Wellness: A Proposed Definition

There has been much written about the importance of promoting "wellness" in value-based care. Yet there is no definitive definition of the concept. In this post I offer a conceptual framework for discussion in which I attempt to delineate many of the key factors discussed in the literature, along with my observations as a clinical psychologist. 

Proposed definition: Wellness is a measure of a person’s overall state of health, which is greatest when a person has and uses a set of abilities, desires, behaviors, and resources to avoid, manage, and cope with physiological, psychological (mental and emotional), and mind-body health problems to the extent possible.

The Following delineates some of the concepts in this proposed wellness definition.

1.      Health problems include (but not limited to):

1.1.   At-risk, acute, subacute, chronic, catastrophic, and end-of-life conditions.

1.2.   Illness, injury, dysfunction, disability, disfigurement, and debilitating distress with associated causes (e.g., contagion, trauma, genetics, etc.) and signs and symptoms (physical, emotional, behavioral, and cognitive).

1.3.   Mind-body (biopsychosocial) health problems in which psychological distress adversely affects a person’s physical health and vice versa.

2.      Requisite abilities, resources, and desires include:

2.1.   Abilities:

2.1.1.      Psychological capabilities that enable people to cope effectively with their health problems in a way that reduces the likelihood of denial, ignorance, self-deception, debilitating depression, irrational despair/discouragement and fear, hostility, blame, shame, and self-destructive behavior. These capabilities include focused awareness, rational and adaptive beliefs/thoughts/cognitions, open-mindedness, adequate drive/motivation/will and impulse control, self-determination, reasonable self-confidence, self-understanding, self-acceptance, sound/logical reasoning, reliable knowledge, and intelligence.

2.1.2.      Behavioral capabilities characterized by proactive, competent, and responsible actions that include adherence to evidence-based care plans/guidelines and making recommended lifestyle changes.

2.2.    Social, economic, and environmental resources (e.g., having access to quality healthcare, good health literacy, money, time, a healthy/safe living environment, social/family support, education and access to useful information, access to foods that support healthy eating patterns.

2.3.    Desire to live and develop one’s potential for a fulfilling life characterized love, learning, accomplishment, and other positive activities, experiences, and feelings.

A Whole-Person Approach to Diabetes Health Education Part 2 of 4

In my last post, I presented an overview of the mind-body approach to diabetes health education. In this post I give a more in-depth examination of the psychological factors influencing blood glucose control, starting with the effects of emotional depression.

Psychology of Diabetes: How Mind Affects Health

Diabetes requires extreme changes to many people's lifestyles. They must change from a sedentary to health-conscious lifestyle. Instead of eating junk food and watching television, they have to begin eating healthy food, exercise regularly, monitor their blood sugar level multiple times a day, control their blood pressure and cholesterol, have regular eye and foot exams, stop smoking, and possibly take medications (which may include self-injection). Adopting these lifestyle changes and adhering to these self-management routines requires education and guidance, of course. Many diabetic individuals, however, need more than knowledge and instruction. The reason: Psychological obstacles interfere with their ability and willingness to make such dramatic lifestyle changes.
These psychological obstacles may include maladaptive (inappropriate, detrimental) attitudes, coping skills, and emotions. For example:

• Lack of self-confidence is enough to deter some people from even trying to change their lifestyle since they expect to fail.
• Just looking at a sugary snack can cause some people to worry about the life-threatening aspects of their disease, or feel depressed and angry that they must deprive themselves.
• Failure to keep up their exercise routine or eating poorly can also make them feel those same negative emotions. Unhealthy behavior can also make them feel guilty or ashamed for not doing what they should.

Unfortunately, instead of motivating them to control their diabetes, these attitudes and emotions can have the exact opposite effect; they may cause diabetic people to stop trying because they feel hopeless and helpless. Or equally harmful, they may deal with their painful feelings by ignoring their health through denial and self-deception. Following are some examples of the deleterious effects of these psychological obstacles on diabetic individuals.

