Article Found On Depression And The Use Of Antidepressants

[Rene S.]

Hi. I need major hugs and am scared. I've been through **** in the past year and don't mind admitting to being depressed and anxious with the dysautonomia, divorce, moving, etc, not to mention that my ex is getting married on Sunday. I'm working with a psychiatrist who is driving me crazy. Actually telling me to pick the med and then changing her mind. Grrr. I'm to pick one and start it tomorrow. Now, after reading this article, I don't know what to do. I live alone as many of you know, and have much fear about the article below.

My b/p is labile, borderline hypertensive but then at times it's normal. However, my heart rate at rest is never under 80, which I hate. Beta blockers helped but now that they think I have prinzmetal's angina, I'm not supposed to take them. Do I start the antidepressant? My psych told me to stop reading so much but this is my life we're talking about. Sorry I just found this and it has me majorly spooked!

So, I was researching and this popped up:

Public release date: 9-Mar-2009

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Contact: Amanda Jekowsky

ajekowsk@acc.org

202-375-6645

American College of Cardiology

Feeling down and out could break your heart, literally

Research links depression to cardiac death in women without known heart disease

New data published in the March 17, 2009, issue of the Journal of the American College of Cardiology suggest that relatively healthy women with severe depression are at increased risk of cardiac events, including sudden cardiac death (SCD) and fatal coronary heart disease (CHD). Researchers found that much of the relationship between depressive symptoms and cardiac events was mediated by cardiovascular disease risk factors, such as high blood pressure, high cholesterol and smoking.

"It's important for women with depression to be aware of the possible association between depression and heart disease, and work with their health care providers to manage their risk for coronary heart disease," says William Whang, M.D., M.S., Division of Cardiology, Columbia University Medical Center, and lead investigator of the study. "A significant part of the heightened risk for cardiac events seems to be explained by the fact that coronary heart disease risk factors such as high blood pressure, diabetes, elevated cholesterol, and smoking were more common among women with more severe depressive symptoms."

Dr. Whang and his colleagues prospectively studied 63,469 women from the Nurses Health Study who had no evidence of prior heart disease or stroke during follow-up between 1992 and 2004. Self-reported symptoms of depression and use of antidepressant medication were used as measures of depression. To best identify those with clinical depression, researchers specifically examined women with the most severe symptoms defined by a validated 5-point mental health index score of less than 53 or regular antidepressant use.

The study found that women with more severe depressive symptoms or those who reported taking antidepressants were at higher risk for SCD and fatal CHD. In particular, women with clinical depression were more than twice as likely to experience sudden cardiac death. Surprisingly, this risk was associated more strongly with antidepressant use than with depressive symptoms.

"These data indicate the link between depression and serious heart rhythm problems may be more complex than previously thought," says Sanjiv M. Narayan, M.D., F.A.C.C., University of California, San Diego, who co-authored the accompanying editorial with colleague, Murray Stein, M.D. "It raises the question of whether this association may have something to do with the antidepressant drugs used to treat depression."

Both Drs. Whang and Narayan stress that although the relationship between antidepressant medicines and SCD merits further investigation to determine whether antidepressant medications directly increase the risk for heart rhythm disorders, at present the benefits of appropriately prescribed antidepressants outweigh the risk of sudden cardiac death. There was no relationship between antidepressant use and fatal CHD or nonfatal heart attack.

"We can't say antidepressant medications were the cause of higher risk of sudden cardiac death. It may well be that use of antidepressants is a marker for worse depression," adds Dr. Whang. "Our data raise more questions about the mechanisms by which depression is associated with arrhythmia and cardiac death."

Plausible explanations for the link between depression and SCD may include autonomic dysfunction, higher resting heart rates and reduced heart rate variability, according to Dr. Whang. Researchers also found an association with nonfatal MI, but this became borderline non-significant when adjusted for multiple other CHD risk factors.

Still, these study findings reinforce the need for patients with depression to be monitored closely for risk factors for coronary heart disease, since management of these risk factors can reduce the risk for mortality from coronary heart disease and sudden cardiac death.

###

Dr. Whang reports no conflict of interest.

The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 36,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at www.acc.org .

The American College of Cardiology (ACC) provides these news reports of clinical studies published in the Journal of the American College of Cardiology as a service to physicians, the media, the public and other interested parties. However, statements or opinions expressed in these reports reflect the view of the author(s) and do not represent official policy of the ACC unless stated so.

