It is now firmly documented that depression, anxiety, and sub-syndromal characteristics like "hopelessness" are powerful independent risk factors for the etiology of cardiovascular disease(CVD) and CVD- related morbidi ty and mortality-being as dangerous to cardiovascular health as smoking. Depression and anxiety are also the chief reasons why people smoke and have a difficult time quitting, fail to exercise regularly or eat a heart-smart diet, do not see a physician when they should, and fail to follow physician's orders. Indeed, the latest research strongly suggests depression and anxiety may well pose the single largest overall risk for heart di sease et iology and poor prognos i s. Approximately two-thirds of all heart patients experience depression or anxiety at some point along the disease continuum.

Etiologically, anxiety and depression are caused chiefly by chronic stress. The World Health Organization estimates that, owing to increasing levels of stress worldwide, the incidence of depressive disorders is rising rapidly, so much so that by 2030, depression is expected to be the number one cause of disease burden worldwide, even eclipsing CVD. Nowhere can this trend be seen more clearly than in India, where rates for depression and anxiety are among the highest in the world: twice that of the United States and three times higher than the average rates for all other developing nations. These data indicate that any successful strategy to reduce CVD-related morbidity and mortality in India would include a focus on the early detection and treatment of depression and anxiety among heart patients and those at risk for heart disease (i.e., patients with metabolic syndrome, hypertension, and diabetes).

Screening and treating heart patients for depression and anxiety, though it is now the standard of practice in the United States and Europe, has proved challenging in the cardiac setting owing to limited clinical staff time and financial resources. In India, the biggest barrier to addressing the psychological needs of heart patients stems from the absence of doctoral-level mental health professionals capable of treating this population. This article looks at the association between clinical and sub-syndromal depression, anxiety, and heart disease with an emphasis on the following: 1) the magnitude of the association, 2) what is required for effective treatment of depression and anxiety for patients with CVD, and 3) one innovative, low-cost way to deliver mental health care to heart patients that does not require additional time from the busy physician.