Depression and Diabetes Management

Health Effects of Depression
Research shows that depression in diabetic people is associated with poorer diet and medication adherence, functional impairment, and higher health care costs.[1][2] This is often a vicious cycle. When the demands of diabetes care or complications of the disease lead to depression, a person feels overwhelmed, hopeless, helpless, and exhausted. These feelings, in turn, destroy one's motivation, which impairs self-management. Failure to manage one's diabetes results in greater health problems, which exacerbate the depression. And the cycle repeats.

Likewise, depressed people are unlikely to modify their behaviors to extend their lives because the prospect of living longer in chronic emotional pain shatters their willingness to change. Furthermore, depressed diabetic individuals may refuse to acknowledge that their illness can severely harm or kill them because the idea is too emotionally painful to accept. This means that the threat of serious complications or death is not a powerful motivator for some. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Dealing with Depression
Fortunately, there are effective ways to help diabetic people overcome the psychological obstacle of depression. For example, compelling discoveries in the fields of cognitive science, linguistics and neuroscience are demonstrating the promise of "reframing" techniques. One useful reframing method helps depressed people develop a vision of "joy of living" rather than a "fear of dying," since joy can be a more powerful motivator than fear. Incorporating this kind of reframing approach into diabetes health education can promote positive changes in people's way of thinking, resulting in increased motivation to live more healthily.[3]

Diabetic people also need good coping strategies for dealing with depression (and other emotional disturbances). Some coping strategies attempt to reduce one's emotional distress by promoting adaptive (effective, useful) ways of thinking, feeling, and acting when trying to manage their illness (or other problems); other strategies, however, are maladaptive. Ten common strategies people use include five adaptive and five maladaptive coping methods.

The five positive, adaptive coping strategies help a person solve a problem or learn to accept it with minimal distress:

• Logical Analysis involves trying to understand what caused the health problem and different ways to handle it.
• Problem Solving involves developing specific plan of action to manage the problem, implementing it, learning from the results, and then modifying the plan and trying again if necessary.
• Social Support involves explaining the problem to other people and asking them for advice or help; this includes peer group support.
• Positive Reappraisal involves viewing the problem as helping the person change or grow in a good way, find new faith, or learn valuable lessons.
• Rational Acceptance involves accepting—without undue emotional distress and without self-defeating behaviors—that nothing can be done to cure one's illness; at the same time, it encourages the person to do what is necessary to prevent complications.
• The five negative, maladaptive coping strategies fail to resolve one's problems, do not enable healthy acceptance, and may even make the situation worse:
• Behavioral Distraction involves trying to feel better emotionally by doing enjoyable or interesting things, rather than dealing with the health problem proactively or coping with it through positive reappraisal and rational acceptance. While it may help reduce a person's emotional distress temporarily, this strategy is maladaptive because it will never improve the situation, does nothing to help one cope with it long-term, and can actually make matters worse through inaction. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem.
• Cognitive Avoidance involves acting as if there is no problem, or trying not to think about the problem. As with behavioral distraction, the strategy may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Emotional Discharge involves expressing negative emotions by yelling or crying, taking it out on others, or avoiding certain situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never improve the situation and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people who could have been helpful and push them away.
• Wishful Thinking involves hoping a miracle will somehow make things better, or that one's wishes or prayers would somehow be answered. This, too, may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Resignation happens when a person determines that nothing can be done to fix a problem, so he or she does nothing, while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helpless), and/or anger. This, too, is obviously maladaptive.

It stands to reason, therefore, that helping depressed persons in diabetes health education programs deal with their depressions—through reframing, coping skill training [4], and other methods—will result in better outcomes (i.e., more effective control of blood glucose, blood pressure, etc.).
In my next post, I discuss how mental stress and personality factors affect diabetes management.

