Depression with heart disease, stroke, diabetes and pain

A heart attack, a stroke, diabetes or pain that never goes away can change your whole life. Feeling sad or worried for a while is a normal reaction. But for many people, the low mood does not lift. It becomes depression, a real medical illness that needs care of its own.

Depression and physical illness often travel together, and each one can make the other worse.¹ The good news is that depression can be treated, even when you have other health problems.¹ Treating it can help you feel better and take better care of your body.

A two-way street

Doctors now see depression and physical illness as linked in both directions.¹

How illness can lead to depression. Living with a long-term illness is stressful. You may lose things you loved, like work, driving or hobbies. Some illnesses change the brain directly, as a stroke or Parkinson's disease can. Some medicines can also affect mood.¹ A past history of depression raises the risk too.¹

How depression can lead to illness. People with depression have a higher risk of heart disease, diabetes, stroke and pain.¹ Low energy makes it hard to eat well, move your body and keep doctor visits. Depression also changes the body. It is linked to more inflammation (the body's swelling and repair response), changes in heart rhythm control and stress hormones.¹ Learn more in what stress does to the body.

When a person has both, the symptoms of each tend to be worse.¹ That is why it helps to treat both at the same time.

Depression and heart disease

After a heart attack, many people worry about having another one. Some feel down or find it hard to adjust to new habits.⁸ For a large group, this turns into depression or anxiety. A 2023 heart guideline estimates that about 2 to 4 in 10 people with long-term heart disease (20% to 40%) also live with a mental health condition such as depression or anxiety.²

Why it matters for recovery. Depression makes it harder to take heart medicines, go to cardiac rehab, eat well and stay active. It can also make it harder to control blood pressure and cholesterol.² After a recent heart attack or similar heart event, people who screened positive for depression had about twice the risk of another major heart problem.² In one large study, people whose depression was not treated were more likely to die within a year than those whose depression was treated.²

Getting checked. The guideline says it is reasonable for heart doctors to ask about mood, screen for depression and refer people for care.² If no one asks you, bring it up yourself. A short questionnaire, like the ones on our getting checked for depression page, takes only a few minutes.

Cardiac rehab helps mood too. Cardiac rehab is a supervised program of exercise, education and counseling for people recovering from heart problems.⁸ The guideline says it improves depression as well as heart health and survival.² Medicare Part B covers cardiac rehab after a heart attack in the past 12 months, bypass surgery, stents, valve surgery, stable angina (chest pain), stable heart failure and some transplants. You usually pay 20% after the yearly deductible.⁹

Depression after a stroke

A stroke injures the brain, and the brain controls mood. So depression after a stroke can come partly from the injury itself, not only from the hard changes in your life.⁵

It is very common. A review of 61 studies with more than 25,000 people found that about 1 in 3 stroke survivors (31%) had depression at some point. About 1 in 4 still had it one to five years later.⁴ The rate has not dropped over the years, even though good screening tools and treatments exist.⁴

Why it matters for recovery. Depression can make rehab harder. The person may not have the energy or hope to practice walking, speech or daily tasks.⁵ Treating depression and anxiety can help both mood and physical and thinking recovery.⁵

Signs to watch for. Look for sadness, emptiness or hopelessness, loss of interest, tiredness, poor focus, changes in sleep or appetite, or talk of death. If these last more than two weeks, contact the care team.⁵ Depression can be harder to spot when a stroke has affected speech. Ask the stroke team to check mood at follow-up visits, not only movement and speech.

The American Stroke Association runs a Stroke Family Warmline at 1-888-478-7653 for survivors and families, on weekdays.⁵ If you are caring for someone after a stroke, see caregiver burnout and vascular dementia, since stroke can also affect memory.

