DID YOU KNOW... That having a Mental Illness increases your Risk for Heart Disease?

Prepared by John. A. Sawdon M.Sc. Public Education & Special Projects Director,
Cardiac Health Foundation of Canada, December 2017


Introduction

There have been numerous studies that have linked cardiovascular disease with individuals diagnosed with severe mental illness. Between 1912 and 1932, 980 patients admitted to Brooklyn State Hospital for manic depression died during their stay. Forty percent died from “exhaustion from acute mental illness” with 31% dying from cardiac disease.1 This association of serious mental illness with cardiovascular disease especially for bipolar disorder existed prior to the advent of antipsychotics, tricycle antidepressants and lithium.1A Depression, anxiety disorders, schizophrenia and bipolar disorder (BD) have all been identified as risk factors for cardiovascular disease. 2,3 Although research that surfaced this connection of severe mental illness and CVD has been identified over the past 70 years, little action has occurred in reducing the cardiovascular disease risk amongst individuals with a major mental illness. This shocking fact becomes even more outrageous when you consider that cardiovascular disease mortality has been reduced for the general population over the past twenty years while the CVD mortality rates have increased for those with a serious mental illness.

Much of this is attributable to the stigma of mental illness and the lack of integration with primary health care and mental health services for individuals with a serious mental illness.4

What the Research Tells Us

An International study involving 3.2 million people with severe mental illness conducted by Kings College in London and published online through World Psychiatry found a substantially increased risk for developing cardiovascular disease compared to the general population. This new meta-analytic study of SMI and cardiovascular disease involving 113 million people from the general population compared to 3.2 million people with a SMI is one of the most definitive studies of our time on this topic. This far reaching study involving 92 individual studies conducted across 16 countries found that 10% of people with SMI had cardiovascular disease (schizophrenia 11.8%; depression 11.7%; bipolar disorder 8.4%) This same study found that individuals with severe mental illness have a 53% higher risk for cardiovascular disease than healthy controls. This study also revealed that individuals with SMI have a 78% higher risk of developing CVD over the long term and a 85% higher risk of dying from cardiovascular disease compared to the general population.4 Another large UK study involving 46,000 people with severe mental disorder (schizophrenia spectrum, major depression, bipolar disorder) and 300,000 controls found a CVD hazard ratio of three fold for the 18 to 49 year age group and twofold for the 50 to 75 year old group for cardiovascular disease.

Many studies have also identified the impact of cardiovascular disease on life expectancy. In a Swedish study involving 8300 persons with schizophrenia found hazard ratios for CVD mortality to be 12 years reduced life expectancy for women and 15 years reduced life expectancy for men. In a Sweden, Finland and Denmark study found that individuals with schizophrenia and cardiovascular disease the life expectancy is 15 to 20 years shorter than the general population. In the large meta analytic study of individuals with severe mental illness found life expectancy shortened by 10 to 17.5 years compared to the general population.5,6 In a Cochrane review the life expectancy for individuals with bipolar disorder is between 11 to 20 years depending on the age of onset of the illness. Although suicide has been identified as accounting for 20% of this reduced life expectancy, physical diseases account for the overwhelming majority of premature deaths7 In psychiatric populations very little attention has been paid to reducing the risk of the physical conditions that give rise to premature deaths within this population.