Video feed contains footage and soundbites of William Whang, M.D., and B-roll. A suggested script is attached.

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[iheartcats]

I think it really depends on the numbers and your comfort with risk.

I took a medicine where there was a big headline of increase of stroke/death.

When I took it in my hands to research it and took a report from an established hospital to my former and wonderful PCP, she agreed with my continued use as I understood the numbers.

A three-fold increase ended up being about 60 women out of 100,000 instead of 20 women out of 100,000. It's '3-fold' - 20 X 3 = 60 but that's media scare tactic/bad math in my humble opinion.

In the grand scheme of life, that small percent increase overall was worth my benefit.

Can you find the numbers? X women out of 63000 in a normal population, to X women out of 63000 in this study and discuss this with your doctor?

[Rene S.]

I think it really depends on the numbers and your comfort with risk.

I took a medicine where there was a big headline of increase of stroke/death.

When I took it in my hands to research it and took a report from an established hospital to my former and wonderful PCP, she agreed with my continued use as I understood the numbers.

A three-fold increase ended up being about 60 women out of 100,000 instead of 20 women out of 100,000. It's '3-fold' - 20 X 3 = 60 but that's media scare tactic/bad math in my humble opinion.

In the grand scheme of life, that small percent increase overall was worth my benefit.

Can you find the numbers? X women out of 63000 in a normal population, to X women out of 63000 in this study and discuss this with your doctor?

Thanks fellow cat lover! I went through the article again and it though it gives the amt of women that were studied it doesn't actually say how many of them died. I plan on emailing the author of this article. I need more specifics. Such as was it a particular anti-depressant? Or do they all carry the same risk?

[erik]

I have read that several meds (including some anti-depressants) can be contraindicated if one has "Long QT syndrome". That is a specific arrhythmia that would tend to show up on EKG (sometimes only with stress test). Other than for specific conditions, it is very difficult to interpret the articles that are based on large groups of statistics and apply them to individual situations.

It is unfortunate that you are pressured by the choice and not assisted better by your doc in this regard. That stinks. I'm a saddened at your doc's tact (or lack thereof). They might be hoping that giving you some control of the process will help... but that can also just invite more anxiety too. In general, anti-depressants are a very safe "class" of drug and can usually be ramped up slowly too. The SSRI's are often used to help dysautonomia, so you might get a double benefit there? At the same time, one can get orthostatic intolerance from many psych meds too... so it is ironic and a bit confusing and somewhat trial & error I guess. Various tricyclics have quirky (and often useful) specific characteristics so there could be one that happened to help with other things too, but it's beyond my knowledge. Looking at "off-label" use can give some hints about a drugs less obvious "character" and might be handy.

Have you selected some that you are considering that we could help you "analyze"? Did the doc have a specific one in mind at any point? More importantly, has a cardio doc screened you for basic heart function, perhaps during the dysautnomia diagnostic process... often people with dysautonomia end up having very clean "bill of health" on the heart itself (despite conditions that mimic heart trouble).

[kayjay]

Ruekat, This made me think of the death of my grandfather (when I was 19) and how I felt the physical pain of a "broken heart". For me depression and sadness hurt my heart ( real pain). I think that the benefits of antidepressants most of the time outweigh the risks. I take Lexapro for my POTS and while I do not have depression it helps with the my chest pain. I don't know just a thought. Laughter is supposed to be good for you and sadness and stress are not. I would tend to think that the problems were caused by the depression, not by the meds... although not every kind is good for every one. I know that I was given lexapro when I was 29 and sent to NIH where they looked for a tumor I did not have. I slowly got better. I look back and think that the lexapro help my undiagnosed dysautonomia. Anyway just a thought and a foggy one at that !

[bjt22]

Are you being monitored for risk factors? I know I am. And yup...my cholesterol is high, I'm insulin resistant/borderline diabetic and have a strong family history of cardiovascular diseases. On Sunday, I was guilted into making a trip to the funeral home as my 62 year old cousin had died suddenly of a stroke. I had not seen this cousins in 20 years, and I found that his sister was in a wheelchair due to having had a stroke. Their mother, my great aunt died of a stroke, as did her mother...all in their 50's. My mother's family is even worse...her mother is the only one out of 6 children not to die of some kind of sudden cardiac arrest...two of her siblings died very young, one at 12, another at 32. The rest died by the time they were 60.

