Don't worry, be happy: accenting life's positives makes for healthier hearts.

Studies indicate not only that positive outlooks offer protection against developing heart disease, but also that those who have undergone heart attacks and remain depressed (believing they will never regain their health) stand greater chances of not recovering. For one thing, defeatist attitudes lead to an unwillingness to alter unhealthy eating habits or to begin an exercise program. Also, depression is common among individuals recovering from a heart attack, sapping the person's will to do what's necessary for recovery.

"The first step is to identify the depression, and that tends not to be done in patients who have a medical illness," says Robert Carney, Ph.D., associate professor of psychology in the School of Medicine at Washington University in St. Louis. "Studies suggest that two thirds of people who have a psychiatric disorder on top of any medical disorder go unnoticed and untreated."

"There is clearly a mind-body problem in much of medicine, and there are major physiological changes that result when people are depressed," Carney adds. But he's optimistic because more physicians appear to be paying attention to the new research, although heart patients aren't yet routinely screened for depression. Washington University researchers report that clinical depression may be as big a risk factor as cigarette smoking, elevated cholesterol, or high blood pressure.

Medical insurance, though, adds to the problem, since most don't reimburse physicians when the diagnosis is "depression."

"A stigma is associated with depression," says Andree Stoves, M.D., assistant professor of psychiatry, University of Alabama at Birmingham. "We need to educate the public and physicians about how common depression is. It's a physical disorder that affects the brain, and that needs attention and treatment."

Stoves' research shows how mental stress--a major contributor to depression--increases plaque formation that leads to blood vessel blockages. "We've followed the effects on the blood platelets of depressed patients. Our preliminary data shows that serotonin reuptake inhibitors [certain antidepressants] reduce platelet adhesions. I think a lot of cardiologists are starting to pay attention to it. They need to be sensitive to the emotional states of their patients," Stoves says.

By monitoring the emotional states of heart patients, Carney found that nearly one in five coronary artery disease (CAD) patients had experienced documented incidences of clinical depression prior to their diagnosis, and in the year following their diagnosis the patients were twice as likely as nondepressed patients to have a major coronary event such as heart attack, surgery, or death.

Depression also affects people with congestive heart failure (CHF). Studies at Duke University Medical Center, North Carolina, indicate that CHF patients have a high prevalence of depression, leading to an increased risk of adverse outcomes. Wei Jiang, M.D., at Duke, says that the rate of major depression in a CHF population of 374 during one year at the center was about 17 percent, with 30 to 35 percent mildly depressed, which means that about 50 percent of all CHF patients were depressed to some degree.

A growing number of health experts believe that depression affects the body to such an extent that it causes irregular heart rhythms or the progression of arteriosclerosis (hardening and/or thickening of the arteries), which blocks the blood's flow. Others suggest that depression might adversely affect motivation, and people stop doing the things that keep their hearts healthy, says Carney.

An earlier 27-year study, reported by the American Heart Association in 1996, showed that the risk of heart attack or death from all causes increases in people who are chronically "blue." Depression is thought to increase production of free radicals and fatty acids, which can damage the lining of the blood vessels, placing the person at higher risk for sudden death.

More recent research at Johns Hopkins in Baltimore shows that study participants with a positive attitude were only half as likely as the less optimistic to experience heart problems, regardless of age, race, or sex. Diane M. Becker, Sc.D., M.P.H. of Hopkins' Center for Health Promotion, believes it's possible that optimistic people produce lower levels of stress hormones, which helps protect them from the ravages of heart disease.

Observed over eight years, the studies centered on preventing heart attacks in people at high risk. "It's about well people paying attention to the positive sides of their lives and personalities as a prevention strategy," Becker says. "It is clear that in today's society we spend so much time working and taking care of problems that having a regular pleasurable lifestyle with plenty of relaxation time has fallen by the wayside. A positive outlook could be fostered by looking forward to a host of regular, not sporadic, enjoyable things."

One regular activity that might be included is church attendance, since some studies show that people who regularly attend church suffer the "blues" less often. However, minor depression, or the blues, which affects a majority of the population at some point in their lifetimes, differs from clinical depression, which is a medical diagnosis that is biologically based, and needs treatment with pharmacologies.

A number of published studies have assessed the effects of spiritual factors on health-care outcomes for a variety of illnesses, with 75 percent reporting a positive effect, 17 percent reporting no effect, and 7 percent reporting a negative effect, according to December 2001 articles in the Mayo Clinic Proceedings, a journal published by Minnesota's Mayo Clinic. The studies also found that intercessory prayer had no effect on patients' medical outcomes after hospitalization in a coronary-care unit. Cardiologist Stephen L. Kopecky, M.D., the study's senior author, said, however, that in light of its widespread use in conjunction with illness, intercessory prayer deserves further exploration, and that the research did not measure the power of God. Nor should prayer that is offered for patients by loved ones, relatives and friends be interpreted as not playing a potentially important rote in the healing process."

Other good news, according to the publication, is that in nearly 350 studies of physical health, and 850 studies of mental health, religious activities and involvement (other than prayer) are associated with better prevention and health outcomes.

Becker adds that Americans have developed a stressful lifestyle biologically, behaviorally, and emotionally, and that they create self-induced stress with high-speed communication (200 e-mails a day, for example) and heavy work burdens. "It is so pervasive that it is the norm. People respond differently. There is an emerging culture of spa therapy and complementary medicines, all designed to alleviate stress. The huge American mistake is the search for the elusive `pill' that will give a more positive outlook, or even thinking that a single spa treatment will help. It's like taking pressure off a bedsore for one minute out of every hour."

She emphasizes that changes to alleviate stress mean lifetime health habits, not quick fixes.

After the fact, however, such as following a heart attack, cardiac rehabilitation is the most effective intervention, and the best way to start introducing new lifetime habits, since it involves exercise, says David E. Bush, M.D., of Johns Hopkins Bayview Medical Center. It's not only the exercise that helps, though. "In these types of programs there is group participation and gradual attainment of health-related goals. Patients can usually see measurable progress with regard to increasing their exercise capacity. That is probably the most effective way to overcome the negative health perception. It also helps to reassure family and other concerned individuals that progress is being made."

The drawback, however, is that depressed patients are less likely to participate in cardiac rehabilitation or in changing their health habits than those without depressive symptoms. "In a sense those who need it the most are generally the least likely to participate. This is where family members and friends can offer encouragement," Bush says.

Prevention, of course, is the best treatment of all, with a positive outlook part of the solution.

James Fauerbach, Ph.D., of Johns Hopkins, says that although we're only beginning to understand how to foster positive outlooks, research from a wide array of sources suggests that certain behaviors may be beneficial, starting with an old cliche to which he's added some words of wisdom: "Those who see the glass as half empty and who take on life from a defensive posture are likely to experience more negative effects than those who see the glass as half full and who seek to make the most of their present circumstances.

Rita Robinson writes on health issues from Big Bear City, California.