Review
The impact of mental illness on cardiac outcomes: A review for the cardiologist

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Abstract

Traditional cardiac risk factors, such as smoking, hypertension and obesity, are widely accepted contributors to the onset and progression of cardiovascular disease (CVD), one of the foremost causes of morbidity and mortality worldwide. Largely overlooked, however, is the impact of mental health on cardiac disease. From extensive MEDLINE and PsycINFO searches, we have reviewed the association between specific psychiatric disorders and CVD-related morbidity and mortality, the efficacy and safety of their treatments, and plausible behavioral and biological mechanism through which these associations may occur. The preponderance of evidence suggests that depression, anxiety disorders, bipolar disorder and schizophrenia are all important cardiac risk factors, and patients with these disorders are at significantly higher risk for cardiac morbidity and mortality than are their counterparts in the general population. Antidepressants, antipsychotics, mood stabilizers and benzodiazepines are effective therapeutic interventions, and many are safe to use in cardiac populations. Some, such as selective serotonin reuptake inhibitors and atypical antipsychotics, may even improve cardiac outcomes in healthy individuals and patients with CVD, although more work is needed to confirm this hypothesis. A combination of behavioral and biological mechanisms underlies the association between cardiac disease and mental illness, many of which are shared across disorders. With further research, it may be learned that psychiatric treatments definitively reverse the detrimental effects of mental illness on cardiac health. Currently, however, the challenge lies in raising awareness of mental health issues in cardiac patients, so that basic but critical treatments may be initiated in this population.

Introduction

The heart and mind are intimately linked. Depression, anxiety disorders, schizophrenia and bipolar disorder have all been identified as risk factors for the onset and progression of cardiovascular disease (CVD). Unfortunately, despite their high prevalence and substantial medical impact, psychiatric illnesses in cardiac patients frequently go undiagnosed and untreated. In this paper, we will review the impact of mood disorders, anxiety disorders, and schizophrenia on CVD-related morbidity and mortality. We will consider their prevalence and association with heart disease, the efficacy and safety of existing treatments, and describe potential behavioral and biological mechanisms through which these associations may occur.

Section snippets

Depression

Major depressive disorder (MDD) afflicts approximately 5% of the population at any given time [1], and as many as 15–20% of recently diagnosed CVD patients [2]. Depression has been identified as an independent risk factor for adverse cardiac events, such as coronary heart disease, angina, heart failure, myocardial infarction (MI) and cardiac mortality [3], [4]. In initially healthy individuals, clinically depressed patients are 60–80% more likely to develop CVD compared to non-depressed

Bipolar disorder

Bipolar disorder, a mood disorder characterized by episodes of mania and depression, is also linked with cardiac illness. Indeed, bipolar I disorder, which occurs in approximately 1% of the general population [36], is significantly more prevalent in patients with cardiac disease [37]. Individuals with bipolar disorder die younger than their peers, due largely to an increased prevalence of medical co-morbidities [38], [39], and much of this excess mortality stems from CVD [40], [41], [42]. In

Free floating anxiety

Free-floating anxiety, defined as persistent or recurrent worry or nervousness not meeting criteria for a formal anxiety disorder, is common after an acute cardiac event, and persists in 20–25% of post-MI patients [54]. Evidence regarding anxiety as a predictor of CVD and cardiac mortality is mixed, but overall supports an association [55], [56]. The preponderance of studies support the notion that anxiety increases CVD-related mortality [56], [57], [58], [59] and increases the risk of

Schizophrenia

The life expectancy of patients with schizophrenia, a chronic, disabling illness that afflicts approximately 1% of the population [77], is estimated to be about 10–15 years shorter than that of the general population [78]. Of this excess mortality, 60% can be explained by medical illness [79], especially cardiovascular disease, which contributes approximately 20% of all deaths in schizophrenic patients [80]. Ten year CVD risk is significantly higher in patients with schizophrenia than the

Underlying mechanisms

How might these psychiatric illnesses be associated with the onset and worsening of CVD? A complex combination of behavioral and pathophysiological mechanisms likely underlies the associations between mental illness and cardiac disease. Although the aforementioned psychiatric disorders differ in etiology and symptomatology, they share many of these same predisposing mechanisms.

Conclusions

Depression, bipolar disorder, anxiety and schizophrenia are all associated with increased cardiac disease and mortality, likely by common underlying mechanisms. While treatments exist that are safe and effective at treating psychiatric symptoms in cardiac populations, these disorders commonly go undiagnosed and untreated. It is important to diagnose and treat these disorders, however, not only because symptom remission may improve quality of life, but also because there is evidence to suggest

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