Persistent depressive symptoms are common after angina, heart attack, or other heart problems.

Depressive symptoms also are thought to increase the risk of further heart problems and mortality.

Dr. Michael Rapp from St. Hedwig’s Hospital, Berlin, and his team enrolled 22 patients three months after hospitalization for acute coronary syndrome. The patients had brain scans to highlight any cerebral deep white matter changes or structural abnormalities in areas called the anterior cingulate cortex and the dorsolateral prefrontal cortex. They also completed the Beck Depression Inventory.

Results showed that, after three months, patients with persistent depressive symptoms had “more advanced deep white matter changes” than patients who were not depressed.

Details are published in the journal Psychotherapy and Psychosomatics. The authors believe, “this study provides the first evidence that persistent depressive symptoms after acute coronary syndrome are associated with brain changes.”

They call for long-term studies to see whether depression develops in advance of these brain changes or afterward and which aspects of depression are worthy of further investigation.

Dr. Rapp writes, “Elevated depressive symptoms appear to be a robust risk and prognostic marker of cardiovascular disease. This has led to conjectures that depression is a causal risk factor, and that depression treatment may alter the course of cardiovascular disease.”

In February this year, researchers from the Royal College of Surgeons in Ireland again found that depression predicts the onset and recurrence of heart disease. They looked at which depressive symptoms in particular were linked to poorer outcomes, and found that “fatigue/sadness,” but not other symptoms, were associated with increased risk of having a major cardiac event.

They write that in the context of heart disease, “Depression should be considered as a multidimensional, rather than a unidimensional, entity.”

A 2006 study again highlighted the complexity of the link between depression and heart problems. It found that the Hospital Anxiety and Depression Scale depression subscale, but not the Beck Depression Inventory-Fast Scale, is able to identify heart patients with a raised risk of mortality in the following year.

Previous studies also have found that depression is a strong predictor of future heart disease in healthy people. A 2004 review summed up the evidence. It concluded that depression can double the risk of developing cardiovascular disease, due to a number of plausible reasons such as lifestyle risk factors and differences in the nervous system.

The team also looked at the effects of treating depression in heart patients. They write, “There are currently several empirically validated treatments for depression. However, to our knowledge, there have been only two completed clinical trials treating depression in cardiac patients.”

One of these trials took heart attack patients with depression and gave them either usual care or a psychosocial intervention consisting of at least six sessions of individual cognitive behavior therapy, group therapy, and antidepressants. But the intervention was not effective at reducing rates of mortality or recurrent cardiac events.

The second trial compared the effects of sertraline (Zoloft), a selective serotonin reuptake inhibitor (SSRI) antidepressant and placebo for patients with depression alongside heart problems. In this case, there was a tendency for the patients treated with sertraline to have fewer serious adverse events (death or rehospitalization for heart problems) than those on placebo. This may be because, in addition to reducing symptoms of depression, SSRIs act as an anticoagulant or blood thinner.

The researchers conclude that the effectiveness of depression treatment to improve outcomes for depressed cardiovascular disease patients is still unclear.

Nevertheless, Dr. Hannah McGee of the Royal College of Surgeons in Dublin, Ireland, believes that depression symptoms in heart patients should be measured by health practitioners. Her research leads her to believe, “Routine assessment would identify those at increased risk of poorer outcomes. Short-form depression questionnaires are an acceptable substitute for clinical interviews in a setting where depression would not be routinely assessed.

“Identification of depressed patients is advisable for both service providers and patients. The prevalence of depression and the poorer outcomes seen in this group provide support for the treatment of depression to enhance patients’ quality of life, and to reduce the negative outcomes associated with depression.”