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Gregory Weiss, MD, reflects on recent data and an AHA statement related to mental health and increased risk of mortality among patients with heart failure with mental health disorders.
Links between mental health disorders and organ system disease have long been known. However, a recent study published in Circulation: Heart Failure found that men with heart failure died with greater frequency if they had severe depression, bipolar disorder, or schizophrenia. We know that people with serious mental health conditions develop high blood pressure, diabetes and have myocardial infarctions at younger ages than the general population. What we didn’t know is how mental health interacts with heart failure.
The study looked at over 20,000 patients with heart failure seen at Duke University. After entering the study, patients were followed to 7 years at which time it was discovered that men with severe mental illness were 36% more likely to die from any cause than those with normal mental health. In addition to increased mortality the study showed that people with severe mental health conditions were diagnosed with heart failure up to 7 years earlier than those without. The lead author of the Duke study, Christoffer Polcwiartek, MD, states,
“Doctors and heart failure specialists need to become more aware of mental health disorders among their patients and take early preventive steps.”
Polcwiartek further suggest that bringing cardiologists, general practitioners, and psychiatrists together is the best way to reduce the burden of heart failure in patients navigating the mental health system.
Current guidelines for heart failure recommend screening for depression but not more severe forms of mental illness. When other more severe forms of mental illness are discovered, special effort should be made to minimize the possibility of early-onset heart failure which could lead to increased short- and long-term mortality.
The study and its recommendations received a strong endorsement from clinical psychologist James Blumenthal, PhD, a professor of psychiatry at Duke University, who was not involved in the study. Blumenthal states,
“This is an important study that suggests doctors need to evaluate patients' mental health status in addition to evaluating more traditional heart failure risk factors.”
Blumenthal goes on to suggest that, although this study shines a light on a troubling association between mental health and heart failure, many questions remain. It is still unknown why men with severe mental health problems are more likely to die from heart failure while women are not. From the point of view of the mental health specialist, it could be that mental health conditions in patients with cardiovascular disease may be underrecognized and undertreated. In response to this study, the American Heart Association released a statement calling for the routine assessment of the mental well-being of all heart patients. The emphasis of the statement was on promoting clinician awareness and the concept of holistic treatment rather than a disease-centered model.
As specialists, cardiologists may fall prey to missing the trees for the forest. They train to focus on the cardiovascular system but failing to recognize the mind-body connection is a disservice to our patients. It is quite possible that, with regular screening and modifications to the treatment plan, cardiac patients with mental health conditions can live long full lives. More research is needed to determine the underpinnings of these data but in the meantime, the focus brought, especially to men with heart disease and severe depression, bipolar disease, or schizophrenia, can only stimulate further investigation and innovation in this area.
Not knowing all the answers is a frustrating but necessary position. The American Heart Association recognizes that having questions is the basis for finding answers to those questions. Now we know that men with severe mental health problems are at significantly higher risk of dying from heart failure. As clinicians, we must treat the whole patient at every visit truly winning for both hearts and minds.