Coronary heart disease and depression. Different symptoms, different treatments. One disease acutely life threatening, the other slow and insidious. How can the ups and downs of mood and heart disease possibly be related?

Emerging insights are revealing that, the deeper we probe, the more alike the two disorders appear. The ultimate manifestations differ, but the underlying pathological processes are achingly similar. Beneath the emotional surface of mood and depression, there is a raging physical undercurrent of hormonal distortions, impaired immunity, and inflammation. These disturbances of physiology contribute to growth and abnormal activity of coronary plaque, eventuating in heart attack. Depressed persons, in fact, suffer a four-fold greater heart attack risk compared to the non-depressed.^1,2

If the two seemingly disparate disorders of depression and coronary heart disease share common causes, can there also be common treatments? A surge of exciting, new insights suggests that, yes, there are ways to treat both conditions that take advantage of their shared metabolic origins. The good news is that some of these treatments are nutritional, yet potentially powerful and available to all of us.

Depression—More than feeling bad

We all know what it’s like to feel bad. But what does it mean to be depressed in the full clinical sense?
Loss of interest in activities previously enjoyed, struggling to sleep or early awakening, difficulty concentrating, feelings of worthlessness or guilt, loss of appetite or weight loss, and, of course, suicidal thoughts can all be signs of depression. The more such emotions interfere with daily activities, the longer they last (greater than two weeks), the more likely clinical depression is present.

Depression is more than just a state of mind. Depression is a disease in the true organic sense. It has symptoms, it can be measured, and it has real physical consequences. Clinical investigations of the last decade have uncovered the myriad physical manifestations of depression, phenomena you may be unaware of, yet real with very real consequences.

“One of my problems is that I internalize everything. I can’t express anger; I grow a tumor instead."

- Woody Allen

Feeling good can hinge on a precarious balance of internal dialogue and external events. A tip in the balance of either and the stage is set for negative emotions and their metabolic consequences. At what point do negative emotions begin to add to risk for heart disease? The line separating depression from more commonplace feelings of sadness and anger that are part of everyone’s lives can be somewhat hazy. It’s a matter of degree and duration. Even dysphoria, less severe feelings of hopelessness and sadness that don’t meet diagnostic criteria for depression, also more than double heart attack risk.² People chronically experiencing negative emotions like unexpressed anger, hostility, and resentment, have higher risk for heart attack, as well, similar to that of the fully depressed.³

Emotion and heart disease—the tangled web

There is an inferno of metabolic phenomena blazing beneath the surface of sadness and hopelessness. Inflammatory proteins, such as IL-1β and TNF-α, circulate in the blood at higher levels, suggesting that low-grade, body-wide inflammation accompanies depression. IL-1β and TNF-α correlate with the severity of depression: the deeper your depression, the higher the level of inflammatory proteins.⁴ C-reactive protein (CRP) is another inflammatory protein found at higher levels in depressed persons. All these inflammatory proteins have been clearly linked to increased heart attack risk (see below).^5,6 Extensive clinical trial data show that when the fires of inflammation are burning, coronary plaque is unstable and more prone to “rupture”, the event causing most heart attacks.⁷

Depression activates release of stress hormones. So does anger, frustration, hostility, and anxiety. Hypersecretion of cortisol and norepinephrine result, both responsible for survival responses when the human organism is threatened. Both hormones are potent causes of hypertension, insulin resistance and diabetes, all well-established risks for coronary disease.^8,9 The longer and more chronic these negative emotions, the more likely they lay ground for heart disease.

These same hormones also contribute to development of the metabolic syndrome, a combination of abdominal obesity, hypertension, low HDL cholesterol, and higher blood sugars (>110 mg/dl). Overweight and obesity are epidemic and fueling the skyrocketing increase in metabolic syndrome, estimated to currently affect 47 million adults and a rapidly growing cause of heart disease. Depressed people are particularly prone to develop the features of the metabolic syndrome.^10-12

During periods of depression, along with stress hormones, the “fight-or-flight” sympathetic nervous system operates on an around-the-clock state of heightened activation, while the calming parasympathetic system is suppressed. This can be measured as blunted beat-to-beat variation in heart rate, or heart rate variability, even when the heart rate is normal. Decreased heart rate variability predicts heightened potential for dangerous heart (ventricular) arrhythmias and sudden death.¹³

For years, epidemiologists have explored the curious phenomenon of the unexpectedly low risk of both heart disease and depression in cultures in which fish is eaten in abundant quantities. The common thread seems to be omega-3 fatty acid content of fish oils.¹⁴ Dr. Joseph Hibbeln of the National Institutes of Health has documented in great detail the amazing association between higher levels of fish consumption and lower rates of depression through his studies of fish intake across numerous cultures. He was also among the first to draw the connection between greater fish consumption and the lower likelihood of heart attack.²⁹
Indeed, both depression and heart disease are associated with low concentrations of omega-3 fatty acids in red blood cells. Conventional prescription antidepressant medication fails to correct the omega-3 levels imbalance.¹⁵ It is, therefore, irresistible to suggest that fish oil and omega-3 fatty acid supplementation might provide a common therapy for both. The data discussed below strongly suggest this is true.

Homocysteine represents another intriguing connection between depression and heart disease. Homocysteine is been clearly associated with increased risk for heart attack.^16,17 Less well known is this B-vitamin-dependent molecule’s role in emotions. Depression, poor response to antidepressant medication, and dysthymia (a lesser form of depression) have all been linked to low folic acid blood levels. (Folic acid deficiency causes high homocysteine blood levels.) Folate-deficient people are also more likely to be deeply depressed and for longer periods.¹⁸ Up to 50% of depressed persons have homocysteine levels significantly above normal (>10 μmol/l).^19,20 Anti-depressant medication has little effect on this variety of depression, but it does respond to folic acid. Studies examining depressed persons in a number of settings have firmly established that folic acid replacement, resulting in reduced homocysteine blood levels, is an effective treatment for depression and a useful addition to prescription anti-depressant therapies.^21-23

Inflammation, activation of stress hormones, laying the foundation for the metabolic syndrome, blunted heart rate variability, reduced omega-3 fatty acids, and higher homocysteine levels are some of the fascinating ways for depression, or even lesser levels of anger, hostility, and anxiety, to heighten heart disease risk. Let’s now discuss how these recent discoveries have opened up some possibilities for nutritional supplements.

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Copyright 2006, Track Your Plaque.