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    Feature Article
    Depression Can Contribute To Heart Disease

    Clara Lauderback hasn't had a heart attack since she started taking antidepressant medication nearly three years ago. That is more impressive than it might sound, because she had five heart attacks before then and nearly died twice.

    One time she had ``that feeling that people talk about, of going down a tunnel and seeing a bright light.'' Another time the nurse at the hospital was surprised to see her still alive the next day.

    After all that, Lauderback says, ``I feel more confident about myself and have more energy now.''

    She can't say for sure that the antidepressant is the difference, of course. But she does know that when she tried to wean herself off of it without telling her doctor, ``I was not feeling good. Kind of lethargic, and that type of thing. So I went back to the Zoloft, and I guess that's what keeps me going.''

    Medical researchers have associated heart attacks and clinical depression for some time, usually in that sequence. Who wouldn't be depressed after a heart attack? Life-threatening crises frequently lead to depression, in both the conversational and the clinical sense of the word.

    But it's becoming apparent now that depression is not just a consequence of serious heart disease. It also appears to be a contributor. One study found depression to be a more reliable predictor of coronary heart disease - generally meaning a heart attack or the severe chest pains of angina pectoris - than a Type A personality.

    Depression can be deadly, then, even when it doesn't lead to suicide, says Dayton clinical psychologist Judith Schwartzman. ``Depression does not just affect the brain and emotions. It's also something that definitely affects the body.''

    Treatment for depression should at least include education about the increased risk of coronary heart disease, Schwartzman wrote in her journal article on depression and heart disease in women. She evaluated more than 10 years of research on the subject for the February Professional Psychology: Research and Practice with Kathleen Glaus, a psychologist, professor and associate dean in the School of Professional Psychology at Wright State University.

    Depression correlates with a greater rate of coronary heart disease, they found, and when it surfaces after the heart disease, those patients are sicker and more likely to die.

    Two 1996 studies indicated that as depression symptoms emerge and increase, so does the likelihood of coronary heart disease. Everything else being equal, one study showed that people with some depression symptoms were twice as likely to suffer nonfatal heart attacks as those with no symptoms, and people diagnosed with major depression were 4.5 times as likely.

    After a person suffers a heart attack or angina, another study indicated depression is a better predictor of a patient's prognosis than any other known risk factor for heart disease. Research in the June 26 Archives of Internal Medicine showed that heart attack patients with major depression are eight times more likely to die within a year and a half than those with mild to moderate depression symptoms.

    ``I think a lot of people don't fight as hard to get well when they have depression,'' Lauderback says. ``It takes all the initiative out of you to help yourself, and you don't even realize it.''

    Although the connection applies to men, too, Schwartzman and Glaus focused on women for three reasons. They have twice the rate of depression as men. The public and even doctors tend to underestimate their likelihood of heart disease, which includes worse recovery rates than men from heart attacks. And most research on heart disease has concentrated on men.

    Several researchers suspect heart disease and depression have common origins, Schwartzman says. It's clear they share a number of common symptoms.

    ``You get some mood changes with heart disease,'' she says. People also often experience something called ``vital exhaustion,'' which essentially means they're worn out, shortly before heart disease surfaces.

    ``But is it a symptom of early heart disease or of depression? It could be either.''

    People with depression metabolize sugar differently, Schwartzman says, putting them at higher risk for diabetes, which in turn is a risk factor for heart disease. They also have higher levels of cortisol, a hormone that can lead to osteoporosis by leeching calcium from the bones.

    ``We also know that there are actually changes in brain structures from depression because of the hormones that are associated with it,'' she says. ``Depression can be thought of as an extreme and prolonged response to stress, any many of the physiological changes that happen when you're in fight-or-flight mode also happen when you're depressed.''

    Depression also tends to breed behavioral changes that aren't kind to a person's heart. Men in particular are apt to medicate themselves subconsciously by drinking, smoking or using other drugs.

    Poor appetite is a depression symptom, so Schwartzman says, ``They don't eat as well.'' The depression symptoms of fatigue and general disinterest make people more sedentary.

    ``And all of these things are risk factors for heart disease, too,'' Schwartzman says.

    Lauderback was in her early 60s when she had her first heart attack in 1979. She went the next day to her regular doctor, who told her to go home and go to bed but didn't argue when she said that was not possible, what with her marketing research job and an ailing husband.

    ``That first doctor was so casual about it,'' Lauderback says. ``It was like, 'You cut yourself pretty bad. You better go home and put a bandage on it.'''

    Lauderback always had trouble sleeping, which is a common symptom of depression, but the subject didn't come up with a doctor after that first heart attack or the next three. She had switched to Dr. Julie Lucente for primary care by the time her usual pep and enthusiasm didn't return after her fifth heart attack three years ago.

    ``Untreated depression can add to your emotional distress, and that can be one of the factors in having a heart attack,'' Lucente says, ``especially in someone who's really active like she is.''

    More doctors need to make that connection, Schwartzman says. Heart specialists and primary-care doctors should watch more carefully for signs of depression in heart patients and step in to treat them.

    Beyond that, she says, mental-health specialists, physicians and even family members need to look for heart-disease symptoms in people with depression. ``Talk to your mom about her diet. Keep her active,'' Schwartzman says.

    Doctors have ``a long history'' of blaming women's physical complaints on their emotions, she says. Even in a patient with depression, they shouldn't assume dizziness or fatigue just means the depression is acting up. ``Those things also can signal heart disease, particularly in women.''

    From Lauderback's perspective, men don't necessarily have any easier time getting their doctors to treat them for depression. She says her husband was constantly depressed, attempted suicide three times and never was diagnosed with clinical depression.

    ``I don't think doctors have been trained to even pay attention to it,'' she says. ``They tell you, 'It's all in your head.' Well, of course it's all in your head.''

    A stroke is all in the patient's head, too. So is Parkinson's disease, and multiple sclerosis. They're brain diseases just like depression, Lauderback says. ``But when doctors say 'It's all in your head,' they mean that you're making it up.''

    Don't they read the papers? she wonders. Lauderback has seen plenty of articles about depression without reading medical journals.

    ``It should be one of the first things doctors address,'' she says. ``Then they've got to urge the person to try another medicine if the first one didn't help. I hope they're teaching this to younger doctors.''

    After all, she says, who else but doctors are going to help people understand that depression is no reason to be embarrassed?

    ``It's like not being able to hear or see,'' she says. ``It's a disease. It needs to be treated like anything else.''



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