Cardiovascular outcomes worsen in patients with mental health conditions

Every 34 seconds, someone in the United States dies from heart disease.

As nearly half of the country suffers from some form of cardiovascular disease (CVD), another 1 in 4 adults experience a mental health disorder in their lifetime, signaling an inevitable overlap.

Now, a new report from Emory University shows that certain mental health conditions escalate the risk of developing heart disease by 50-100%-and adverse outcomes from existing heart conditions by 60-170%. 

The report, published in The Lancet Regional Health-Europe, summarizes cardiovascular health disparities among those diagnosed with depression, anxiety, schizophrenia, bipolar and post-traumatic stress disorders (PTSD). The article is part of a series aiming to raise awareness around disparities in CVD health in four populations: women, the elderly, racial minorities and those with mental health conditions. 

Emory University professor Viola Vaccarino, MD, PhD, led this metareview linking mental health conditions to CVD, along with co-authors Amit Shah, MD, and Douglas Bremner, MD, also Emory professors. 

The report associated the following conditions and their corresponding risks of developing CVD:

• Major depression, 72%
• PTSD, 57%
• Bipolar disorder, 61%
• Panic disorder, 50%
• Phobic anxiety, 70%
• Schizophrenia, nearly 100%

The research also shows that these conditions are associated with a poorer prognosis, greater risk for readmission and higher mortality from existing heart conditions. For example, major depression more than doubles the mortality rate in those with existing CVD. 

Additionally, the report emphasizes a bidirectional relationship. “More than 40 percent of those with cardiovascular disease also have a mental health condition,” adds Vaccarino.

The physiology of stress

According to the report, a well-documented relationship exists among depression, schizophrenia, PTSD, and abnormal stress responses in the autonomic nervous system (ANS) and hypothalamic-pituitary adrenal axis (HPA). 

The former allows the brain to manage involuntary responses, such as functions of the liver, heart, sweat glands, and eye muscles. ANS also manages both acceleration and deceleration of these functions, regulating inflammatory responses. Since most major organs have ANS nerve endings, this system impacts most bodily functions. 

The hypothalamic-pituitary adrenal axis (HPA) also influences immune response and metabolism, which can impact cardiovascular function. According to the report, dysregulation of these systems creates “adverse downstream effects that can affect cardiovascular risk chronically, including increased inflammation, metabolic abnormalities, high blood pressure, enhanced systemic vascular resistance and autonomic inflexibility.” Inflammation has also been implicated in both the development of heart disease and mental health conditions. 

Social determinants and quality of care 

The role of social determinants of health in CVD disparities is critical. Those with mental health conditions may face disruptions and barriers in the continuum of care, such as affordability and accessibility. Compromised health literacy or communication can also impede access to health screenings and treatment. 

Clinicians could also be challenged to care for patients with certain mental conditions, which can be compounded by stigma and existing models that fragment mental and physical health care. Stigmas are also present in the field of clinical research, where having a mental health condition is often an exclusionary criterion in randomized trials. 

Moreover, according to the report, current prediction models don’t account for mental health disorders when forecasting the risk of developing heart disease. 

Next steps toward a healthier future

To address the disparities of CVD among people with mental health disorders, the authors recommend an integrated approach with interdisciplinary care encompassing behavioral, mental and cardiovascular health. 

The tight connection between cardiovascular and psychological health warrants changes in the health care system that are more amenable to patients with comorbidities. A clinical team would be ideal for the care of these patients-a team of specialists, social workers, and nursing staff who work in collaboration to provide multidisciplinary care and resources.” 

Viola Vaccarino, MD, PhD, Professor, Emory University 

The report concludes that closing the health disparity gap upholds the rights of those living with a mental health condition to achieve the highest level of health and fully participate in society.