CMHC Pulse Blog

The profound link between the heart and mind has been the subject of much research for some time, with newer studies reinforcing the existing evidence as well as offering deeper insights. A large number of studies have shown that individuals coping with conditions like depression, anxiety, or stress face an elevated risk of cardiovascular problems. Past studies have often attributed this association to behavioral aspects, such as a person coping with emotional distress through smoking or drinking. Other studies have also unearthed more intricate connections which suggests that physiological conditions, underpinned by biological and chemical factors, may also play a pivotal role in influencing cardiovascular disease (CVD). This has prompted many scientists, researchers, and clinicians to reevaluate how mental health impacts heart health and how to best support these at-risk individuals. As we step into American Heart Month, it becomes imperative to delve into the intricacies of this relationship and dissect the latest research findings.

A Brief Look at the Numbers

Cardiovascular disease, a term that refers to all types of diseases that affect the heart or blood vessels, is responsible for over 800,000 deaths in the U.S. each year. In 2021 alone, CVD accounted for over 900,000 deaths in the U.S. and approximately 19.91 million globally.

Mental illnesses are estimated to affect one in five adults in the U.S.  In 2021, approximately 57.8 million adults (aged 18 years and above) were found to have a mental illness. Furthermore, mental illness is seen to be more prevalent in younger adults (aged 18-25 years) and affects a higher proportion of females than males.

What the Research Says

While there are a plethora of studies examining the relationship between the heart and mind, researchers continue to dissect this intricate connection in order to better understand how to best support these patients and their families.

A 2021 cohort study of 118, 706 participants with no prior CVD, evaluated the association between psychological stress and the development of CVD and mortality. Participants were aged 35 to 70 years from low, middle, and high-income countries across five continents. They were assessed at the beginning of the study using brief questionnaires addressing stress at work and home, major life events, and financial stress.

Findings from this study revealed that higher stress levels were linked to an increased risk of CVD and stroke, after taking into account sociodemographic factors and health risk behaviors. In addition, the risks increased with increasing stress levels for death and coronary heart disease.

Another study published in January 2023 in the Journal of the American Heart Association evaluated data from 593, 616 young adults, and found that depression and poor mental health are associated with premature CVD as well as suboptimal cardiovascular health (CVH). Results demonstrated that people with depression had higher odds of CVD and suboptimal CVH than those without. Researchers also noted that a graded relationship existed between poor mental health days (PMHD) and CVD and PMHD and suboptimal CVH.

The authors note that the relationship between CVD and depression is regarded as bidirectional. The higher odds of CVD presenting in people with depression may be due to unhealthy lifestyle habits such as smoking, unhealthy eating, and sedentary behavior. They also note the “multiple physiological pathways, such as abnormalities in glucose and lipid homeostasis and coagulation cascade abnormalities related to chronic stress, by which psychological health and well‐being may influence CVH and CVD risk”.

“It is important to recognize that CVD can also lead to depression. Indeed, several studies have reported higher rates of depression among people with CVD. A rate of 15% of major depressive disorder has been reported in patients after myocardial infarction or coronary artery bypass grafting, and this rate is >20% in patients with heart failure and is much higher in advanced heart failure.”

A review of the existing literature surrounding the link between CVD and depression looked at the epidemiology and main risk factors for the coexistence of depression and CVD. The authors also note the bidirectional relationship between mental health and CVD, highlighting that “effective treatment of CVD can also help prevent depression and improve mental health outcomes.”

“The relationship between the two conditions is bidirectional, meaning that depression can contribute to the development of CVD, and having CVD can increase the risk of developing depression.”

“The relationship between the two conditions is bidirectional, meaning that depression can contribute to the development of CVD, and having CVD can increase the risk of developing depression. Depression can lead to unhealthy behaviors such as poor diet, sedentary lifestyle, smoking, and non-adherence to medication, which are risk factors for CVD. Additionally, depression is associated with physiological changes in the body, including inflammation, hormonal imbalances, and increased sympathetic nervous system activity, all of which can contribute to the development and progression of CVD.”

The authors go on to note that individuals with CVD are more prone to developing depression because of the psychological and emotional impact of having to cope with a chronic illness. The physical limitations imposed by CVD, the fear of future cardiac events, and the disruption of daily life can lead to feelings of hopelessness, sadness, and anxiety.

The review also states that both depression and CVD share common underlying mechanisms, such as dysregulation of the hypothalamic-pituitary-adrenal axis, increased oxidative stress, and endothelial dysfunction. This can help explain why there is such a strong association between the two conditions.

A more recent study, published in January in the Journal of the American Heart Association, looked at patterns of perceived stress from childhood to adulthood and the prediction of adult cardiometabolic risks. The study found that in adulthood, a higher perceived stress scale (PSS) was associated with increased overall cardiometabolic risk, carotid artery intima-media thickness, systolic blood pressure, and diastolic blood pressure. In addition, participants with a consistently high adolescence‐to‐adulthood stress pattern had greater overall cardiometabolic risk, android/gynoid ratio, percent body fat, as well as greater odds of obesity in adulthood, compared to those with a consistently low PSS.

Allison Gaffey, PhD, assistant professor of medicine and clinical psychologist at Yale School of Medicine states, “Over 40 years of evidence indicates that experiencing psychological stress, especially chronically, and related psychological distress, is associated with a greater risk for CVD. The strongest evidence in this area pertains to symptoms of depression and anxiety.”

Screening and Prevention Strategies

Due to the examination of the relationship between these two health domains, we now have more information about the common risk factors and can better understand how mental health conditions may exacerbate or contribute to cardiovascular issues and vice versa. This knowledge is crucial for tailoring effective prevention and intervention programs that may address both physical and mental health.

Yaa Adoma Kwapong, M.D., M.P.H., a postdoctoral research fellow at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease and lead author of the study examining depression, poor mental health and premature CVD, has stated that “…we need to prioritize mental health among young adults and perhaps increase screening and monitoring for heart disease in people with mental health conditions and vice versa to improve overall heart health.”

The study highlights the need for clinicians to recognize the risk of CVD in patients with depression and poor mental health. “Given the increased odds of CVD among patients with depression, it may be necessary to enhance screening for depression and evaluation of mental health in general, as an additional screening tool in evaluating CVH and monitoring for CVD.” The authors also suggest that it may be beneficial to screen individuals who have had a major cardiovascular event for mental health conditions and offer close communication with their friends and family.

Incorporating mental health screening for individuals with CVD may be a valuable approach, as it enables healthcare professionals to provide holistic care, addressing the interconnected nature of these conditions. The same can be said for the reverse situation, allowing for individuals presenting with mental health issues to undergo screening for CVD. This type of approach can ensure that individuals receive comprehensive support, taking into account the mental and physical health aspects and leading to more effective and personalized healthcare interventions.

Concluding Remarks

As further research continues to unravel the complex interplay between these two domains, we continue to gain valuable insights that can help inform preventive measures, screening strategies, and personalized interventions. Recognizing and addressing the bidirectional relationship between cardiovascular and mental health is crucial for promoting overall wellness and quality of life. Health care systems that incorporate mental health considerations into cardiovascular care, and vice versa, are better equipped to provide holistic support, ultimately contributing to more effective prevention, management, and improved outcomes for these individuals.

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