References:
[1] Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. 1: Arch Intern Med. 2000 Nov 27;160(21):3278-85. See http://www.ncbi.nlm.nih.gov/pubmed/11088090

Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, Blais MA, Meigs JB, Grant RW. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. 1: Diabetes Care. 2007 Sep;30(9):2222-7. See this link

[2] Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001 Jun;24(6):1069-78. See this link

[3] Deutschman, A. Change or Die. 2005 May. See this link

[4] Grey, M. Coping and Diabetes. Diabetes Spectrum. 2000 13(3),167. See this link
Grey, M. & Berry, D. Coping skills training and problem solving in diabetes. Curr Diab Rep. 2004 Apr;4 (2):126-31

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 2

Last week, in part 1 of the WPIC solution, I began defining a new type of wellness program based on a whole-person integrated-care (WPIC) model, which takes a whole-person (mind, body, spirit, and environment) view of health, and which coordinates sick-care with well-care across the entire healthcare continuum. I included an introductory discussion of the value proposition of such a wellness program and its goals and methods. I also mentioned that (at least) four types of people with different character traits require different approaches to wellness due to their other thoughts, emotions, behaviors, knowledge & understanding, and coping strategies. In this post and future ones, I examine these differences.

Definitions

Since I'm presenting additional terms, let me take a moment to define them:

• Thoughts refer to a person's attitudes, beliefs, perceptions, assumptions, reasoning, expectations, memories, "self-talk," and other mental processes (i.e., one's cognitions).
• Emotions refer to a person's feelings and moods (i.e., one's affect).
• Behaviors are what a person does (i.e., one's actions).
• Knowledge & understanding are related terms, which I discuss in some detail at this link. Briefly, knowledge refers to information someone knows about essential things, such as relevant people, things, places, times, reasons, rules, and methods. Understanding, on the other hand, is being able to apply that knowledge when doing such things as:
  
  • Explaining, interpreting, discovering, and gaining insights into the nature of things
  • Noticing contradictions/inconsistencies
  • Using logic and evidence to support decisions, make accurate predictions, and judge/evaluate things rationally and sensibly
  • Creating and imagining
  • Focusing attention on what's important (i.e., having good situational awareness), being prepared to act, and justifying one's beliefs/hypotheses.
• Coping strategies are adaptive or maladaptive ways of thinking, feeling, and acting when dealing with problematic situations. Following are ten common coping strategies people tend to use. The first five are positive strategies because they help a person solve a problem or learn to accept it with minimal distress. The latter five are negative strategies because they fail to resolve one's issues or enable healthy acceptance.
1. Logical Analysis is a positive approach strategy in which a person tries to understand what caused the problem and think of different ways to handle it.
2. Social Support is another positive approach strategy in which a person explains the problem to someone or asks others for advice or help. This can help determine what, if anything, can be done to solve it.
3. Problem-Solving is another positive approach strategy in which, after logical analysis, a person determines that a problem can be solved and what has to be done to solve it. Then, a specific action plan is created and implemented, and the person learns from the results and modifies the plan accordingly.
4. Positive Reappraisal is another positive approach strategy in which a person views a problem as helping him/her change or grow in a good way, find new faith, or learn valuable lessons. This strategy can be used whether or not a problem can be solved.
5. Rational Acceptance is a positive non-action strategy in which a person accepts—without undue emotional distress and self-defeating behaviors—that nothing can be done to solve a problem, so s/he does nothing except adopt a rational way of thinking about it, which fosters psychologically healthy acceptance.
6. Behavioral Distraction is a negative avoidance strategy in which a person tries to feel better emotionally by doing enjoyable or interesting things rather than trying to solve the problem or cope with it through positive reappraisal and rational acceptance. While it may help reduce one's upset temporarily, this strategy is maladaptive because it will never solve the problem and does nothing to help one cope with it long-term. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem rather than letting things get worse.
7. Cognitive Avoidance is another negative avoidance strategy in which a person simply acts as if there is no problem or tries not to think about the issue. As with behavioral distraction, the strategy may help reduce one's upset temporarily. Still, it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
8. Emotional Discharge is another negative avoidance strategy in which a person expresses negative emotions by yelling or crying, taking it out on others, or avoiding certain people or situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people, push them away, and waste precise time.
9. Wishful Thinking is another negative avoidance strategy in which a person simply hopes a miracle will make things better or that his/her wishes or prayers will be answered. As with the other avoidance strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
10. Resignation is a negative non-action strategy in which a person determines that nothing can be done, so s/he does nothing while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helplessness), and/or anger.

