Depression, anxiety may cause patients to leave cardiac rehab

Anxiety and depression are common among participants in cardiac rehab programs, and that poor mental health may cause them to drop out, a new study finds.

One in five patients in cardiac rehab after a heart attack or a procedure to open clogged coronary arteries may suffer from moderate to severe anxiety or depression, Australian researchers say.

And one in four of those with moderate depression, anxiety or stress symptoms may drop out of their cardiac rehabilitation programs, according to the report published in the European Journal of Preventive Cardiology.

“Health professionals need to provide extras support for those with co-morbid mental health symptoms to enable them to experience the full benefits of physical and mental health that cardiac rehabilitation programs offer,” said lead researcher Angela Rao, a PhD candidate at the University of Technology in Sydney.

“Cardiac rehabilitation programs do refer people to primary care for ongoing management if their psychological symptoms are severe or if people have mental health disorders,” Rao said in an email. “However, half of those with moderate symptoms remain depressed, anxious or stressed on completion of these programs and return to their usual environment without additional support.” To take a closer look at the impact of mental health on cardiac rehab patients, Rao and her colleagues studied 4,784 heart patients treated at two Sydney hospitals between 2006 and 2017. All the patients completed mental health questionnaires upon entering the rehab programs.

Nearly one in five, 18%, had symptoms of moderate to extremely severe depression. More than one in four, 28%, had symptoms of moderate to extremely severe anxiety. And more than one in 10, 13%, reported symptoms of moderate to severe stress.

Rehab appeared to improve mental health symptoms for some patients, but nearly half of those with moderate anxiety or depression symptoms did not show significant improvement by the end of the program.

While both Australian and American cardiology groups recommend that cardiac rehab patients be screened and referred for treatment of depression and anxiety, this advice is often not followed in Australia, Rao and colleagues reported. “Standard screening and referral procedures for depression are not standard practice during hospitalization, and omission of screening varies between 29%-68% in CR programs,” they noted.

The new study should serve as a reminder to both patients and their doctors, said Dr. Mary Ann McLaughlin, director of Cardiovascular Health and Wellness at Mount Sinai Heart in New York City.

“Physicians should remember depression is a risk factor for cardiovascular disease,” McLaughlin said. “In general, we don’t screen for depression and anxiety as early as we should.”

The finding that 50% of patients still have symptoms after rehab means physicians need to encourage patients to follow-up with a psychologist or psychiatrist, McLaughlin said. “This is a perfect opportunity to make a difference in our patients’ lives,” she added. “We need to reinforce the need for mental health treatment. Just as taking aspirin and statins are important, treatment for depression and anxiety is critical.” While the paper focuses on patients in cardiac rehab programs, many patients with depression don’t even show up for these programs, said Kerry Stewart, director of clinical research and exercise physiology at Johns Hopkins Medicine in Baltimore.

There needs to be more of an effort to get these patients into rehab because it can help with both physical and mental health symptoms, Stewart said.

“While you can do a lot of what is done in cardiac rehab at home - you can walk on a treadmill on your own - you would miss the benefits of being in a group of people who have gone through what you are going through,” Stewart said. “That provides a social network that helps everybody. To me that is one of the biggest benefits of cardiac rehab.”