Mental health disorders may be associated with 14.3% of all deaths worldwide, accounting for about 8 million deaths every year. Individuals with severe mental illness—including bipolar disorder, major depressive disorder, and schizophrenia—have a mortality rate 2 to 3 times higher than that of the general population, corresponding to a 10- to 25-year decreased life expectancy.

 

Cardiovascular-related mortality and mental illness

A 2022 comprehensive systematic review and meta-analysis of over 100 studies published in Plos Medicine found that the cardiovascular disease-related mortality rate for individuals with severe mental illness is approximately two times that of the general population.

Lambert AM, Parretti HM, Pearce E, et al. Temporal trends in associations between severe mental illness and risk of cardiovascular disease: A systematic review and meta-analysis. PLoS Med. 2022;19(4):e1003960.

 

While the study of over 30 million participants found that individuals with schizophrenia were at greater risk compared to those with bipolar disorder, this discrepancy existed throughout all types of severe mental illness as well as cerebrovascular and cardiac mortality.

Interestingly, the association of cardiovascular-related mortality with both schizophrenia and bipolar disorder has grown stronger between the 1970s and the 2000s.

Mental illness associated with increased death from cardiovascular disease. Science Daily. April 19, 2022.

For example, the hazard ratio of mortality due to coronary heart disease is identified to be 1.61 when comparing people with schizophrenia in the 1980s to the 1990s.

 

 

What are the potential underlying mechanisms?

While the mechanisms that underlie how mental illness contributes to the increased risk of coronary heart disease (CHD) are complicated and not fully understood, there are potential explanations.

De Hert M, Detraux J, Vancampfort D. The intriguing relationship between coronary heart disease and mental disorders. Dialogues Clin Neurosci. 2018;20(1):31–40.

 

These mechanisms can be classified into the following categories: biological, genetic, behavioral and psychological factors.

 

Biological mechanisms

Various physiologic pathways have been implicated in the progression of CHD with mental disorders, including dysfunction of the autonomic nervous system, hypothalamic-pituitary-adrenal (HPA) axis hyperactivity, inflammation, oxidative stress, increased platelet reactivity, and lipid pattern abnormalities.

The use of antipsychotic and antidepressant medications (as well as mood stabilizers) may put patients at increased risk of developing CHD. For example, antipsychotic treatments for schizophrenia may trigger autonomic nervous system dysfunction by blocking peripheral dopamine receptors and increasing sympathetic activity.

 

Behavioral mechanisms

For example, individuals with these disorders are more likely to engage in unhealthy behaviors such as smoking, alcohol or substance use, and lack of physical exercise. These patients have also been documented to be less likely to adhere to medications, which can include cardioprotective drugs.

 

Psychological mechanisms

Stress and anxiety can cause hyperactivation of the HPA axis which can lead to elevated Cortisol and catecholamine levels. This can lead to downstream effects such as infla

Heart disease and mental health disorders. Centers for Disease Control and Prevention. May 6, 2020.

mation, hypertension, insulin resistance, and ultimately the progression and development of CHD.

 

For patients who suffer from PTSD, depression as well as a lack of family support and solitude can lead to heighted CHD risk, which can be further exacerbated by sleep disturbances.

 

Genetic factors

Major depressive disorder, bipolar disorder, schizophrenia, as well as cardiometabolic diseases, are highly genetic in nature, with genetic factors contributing to from 30% to 60% in CHD, and even to 80% in schizophrenia.

While genetic studies have only shown a modest genetic relationship between cardiometabolic concerns, CHD, and mental illness, future studies will determine if there are shared gene loci linked to mental disorders and cardiometabolic diseases.

 

Groups at increased risk of heart disease

The following populations are at increased risk of heart disease due to pre-existing mental health conditions:[4]

• Veterans: As a result of combat, veterans who suffer from PTSD are at higher risk.

• Partners of someone who has PTSD: In relationships where one or both individuals were diagnosed with PTSD, couples experienced greater conflict, anger, and cardiovascular reactivity compared to couples where neither partner did.

• Women: Studies have shown that women with PTSD and depression are at increased risk of CHD-related morbidity and mortality.

• Racial and ethnic minorities: Studies have found that depression, stress, and anxiety puts certain subpopulations at increased risk for heart disease, hypertension, cardiovascular reactivity and poor cardiovascular health outcomes.

 

What can healthcare providers do?

Mental health screenings should be incorporated into patient care, particularly whenever a major cardiovascular-related event occurs.

For individuals who suffer from severe mental health conditions and have pre-existing heart disease, clinicians should consider prescribing medications, whenever possible, with a lower risk for heart disease.