Risk Factors for Cardiovascular Disease

Cardiovascular disease diagnoses occur 6 years earlier for those with bipolar disorder than with depression and 15 years before the general public. Many factors contribute to this including the effects of psychotropic medications, metabolic syndrome, high cholesterol, hypertriglyceridemia, lifestyle including tobacco use and substance abuse, physical inactivity and poor diet. Several studies have shown the prevalence rates of modifiable cardiovascular risk factors including obesity, smoking, diabetes, and dyslipidaemia that explain much of the excess cardiovascular mortality rates. These risk factors also occur at a younger age. Researchers from the Universities of Edinburgh and Southhampton in the UK and the Karolinska Institute in Sweden using data from the Swedish Cause of Death Registry and the Country’s National Hospital Discharge Register evaluated over 1,000,000 Swedish men born between 1950 and 1976. These men underwent psychiatric and medical assessments at an average age of 18.3 years and were followed up for 22 years. This study found an increased risk for developing heart disease in men diagnosed with a mental disorder around the age of 18. This study identified an increased risk for CVD across a wide range of mental health conditions including schizophrenia, bipolar disorder, depression, neurotic disorders, personality disorders and substance-use disorders.7B A follow up study by the Youth Committee of the Council on Cardiovascular Disease of the American Heart Association that was published in August 2015 identified pathophysiological factors including inflammation, oxidative stress, autonomic dysfunction and endothelial dysfunction linked to early onset CVD in those with a major depressive disorder and mood disorders. These processes were likely set in motion by negative lifestyle behaviours including early adversity/abuse; sleep disturbance; sedentary lifestyle, poor nutrition and tobacco, alcohol and substance abuse. In addition medication related factors also contributed to early onset of CVD including antidepressants that lead to weight gain, second generation antipsychotics also lead to more severe weight gain, along with dysglycemia and dyslipidemia.7C This study also found a genetic link whereby children without a mental illness of parents who did have a mental illness were found to have endothelial dysfunction and stiffened arteries.


In the US Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study found 25% of men with schizophrenia had metabolic syndrome compared to fewer than 10% of the general population.8 The following prevalence rates of modifiable risk factors adapted from the DeHert Et al 9 and Richard IG Holt in PCCJ Practise Review is summarised as follows for those diagnosed with schizophrenia and bipolar disorder:

Modifiable Risk Factor Schizophrenia Prev Rel-Risk Bipolar Disorder Prev Rel-Risk
Smoking 50-80% 2-3 54-68% 2-3
Dyslipedemia 25-69% <5 23-38% <3
Diabetes 10-15% 2-3 8-17% 1.5-3
Hypertension 19-58% 2-3 35-61% 2-3
Obesity 45-55% 1.5-2 21-49% 1-2
Metabolic Syndrome 37-63% 2-3 30-53% 2-3

Recent studies have reported obesity rates that are doubled for people with serious mental illness with higher hip to waist ratio and increased visceral fat. Smoking which is independently associated with suicide risk, poorer response to treatment and structural changes to the brain is high within this group. In terms of Type 2 diabetes while the official diabetic rate is between 10 to 15 percent among individuals with a serious mental illness, it is suspected that the rate of undiagnosed diabetes is 70 percent as compared to the undiagnosed rate of the general population at 25%.

There is well documented evidence and concern over antipsychotics and their contribution to both cardiovascular risk and Type 2 Diabetes including inducing weight gain, worsening lipid profiles and blood glucose levels. Antipsychotic treatment is also associated with increases in low density lipoprotein (LDL), cholesterol, and triglycerides and decreased HDL cholesterol. Lithium a major treatment for Bipolar disorder is associated with weight gain and adversely influences glucose metabolism.10

Another risk factor that contributes to cardiovascular risk is nutrition including eating regular meals on time. Often due to lack of income compounded by symptoms of individual illnesses, individual diets are comprised of fats and sugars often without vegetables and fruits. In a study of 1046 Australian women, poor diet quality was associated with twice the odds for bipolar disorder. In another study comparing 2032 participants with BD in the general population, having BD was associated with significantly poorer eating behaviours, including fewer meals, difficulty both obtaining food and cooking food, along with high caloric intake. Diets rich in calories, fats and carbohydrates contribute to metabolic syndrome and cardiovascular disease. Unhealthy diets are prevalent in people diagnosed with schizophrenia and may be exacerbated by poor hygiene and taking care of oneself. Negative symptoms and cognitive deficits contribute to unemployment which then limits access to healthy lifestyle, and healthy foods. 11,3

Lack of physical activity and physical fitness contributes to metabolic syndrome and cardiovascular disease for both the general population and individuals with serious mental illness. Individuals with a serious mental illness often lead sedentary lives and are physically inactive significantly more than the general population.

Looking Forward: How do we reduce metabolic syndrome and cardiovascular disease in people with a serious mental illness?