Describing the Characteristics of Four Types of Individuals

As I discussed in my previous post, wellness programs should address the particular needs of (at least) four types of people: Activists, Wannabes, Inactives, and Ignorers/Deniers. In this post, I present the Activists. They are most motivated to deal actively and eagerly with health & wellbeing issues and are most likely to take advantage of wellness programs.

Activists

Activists' attitudes about managing their physical and mental health can be summed up in thoughts such as: "I believe I can do whatever must be done, and I'm willing to do it!" Such views reflect a joy of living and a willingness to take constructive action to reduce fear, uncertainty, and doubt through problem-solving (if their health problems can be resolved) or rational acceptance (if the problems can't be fixed). Activists tend to be confident, motivated, aware, rational, and assertive regarding their character traits. From a whole-person integrated-care perspective, they seek knowledge about their physical and mental health status and risks to help them make wise decisions. And they try to understand how to avoid health problems, self-manage chronic conditions, treat existing problems most safely and cost-effectively, and use their knowledge to live healthy lifestyles. Activists, in other words, are rational people who deal with their physical and mental health problems (existing conditions and risks) by using positive, proactive coping strategies, such as:

• Trying to understand what caused the problems by thinking of different ways to handle it
• Talking to someone about what they are going through and asking certain people for advice or help.
• Determining what must be done to solve a problem and then using a specific action plan.
• Viewing a problem as something that helps them change or grow in a good way, find new faith, or learn valuable lessons
• Rationally accepting when a problem cannot be solved to minimize their emotional distress.

When dealing with an existing health problem, Activists actively seek knowledge and guidance to understand the pros & cons of different treatment options. And when dealing with their health risks, they seek to understand the pros & cons of varying prevention options. If Activists have money problems—which prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)—they strive to find a way to afford what they need, including political action. If they have family and other demands that consume their time and thus make lifestyle change difficult, they find ways to make time available. And if they have physical handicaps or cognitive impairments that interfere, they will explore alternative approaches to health improvement that accommodates these limitations. Finally, the more a person's character traits resemble an Activist, the more likely s/he is to gain from a wellness program and improve his/her health and wellbeing. In my next post, I examine the Wannabes and Inactives.

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 1

In this post, I discuss how to bring high value to the healthcare consumer through a new wellness program we're developing, offering a whole-person integrated-care solution. I welcome your questions and comments.

What is Whole-Person Integrated Care?

As the name implies, whole-person integrated care has two related parts: Whole-Person care and Integrated care.

Whole-Person Perspective

Whole-person perspective focuses on improving a person's health and well-being by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity whose body and mind are interconnected.

The whole-person perspective is critical for preventing and cost-effectively treating health problems because it helps lower overall healthcare expenditures, improve care outcomes, and enhance well-being since many physical disorders and psychological issues are related; for example:

• Disturbances of physiology that are related in some way to situational/psychological conditions but without actual permanent end-organ damage, such as migraines, functional bowel disease, and types of chronic pain
• Disturbances where actual physiological and psychological pathologies are evident, such as hypertension, peptic ulcer disease, hyperthyroidism, asthma, and chronic skin disorders
• Severe physiological disorders that tend to appear or flare up with significant life changes and stress, such as disturbances in autoimmunity
• Mental health problems caused by biomedical factors such as delirium, dementia, organic hallucinosis, and organic delusional, mood, personality, and anxiety syndromes
• Illnesses such as coronary heart disease and cancer may be helped with adjunctive treatments which promote changes in patients' behaviors (e.g., improve eating, sleeping, and exercise habits) and psychological states (e.g., reducing resentful anger and stress-proneness)
• Emotional difficulties are often associated with medical illnesses and procedures such as AIDS, bone marrow transplants, severe burns, heart or liver transplants, end-stage kidney disease entailing dialysis, hip fracture, open-heart surgery, and plastic surgery.
• Maladaptive behaviors and attitudes that have noticeable deleterious health effects on oneself and/or others, such as substance and alcohol abuse, anorexia, bulimia, obesity, smoking, unsafe sex, recklessness, suicidal tendencies, and abusive behavior toward others.

