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The physical needs of someone recovering from a heart attack, cardiac arrest or major heart surgery can be easy to understand. For many people, the mental and emotional healing may be less so.

Issues such as depression, anxiety and post-traumatic stress regularly affect not just patients but their loved ones, experts say, and have a direct influence on healing.

"Addressing depression is important," said Julie Cunningham, a clinical health psychologist who works with cardiac patients at Samaritan Medical Group in Corvallis, Oregon. "Not just for mental health – it's actually really important for cardiac health, too."

Patients who have depression recover more slowly after heart surgery, she said. "They are going to have a harder time engaging in and completing programs like cardiac rehab, which are really, really important to their recovery," she said. And a depression diagnosis after a heart attack can lead to a higher risk of death, according to a study published in in 2017.

Mental health disorders can follow all sorts of cardiac problems. Studies have shown that depression or anxiety affect more than 30% of people who have their aortic heart valve replaced and 30% to 40% of people who have heart bypass surgery.

Traumatic experiences

Each cardiac experience poses a different type and level of mental health risk, said Dr. Sachin Agarwal, director of the NeuroCardiac Comprehensive Care Clinic at Columbia University in New York.

Someone who has a heart attack – where blood flow to the heart is blocked – may experience chest pain or shortness of breath and may seek emergency treatment. Agarwal, who also is an associate professor of neurology, said 1 in 8 heart attack survivors will experience post-traumatic stress.

People who experienced even minor strokes talk about feelings of terror, and nearly 1 in 4 survivors of any stroke report PTSD a year later, according to a study published in in 2018.

Someone who goes into cardiac arrest – where the heart stops suddenly – is unconscious while their life hangs in the balance but wakes up days or weeks later in an ICU with no memory of how they got there. A third will have PTSD symptoms, Agarwal said, and as many as half will have depression at hospital discharge.

Agarwal, who studies psychological distress in cardiac arrest survivors, said people who experience such PTSD symptoms often become anxious, show signs of hypervigilance, have trouble with concentration or sleeping and avoid the places and behaviors that remind them of the traumatic event.

Heart surgery can sometimes also cause cognitive problems along with mental health issues, Agarwal said. A prolonged hospitalization can lead to post-hospital syndrome or post-ICU syndrome, umbrella terms that encompass a range of physical and psychological problems.

Researchers are aware of many biological links between depression and heart disease. And Cunningham said a heart crisis can trigger many emotional issues. Patients can dread a recurrence of a sudden problem or feel glum if care is needed because of a worsening long-term condition.

They could grapple with reduced physical ability. "They may not be able to work any longer," she said. "They may not be able to engage in hobbies, or exercise to the degree they had in the past."

Someone who was always a caregiver might suddenly be the one who needs care. And their caregivers face risks themselves.

A shared problem

A cardiac crisis "can affect the family unit in a lot of ways," Cunningham said. "Frankly, I see patients come to visit me far more often with loved ones than with any other patient population I've worked with."

Some loved ones, she said, might want to help with the recovery but feel stress because it's outside of their control. Adult children may be shocked to learn they stand to inherit a condition that threatens their own health.

Agarwal said that with cardiac arrest, family members may experience an entirely different type of trauma than their loved one. Most out-of-hospital cardiac arrests, he noted, happen at home. It's often a family member who calls 911, begins CPR, makes hard decisions and wonders whether their loved one will wake up.

While survivors face existential issues once they learn what happened and become more concerned about the future, witnesses – most often close family members – have memories of everything and still grapple with hallmark features of PTSD such as flashbacks. Agarwal was senior author of a review of prior research, published in March in the journal , showing that in some studies, family members reported even higher levels of distress than cardiac arrest survivors.

Such emotional problems can affect the heart patient's health, he said, if it limits caregivers' ability to tend to them.

Cunningham said a mental health issue can appear in many forms. Depression alone can involve a loss of interest in something a person used to enjoy. It also can cause irritability, frustration or apathy. It can include sleep issues or appetite changes.

"It doesn't have to just be sadness or feeling down," she said, and all those symptoms "can then make it really hard to do the things we need to do to take care of our health," such as go to medical appointments.

Heart-specific anxiety, Agarwal said, often shows up in survivors as a preoccupation with minor changes in body symptoms, such as increased heart rate, combined with an inability to distinguish between those that are threatening and those that aren't. Cardiologists, he said, are used to getting calls from patients whose only symptom is a fear that "something's not right," after which emergency room doctors find no signs of trouble.

How to cope

For many patients, Cunningham said, a crucial step to dealing with such issues is to go through cardiac rehabilitation, a specialized program that typically includes education about stress and emotional factors. It also includes supervised exercise, which in itself has been shown to help reduce symptoms of moderate depression. Cardiac rehab staff also can be a source of emotional support for patients, she said, and help make referrals to therapy.

Cardiac rehab also is an opportunity to socialize with other heart patients. "That's really important," she said. It can also teach about the recovery process and help with "normalizing the fact that these emotional responses are common."

For people not in cardiac rehab, a cardiologist or primary care doctor can offer suggestions for therapists, Cunningham said. Her own counsel to patients often starts with encouraging them to get back to daily routines as best as they are physically able.

"As they're recovering from surgery, they might not be doing as much as they had done before surgery," she said. But even things like getting out of bed, getting dressed and having breakfast are important.

"There's a fancy term for that," she said. "We call it behavioral activation." That's simply "the idea of getting people back into enjoyable and meaningful activities to feel better, and it works."

Agarwal said he and other researchers are actively looking into ways to predict mental health issues in cardiac patients and for ways to incorporate families into the healing process.

He said he was drawn into this area of research because families were desperate for help, and it was clear that health care systems needed to do more. "You can't leave it on the families and the patients to find us or find the resources," he said. "The onus is on us to find equitable ways to get resources into the hands of people who need it the most."

Cunningham has had similar experiences. "I think sometimes, medical teams assume patients may know that they have depression and anxiety because we see it," she said. "But it can be pretty powerful to have a conversation with patients and help them connect the dots, because somebody may not have yet told them."

Heart patients and families need to be aware how common depression and anxiety are, Cunningham said. "It doesn't mean there's anything wrong with you as a person. We know that this is a really common response."