The first issue to address is the difficulty in both diagnosing cardiovascular disease and in accessing the primary care health network to identify and screen for cardiovascular disease and type 2 diabetes. On the surface this appears to be largely due to the mental illness stigma and reluctance of health care networks and clinics to receive patients with a mental illness. A compounding problem is the mental illness itself, which both inhibits individuals from seeking out physical health care support and leads to behaviours that lead to being excluded from healthcare clinics and or family practitioners. As mentioned at the outset of this article, the general public has benefited greatly from cardiovascular research and breakthroughs. Eighty percent of children born with congenital heart conditions now live beyond their adolescent years. Equally mortality rates from heart disease in Canada have dropped significantly while CVD mortality rates for those with a mental illness have increased.


Dr Katie Goldie who worked at the Centre for Addiction and Mental Health CAMH presented a study at the Canadian Cardiovascular Congress that was cohosted by Heart and Stroke Foundation and Canadian Cardiovascular Society in 2014 indicating that people with mental health disorders were twice as likely to have heart disease or stroke compared to those without a mental health disorder. She also called upon the primary healthcare providers to better integrate their services with the mental health system in addressing cardiovascular risk and reducing mortality rates. She identified stigma with a mental health disorder as a barrier to addressing the cardiovascular health issues of individuals with a mental health disorder.

Dr. Brian Baker of the Heart and Stroke Foundation of Canada suggested that prevention strategies are the same for people with mental health issues. That means eating a healthy diet, being physically active, being smoke free, managing stress, and limiting alcohol consumption. Dr. Benjamin Goldstein is the Director of the Centre for Youth Bipolar Disorder at Sunnybrook Hospital and has researched extensively the shared biology between heart health and brain health in adolescents showing early onset of cardiovascular disease in people with bipolar disorder. His focus and interest is in testing treatments typically used for treating heart disease including diet, exercise and heart medications is their applicability in both treating and potentially eliminating Bipolar Disorder. This new Centre may help us determine whether Dr. Brian Bakers recommendations work with individuals with a serious mental illness.( )

A quick review of the literature suggests this isn’t so easy to implement and secondly some strategies have to be modified to address specific idiosyncrasies of the mental health disorder. In our next article we will describe some of the findings from outcome studies that have attempted to address those modifiable risk factors that lead to cardiovascular disease. We will also do a follow up to the CMHA Ontario Division’s 3 year project Minding our Bodies and the Dietitians of Canada’s initiatives in promoting improved nutrition as means of addressing chronic health conditions of those experiencing a mental illness. Although Bell Canada has opened the dialogue on mental illness in Canada as a way of reducing stigma, we have yet to address the disparities for accessing healthcare and reducing the chronic disease mortality rates of those afflicted with a serious mental illness. Our goal will be to initially raise awareness of this issue and secondly facilitate the undertaking of a pilot project that addresses the risk factors for cardiovascular disease.

In the interim if we have piqued your curiosity, or raised some questions, please send these into us by contacting jsawdon@cardiachealth.ca. We will attempt to address these either directly or alternatively by incorporating the responses within our next article.

References:

  1. Goldstein BenjaminI MD, PhD, FRCPC; Fagiolini Andrea MD, FRCPC; Houck Patricia; Kupfer David J MD Cardiovascular disease and hypertension among adults with bipolar 1 disorder in the United States HHS Public Access NIHMS384711 doi: 10.1111/j. 1399-5618.2009.00735.x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401900/
  2. Weiner Miriam, Warren Lois, and Fiedorowicz Jesse G. Department of Psychiatry, Roy J. & Lucille Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242 Cardiovascular Morbidity and Mortality In Bipolar Disorder NIH Public Access, Ann Ckin Psychiatry. 2011 February; 23(1): 40-47
  3. Vukan-Cusa Bjanka, Marcinko Darko, Sagud Marina, & Jakovljevic Miro The Comorbidity of Bipolar Disorder and Cardiovascualr Diseases from Pharmcotherapy Perspective Pschiatria Danubina 2009, Vol 21, No3, pp382-385 @medicinska Naklada-Zagreb,Croatia
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The articles, on the Cardiac Health Foundation of Canada website, are presented with the understanding that the Foundation is providing information only and not rendering medical advice. Please check with your family physician, specialist or health care professional before implementing any of the ideas expressed in these articles.