A whole-person approach is essential, therefore, because:

• Up to half of all primary care physicians' cases are either accompanied by or constitute psychological (emotional and behavioral) problems.[1]
• Psychological problems cause, exacerbate or impede the healing of many physical illnesses.[2]
• Psychological treatment (of emotional and behavioral problems) helps remedy many physical ailments and thus reduces overall medical costs.
• People who are physically and psychologically healthy have greater peace of mind, are more focused and energized, are more productive, make fewer mistakes, have fewer accidents, and are more satisfied with their lives and work.

Integrated-Care Model

Integrated care brings together well-care and sick-care:

• Well-care focuses on preventing physical, mental, and mind-body health problems from occurring or worsening, achieving a sense of emotional well-being and peace of mind through healthy living, wise decision-making, and responsible action to deal with distressing life situations, and using effective coping strategies.
• Sick-care treats acute, sub-acute, and chronic health problems (physical, mental, and mind-body) through traditional allopathic procedures and/or complementary and alternative methods.

Thus, instead of viewing sick-care and well-care as two separate avenues on the road to health, this integrated approach involves a new kind of coordination and collaboration between (a) medical and related sick-care practitioners focused on the diagnosis and treatment of health problems and (b) well-care practitioners focused on prevention, recovery, and well-being, as well as peak performance.

By integrating sick-care & well-care in this way, overall healthcare costs would be reduced, health outcomes would be improved, and people's quality of life and productivity would be increased. These desirable results would be achieved by coordinating efforts to prevent and treat illness and dysfunction. This integrated approach is vital to solving the current crisis and bringing greater value to the consumer.

Altogether Now: Whole-Person Integrated Care

This whole-person integrated care strategy offers a sensible way to help people:

• Remain healthier longer through better self-care/self-maintenance
• Recover from illness and dysfunction more quickly and avoid complications of chronic disease through greater compliance with plans of care.
• Gain greater peace of mind by removing or coping with stress more effectively.
• Save money through reduced sick-care expenditures.
• Be more productive and focused through reduced stress and emotional distraction.

Employers also benefit when employees are healthier, happier, and more focused. These benefits include increased employee productivity and employee retention, lowered healthcare expenditures, reduced sick time, and fewer workplace accidents and errors.

It is crucial to solving the healthcare crisis by reducing overall expenditures.

Implementing this strategy requires a new kind of wellness program that:

• Performs a comprehensive health and well-being assessment and generates a whole-person health profile that includes a full mind-body work-up.
• Uses the health profile to create an individualized wellness plan focused on improving one's health, happiness, and achievement through lifestyle changes, wise decision-making, and effective coping skills.
• Provides ongoing guidance and support from networks of wellness coaches/counselors who use the health profiles and collaborative communication tools to increase the person's knowledge, understanding, and motivation.
• Supplies essential information that enables sick-care practitioners to understand more fully:
• How to handle the interplay between a person's physical problems, mind-body health needs, emotional drivers & obstacles, and psychological boosts & blocks
• Complementary & alternative intervention options to traditional medical treatments.

What is the Goal of Whole-Person Integrated Care?

The goal of such a program is to improve people's health and well-being by helping them reduce their stress & distress levels (i.e., increasing peace of mind) and change their maladaptive behaviors (i.e., making lifestyle/ compliance changes) via counseling & education process that deals with the interactions between one's:

• Cognitions (beliefs, attitudes, perceptions, thoughts)
• Emotions
• Behaviors
• Level of Knowledge & Understanding
• Coping strategies.

How is it Done?

