Heart-attack victims show fatal depression.

In the first six months after surviving a heart attack, people who suffer from severe, or major, depression experience three to four times the death rate of nondepressed individuals, according to a prospective study in the Oct. 20 JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.

"Although the precise mechanisms remain unclear, having major depression seems to be a strong short-term risk factor for dying after a heart attack," asserts Nancy Frasure-Smitth, a psychologist at the Montreal (Quebec) Heart Institute. "We don't know if long-term mortality risks also include depression."

Another new study has found that the women most likely to die in the eight to 10 years following their first heart attack display a near absence of hostility and lack any urgency to finish tasks, two possible indicators of underlying depression (SN: 10/16/93, p.224). However, suppression of a spectrum of negative emotions, including resentment and anger, might also produce the psychological symptoms noted in these women.

Between August 1991 and July 1992, Frasure-Smith's group recruited 222 people discharged from a hospital after treatment for a heart attack. Participants ranged in age from 24 to 88; men made up three-quarters of the sample.

Each volunteer granted a psychiatric interview within 15 days of leaving the hospital. Thirty-five were diagnosed with major depression, a condition characterized by loss of interest in formerly enjoyable activities, feelings of helplessness and hopelessness, and overwhelming sadness.

Six months after discharge from the hospital, six depressed people, or 17 percent of the depressed group, had died; six nondepressed adults, or 3 percent of the nondepressed group, also died in that time period.

Depressed volunteers did not have more severe heart disease or more prior heart attacks than their nondepressed counterparts, the researchers assert.

Depression may wreak its lethal effects through one or both of two possible channels, they maintain. Depressed individuals may be less willing to take medications, exercise, stop cigarette smoking, and eat healthful meals. Evidence also suggests that depression may undermine the heart's ability to pump normally and, through its chemical effects, may promote blood clots and thickening of artery walls (SN: 7/31/93. p.79).

However depression does its damage, identification and treatment of the disorder in heart-disease patients now take center stage, Frasure-Smith says.

"We don't know for sure how to treat depression in cardiac patients," she remarks. "Studies of psychotherapy and drug treatments need to be done."

Depression occurred most often among heart-attack survivors who reported having no close friends, suggesting that treatment may need to focus on shoring up social support, the Montreal psychologist says. Researchers also need to consider possible protective factors that aided survival among 83 percent of depressed patients in the study, she holds.

The findings may signal a move away from the long-standing emphasis on Type A behavior and its components, such as hostility and cynicism, as fatal contributors to heart disease, Frasure-Smith adds.

Redford B. Williams, a psychiatrist at Duke University Medical Center in Durham, N.C., agrees that depression can prove deadly after symptoms of heart disease emerge. But other studies indicate that hostility and Type A behavior help foster the initial development of heart disease, Williams argues.

In a commentary accompanying the new study, Williams and Margaret A. Chesney, a psychologist at the University of California, San Francisco, call for research into treating depressed cardiac patients with support groups and new antidepressant drugs that show no harmful effects on the heart.