Knight Ridder/Tribune Business News
SAN MATEO, Calif. - More doctors should prescribe exercise therapy along with antidepressants for their heart disease patients coping with the blues, according to a study published Tuesday in the Journal of the American Medical Association.
The study broke new ground in identifying lack of physical activity as the main culprit behind depressed patients' increased risk of a heart attack, stroke or other cardiac problems, as opposed to possible biological side effects of depression. For years, it's been known depressed patients have higher rates of recurring cardiac complications, but the reasons have been unclear.
But the findings also mean genuine healing for these patients can only come from a more challenging remedy - physical activity - as opposed to simply popping another pill.
"That's the good news and the bad news," said Dr. Mary Whooley, lead author of the study and a researcher with the Veterans Affairs Medical Center in San Francisco. "It's something really cheap we can do. The bad news is it's hard to get people to change their behaviors."
The study of 1,017 Bay Area adults with coronary disease found those with depression had a 31 percent increased risk of a recurring heart attack, stroke or other cardiovascular event, and that antidepressants did little to lower that rate. Regular physical activity, however, virtually wiped out the increased risk.
The study is another "call to action" to provide more physical rehabilitation services for patients with cardiovascular disease, said Marie Bass, executive director of the American Association of Cardiovascular and Pulmonary Rehabilitation in Chicago.
Currently, only about 30 percent of these patients are referred to such services, according to a 2007 report by three major cardiology groups, including Bass's organization and the American Heart Association, leaving the rest to devise their own physical therapy regimes.
"If you can't get these guys into formal rehabilitation, it's not going to happen," said Dr. Junaid Khan, president of the East Bay division of the American Heart Association and a cardiac surgeon with Alta Bates Summit Medical Center, with campuses in Berkeley and Oakland.
"If they haven't done it the first 60 years, why would they start now?" Khan asked.
Whooley's carefully designed study analyzed numerous suspects behind the well-known connection between depression and recurring cardiovascular disease. Those included disruptions in levels of neurotransmitters that affect mood and behavior, among other qualities, inflammation, low levels of omega-3 fatty acids, heart rate variability, and increased tendency to form blood clots, as well as aspects like exercise, smoking and a diabetes diagnosis.
Whooley said she expected to find that depression triggered physiological changes that strained the cardiovascular system. But after she and other researchers accounted for all these other factors, exercise still stood out as having the most pronounced effect. The other factors had a minor or non-detectable influence.
"That's phenomenal," said Khan.
Simon Villa, 75, took part in the study, and it helped motivate the San Francisco resident to adopt a regular exercise routine. Errands get him walking most days, and after lunch or dinner he rides a stationary bike for five to 10 minutes. Villa is a retired licensed vocational nurse who had a heart attack in 1997 and again in 2001. The study questionnaire showed he wasn't depressed, although he still has to push himself sometimes to exercise, he said.
"I know if I don't, I'll get into trouble," Villa said. "And you feel better after exercise."
And the research found that even a little exercise was better than nothing.
Wiley Cowan, an 83-year-old study participant, walks to a nearby market in San Francisco regularly, gaining some benefit. But still, he faults himself for not exercising more.
In high school, Cowan earned letters in football, basketball and tennis; during World War II, the former Marine joined fierce fights in Okinawa, Gaudalcanal and other battlegrounds. But now he's at "five percent" of his former physical activity level, he said.
A questionnaire at the start of the study showed that Cowan suffers from depression, and he finds it almost impossible to rouse himself to exercise. Yet after a quadruple bypass surgery in 1999, and two subsequent strokes, he knows he should.
"I guess it's lack of motivation," Cowan said. "I don't have the strength I had before, and calisthenics to me are extremely boring." Two herniated disks also limit his ability to walk.
But Cowan also shared his fears of exercising alone.
His senior center has exercise equipment in the often empty TV room.
"I would like to be monitored while I use it, in case I overextend myself," he said. "And there's no one there to do that."
"We see that all the time," said Cathy Luginbill, RN, coordinator of the cardiac rehabilitation program at Alta Bates Summit Medical Center.
"When people come in, they are very worried about exercising."
It's one reason Luginbill, who's president-elect of the California Society for Cardiac Rehabilitation, and others in her field are pushing hard to expand use of cardiac rehabilitation services.
The Department of Veterans Affairs doesn't offer physical rehabilitation services for its coronary patients, Whooley said, although in some cases Medicare will provide coverage. Medicare has also limited the use of cardiac rehabilitation services, although that's set to change in 2010, after vigorous lobbying by national cardiology groups to expand eligibility for these services.
At Alta Bates Summit, coronary patients are regularly referred to rehabilitation, said Khan, the cardiac surgeon.
"It's more than just exercise," he said. "It's really the educational component."
There's rarely time to adequately discuss exercise during doctor visits, Khan said. "But the rehabilitation facilities are focused on just doing that."
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