REVIEW ARTICLE published: 01 July 2013 doi: 10.3389/fpsyg.2013.00384 Social support, depression, and heart disease: a ten year literature review Angelo Compare 1 *, Cristina Zarbo 1 *, Gian Mauro Manzoni 2,3 , Gianluca Castelnuovo 2,3 , Elena Baldassari 1 , Alberto Bonardi 1 , Edward Callus 4 and Claudia Romagnoni 5 1 Department of Human and Social Sciences, University of Bergamo, Bergamo, Italy 2 Psychology Research Laboratory, Istituto Auxologico Italiano IRCCS, Ospedale San Giuseppe, Verbania, Italy 3 Department of Psychology, Catholic University of Milan, Milan, Italy 4 Pediatric and Adult Congenital Heart Disease Centre, IRCCS Policlinico San Donato, Milano, Italy 5 Cardiovascular Division, "L. Sacco" University General Hospital, University of Milan, Milano, Italy Edited by: Chris J. Gibbons, University of Liverpool, UK Reviewed by: Beth Grunfeld, University of Birmingham, UK Colin M. Bosma, Harvard University, USA *Correspondence: Angelo Compare and Cristina Zarbo, Department of Human and Social Sciences, University of Bergamo, Piazza S. Agostino 2, 24129 Bergamo, Italy e-mail: angelo.compare@unibg.it; cristinazarbo@gmail.com Background: Coronary heart disease is the major cause of morbidity and mortality in the world. Psychosocial factors such as depression and low social support are established risk factors for poor prognosis in patients with heart disease. However, little is known about the hypothetical relationship pattern between them. Purpose: The purposes of this narrative review are (1) to appraise the 2002–2012 empirical evidence about the multivariate relationship between depression, social support and health outcomes in patients with heart disease; (2) to evaluate the methodological quality of included studies. Method: PubMed and PsychINFO were searched for quantitative studies assessing the multiple effects of low social support and depression on prognosis outcomes in patients with heart disease. The following search terms were used: social relation ∗ , cardiac disease, support quality, relationship, and relational support. Results: Five studies (three prospective cohort studies, one case-control study, and one randomization controlled trial) were selected and coded according to the types of support (social and marital). The majority of findings suggests that low social support/being unmarried and depression are independent risk factors for poor cardiac prognosis. However, all analyzed studies have some limitations. The majority of them did not focus on the quality of marital or social relationships, but assessed only the presence of marital status or social relationship. Moreover, some of them present methodological limitations. Conclusion: Depressive symptoms and the absence of social or marital support are significant risk factors for poor prognosis in cardiac patients and some evidence supports their independence in predicting adverse outcomes. Cardiac rehabilitation and prevention programs should thus include not only the assessment and treatment of depression but also a specific component on the family and social contexts of patients. Keywords: depression, cardiac disease, social support, marital status, social relationship INTRODUCTION The World Health Organization (2002) reports that coronary heart disease causes approximately 7.2 million deaths every year. There is increasing evidence that psychosocial factors are associated with Coronary Artery Disease (CAD) morbidity and poor prognosis in acquired heart disease conditions (Claesson et al., 2003; Rozanski et al., 2005, 1999; Aldana et al., 2006; Fukuoka et al., 2007; Compare et al., 2011a). Literature has outlined that depression is a primary risk factor for adverse out- comes in several cardiac populations. Both direct (biological) and indirect (behavioral) mediating processes explain the negative effect of depression on cardiac disease. The biological mecha- nisms include inflammatory and immune processes, alterations in activating HPA, variability in heart rate, increased activity of the sympathoadrenal and pituitary–adrenal axes, reduction in circulating endothelial progenitor cells, increase of cortisol and catecholamine levels, alteration of activities of autonomic nervous system and oxidation processes (Maier et al., 2007; Compare et al., 2011a,b, 2013; Nemeroff and Goldschmidt-Clermont, 2012). Moreover, unhealthy lifestyles often linked to depression, such as no medical adherence, increased consumption of tobacco, alco- hol, and illicit substances, reduced physical activity, and overeat- ing may contribute to a worse prognosis of cardiac disease as well (Maier et al., 2007). A further psychosocial risk factor for cardiac disease morbidity and mortality is low or no social support (Case et al., 1992; Williams et al., 1992; Hemingway and Marmot, 1999; Kuper et al., 2002). The association between social support and depression is particularly relevant because low social support may lead to the development or worsening of depression (Lett et al., 2005), while high levels of social support were shown to protect www.frontiersin.org July 2013 | Volume 4 | Article 384 | 1