562-4.  Back to cited text no. 25
26.Yeragani VK, Rao KA, Smitha MR, Pohl RB, Balon R, Srinivasan K. Diminished chaos of heart rate time series in patients with major depression. Biol Psychiatry 2002;51:733-44.  Back to cited text no. 26
27.Kleiger RE, Miller JP, Bigger JT Jr, Moss AJ. Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. Am J Cardiol 1987;59:256-62.  Back to cited text no. 27
28.Udupa K, Satyaprabha TN, Thirthalli J, Kishore KR, Lavekar GS, Raju TR, et al . Alteration of cardiac autonomic functions in patients with major depression. A study using heart rate variability measures. J Affect Disord 2007;100:137-41.  Back to cited text no. 28
29.Rechlin J, Weis M, Spitzer A, Kaschka WP. Are affective disorders associated with alterations of heart rate variability. J Affect Disord 1994;32:271-5.  Back to cited text no. 29
30.Carney RM, Blumenthal JA, Freeedland KE, Stein PK, Howells WB, Berkman LF, et al. Low heart rate variability and the effect of depression on post myocardial infarction mortality. Arch Intern Med 2005;65:1481-91.  Back to cited text no. 30
31.Yeragani VK, Pohl R, Jampala VC, Balon R, Ramesh C, Srinivasan K. Effects of nortryptiline and paroxetine on QT variability in patients with panic disorder. Depress Anxiety 2000;11:126-30.  Back to cited text no. 31
32.Srinivasan K, Ashok MV, Vaz M, Yeragani VK. Effect of imipramine on linear and nonlinear measures of heart rate variability in children. Pediatr Cardiol 2004;25:20-5.  Back to cited text no. 32
33.Kop WJ, Gottdiener JS. The role of immune system parameters in the relationship between depression and coronary artery disease. Psychosom Med 2005;67 Suppl 1:S37-41.  Back to cited text no. 33
34.Danner M, Kasl SV, Abramson JL, Vaccarino V. Association between depression and elevated C-reactive protein. Psychosom Med 2003;65:347-56.  Back to cited text no. 34
35.Burg MM, Martens EJ, Collins D, Soufer R. Depression predicts elevated endothelin-1 in patients with coronary artery disease. Psychosom Med 2011;73:2-6.  Back to cited text no. 35
36.Anderson RJ, Freedland KE, Clouse RE, Lustman RJ. The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care 2001;24:1069-78.  Back to cited text no. 36
37.Thakore JH, Richards PJ, Reznek RH, Martin A, Dinan TG. Increased intra-abdominal fat deposition in patients with major depressive illness as measured by computed tomography. Biol Psychiatry 1997;41:1140-2.  Back to cited text no. 37
38.Musselman DL, Tomer A, Manatunga AK, Knight BJ, Porter MR, Kasey S, et al. Exaggerated platelet reactivity in major depression. Am J Psychiatry 1996;153:1313-7.  Back to cited text no. 38
39.Vaccarino V, Votaw J, Faber T, Veleder E, Murrah NV, Jones LR, et al. Major depression and coronary flow reserve detected by positron emission tomography. Arch Intern Med 2009;16:1668-76.  Back to cited text no. 39
40.Glassman AH, O'Connor CM, Califf RM, Swedberg K, Schwartz P, Bigger JT Jr, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002;288:701-9.  Back to cited text no. 40
41.Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The enhancing recovery in coronary heart disease patients (ENRICHD) randomized trial. JAMA 2003;289:3106-16.  Back to cited text no. 41
42.Lesperance F, Frasure-Smith N, Koszcyki D, Laliberte MA, van Zyl LT, Baker B, et al. Effects of citalopram and interpersonal therapy on depression in patients with coronary artery disease: The Canadian Cardiac Randomized evaluation of antidepressant and psychotherapy efficacy (CREATE) trial. JAMA 2007;297:367-79.  Back to cited text no. 42
43.Davidson KM, Rieckmann N, Clemow L, Schwartz JE, Shimbo P, Medina V, et al. Enhanced depression care for patients with acute coronary syndrome and persistent depressive symptoms: Coronary psychosocial evaluation studies randomized controlled trial. Arch Intern Med 2010;170:600-8.  Back to cited text no. 43
44.Roest AM, Thombs BD, Grace SL, Stewart DE, Abbey SE, de Jonge P. Somatic /affective symptoms, but not cognitive / affective symptoms of depression after acute coronary syndome are associated with 12-month all-cause mortality. J Affect Disord 2011;131-158-63.  Back to cited text no. 44
45.Blumenthal JA, Sherwood A, Rogers SD, Babyak MA, Doraiswamy PM, Watkins L, et al. Understanding prognostic benefits of exercise and antidepressant therapy for persons with depression and heart disease: The UPBEAT study-rationale, design and methodological issues. Clin Trials 2007;4:548-59.  Back to cited text no. 45

Correspondence Address:
Krishnamachari Srinivasan
Department of Psychiatry, St. John's Medical College and St. John's Research Institute, Bangalore - 560 034, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5545.86797

Rights and Permissions