The Head and the Heart: Managing a ‘Silent Epidemic'
Cardiovascular disease (CVD) is the leading cause for premature mortality in patients with mental illness, particularly those with severe psychiatric disorders.
The numbers bear out the link: The life expectancy of a person with severe mental illness is 15-20 years shorter than that of unaffected individuals, largely thanks to the effects of cardiac conditions. Patients with depression have a two to fourfold increased risk for developing CVD and a two to fourfold higher risk for mortality after experiencing a cardiac event compared to individuals without depression.
A panel discussion at the 2025 annual meeting of the European Society of Cardiology held in Madrid, Spain, in conjunction with the Inter-American Society of Cardiology explored the intersection of the heart and the mind. Panelist Donata Kurpas MD, PhD, of Wroclaw Medical University, in Wrocław, Poland, called the burden of CVD in people with mental illness a 'silent epidemic' and encouraged attendees to 'rethink cardiovascular prevention' in the psychiatric conditions of their patients.
Historically, cardiologists 'haven't paid too much attention to psychiatric symptoms, such as anxiety or depressive mood, and psychiatrists haven't spent much time looking for cardiovascular risk factors in their patients,' Panelist Maria Manuela Neves Abreu, MD, of the University of Lisbon, in Lisbon, Portugal, told Medscape Medical News . But this fragmentation has done a disservice to patients who were psychiatrically ill with CVD. Abreu said she encourages 'collaborative approach, which should be a team effort between cardiologists and psychiatrists.'
'It's important for all of us, as cardiologists and as doctors, to remind ourselves to try not to treat only the disease but rather, as much as realistically possible, to treat the patient as a whole,' said Glenn Levine, a professor of medicine at the Baylor College of Medicine and chief of the Cardiology Section at the Michael E. DeBakey VA Medical Center, in Houston.
Complex Biological Mechanisms
Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto, Toronto, Ontario, Canada, who was not a participant in the panel, said the intersection of CVD and psychiatric illness can be 'considered across different levels.' Biological and 'social and economic determinants that play a role' in both conditions, McIntyre, who was not a member of the panel, told Medscape Medical News . Both have biological, behavioral, psychological, and genetic etiologies.
Abreu, a cardiologist and a psychiatrist, said the intersection of mental illness and CVD likely involves a 'complex biological mechanism that integrates the inflammatory and immune systems, and hypothalamic-pituitary-adrenal axis, the sympathetic nervous system, reduced heart rate variability, and platelet dysfunction' as well as 'several shared genetic features common to both.'
Kurpas noted sleep disorders, stress, and autonomic dysfunction 'amplify cardiovascular risk.' Given the biological commonalities, it appears that addressing each condition can benefit the other and particularly improve cardiovascular health in people with psychiatric illness, McIntyre said.
Cardiac Effects of Psychotropic Drugs, Psychiatric Effects of Cardiac Drugs
Psychotropic drugs used to treat psychiatric conditions can have cardiovascular effects. These may induce arrhythmias and cardiometabolic disturbances such as weight gain, dyslipidemia, and hypertension.
Abreu noted that selective serotonin reuptake inhibitors typically are used as first-line treatment for depression in patients with cardiac disorders 'because they're well-tolerated and safe, in terms of cardiac rhythm, blood pressure, and interaction with cardiologic medication.'
On the other hand, she said, they can have disrupt platelet aggregation — an effect that is enhanced when they're taken with antiplatelet aggregation or anticoagulant drugs. And fluoxetine and fluvoxamine can interact with aspirin, nonsteroidal anti-inflammatory drugs, or anticoagulants. And escitalopram and citalopram 'require greater caution, when it comes to QT interval prolongation and bradyarrhythmias.' A review by Pina and colleagues summarized the cardiac effects of commonly-prescribed antidepressants.
Certain second-generation antipsychotics can have adverse cardiac effects, — myocarditis, cardiomyopathy, tachycardia, and arrhythmias, notably, prolongation of the QT interval, which can increase mortality risk. Many of these drugs also have cardiometabolic effects.
A 2020 review comparing 18 second-generation antipsychotics found olanzapine and clozapine to have the most metabolic side effects, while aripiprazole, brexpiprazole, cariprazine, lurasidone, and ziprasidone have the most benign metabolic profiles. Abreu recommended following the protocols outline in a consensus statement created jointly by four organizations, including the American Diabetes Association, which delineates a schedule of screening and monitoring for patients taking these agents.
Second-generation antipsychotics are not the only psychotropic drugs with potential cardiometabolic effects, Abreu added. Some mood stabilizers also can affect heart health. In particular, valproic acid and lithium are associated with weight gain.
'When prescribing psychotropic medications, the approach is to 'start low and titrate slowly,' and to monitor patients for adverse side effects and interactions with cardiac medications,' Abreu advised. 'Choose medications with lower potential for adverse metabolic effects as initial therapy and make adjustments and dose reductions of medications to the lowest therapeutic doses when feasible.' She also recommended adjunctive strategies for patients taking second-generation antipsychotics, including starting metformin upon initiation of treatment initiation.
Just as psychotropic drugs can affect the heart, cardiac drugs can have adverse psychiatric effects. For example, alpha- and beta-adrenergic blockers, angiotensin converting enzyme inhibitors, anti-arrhythmics, and statins can cause sedation, sleep disturbances, depression, and sometimes anxiety, and cardiovascular and psychotropic drugs can interact with one another.
