Depression, Anxiety a Deadly Combination for Older
People with Heart
Two new studies look at anxiety and depression among
older heart disease patients and find these patients need closer monitoring
20, 2013 — Heart disease patients who have
anxiety have twice the risk
of dying from any cause compared to those without anxiety. It they
suffer both anxiety and depression they have a triple risk of dying.
Then, a second study finds heart failure patients with moderate or
severe depression have four times the risk of dying.
The study of anxiety and depression among older heart
disease patients was released in the Journal of the American Heart
Association. The new research on depression and heart failure
patients with an average age of 72 is reported in Circulation: Heart Failure, an American
Heart Association Journal.
Study 1: Increased
monitoring needed for heart patients with anxiety and depression
“Many studies have linked depression to an
increased risk of death in heart disease patients,” said Lana Watkins,
Ph.D., lead author of the study and an associate professor in Psychiatry
and Behavioral Sciences at Duke University Medical Center in Durham,
N.C. “However, anxiety hasn’t received as much attention.”
Studies show that depression is about three times
more common in heart attack patients. The American Heart Association
recommends that heart patients be screened for depression and treated if
Depressed heart disease patients often also have
anxiety, suggesting it may underlie the risk previously attributed
solely to depression, Watkins said. “It’s now time for anxiety to be
considered as important as depression, and for it to be examined
In the study, 934 heart disease patients, average
age 62, completed a questionnaire measuring their level of anxiety and
depression immediately before or after a cardiac catheterization
procedure at Duke University Medical Center. Patients had anxiety if
they scored 8 or higher on a scale composed of seven common
characteristics of anxiety, with each item rated from 0 to 3 (range of
possible scores: 0-21). Depression was measured using a similar scale
composed of seven symptoms of depression.
Researchers, after accounting for age, congestive
heart failure, kidney disease and other factors that affect death risk,
• 90 of the 934 patients experienced anxiety only, • 65 experienced depression only and • 99 suffered anxiety and depression.
Among 133 patients who died during three years of
follow-up, 55 had anxiety, depression or both. The majority of deaths
(93 of 133) were heart-related.
Researchers measured anxiety and depression during
cardiac catheterization because levels better reflected how patients
normally handle stressful situations.
Anxiety and depression each influence risk of death
in unique ways. Anxiety, for example, increases activity of the
sympathetic (adrenaline-producing) nervous system that controls blood
“People who worry a lot are more likely to have
difficulty sleeping and to develop high blood pressure,” Watkins said.
The link between depression and mortality is more
related to behavioral risk factors, she said. “Depression results in
lack of adherence to medical advice and treatments, along with behaviors
like smoking and being sedentary.”
Future studies should test strategies to manage
anxiety alone and with depression in heart disease patients, Watkins
“Anxiety reducing medications combined with stress
management could improve outcome for patients with just anxiety, whereas
patients with anxiety and depression may need a stronger intervention
involving more frequent outpatient monitoring and incentives to improve
adherence,” she said.
Co-authors are: Gary G. Koch, Ph.D.; Andrew
Sherwood, Ph.D.; James A. Blumenthal, Ph.D.; Jonathan R.T. Davidson,
M.D.; Christopher O’Connor, M.D.; and Michael H. Sketch Jr., M.D. Author
disclosures are on the manuscript.
The National Institutes of Health funded the study.
Study 2: Heart failure
patients with depression have four times risk of death
March 19, 2013 —
Heart failure patients who
are moderately or severely depressed have four times the risk of dying
and double the risk of having to go to the emergency room or be
hospitalized compared to those who are not depressed, according to new
research reported in Circulation: Heart Failure, an American Heart
“Depression is a key driver of healthcare use in
heart failure,” said Alanna M. Chamberlain, Ph.D., M.P.H., the study’s
lead author and assistant professor of epidemiology in the Department of
Health Sciences Research at the Mayo Clinic in Rochester, Minn.
“Treatment programs should be tailored to each patient’s needs with
greater emphasis on managing depression either through medication or
In 2007-10, 402 heart failure patients (58 percent
male, average age 73) in three Minnesota counties completed a
nine-question survey. Based on the answers, 59 percent of patients were
classified as having no depression, 26 percent had mild depression and
15 percent had moderate-to-severe depression. Researchers gathered
information on the participants for about a year and a half.
Even those who reported mild depression had almost
a 60 percent increased risk of death, but a much smaller increased risk
of emergency room visits (35 percent) and hospitalizations (16 percent),
Because the patients studied were mostly white and
lived in southeastern Minnesota, the results may not apply to all heart
failure patients throughout the United States, researchers said only a
third of the patients with moderate-to-severe depression were taking
antidepressant medication. Depression may be under-diagnosed in these
patients; however, some may have been undergoing therapy that didn’t
include prescription drugs, researchers said.
“We measured depression with a one-time
questionnaire so we cannot account for changes in depression symptoms
over time,” Chamberlain said. “Further research is warranted to develop
more effective clinical approaches for management of depression in heart
Co-authors are: Amanda R. Moraska, B.A.; Nilay D.
Shah, Ph.D.; Kristin S. Vickers, Ph.D.; Teresa A. Rummans, M.D.; Shannon
M. Dunlay, M.D., M.Sc.; John A. Spertus, M.D., M.P.H; Susan A. Weston,
M.S.; Sheila M. McNallan, M.P.H.; Margaret M. Redfield, M.D.; and
Veronique L. Roger, M.D., M.P.H. Author disclosures are on the
The National Heart, Lung, and Blood Institute and
the National Institute on Aging funded the study.