Now, this sounds depressing, but I know exactly what it is that I need to watch out for. My mother and her sisters are in their seventies. Yup...they all had hypertension by the time they were in their 40's, and two are diabetic. All with high cholesterol, but they are taking care of these problems through treatment and awareness. I'm trying my damnedest to do the same. Heart disease is the number one killer. Probably half of the adult population is at at least as high a risk as you are. Those are just the sad facts.

Should you take the anti-depressant? I can't tell you that. All in all, I'm not a big fan of them. Some studies indicate that they are very little better than placebo at treating depression. However, I know many, many people who feel they have literally given them their lives back. I take a beta blocker despite having prinzmetal angina. It's actually helped. Its not a "typical" beta blocker in that it's non-selective and works as an alpha blocker as well. It keeps my blood pressure from spiking, helps, along with other drugs, in keeping my heart from soaring away at 160 bpm and yes, it helps the chest pain.

[iheartcats]

I think it really depends on the numbers and your comfort with risk.

I took a medicine where there was a big headline of increase of stroke/death.

When I took it in my hands to research it and took a report from an established hospital to my former and wonderful PCP, she agreed with my continued use as I understood the numbers.

A three-fold increase ended up being about 60 women out of 100,000 instead of 20 women out of 100,000. It's '3-fold' - 20 X 3 = 60 but that's media scare tactic/bad math in my humble opinion.

In the grand scheme of life, that small percent increase overall was worth my benefit.

Can you find the numbers? X women out of 63000 in a normal population, to X women out of 63000 in this study and discuss this with your doctor?

Thanks fellow cat lover! I went through the article again and it though it gives the amt of women that were studied it doesn't actually say how many of them died. I plan on emailing the author of this article. I need more specifics. Such as was it a particular anti-depressant? Or do they all carry the same risk?

One can never have too many cats, I feel...although I only can handle one right now!

Please let us know if the author emails you back. It's hard to compare...if they say twice as many, is that 3 women in 63k to 6 women in 63k, or 75 women in 63k to 150 women in 63k? I have a Journalism Degree so I hate when all the facts aren't presented!

I take a Beta Blocker even though I have some awful allergy issues going on. My Allergist/Cardio felt the benefits outweighed the risks (150+ BPM/Chest Pain/Fatigue from HR) is a horrible daily thing to live with. Life isn't perfect on the BB, but it's better.

And boy, was I worried to start the BB but am glad I did! I read a lot, too, and think I drive some of my physicians bananas so don't feel bad.

[MightyMouse]

As someone who does research for a living (was well as apply research in educational settings) you need to pay attention to the line:

"association between depression and heart disease"

all that means is that both are some how related to each other--and as of now, they still don't understand the NATURE of that relationship. Chicken? Egg? What we do know is that untreated depression increases more risks than most other things. Untreated heart disease is also dangerous.

My best suggestion: take care of both to protect your health.

Nina

[erik]

Here are some specifics on the Long QT issue:

http://www.hrspatients.org/patients/heart_...qt_syndrome.asp

http://www.sads.org.uk/drugs_to_avoid.htm

A family history can be considered. A relative with this diagnosed is said to be reason for specific screening of an individual. My pops has this, so I'm eligible for screening (or should be... though I'll be called a hypochondriac for considering my life to be valuable). It is something one can proactively check for and monitor during initial use of a medication in the rare event that such a condition exists. It is an issue that can be safely managed.

In terms of critiquing the study... I note that they are unaware of LQTS and it's association with sudden death and anti-depressant medications. They should have at least mentioned this in their "research" (even if they dispute it for some reason) since it is a documented circumstance and can explain some of their statistical findings. Hmm. Maybe UCSD's internet link was down for a while and they couldn't google this issue?

[Rene S.]

Hi. My choices were supposed to be between Paxil, zoloft and celexa. I've been on all except the celexa. In the past I've been on Lexapro. I was to start Celexa, but since they don't have the brand only generic, the pysch said we'll do the paxil. I told her how much I hated it, but she said she's giving me such small amts to start. But I have a diary of when I used it the last time and it was horrid. I lasted about 2 weeks with the worst side effects. I'm more anxious than depressed and do take klonopin. The zoloft pooped out on me last year. Great for depression not so great for anxiety

Bit, which beta are on you? Is is Coreg? I tried that in the past and it gave me palps but maybe I should try it again. Did try Cardizem CD (Calcium channel blocker) but found it increased my heart rate.

Thanks Nina, but the article mentioned that these were women with no heart disease.

