Singing the Blues: Stress, Depression and Risk for Stroke

Depression is common in US adults over the age of 65. As we age, we are faced with our own mortality and often lose family and friends to disease. According to the CDC, over 80% of elderly adults have at least one chronic medical condition and nearly 50% have more than two. Dealing with multiple prescription medicines, multiple doctor visits and treatments add stress to life. Many seniors live on fixed incomes and financial pressures are often quite significant. To make matters worse, seniors are often misdiagnosed and many medical professionals do not recognize depression in this age group. Many physicians believe that feelings of sadness experienced by the elderly is just part of the natural aging process. Older patients themselves do not even recognize that they are depressed and believe that their feelings are part of the natural aging process–they never seek help.

Just a few days ago, the AHA Journal Stroke published a study linking increased risk of fatal stroke in older Americans. In the study, over 4000 adults in the Chicago area were followed and their level of psychological distress was measured using standardized, reliable assessments. The results of the investigation demonstrated a statistically significant increase in both fatal and nonfatal stroke in patients who were depressed and had increased levels of psychosocial distress. Clearly, there is an association between mental health and cardiovascular disease. Prior studies in patients with congestive heart failure have also demonstrated negative outcomes in patients with untreated or concomitant depression. In fact, in this newly published stroke study, a clear dose response relationship was seen between the level of psychological distress and stroke; those with higher levels had a 2 fold incidence in fatal stroke and a 30% increase in incident stroke rate.As scientists, we are driven to demonstrate a cause-effect relationship when approach disease. In order to treat a disease, we must target specific biologic connections. However, the biology of the association between stroke and emotional distress is difficult to definitively determine and has yet to be proven. Several biologically plausible hypotheses have been offered:

1. Emotional distress and depression may create higher levels of stress hormones and inflammation that contribute to events.

2. Patient who are emotionally distressed and depressed may be more likely to be non compliant and unengaged in their own healthcare. They may be more likely to live unhealthy lifestyles.

3. Emotional distress and depression may produce a hypercoagulable state where a patient is more likely to form a thrombus and experience a thrombotic event (embolic stroke).

The emotional well being of a patient can clearly have an impact on cardiovascular health. As healthcare providers, we must diagnose and treat depression, anxiety and other mood disorders as part of routine care. As cardiovascular healthcare professionals, we must develop relationships with mental health providers, counselors and psychiatrists so that we are able to refer our patients for specialized care when appropriate. The link between emotional health and physical illness is real. The heart-brain connection has been reported in the past and studies such as this one in the journal Stroke continue to emphasize the complexity of this association. Elderly patients are at particularly high risk for the detrimental effects of psychological distress simply due to its high prevalence in this population.

As we enjoy the holiday season and move to the New Year, let’s all commit to providing comprehensive care for our patients. Let us all strive to recognize signs of psychological distress and help our patients deal with their feelings in a productive, positive way. Help our patients by recognizing financial strain and prescribing generic medications. Make it clear to your older patients that depression and sadness is NOT a part of the aging process. Help integrate care by communicating with primary care providers and other specialists in order better coordinate care for our patients. Regardless of the specific biology of the association between emotional distress and cardiovascular disease and stroke, we can reduce risk by helping our patients to improve their own psychological health.