Hearts and minds. (Justin Renteria / For The…)
The melancholy mind and the broken heart: For poets and philosophers through the ages, the two have been fellow travelers, chicken and egg, bookends in a long litany of tragedies.
Leave it to medical researchers, then, to put the dark bond between heart and mind under a microscope — and find even deeper mysteries.
Nearly 25 years of research has drawn a clear connecting line between depression and heart disease, making the link Exhibit A in the modern compendium of mind-body connections.
But that research has yet to explain the connection. And it has yet to convince many cardiologists that depression care could be a tool in preventing and treating heart disease.
"That you can die of a broken heart isn't a new idea. But unfortunately, the idea is much more complex than any of us expected," says Dr. Alexander Glassman, a psychiatrist with the New York Psychiatric Institute.
Complex, yes. But the bond between heart disease and depression is also undeniable.
People who have had episodes of depression are roughly twice as likely as those with no such history to develop cardiovascular disease in their lifetimes — making depression a more powerful predictor of heart disease than high blood pressure, elevated cholesterol readings, a history of smoking or diabetes.
After a heart attack, surgery to clear blocked arteries or a diagnosis of heart failure, a person is three to four times more likely than a healthy peer to show signs of clinical depression. Those who show depressive symptoms in the weeks and months following a heart attack or an artery-clearing procedure are two to three times more likely than those who don't to die or have another cardiovascular "event" within a year. The more severe a patient's depression, the worse the prognosis.
The link is not lost on many seasoned cardiologists. Dr. Marc Penn of the Cleveland Clinic's Bakken Heart-Brain Institute says it's hard not to be pessimistic when he sees a patient with clear signs of depression. In such cases, it's a cardiologist's ethical obligation to ensure that a patient gets treated for depression, he adds — even though there's no proof that such treatment will improve the outcome of his heart disease.
That lack of proof is only one of the puzzles. Many central questions remain: Which affliction comes first, and does one cause the other? Or do the two spring from some common source?
Could early depression treatment head off development of heart disease in the first place — or could better management of cardiac risks prevent depression?
And why, when the connection between the two seems so clear, would anyone tend to the heart and not the mind?
For busy cardiologists, these uncertainties pose a dilemma. In 2008, the American Heart Assn. called for routine depression screening of heart patients. Three years on, many remain wary of the value of doing so.
"When the rubber hits the road in cardiology clinics, routine screening [for depression] is hard," says Dr. Jeffery Huffman, a Harvard University psychiatrist and researcher who consults with heart patients admitted to Massachusetts General Hospital. The questions eat up time, he says — and then, if a patient says he or she is depressed, what next? Few heart specialists have developed close working relationships with mental health professionals, Huffman says, and patients — already overwhelmed with their heart troubles — are often resistant to going.
The hurdles are both medical and cultural.
Treating an ailing heart is no medical walk in the park, but treating depression is a thicket of murk and uncertainty by comparison. The well-charted sinews, electrical currents and hydraulic dynamics of the heart lend themselves to clean diagnoses, straightforward treatments and clear measures of whether treatment has worked.
Depression, by contrast, is shrouded in social stigma, difficult to assess, tricky and time-consuming to treat, and in as many as half of patients, remarkably stubborn. It's an awkward subject for physicians more comfortable explaining QT intervals and ejection fractions than inquiring about feelings of worthlessness or guilt.
Physicians "are frequently timid about assessing emotional problems," wrote UC San Diego psychiatrist Joel E. Dimsdale in the American Journal of Cardiology in June, while commenting on two finding that early anxiety is strongly linked to later heart problems. "It is odd that we thread catheters, ablate lesions, and give rectal exams but are uncomfortable asking patients about their lives."