Tag Archives: anxiety

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.


Election Day Stress: Simple Tips For Minimizing the Negative Physical and Psychological Impacts

Tomorrow is election day. There is much at stake in this year’s election. Many agree that this may be the most significant presidential election in my lifetime and may very well determine the the future of the United States’ place in the world. That being said, this is not intended to be a political commentary, nor is it an endorsement of any one candidate. I will leave these important decisions to the reader.

This weekend, I came across an interesting article published in the European Psychopharmacology Journal that examined the psychological effects of election day on individuals participating in national elections. In the study, the investigators found that voting in national democratic elections created significant emotional and physical stress that could alter decision making capabilities. In this presidential election, more than any other I can remember, the country is polarized and most Americans are engaged and have a definite opinion–many of these opinions are emotionally charged.

The “fight or flight” stress response is an important adaptive mechanism for humans and other mammals. Cortisol, one of the most important stress hormones is produced in response to threat or in periods of physical or emotional stress. In the study, conducted in 2009 during national democratic elections in Israel, registered voters took a brief survey and had cortisol levels tested at baseline (both pre and post election) and immediately before approaching the ballot box to cast their votes. The cortisol levels were found to be three times baseline just prior to approaching the ballot box. In the survey conducted in association with the cortisol testing, investigators found that if a particular candidate is not popular in the polls and is unlikely to win that supporters have even higher levels of emotional stress and cortisol levels. As I examined this study, I began to wonder if part of the issue producing the excessive stress may be a perceived lack of control and the fact that the outcomes of the election process can have a profound effect on each individual’s daily life. Worries over fairness, fraud, and the political process itself are exacerbated by the way in which mainstream media attacks election coverage. Political ads and negative campaigning serve to further contribute to pre-election stress. To date, no study has looked at the rates of cardiovascular events during the days leading up to a national election, but I must guess that they may be significantly higher is susceptible patients. We know that other significant life stressors such as the loss of a spouse or loved one, or traumatic events are associated with increased risk for heart attack–its easy to assume that major political change may be as well.

So, what can each of us do to minimize the psychological impact of tomorrow’s election? Most importantly, understand what you can do and what things you have no control over. Understand what is important to you; family, friends, career and other interests. These will all exist even if your candidate loses the election.

What you can do to affect political change:

1. Participate and VOTE-if you do not vote tomorrow, your voice will not be heard. Remember, many lives have been lost over the years in order to ensure that every American has the right to cast a ballot on election day.

2. Campaign for your favorite candidate. Participate in fundraising efforts. Get involved in the grass roots efforts to get out the vote.

3. Write to elected officials. Let your viewpoints and opinions be expressed.

What things will not affect political change and will contribute to increased stress and anxiety during the election?

1. Constantly watch and read political coverage by the media. Certainly, it is important to remain informed, but don’t obsess with round the clock babble by popular political pundits.

2. Don’t’ agonize over the outcome. Although your candidate may not win the election, the life of the country will go on. Become or remain involved in your particular party in order to work for change in the next election

3. Don’t threaten to “abandon ship”. Moving to Canada and becoming an expatriate is never a viable option.

Tomorrow is a big day in the life of our country. Many important issues are on the table, including healthcare reform, foreign policy strategy and economic recovery at home. As US citizens we all have the right to vote. The election is a celebration of our freedom and of the men and women who have fought and died in wars to provide and protect that very freedom. Although change can be stressful and this particular presidential race is quite polarizing, make sure that you put election day in perspective. Control what you can control. Do not let the media, and the emotion of the process and the outcome negatively affect your physical and psychological health. Most importantly, get out and vote.