I have a horrible family history. My dad was the oldest living male, and he died at 66. Mom died at 72 - bothof heart attacks. My younger brother just died and he was 48. Autopsy concluded CAD. I feel doomed, even though I had a clean cath.

I know that stress and worrying only increases my heart rate, but I hate having it go up so high when walking up steps. I know, it's part of the dysautonomia.

Doctors here in to me seem not to know what they are doing, unless I keep getting the worst of the bunch.

There must be life after being diagnosed with dsyautonomia!

I should just go back on the betas and not fear the Prinzmetal's because the pain from my heart beating so fast is horrible.

And yes, I've had every cardiac test done. They all keep telling me it's anxiety! Grrr.

So tomorrow I will stare blindly at the bottles of antidepressants and be paralyzed. The article mentions arrythmias and when I was on Lexapro (which I thought was a great drug) I had one incident of non sustained V-tach for 9 beats (captured on a cardionet monitor). They made me come off of it. Zoloft worked great for depression, nothing for anxiety.

Any imput would be appreciated. Can you tell that I'm just a wee bit frazzled?????

Oh last but not least - yes researching again - women with h/r of over 76 at rest (that's me!) were more likely to have heart attacks. Geez, prior to last Oct. my heart rate at rest was 60a and b/p was 90/60. What I wouldn't give to have those days back.

Thank you all. I'm so glad you are here. And Cat Lady, I have two wonderful cats that I wouldn't trade for the world!

Hugs to all!

Rene

[bjt22]

Rene,

I take labetalol. I also use Catapres. Between the two of these drugs, my angina attacks have been curtailed immensely. It does still happen from time to time, but not on a daily basis! My heart rate is controlled, and while I'm still very orthostatic (my bp plummets when I'm upright), I can't tell you how much I'd rather deal with that than the sky high heart rate. I can't say I'm particularly more functional, but I am more comfortable, and you know, that counts for a heckuva lot these days.

I was very afraid of starting labetalol. Years ago, I had been put on atenolol, and it was horrible for me....truly made me feel as if I were dying. Took me a long time to reconsider beta blockers. I was finally told that I needed to control my heart rate and blood pressure, not because it would make me "better", but because I wanted to live to see my kids raised. Made an impact on my way of thinking. So, I took the labetalol, had a few side effects for a month or so, but I'm so glad I stuck it out. Wasn't anything like my reaction to atenolol.

I've tried a few anti-depressants for autonomic dysfunction. Some I couldn't tolerate at all, but I could tolerate a low, low dose of Welbutrin...everytime I tried to increase it past a pediatric dosage, it made me feel as if I was going to stroke out. So, needless to say, I didn't increase it. I thought it made me feel a little better at the time, but after a couple of years, I discontinued it and to tell you the truth, I could tell no difference.

[erik]

Buspirone comes to mind off the bat. However, since you're on a benzo already they say it won't feel as anxiolytic to you by comparison (and takes time to kick in). However, it is intriguing because they do try to ween people from benzos to it at times. It is anxiolytic AND antidepressant. (It will not replace your beta-blocker function directly... not many things will, but perhaps it can have indirect benefit)

They also used it to augment other antidepressants that aren't cutting it for anxiety. I don't know if it is compatible specifically with zoloft, but if zoloft was good for your depression but lacked anxiolytic effect perhaps it could be augmented with this??? I know it is odd to consider "two" new meds, when there is enough anxiety over adding "one"... but since you were otherwise comfortable with zoloft perhaps this is a possibility.

Also, there is the remote chance that benzos can aggravate depression (and also are known to become less effective over time). Sometimes SLOWLY tapering them while replacing with something else can get someone to a better place after the transition. As you know all too well, every med has its ups & downs. Transitions can be difficult or have to be altered if they don't work out.

I applaud your fortitude in addressing the anxiety and maddening/saddening aspect of autonomic dysfunction directly! It seems so important to manage the physical factors thoroughly to minimize psychological factors... and it is important to manage psychological factors since they aggravate the physical autonomic symptoms. You are wise to take such a proactive approach. I think you have more bravery than you give yourself credit for Since you have been well screened in terms of cardiac conditions, there shouldn't be a big risk from anti-depressant medications.

As always, I'm expert at little and certainly no doctor! Just brainstorming things to consider. Obviously, professional medical consideration is essential.

http://en.wikipedia.org/wiki/Buspirone

[Tachy Phlegming]

Any imput would be appreciated.