The Whole-Person Integrated Care process is also personalized; it is tailored to the needs of different types of individuals with drastically different characteristics:

• Activists are motivated to deal with health & well-being issues actively
• Wannabes talk about improving their health & well-being but never seem to act on it or do so half-heartedly
• Inactives think about their health on occasion but do not believe they should or can do anything to improve their health & well-being.
• Ignorers/Deniers are not health conscious because they don't accept that they have health problems or risk factors or don't care.

In the next post in this series [at this link], I examine the character qualities of these four groups, i.e., the cognitions, emotions, behaviors, knowledge & understanding, and coping strategies that promote or impede one's willingness and ability to adhere to healthy living strategies.

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[1] Research shows that a significant percentage of all primary care billing is for stress-induced or behaviorally-related disorders, with a minimum of about 20 percent of patients in a primary-care practice suffering specifically from anxiety or depression. And if one assumes undiagnosed complaints are related to underlying anxiety disorders or depression, the proportion of patients seeking treatment for psychological reasons jumps to 40 to 50 percent. Depression alone, the fourth most disabling illness worldwide, has been estimated to cost the United States $83 billion in 2000. Of this amount, $57 billion is attributed to depression-related absenteeism, reduced productivity at work, and the value of lifetime earnings lost due to suicide-related deaths, leaving $26 billion in direct out-of-pocket expenses for healthcare treatment costs.

References: Goleman, D. (December 14, 1994). Push is on for Family Doctors to Spot Psychiatric Problems. New York Times. Available here AAFP white paper on providing mental health care services by family physicians - American Academy of Family Physicians Commission on Health Care Services. American Family Physician. (May 1, 1995). Available at http://www.findarticles.com/p/articles/mi_m3225/is_n6_v51/ai_16874729 NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study at http://www.nimh.nih.gov/healthinformation/stard_qa_general.cfm

[2] A growing body of research in mind-body medicine demonstrates an undeniable interplay between biomedical, psychological, and social factors and points specifically to a causal link between mental/emotional problems and many physical illnesses. The field of psychoneuroimmunology demonstrates that stressful life events can adversely affect the immune system. Other researchers are identifying "coronary-prone behaviors" such as insecurity and a perceived lack of self-efficacy. Still, others find a connection between optimism, coping skills, and physical health. Potentially high-cost, medically dangerous behaviors — such as excessive consumption of alcohol, use of illicit drugs, violence, and unsafe sex — also find their roots in behavioral disorders. For example, researchers found that depression is a precursor to heart disease, with certain depressed patients being 50 percent more likely to develop or die from heart disease than those without such symptoms, even though they had no prior history of heart disease. Depression, therefore, likely affects the mind and physical health by being linked to increased blood pressure, abnormal heart rhythms, and chronically elevated stress hormone levels, which can increase the heart's workload.

References: Borysenko, J. (1988). Minding the Body, Mending the Mind. New York: Bantam Cousins, N. (1990). Head First: The Biology of Hope and the Healing Power of the Human Spirit. New York: Viking Penguin Dienstfrey, H. (1991). Where the Mind Meets the Body. New York: Harper Collins Gordon, J. S. & Bresler, D. (Eds.). (1984). Mind, Body, and Health: Toward an Integral Medicine. New York: Human Sciences Press Gordon, J. S. (1990). Stress Management. New York: Chelsa House Ornstein, R., & Sobel, D. (1988). The Healing Brain. New York: Simon & Schuster Ornstein, R., & Sobel, D. (1990). Healthy Pleasures. Reading, Mass: Addison-Wesley Kroenke, K. (2002). Psychological medicine: Integrating psychological care into general medical practice. BMJ;324:1536-1537. Available at http://bmj.bmjjournals.com/cgi/content/full/324/7353/1536 Huggins, C.E. (March 1, 2006). Depression and heart disease often go hand in hand. Reuters Health. Available at http://go.reuters.com/newsArticle.jhtml?type=healthNews&storyID=11380752&src=rss/healthNews