It may be that a certain type of depression is more closely associated with inflammation and CV risk, according to research that appeared in a 2014 issue of the Journal of Behavioral Medicine.3 An estimated 15% to 40% of patients with depression have atypical depression, which is characterized by situational mood improvement and other symptoms such as excessive appetite and oversensitivity to rejection and perceived criticism.4 The study findings showed that twice as many participants with atypical depression had CRP levels that were indicative of increased CV risk.3

These findings underscore the importance of paying “attention to psychosocial health, not just the nuts and bolts of what we do,” Dr Quyyumi told Cardiology Advisor. It is important for clinicians to recognize that depression may have a more significant influence on CV health than previously known, and treating it may improve CV outcomes, he added.

The IMPACT Intervention trial found that patients with depression who were treated with antidepressants and psychotherapy had a 48% lower risk of heart attack and stroke than patients who did not receive psychological treatment.5 However, early intervention appears to be key, as no change in risk was observed for patients who already had heart disease when the study began.

“[We need to] recognize that the incidence of depression is high in this population, and if depression is present, outcomes are much worse,” said Dr Quyyumi. The BDI-II is very simple to administer: It only takes 5 minutes or less to complete and is easy to score. “Simply asking about depression can alert you to the fact that this patient may be at higher risk of adverse outcomes.” Even if depressive symptoms do not improve at a given time, he said, patients should still be encouraged to exercise regularly in an effort to minimize the potentially negative effects of depression of CV risk, as exercise helps reduce some of the factors that drive heart disease.

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Andrew M. Freeman, MD, director of clinical cardiology at the National Jewish Health facility in Denver, Colorado, recommends that exercise be part of a daily “power hour,” in which patients who are medically cleared for it spend the first 30 minutes doing exercise like jogging, walking or swimming. For the remaining 30 minutes they should engage in a mindful activity of their choosing, which might include watching the sunset, engaging in a favorite hobby, or doing yoga, meditation or deep breathing, for example.

The key is to neutralize some of the buildup of stress that may be linked with depression and CV risk. “The mindfulness part of treatment is generally absent,” in this population, said Dr Freeman, who spoke with Cardiology Advisor on behalf of the American College of Cardiology’s Patient-Centered Care Committee.  “The medical word we came up with for high blood pressure is hypertension, which literally means ‘too much tension,’ but when was the last time you asked about the psychological tension in a patient’s life?”

Being patient-centered and taking time to really listen is essential, said Dr Freeman, who encourages physicians to explore the metaphor of heart disease in patients’ lives. Considering that inflammation is another word for irritation, for example, clinicians might ask a patient to think about what could be “inflaming” or irritating him or her.

Clinicians should also be sure to ask standard questions like those included in the SIG E CAPS (Sleep disturbance, Interest/pleasure reduction, Guilt feelings or thoughts of worthlessness, Energy changes/fatigue, Concentration/attention impairment, Appetite/weight changes, Psychomotor disturbances, Suicidal thoughts) screening for depression, which touches on various cognitive and somatic symptoms of depression.6 Dr Freeman advises clinicians to be equipped to suggest some stress-reduction techniques or mental health referral sources if needed. A psychological emergency could potentially be detected and averted just by taking time to ask the right questions.


  1. Al Mheid I, Held E, Uphoff I, et al. Depressive symptoms and subclinical vascular disease: The role of regular physical activity. J Am Coll Cardiol. 2016;67(2):232-234.
  2. US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Physical Activity Guidelines for Americans. Accessed January 22, 2016.
  3. Hickman RJ, Khambaty T, Stewart JC. C-reactive protein is elevated in atypical but not nonatypical depression: data from the National Health and Nutrition Examination Survey (NHANES) 1999– 2004. J Behav Med. 2014;37(4):621-629.
  4. Quitkin FM. Depression with atypical features: diagnostic validity, prevalence, and treatment. Prim Care Companion J Clin Psychiatry. 2002;4(3):94-99.
  5. Stewart JC, Perkins AJ, Callahan CM. Effect of collaborative care for depression on risk of cardiovascular events: data from the IMPACT randomized controlled trial. Psychosom Med. 2014;76(1):29-37.
  6. Powell DL. Depression–Review of Symptoms. 2005. Accessed online on 01/22/2016 at