Far-Reaching Effects
Psychosocial and lifestyle factors significantly affect cardiovascular risk in people with psychiatric illness. 'People with poor psychological health — be it depression, anxiety, or stress — are less likely to take their medications consistently and may be less likely and more averse to seeking evaluation of their symptoms,' Levine said. They 'may tend to exercise less, eat poorly, have less-controlled diabetes, and thus be more prone to developing metabolic syndrome.'
McIntyre, board chair of the Depression and Bipolar Support Alliance, a US-based national organization focusing on mood disorders, including depression and bipolar disorder, highlighted poverty, inadequate access to care, malnutrition, the need for food stamps and childhood adversity, particularly, physical or sexual abuse, as risk factors associated with the combination of mental illness and CVD.
The healthcare system, too, can aggravate the problem. 'This includes stigma, negative attitudes, discrimination toward patients [with mental illness] and disparities in cardiovascular care, often resulting in fewer diagnostic procedures and delayed treatment initiation,' Abreu said.
Karl-Heinz Ladwig, PhD, MD, senior research professor at the Medical Faculty of the Technische Universität Muenchen, in Munich, Germany, and a member of the panel, elaborated on some of the lifestyle and behavioral patterns of patients with CVD and depressive comorbidity. These include tobacco use, greater likelihood of not returning to work following an myocardial infarction, and co-occurring sleep disturbances and insomnia. In addition, decreased ability to maintain intimate relationships may occur, with a 'mutually reinforcing triad of depressive symptoms, CVD, and erectile dysfunction.'
Levine pointed to a 2021 scientific statement from the American Heart Association (AHA), which concluded that psychological health 'may be causally linked to biological processes and behaviors that contribute to and cause' CVD. Contributors to negative psychological health, include chronic stress and social stressors, such as social isolation and loneliness, work-related challenges, financial hardships, and discrimination; posttraumatic stress disorder; anger and hostility, anxiety, depression, and pessimism.
The AHA statement, on which Levin was the first author, did not focus only on the deleterious impact of negative psychological states. It stressed that positive psychological health, including a sense of optimism and purpose, happiness and positive affect, mindfulness, and higher emotional vitality can improve psychological well-being and, in turn, cardiovascular health.
Multidisciplinary Collaboration
Multidisciplinary collaboration is a critical component of addressing cardiovascular health in people with mental illness. 'No single provider can address psychiatric, behavioral, and somatic needs alone,' Kurpas said. 'A collaborative model has been shown to improve detection, continuity, and accountability and significantly improve patient outcomes.'
Cardiologists should keep mental health factors in mind, and psychiatrists should keep cardiac concerns on their radar. 'Collaborative care should be a team effort between cardiologists and psychiatrists,' Abreu said.
McIntyre agreed. 'All persons with mental illness should be screened for cardiovascular disease and metabolic syndrome, and all persons with heart disease should be screened for depression, as depression is the most robust prognosticator of cardiovascular death in people' after a myocardial infarction.
The AHA statement recommended the Patient Health Questionaire-2 depression screen tool as well as the Generalized Anxiety Disorder Questionnaire-2, which can be administered by staff such as nurses or medical assistants. Positive screens can open a discussion about additional symptoms and can be used for making appropriate referrals to mental health providers. The statement offers specific talking points that cardiologists can use when addressing these issues with their patients.
Even in the absence of a formally filled-out measurement tool, it 'may become apparent during the patient interaction that the patient is depressed or unduly stressed,' Levine said.
Many cardiologists 'don't feel comfortable formally diagnosing or treating patients for depression, but it's fair game and appropriate to gently mention to the patient that it seems like they may be depressed or stressed and gently inquire if they have interest in seeing a mental health professional, which we can help arrange a referral to,' he said. 'That's a time-efficient and nonthreatening way to talk to patients, acknowledge their symptoms, and offer a pathway forward if they're interested.'
Patients might 'recoil' at the suggestion of a psychiatrist, due to cultural values or fear of stigma, Levine added. 'They're more likely to be amenable if you recommend a 'mental health professional.''
Specific approaches to behavioral counseling are laid out in the 2016 joint recommendations of the European Society of Cardiology, Ladwig said. They include cognitive-behavioral strategies to facilitate lifestyle changes; utilizing multimodal interventions integrating medical resources with education, enhancing physical activity, stress management, and counseling regarding psychosocial risk factors; and referral for psychotherapy, medication, or collaborative care.
The AHA statement includes similar recommendation regarding interventions for psychiatric disorders or symptoms, including pharmacotherapy, psychotherapy —particularly cognitive-behavioral therapy — care management, stress management programs, meditation training, and mindfulness-based interventions.
The bidirectional relationship between psychiatric disease and CVD, which can become a vicious cycle, each exacerbating the other. Cardiologists should be cognizant of the role that addressing psychiatric illness can have in improving cardiovascular outcomes. In the words of Ladwig, 'the brain heals the heart.'
The opposite side of the coin is also true, according to McIntyre. Healing the heart can also benefit the brain. Addressing both together is optimal to improving both mental and cardiovascular health.
Kurpas, Abreu, Ladwig, and Levine declared no relevant financial relationships. McIntyre had received research grant support from CIHR/GACD/National Natural Science Foundation of China (NSFC) and the Milken Institute; speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Neurawell, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, Abbvie and Atai Life Sciences.
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