Health Report:

Depression, Stress, Anger & Heart Disease


"A critical weekly review of important new research findings for health-conscious readers..."

By, Robert A. Wascher, MD, FACS

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Last Updated:  03/15/2009

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author.  Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.


According to recent surveys, about 75 percent of Americans are worried, depressed or angry about the economy.  All of us, it seems, know someone who has lost their job recently, and many of us worry that we might be next.  Sleep is hard to come by for many of us during these turbulent and uncertain times, and as I have discussed in recent articles on this website, chronic sleep deprivation, itself, has previously been linked to higher mortality rates in some clinical studies.

A number of illnesses have previously been linked to periods of prolonged stress, and particularly those situations that leave people feeling “helpless and hopeless” with respect to the events that are causing them to feel stressed.  Prolonged periods of severe stress tend to disrupt the normal function of critical systems in our bodies, including the brain, the GI tract, the immune system, the reproductive system, and the cardiovascular system.  Two important and timely news studies, just published in the Journal of the American College of Cardiology, further add to our understanding of the potentially adverse impact of chronic stress on our health.

In the first study, from Harvard University, more than 63,000 women participating in the enormous prospective Nurses’ Health Study were evaluated.  All of these women underwent extensive psychological and physical evaluations in 1992, 1996, and again in 2000.  None of these women had any clinical history of coronary artery disease or stroke at the time that they underwent their initial evaluation in 1992.  The incidence of sudden cardiac death, heart attack, or death due to heart attack was then assessed in this huge cohort of adult women during the 8-year monitoring period.  Additionally, the incidence of clinical depression (as measured by standardized mental health questionnaires and the use of antidepressant medications) was evaluated and analyzed in these patient volunteers.

The presence of clinical depression was found to significantly correlate with the risk of cardiac events in this study, even after controlling for other preexisting coronary artery disease risk factors in these 63,469 women.  The presence of clinical depression was associated with a 49 percent increase in the risk of fatal heart attack (myocardial infarction) due to coronary artery disease.  Sudden cardiac death was also much more common among the depressed women in this gigantic clinical study, and especially among the women who were taking antidepressant medications.  In fact, the women who were taking antidepressant medications experienced more than twice the risk of sudden cardiac death (2.33-fold increased risk) when compared to the women without any history of depression or antidepressant use!

Therefore, clinical indicators of depression, including depression confirmed by standardized mental health screening questionnaires or the use of antidepressant medications, were associated with a strikingly increased risk of coronary artery disease, heart attack, fatal heart attack, and sudden cardiac death.  If you believe that you are depressed (or if family or friends believe that you may be depressed), please see your physician or a mental health expert, as chronic depression can, indeed, be a matter of life or death.

The second, and related, research study that I would like to discuss today focuses more on the role of anger and hostility in coronary artery disease risk.  In the 1970s and 1980s, a great deal of “pop psychology” was given over to classifying personalities into various general types.  Highly driven people, who tend to be impatient, easily-angered, and prone to hostile responses, were categorized as having “Type A” personalities, while their calmer and less driven counterparts were considered to have “Type B” personalities.  Type A people, it was said, are more likely to engage in risky behaviors that increased the likelihood of premature death due to accidents and cardiovascular disease.  Some older research has even suggested that having a Type A personality might be directly associated with a higher risk of cardiovascular disease as a result of chronic anger and hostility, rather than indirectly from engaging in lifestyle behaviors known to increase the risk of heart disease.

In this second clinical study, researchers in London comprehensively reviewed 25 previously published clinical studies of coronary artery disease risk in healthy populations, as well as another 19 studies of patient volunteers with existing coronary artery disease.  All of these studies included assessments of personality profiles among the patient volunteers who participated in these clinical research trials. 

Among the studies of previously healthy volunteers, those patients who scored highly on psychological assessment tools in terms of anger and hostility were nearly 20 percent more likely to develop evidence of new coronary artery disease (including heart attack) when compared to the patients who had very low hostility and anger scores.  Among the patients who were known to already have coronary artery disease at the time that they enrolled in these studies, there was a 24 percent greater likelihood of serious complications associated with coronary artery disease among the angry and hostile patients, including death due to heart attack, than was observed among the heart disease patients who were not predisposed to anger and hostility.  Interestingly, as has been observed in previous research studies, the incidence of coronary artery disease events, including heart attack and death due to heart attack, appeared to be significantly higher among angry and hostile men than was observed among angry and hostile women, particularly among the study volunteers who had no prior history of coronary artery disease at the time that they enrolled in these studies. 

In summary, this comprehensive review of previously published data appears to confirm the findings of earlier studies that chronic anger and hostility appear to be associated with an increased risk of coronary artery disease and heart attacks, even when other preexisting coronary artery disease risk factors are controlled for.  Furthermore, this analysis suggests that having an angry and hostile predisposition is probably more dangerous for men than for women, although both genders probably experience an increased risk of heart disease if they are chronically angry or hostile.  Finally, angry and hostile people who develop coronary heart disease appear to have a worse prognosis when compared with mellower folks who also have the equivalent extent of heart disease. 

As with the link between chronic depression and heart disease, chronic feelings of anger and hostility appear to increase one’s risk of developing heart disease too.  If you believe that you are susceptible to depression, or to regular or frequent feelings of anger and hostility towards others (or towards yourself, for that matter), then you owe it to yourself, and to those who care about you, to seek help.  These mental health and personality difficulties are often extremely difficult to resolve by yourself, no matter how much insight and motivation you might already have.  If you struggle with any of these issues, or if other people who know you and care about you have suggested that you have problems in these areas, then please seek help now.

Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity


Dr. Wascher is an oncologic surgeon, a professor of surgery, a widely published author, and the Physician-in-Chief for Surgical Oncology at the Kaiser Permanente healthcare system in Orange County, California




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Copyright 2009.  

Robert A. Wascher, MD, FACS.  

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