I'm writing in only because you wrote this -- I have no experience with a desire/feeling I should be on these medications. I actually have filled a prescription for one for some physical condition (part of this syndrome) but just couldn't get myself to try it.

What I usually ask myself when I think about trying a new medication are the following questions:

1. Is it pretty generally safe?

If so, I usually try it for whatever is ailing me without thinking twice about trying it -- despite not liking to take medications.

2. How miserable am I?

Severe physical agony will get me to weigh the benefits of a drug I think could be dangerous.

Sometimes severe physical agony will get me through the five seconds I need to swallow a pill without thinking about possible side effects.

I think you are taking the right approach. I think research is a good idea.

If you want to try to find mental excuses not to take it, my suggestions (keeping in mind that I really don't have enough experience to know if this will work) are:

1. Find something you love to do and just do it to distract yourself.

2. Think of taking the dangerous drug as something which will cause you to be depressed in and of itself. Then, think how happy you are for not having to take it.

[MightyMouse]

I really like and trust my EP cardio, but he's not an ANS specialist--he IS, however, good a trying to understand my "big picture". I don't have the greatest history either--my dad has had mult heart attacks and is now pace maker and implanted defibrilator dependent. I think that all started about age 60...

his mom died at 72 after mult heart attacks...

however, my father's dad lived a long life into his 80s...but with MAJOR vascular problems and was a double amputee above the knee for the last 2 decades of his life

Mom's side:

My grandfather died in his 40's of a heart attack

My grandmother made it to about 50...

My cholesterol is obscenely high(high 300's to low 400's)--and this year I've developed cholesterol deposits in both my eyes, surrounding my irises--way too young for that. Supposedly, my ratio of hdl/ldl improved over last year and dropped my risk for atherosclerosis, but given all of the above, I don't know what to believe. I can't tolerate statins.

Hang in there--it may take some more trial and error to be feeling whatever will be your best. On lexapro, and Celexa before that, I had a good 2 weeks of misery before things got better--and I did well on both. Paxil didn't work well for me--anxiety provoking, which has never otherwise bothered me; Welbutrin made me way too manic--couldn't sleep and my brain just wouldn't shut the heck up...chattered to myself (in my head) nonstop. I think I tried one other but it was years ago ... can't remember the name but had same problems.

[pat57]

Erik,

Thanks for that info on the long QT wave. I have to watch mine. I might just print that med list out.

[MomtoGiuliana]

I asked my EP/POTS specialist about this article today. (I just about got my head taken off for asking about a medication I am not currently taking. The reason I was asking was b/c I had taken SSRI in the past and it helped and was thinking about re-starting due to current flare-up that does not seem to be calming down. Anyway, his answer, minus the annoyed demeanor, was helpful).

He said as others have noted that what is not mentioned in the article is that SSRI's can cause a long Q-t interval which can cause sudden death. He said strongly that autonomic dysfunction has nothing to do with it--the researcher speculating that it does apparently "doesn't understand electrophysiology". He said taking another med that might contribute to long Q-t interval, or otherwise having a pre-disposition to it, would make you more at risk for sudden death from taking an SSRI. But he said it cannot be predicted. Although the risk is small, anyone could have sudden death from developing a long q-t interval cause by taking an SSRI. He said this is why doctors and patients must always evaluate the risks and benefits of any medication. He said if he starts someone on an SSRI that has risk factor for a long q-t interval he will have them use lowest dose possible and come in for an EKG regularly.

Anyway, I decided not to re-start the SSRI -- not feeling badly enough to go through the adjustment period, and this info of this small added risk (along with other small risks the SSRI poses) makes it not worth it, for me.

Maybe this will be helpful to someone else too.

[vemee]

When I was on cymbalta my ekg started showing first degree heart block and partial right branch bundle block (not a life threatening condition). When I got off all antidepressants my ekg became normal. Also when I was on ssris I was showing borderline evidence of an old heart attack, this cleared up also after getting off antidepressants. Like any meds there are side effects which show up on different people. With me antidepressants did seem to affect my heart but not seriously.

[potsgirl]

I just wanted to add that depression, especially when it gets to a clinical level, is dangerous for your all-around health, not just your heart. It can be a factor in many diseases, and can lower your immune system so that you pick up colds/flu's more easily. This is especially true if one does not engage in social interactions and isolates.

Hope you get on the right meds, if that's what you decide!

Cheers,

Jana