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Comorbidities: Depression and Anxiety

Reviewed by: HU Medical Review Board | Last reviewed: November 2019

Comorbidities, the presence of multiple medical conditions in one person, make managing these conditions difficult. The goal is to manage symptoms and select the most appropriate treatment plan. Medical conditions such as kidney disease, diabetes, or even obesity that get the most attention in treatment. Yet psychological factors can also impact the development and course of heart conditions.1


According to the American Psychiatric Association, depression is a condition that negatively affects the way you feel, think, and how you act. It can bring about feelings of sadness, a loss of interest in activities, and a variety of emotional and physical problems.

Depression and heart failure are frequently experienced together.2 People who have a diagnosis of depression develop heart disease at a higher rate than the general population and 1 in 5 people with HF have major depression.3

Depression is a significant concern for people with heart failure (HF) as it is considered a risk factor for mortality.3 The physiologic effects of depression are thought to influence the variability of both heart rate and blood pressure, contributing to worsening symptoms and an advanced level of disease.1,3 People with both HF and depression have a lesser chance of recovery and a higher risk of death than for those without depression.2

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Stress can impact heart health.4 Around 20% of those with HF experience some depression and of those, nearly half develop significant depression.3 This is higher than the rate experienced in the general population which has raised concerns with researchers about the influence of depression on the early identification and management of cardiac conditions.

Heart disease and depression have common symptoms including fatigue, low energy, and difficulty sleeping. Daily activities can feel overwhelming.2 The presence of depression can intensify the sensations of pain, fatigue, and social isolation.4 These can also make the condition of heart failure worse.

Heart failure can be classified according to a functional scale based on the severity of self-reported symptoms. Studies indicate that the prevalence of depression increases as the class of heart failure progresses. When evaluating depression in HF, the most substantial change is seen between The New York Heart Association (NYHA) classes II and III.3

Women experience higher levels of depression than men and women with heart disease are even more likely to have depression.2 This is in part because HF often affects the aging population; and as women tend to live longer and often alone, they may not have a support network that is beneficial to recovery.2


There is no consensus on the optimal treatment for depression, particularly for those with heart failure; but it is clear that without treatment, depression can worsen.1,3-4 The American Heart Association (AHA) recommends all cardiac patients should be screened for depression.4

Attitude can influence the response to treatment. A positive attitude can improve motivation to follow treatment regimens, including taking medications, attending doctor visits, and following a healthy diet and exercise plan.2


Anxiety is a mental and physical reaction to stressful, dangerous, or unfamiliar situations. It can cause a sense of uneasiness or distress.7 A certain level of anxiety is normal and can be helpful keeping people both aware and more productive.6-7 But anxiety can also be debilitating with some people experiencing a high degree of fear and uncertainty.6

Although the relationship between anxiety and heart disease has not been studied as extensively as depression and heart disease, anxiety is a contributing factor to the increase in hospitalizations and mortality rates for people with heart failure.1,6 Like with depression, there is a higher prevalence of anxiety in women. Women more commonly experience panic disorder, generalized anxiety disorder, and other related conditions.6

Anxiety can affect one’s feeling about the ability to breathe and the quality of each breath, causing a sense of panic and chest pain which can be mistaken for or worsen the symptoms of HF.1 Anxiety can cause a physiological reaction that puts an extra strain on their heart. These symptoms can exacerbate existing cardiac conditions by causing an increase in blood pressure and heart rate (tachycardia).6


Effective treatment involves protocols similar to treating heart failure. Following your healthcare team’s instructions, taking prescribed medications, eating a heart-healthy diet, getting sufficient sleep, and resuming social and professional activities.6

Cognitive-behavioral therapy (CBT) and medications are two of the most common and effective treatments for anxiety.6Exercise, which is good for your heart health, is also good for the mind. Yoga, mindfulness meditation, and other relaxation techniques are also helpful in reducing anxiety.7

It is important to differentiate between a panic attack caused by anxiety and having a heart attack because the symptoms are quite similar. Always seek an emergency evaluation for any sudden onset of symptoms including severe chest pain.7