Building on evidence from numerous studies citing the adverse health consequences of  depression on a patient’s recovery after a cardiovascular event and other serious illnesses, researchers in Duke’s Department of Psychiatry and Behavioral Sciences are focusing on the benefits of stress management, physical exercise, and other lifestyle changes to diminish depressive symptoms and improve clinical outcomes.

“Historically, depression and anxiety have been underrecognized and undertreated, but through a number of studies we know that patients with depression are at increased risk to die after a heart attack compared to patients without depression,” says James A. Blumenthal, PhD, a Duke clinical psychologist and a JP Gibbons Professor of Psychiatry. “In the same way we recognize cigarette smoking, high blood pressure, and elevated cholesterol levels as cardiovascular risk factors, stress and depression are also important considerations in evaluating risk,” he says.

In several studies of patients with major depression or with ischemic heart disease and elevated symptoms of depression (see Additional Resources), researchers found that exercise appears to be just as effective as antidepressants and better than placebo in treating depression.

Findings from another recent study showed that providing stress management training also improved clinical outcomes in patients after a myocardial infarction when paired with exercise-based cardiac rehabilitation, as opposed to exercise-based rehabilitation alone. “These are important findings. Although cardiac rehabilitation is the standard of care for patients with coronary disease it tends to be underutilized, with only about 20% of patients actually participating in programs for a variety of reasons,” says Blumenthal, who was the study’s lead investigator.  “While stress management is not typically included routinely in cardiac rehabilitation programs, our findings demonstrate that stress management provides added value to cardiac rehabilitation and should be included as a component of cardiac rehab for all patients.”

Another group of patients that Duke is studying are those who have undergone lung transplantation. Blumenthal reports that new research, in collaboration with Scott Palmer, MD, director of the pulmonary research program at the Duke Clinical Research Institute, and Duke’s Department of Medicine and Division of Pulmonary Medicine, will examine the potential benefits of a telehealth intervention to improve patients’ coping skills and help them engage in more physical activity postoperatively. “These patients may be anxious and distressed when they return home after undergoing a transplant, so we want to provide a bridge between hospital and home—encouraging patients to do regular physical activity, take their medications as prescribed, and learn skills for coping more effectively with everyday stressors.”

With one of the largest solid organ transplant centers in the U.S., Duke’s transplant program engages faculty from the Department of Psychiatry as consultants on patients’ care teams. “We see virtually every patient undergoing lung transplantation and many patients undergoing heart, liver or kidney transplantation,” says Blumenthal. “Physicians recognize that it is important to make sure that patients are coping with the stress of surgery and the ongoing challenges of living with chronic illness,  so part of our role is to help patients adopt healthy lifestyles and cope with the stress and anxiety that they face.”

Blumenthal notes there are a number of ways in which physicians can help their patients with serious illnesses combat depression and enjoy a better quality of life, in addition to improving clinical outcomes:

• Recognize that depression is not uncommon in patients with chronic illness, and is associated with increased medical expenses, reduced quality of life, and worse clinical outcomes.

• Recommend a regular program of physical activity for most patients who can exercise safely to improve their cardiovascular risk factors and emotional well-being, whether it’s a structured program or something patients can do on their own.

• Refer patients with persistent depression or anxiety to a mental health professional.

Additional Resources

Blumenthal was the lead investigator for these studies on the effects of exercise on depression:

• Effects of exercise training on older patients with major depression
• Exercise and pharmacotherapy in the treatment of major depressive disorder
• Exercise and pharmacological treatment of depressive symptoms in  patients with coronary heart disease: results from the UPBEAT (understanding the prognostic benefits of exercise and antidepressant therapy) study