Q J Med 2000; 93: 385-387
© 2000 Association of Physicians
Correspondence |
Seasonal variation in coronary heart disease and seasonal mood changes
Section on Biological Rhythms, National Institute of Mental Health, Bethesda MA, USA
Sir,
I read with interest two articles on seasonal variations in coronary heart disease that were recently published in your journal.1,2 I would like to offer a comment related to these papers.
Coronary heart disease shows a winter peak and summer trough in incidence and mortality.1–3 For example, a recent observational study suggests that there is a seasonal occurrence of acute myocardial infarction that is characterized by a marked peak of cases in the winter month and a nadir in the summer months.3 This pattern was observed in all subgroups analysed as well as in different geographical areas. Pell and Cobbe1 suggest that the seasonal variation in coronary artery disease incidence and mortality is likely to reflect seasonal variations in one or more risk factors: environmental factors such as temperature and ultraviolet radiation; lifestyle risk factors such as diet, obesity, exercise and smoking; other risk factors such as blood pressure, serum cholesterol level, coagulation factors and glucose tolerance; and acute and chronic infections. I propose that seasonal mood changes may contribute to the increased incidence and mortality of coronary heart disease in the winter.4–6
Studies of psychiatric patients, community samples and patients with known heart disease show that depression is associated with increased incidence, morbidity, and mortality of coronary artery disease.7–9 A number of research studies have replicated a consistently strong association between depressed symptoms and risk for coronary heart disease across different population groups and male/female gender. Considerable evidence suggests that depression is an independent risk factor in the pathophysiologic progression of cardiovascular disease.10 Affective disorders adversely influence compliance with therapy and psychosocial rehabilitation, increase medical comorbidity, predict future cardiac events, and hasten mortality.
Since ancient times, people have known about seasonal changes in mood and behaviour.11 The degree to which seasonal changes affect mood and behavior has been called ‘seasonality’.12 Seasonality can manifest to different degree in different persons. A survey in Montgomery County, Maryland, found that 92% of the survey subjects noticed seasonal changes in mood and behavior to varying degrees, and for 27% of the sample, seasonal changes were a problem in their lives.12 Winter seasonal affective disorder, a condition in which depressive episodes in fall and winter alternate with non-depressed periods in the spring and summer, is an extreme form of seasonality.13 Recent studies have demonstrated that seasonal mood changes are related to the genetic factors.14,15 It means that people may have genetically-determined sensitivity to seasons. Because depressive disorders affect incidence, morbidity, and mortality of cardiovascular illness, persons with high levels of seasonality may be at increased risk of developing or worsening of coronary heart disease in the winter.
Patients with cardiovascular disorders who have seasonal mood changes should be identified and receive the appropriate treatment (light therapy, etc.). These patients need more careful medical management during the winter months. The significance of depressive disorders as a public health issue should become a research priority, because of its strong association with coronary heart disease at a time when cardiovascular disorders are still the leading cause of mortality.
References
1.
Pell JP, Cobbe SM. Seasonal variation in coronary heart disease. Q J Med1999; 92:689–96.
2.
De Lorenzo F, Sharma V, Scully M, Kakkar VV. Cold adaptation and the seasonal distribution of acute myocardial infarction. Q J Med1999; 92:747–51.
3.
Spencer FA, Goldberg RJ, Becker RC, Gore JM. Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction. J Am Coll Cardiol1998; 31:1226–33.
4.
Sher L. Seasonal distribution of myocardial infarction and seasonal mood changes. J Am Coll Cardiol1999; 33:2088–9.
5.
Sher L. The possible role of seasonal mood changes in the seasonal distribution of acute myocardial infarction. Psychosomatics1999; 40:364.
6. Sher L. The possible effect of seasonal mood changes on the seasonal distribution of myocardial infarction. Med Hypotheses2000;in press.
7. Barrick CB. Sad, glad, or mad hearts? epidemiological evidence for a casual relationship between mood disorders and coronary artery disease. J Affect Disord1999; 53:193–201.[Web of Science][Medline]
8. Swenson JR. Management of comorbid depression and heart disease: the time has (almost) come. J Psychiatry Neurosci1997; 22:300–2.[Web of Science][Medline]
9. Sher L. Effects of psychological factors on the development of cardiovascular pathology: role of the immune system and infection. Med Hypotheses1999; 53:112–13.[Web of Science][Medline]
10. Nemeroff CB, Musselman DL, Evans DL. Depression and cardiovascular disease. Depress Anxiety1998; 8(Suppl. 1):71–9.
11. Wehr TA. Seasonal affective disorder. A historical overview. In: NE Rosenthal, MC Blehar, eds. Seasonal affective disorder and phototherapy. New York, Guilford Press, 1989:11–32.
12.
Kasper S, Wehr TA, Bartko JJ, Gaist P, Rosenthal NE. Epidemiological findings of seasonal changes in mood and behavior. Arch Gen Psychiatry1989; 46:823–33.
13.
Rosenthal NE, Sack DA, Gillin JC, Lewy AJ, Goodwin FK, Davenport Y, Mueller PS, Newsome DA, Wehr TA. Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry1984; 41:72–80.
14. Sher L, Goldman D, Ozaki N, Rosenthal NE. The role of genetic factors in the etiology of seasonal affective disorder and seasonality. J Affect Disord1999; 53:203–10.[Web of Science][Medline]
15.
Sher L, Hardin TA, Greenberg BD, Murphy DL, Li Q, Rosenthal NE. Seasonality associated with the serotonin transporter promoter length polymorphism. Am J Psychiatry1999; 156:1837.
Thrombosis Research Institute, London
Sir,
Sher concluded that patients with cardiovascular disorders who have seasonal mood changes should be identified and receive the appropriate treatment (light therapy, etc.). He also reported a strong association between coronary heart disease (CHD) and depressive disorders.
At present there is clear evidence of seasonal variation of known cardiovascular risk factors (serum lipids and coagulation factors) and increased cardiovascular mortality during the winter months. However, it might be that several other factors also influence the increased incidence rate of coronary heart disease during winter.
To confirm the importance of seasonal mood changes as an independent cardiovascular risk factor for increased CHD mortality during winter, a multivariate analysis in a large population prospectively studied should be performed.
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