Depression and diabetes

People with diabetes are 2 to 3 times more likely to have depression than people without it. Yet only about a quarter to a half of them are diagnosed and treated.⁷

Why it matters. Diabetes asks a lot of you every day: checking blood sugar, taking medicine, watching food and staying active. Depression drains the energy you need for all of that. When diabetes care slips, the risk of diabetes-related health problems goes up. Stress can also make blood sugar rise or fall in ways that are hard to predict.⁷

Depression or diabetes distress? Many people with diabetes feel worn out or discouraged by the daily work. This is called diabetes distress. It affects about 1 in 3 to 1 in 2 people with diabetes in any 18-month period.⁷ It can look like depression, but it is different, and medicine does not treat it well. What helps more is support from a diabetes educator, a counselor who knows chronic illness, and focusing on one or two small goals at a time.⁷ Your doctor can help sort out which one you have, or whether you have both.

Depression and chronic pain

About 1 in 5 U.S. adults (21%) live with chronic pain, meaning pain on most days for three months or more.¹⁴ Pain and depression feed each other. Long-term pain can disturb sleep, limit movement and bring on anxiety and depression.¹³ Depression, in turn, raises the risk of pain problems.¹

Several approaches help both pain and coping.¹³ Cognitive behavioral therapy (CBT) and mindfulness programs can lower pain and improve how well people function. Tai chi and yoga help some kinds of back and joint pain.¹³ Read more in chronic pain and mood, ACT for chronic pain and tai chi.

Some antidepressants are also approved for pain. Duloxetine, a type called an SNRI, is FDA-approved for depression and also for nerve pain from diabetes, fibromyalgia and long-lasting muscle and joint pain.¹¹ For a person with both pain and depression, one medicine may help with both. Ask your doctor whether this fits you.

Treatment that is safe alongside your other care

Depression in people with physical illness is treatable. Options include talk therapy, medicine, or both.¹ You may need to try more than one before you find what works.¹

Medicine safety when you have other illnesses

Most people with heart disease, stroke or diabetes can take an antidepressant safely. But the choice needs care, especially in older adults who take many medicines. Your doctor usually starts low and goes slow. Some points doctors weigh:

• Heart rhythm. Citalopram can change the heart's electrical rhythm, a problem seen on an ECG (heart tracing). The risk goes up with higher doses, and the FDA set a lower top dose for people over 60. Doctors take extra care in people with a recent heart attack, heart failure, a slow heartbeat, or low potassium or magnesium.¹⁰
• Older antidepressants. Tricyclics, such as amitriptyline, are not recommended in the early recovery period after a heart attack. They can cause heart rhythm problems and raise the risk of falls in older adults.¹²
• Bleeding. SSRIs and SNRIs can add to bleeding risk when taken with aspirin, NSAID pain relievers (like ibuprofen or naproxen) or blood thinners such as warfarin.¹¹ Many heart and stroke patients take these, so every doctor needs your full list.
• Low sodium and blood pressure. Older adults are more likely to get low blood sodium on SSRIs and SNRIs, especially if they take water pills (diuretics). Duloxetine can raise blood pressure a little, so it should be checked.¹¹
• Side effects after stroke. In stroke trials, antidepressants caused more confusion, sleepiness, shaking and stomach upset than placebo.⁶

Tell all your doctors and your pharmacist about every medicine, vitamin and supplement you take.¹ Talk with your doctor or pharmacist before changing anything. Learn more on antidepressant medicines and medicines and mood.

Tips for living with both

• Ask for a mood check. Medicare Part B covers one depression screening a year in a primary care office at no cost to you, when the doctor accepts Medicare's payment.¹⁶ You can also try our private check-in.
• Keep one medicine list. Bring it to every visit, including the heart doctor, the neurologist and the pharmacy.
• Take small steps. Short walks, a call with a friend or one small task can lift mood a little at a time. See self-help for depression and behavioral activation.
• Find support. Stroke, heart and diabetes support groups can ease loneliness. See support groups.
• Bring someone along. A family member can help remember what the doctor says and notice changes in mood. See helping someone with depression.

When to get help

Make an appointment if low mood, loss of interest or hopelessness lasts more than two weeks, or if you are skipping medicines, rehab or meals because you feel too down. Start with your primary care doctor, who can treat you or refer you to a counselor or psychiatrist.¹

For the bigger picture, return to the depression overview or read depression in later life. Anxiety often comes along with heart and lung disease; see anxiety in later life.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.