What’s it like to have a heart attack when you’re young?
Dr Chris Merritt is a Clinical Psychologist who divides his time between mental health research at King’s College London and clinical work in South London and Maudsley NHS Foundation Trust. He works with patients who have depression, anxiety problems and Post-Traumatic Stress Disorder, as well as those managing physical health conditions.
Heart attack is one of the biggest killers in the UK, but it’s relatively rare in younger adults.
Among over-75s, around one in eight people in Britain has had a heart attack. Compare that to under-45s, and the figure becomes one in two thousand. Rare, but across the whole country that still amounts to a lot of people — and thousands of new cases every year.
There are two interesting things about this young heart attack population.
First, in this age group the rate of heart attacks is not decreasing, as we have seen over the last thirty years for middle-aged and older adults. The reasons for this are unclear, but may point to lifestyle factors for younger people: smoking, long periods of inactivity (e.g. on computers at desk jobs), unhealthy diets.
Drug use can be a contributing factor in some cases, particularly from cocaine and amphetamine use, because of their effects on the heart and the coronary arteries. These factors need to be addressed to help prevent heart attacks in young people.
Second, because a major health event like a heart attack is not normal at that age, it has a massive psychological impact — much greater than for an older person.
Detailed measurement of mental health post-heart attack tells us that younger patients experience greater levels of depression, anxiety and Post-Traumatic Stress Disorder (PTSD). This is despite typically being in better physical health after the event than older heart attack patients.
However, very few studies have looked at what it was like to have a heart attack if you’re young — and what that might tell us about why younger patients experience more mental health difficulties after the event. In fact, no one had studied exclusively under-45s using in-depth interviews. I set out to do this as part of a research project at King’s College London on heart attacks in young adults.
Since 90% of heart attack patients below 45 years old are men, I focussed on male patients.
I interviewed a group of them and analysed the themes from what they told me. So what did I find? Here are four key points:
1. ‘Life loses its colour’ — younger men who’ve had a heart attack find that life changes overnight. One day they’re active, strong, working, socialising, in relationships, perhaps a parent of young children, feeling in the prime of life. Next day they’re at home, recovering from a heart attack. The first problem that sets in is boredom. They’ve usually been told to rest, and soon they get a visit from a cardiac nurse who tells them not to smoke, drink alcohol, eat fatty foods or any of the other things they probably enjoyed in life pre-heart attack. This loss of activity and pleasure would cause anyone to feel low, even depressed, let alone someone who’s had a heart attack.
2. ‘Shortened horizons’ — the heart attack is typically the first time that a younger adult seriously considers the possibility of their own death. This tends to cause anxiety, in two ways. Firstly, worry about the future. Many began to wonder how much longer they had left to live, and what would happen to loved ones if they died. Secondly, any small physical sensation in their body (an arm ache, a chest pain) makes the patient think there might be another heart attack on the way, which sets off symptoms of panic. The racing heartbeat, sweating, hotness and other symptoms of panic are very similar to the heart attack itself, which feeds the belief that it’s a heart attack again. Many younger patients don’t want to experience this, so they reduce activity levels. As we saw in the first point above, this can lower mood and cause depression, as well as negatively affecting rehab.
3. ‘I’m less of a man’ — many younger men felt that the heart attack had taken away some of their manliness. They believed this had happened in areas of life where men are — according to social norms and expectations — supposed to be ‘capable’. Many felt their independence was lost, and they were no longer able to do simple things for themselves. Physical strength was threatened: young men described the embarrassment of female partners or older parents offering to carry and move things for them. Financial power took a hit too: for those self-employed patients or others who felt their job stress contributed to the heart attack, the thought of reducing work or even changing careers usually meant earning less money. And that meant they couldn’t provide for their families. Again, stress resulting from a perceived ‘male’ role.
4. ‘It’s not all bad’ — there was hope too, despite the many aspects of negative psychological impact. All the younger men I interviewed could find something positive about the heart attack, even just a few months afterwards. This was usually either a positive lifestyle change they had made, for instance quitting smoking and noticing their breathing was easier, or cutting down fatty foods and noticing they were trimmer. But it also included passing on new knowledge about diet, smoking and exercise to others close to them: family, partners, friends, colleagues. They wanted others to avoid the same mistakes they had made, and many said this ability to help others was the greatest benefit of the heart attack.
Bringing these findings together, what can we learn?
First, it gives us some idea why younger people experience more mental health problems than older patients post-heart attack. They’ve lost a life of high activity, an identity as a ‘capable’ person in the prime of life, and their future now seems shorter. These problems rarely occur for older patients (over-75) because their lives are different: typically they are less active than a forty-year-old, no longer work or have parenting responsibilities, and would not expect to live another forty or fifty years.
These mental health difficulties for younger patients can impact on rehab. If you’re depressed and anxious, you’re much less likely to do attend rehab, exercise, take medications, and make lifestyle changes (like quitting smoking). All of that makes recovery from a heart attack harder.
So, I believe we need to focus more on the mental health of young heart attack patients. This is often neglected because their physical health is usually fine after a heart attack, and they tend to be discharged more quickly than an older patient. But what may be suffering is their mental health — and that can affect their physical rehab in turn.
Awareness of why young people experience mental health problems after a heart attack can help us set up systems to treat these problems — screening, assessment and intervention from psychologists and other mental health specialists embedded in cardiac teams, or referral by cardiac teams to local psychology services. We could also provide quick access to cardiac rehab and develop peer support groups to allow younger heart attack patients to connect with each other. Many younger patients feel alone and benefit from meeting someone else who’s been through the same experience.
Heart attacks in younger adults are rare, but associated with greater mental health challenges than older patients tend to experience. And because psychological health affects physical rehab, we can do more to help this group recover.
See more of Chris’s blogs and psychology writing at www.cjmerritt.co.uk he can be found tweeting at @DrCJMerritt