Patients with depression, anxiety or stress are more likely to drop out of cardiac rehabilitation, reports a study published on World Mental Health Day in the European Journal of Preventive Cardiology, a journal of the European Society of Cardiology (ESC).

'Heart patients living with depression are more likely to feel despondent and hopeless, which reduces their ability to manage their symptoms,' said study author Angela Rao, of the University of Technology Sydney, Australia. 'They may minimise successes and exaggerate failures, thereby reducing their motivation to exercise and complete a cardiac rehabilitation programme.'

'Anxiety may lead to fear of another cardiac event and stop people from being active,' she continued. 'Depression and anxiety can also impair the ability to retain new information needed to make health-related behaviour changes.'

After a heart attack or procedure to open blocked arteries, patients should be supported to quit smoking, take up exercise, improve their diet, reduce stress, and control blood pressure and cholesterol -- this is achieved through cardiac rehabilitation.

This retrospective study examined the prevalence and impact of depression, anxiety and stress in patients attending cardiac rehabilitation at two hospitals in Sydney between 2006 and 2017. A total of 4,784 patients completed the Depression Anxiety Stress Scale (DASS-21) questionnaire.

Some 18%, 28% and 13% of participants had moderate to extremely severe depression, anxiety or stress, respectively. Patients with moderate symptoms of depression (24% versus 13%), anxiety (32% versus 23%) or stress (18% versus 10%) were significantly more likely to quit cardiac rehabilitation compared to those with no or mild symptoms.

'Depression can dampen positive intentions to exercise even when receiving support from health professionals and being aware of the benefits,' said Ms Rao. 'People with anxiety may underestimate their abilities -- for example to walk on a treadmill during a rehabilitation class.'

Around one half of those with moderate depression or anxiety who completed cardiac rehabilitation did not show significant improvements in these conditions.

Depression, anxiety and stress were related, with one increasing the likelihood of the other. Patients with anxiety or stress were more than four times more likely to be depressed than those without. Anxiety was three times more common in patients with (versus without) depression and more than five times more frequent in those with (versus without) stress. 'These relationships were independent of age, sex, clinical characteristics, medication use and quality of life,' said Ms Rao.

She urged clinicians to screen for depression and anxiety at the start and end of rehabilitation to identify those needing extra help. Stress management, cognitive behavioural therapies, meditation and mindfulness can be included to improve mental health and raise participation. Patients should be asked if they wish to be referred for additional psychological assistance.

She concluded: 'Patients who attend cardiac rehabilitation programmes do better than those who don't. If you think you may need extra support or are hesitant to seek help, it's advisable to attend the initial assessment as a first step. There may be options you feel more comfortable with, such as completing a programme at home.'