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There are several theories as to the connection between heart surgery and suicide, one being that surgery can lead to post-traumatic stress disorder.Fred Lum/The Globe and Mail

No one knows what led Robin Williams to kill himself. It wasn't just one thing, but likely a fatal stew of lingering alcohol and drug addiction, depression, being middle-aged and male, and the prospect of facing Parkinson's disease.

Rarely mentioned, though, is the open-heart surgery he'd undergone five years ago. But according to the Heart and Stroke Foundation, research suggests up to 40 per cent of Canadians may suffer from depression after heart surgery – a one-two calamity with potentially deadly consequences.

Three years ago I was one of those people.

Even when the surgery to replace my aortic valve was a success and my lingering irregular heartbeat had been stabilized – in other words, even after I was "well" – I fell into a deep depression. It took me more than a year to crawl back out, plenty of time to wonder how I could be so much better in my body and so much worse in my mind.

What's the connection between heart surgery and depression?

One media report following Williams's death pointed to three possible scenarios: Tiny particles of plaque could break off from the heart and move to the brain, altering its structure; the lowering of body temperature during surgery could cause a change in brain chemistry; or major surgery could lead to post-traumatic stress disorder.

(I'll go with a fourth, more personal explanation: that stopping your heart in order to replace part of it represents a "gross insult" that your heart resents at some profound and mysterious level.)

What's not in doubt is that we remain dangerously unaware of the connections between heart surgery, depression and suicide. I need to be cautious here: Researchers can't prove a direct causality between the three. But there is a demonstrable connection between heart surgery and depression, and an even more obvious one between depression and suicide. So the irresistible inference is that we need to pay more attention to the connection.

Approximately 11 out of 100,000 Canadians commit suicide each year, according to Statistics Canada, with depression the most common illness among those who die by suicide.

This may be shocking, but it shouldn't be surprising. A recent study by the World Economic Forum revealed that in rich countries like ours, 38 per cent of all illness is mental illness, and when it comes to people of working age, mental illness accounts for half of all illness. Yes, half.

The daunting size of these numbers suggests there's little we can do about them. But we can. Depression can kill, but it's not necessarily a fatal disease.

Still, too many of us are ashamed of feeling helplessly sad. So we're slow to seek treatment, and once we do, it's tough to find timely help in Canada where less than six per cent of our health-care dollars go to treating all mental illnesses.

Things are changing, especially around the tangled trip-wire of heart surgery, depression and suicide. Toronto's University Health Network has three staff psychologists who specialize in cardiac psychology. One of them is Dr. Adrienne Kovacs.

She strongly recommends that all cardiac patients enter cardiac rehab programs after their surgery. You'd think everyone would, but the astounding fact is that, according to University Health Network research, almost 80 per cent of patients leave the hospital after heart attack or heart surgery and don't enter cardiac rehab. So one step is to get more of us into rehab, which is offered at no cost in Canada.

The second idea is to add a strong component of psychological rehab to the process.

"I think cardiac psychology is a decade behind psycho-oncology," Kovacs says. "You wouldn't think of building a cancer centre today without building in a program to deal with depression and anxiety. I'd like to think we're headed that way, too."

She also points to another major risk around depression that's not getting the attention it deserves – the fact that depression leaves you much more susceptible to heart disease. According to the Canadian Mental Health Association, "if you have any medical condition, you are far more likely to have depression than someone who doesn't."

And, Kovacs says, you have double the risk of another cardiac event if you're depressed.

American author Andrew Solomon, who has written on depresson and suicide, summed up the situation well in a recent piece for the New Yorker: "Depression is a risk factor for heart disease; open-heart surgery is a risk factor for depression."

Poor Robin Williams, whose heart was so large. He may have broken ours' because of all this.

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