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Learning objectives
To understand the importance of detecting and managing common non-organic mental disorders for the outcome of patients with cardiovascular disease.
To be able to identify common mental disorders and to inform the patient about it.
To be able to manage the mental healthcare needs of patients in cardiological settings (referral, interdisciplinary patient care).
To be able to explain basic mechanisms of common mental disorders to the patient.
To be familiar with common treatment options for patients with mental disorders.
Introduction
Mental disorders are prevalent. They impair patients’ quality of life severely and are associated with an increased risk of developing cardiovascular disease (CVD) and worse prognosis.1–4 Although these facts have been well established, there is still a gap in diagnostic awareness and treatment of mental disorders in patients with CVD.5–8 Therefore, we aim to educate cardiologists about the importance of mental disorders and how to address the widely unmet healthcare needs of patients with a mental disorder in their clinical practice.
Mental disorders increase the risk for subsequent CVD
All mental disorders are associated with an increased risk of developing CVD.9–11 As an example, we show the risk estimates from a recent extensive population-based cohort study from the Danish national registries, observing 5.9 million persons for 15 years (table 1).10 In general, the risk of developing CVD increases with the number of comorbid mental disorders, for example, from 1.5-fold to 3.0-fold for one as compared with five diagnoses.11
Association between mental disorders and subsequent CVD10
The onset of CVD triggers mental disorders
The onset of CVD escalates the risk of developing mental disorders by 2.2-fold. The 12-month prevalence of mental disorders in patients with CVD is reaching prevalence rates of 43.7% for inpatients and 42.2% for outpatients.12 These mental disorders are worsening cardiac prognosis significantly.5 13–15 For example, the most common symptoms of mental disorders, anxiety and depression are associated in a dose-dependent manner with an average 50% elevated risk for fatal events in patients with CVD.16 17 Moreover, the onset of CVD is a significant trigger of suicide, especially in the first 6 months after the cardiovascular event.18 Notably, the survival of cardiac arrest is associated with a particularly high risk of committing suicide (incidence rate ratio of 4.75).18 These findings highlight that coping with cardiovascular illnesses requires complex emotional-cognitive adaptations, which can overstrain the individual’s capacities leading to mental disorders and suicide.
How mental disorders impair cardiovascular health
Multiple pathways are linking mental disorders with cardiometabolic disease:5 13–15
Higher risk of poor nutrition habits, low physical activity, high smoking rates and substance abuse due to low self-caring capacities.
The hyperactivation of the amygdala-based fear-defence system, a fundamental neurobiological underpinning of mental disorders, directly fosters inflammation and artherosclerosis and increases endothelial dysfunction, platelet activation, coagulation and pro-arrhythmogenic potential.5 13
Patients with mental disorders are more exposed to socioeconomic stressors like unemployment, poverty, disadvantaged neighbourhoods and social isolation,13 14 activating the fear-defence system.
Psychiatric drugs, especially antipsychotic drugs, often have severe cardiometabolic side effects.1 19 20
Patients with mental disorders are often handicapped in using the healthcare system effectively. Due to their mental illness, they have a lower ability to trust and seek help, to express their needs adaptively or to adhere to treatment regimes and motivate themselves to initiate healthy lifestyle choices because of their impaired sense of self and ability for self-care.5 21 22
Mental disorders: basic epidemiological facts
The 12-month prevalence is about 27% in the general European population, accounting for 26.6% of the disability burden.23
The lifetime prevalence of any mental disorder is around 50%,24 with higher rates in high-risk populations (eg, low socioeconomic status, migration background).
Most mental disorders have their onset before age 25 and thus can affect the life course profoundly.
All mental illnesses, depending on severity and age of onset, have a reduced life expectancy of up to 10 and more years.1–4
At least two of five patients in general practitioner or cardiological settings have a mental disorder.25–27
Most mental disorders remain undetected and untreated for years.25–27
The most common mental disorders
A short overview of the four most common mental disorders the cardiologist will encounter in his daily practice is given in table 2, excluding substance use disorders. These disorders are often comorbid, and their first line-therapy is psychotherapy or psychotherapy and medication.
Clinical pictures of patients with common mental disorders
Understanding mental disorders
Childhood adversity is the single biggest risk factor for mental disorders.28–30 Other risk factors are a family history of mental disorders, low socioeconomic status, work stress, job insecurity and critical life events (eg, divorce, bereavement, myocardial infarction).31 The early experiences of the infant with his caregivers shape the brain profoundly and have a long-lasting impact on the way of feeling, perceiving and thinking.32 The central neurobiological underpinning of mental disorders is the activation of the amygdala-based fear-defence system. The clinical picture of the specific mental disorder is characterised by diverse symptoms and behaviours built by anxiety and the specific intrapsychic and interpersonal defences (eg, turning anger inward, rumination, submissive behaviour), their psychophysiological correlates (eg, muscle tension, cognitive-perceptual disruption) and consequences (eg, avoidance) and ways of coping with it (eg, drug abuse as self-medication).21 27 33 34 The diagnosis of a mental disorder is made if these symptoms and behaviours surpass a certain threshold of distress and impairment.
The patient–doctor relationship
The patient–doctor relationship is central to healthcare. Physicians need to be aware that being dependent on a caring person mobilises early attachment experiences of the patient. This process of inducing complex emotions, expectations and behaviours in the patient towards the doctor is called transference. Generally, this is not interfering with the successful establishment of a working alliance. However, remembering the high prevalence of mental disorders in patients with CVD, it is not uncommon that adverse childhood experiences are automatically transferred to healthcare professionals.21 27 Interactional difficulties and poor adherence of the patient can be indicative of a personality disorder with a need for psychotherapeutic evaluation and treatment.35
Identification and management of mental disorders
The enormous diagnostic gap of mental disorders in the field of cardiology calls for proactive screening, as recommended in current guidelines.5 6 36 37 Rarely patients spontaneously disclose that they suffer from mental illness. They usually present with typical stress symptoms such as fatigue/exhaustion, chest tightness, shortness of breath or palpitations, abdominal discomfort, dizziness, limb weakness and so on, signs which are overlapping with those of common cardiac diseases (eg, atrial fibrillation, heart failure, angina). Therefore, the cardiologist should be aware from the beginning of the consultation that emotional problems might cause or aggravate some of these symptoms, avoid an either/or attitude regarding medical or psychological causes and ask proactively about symptoms of mental disorders and stressful situations. Under the time constraints of the medical settings, regular screening of all patients with CVD has proven an easy, time-efficient and effective measure to improve the identification of mental healthcare needs, which alone has demonstrated potential beneficial effects on CVD outcomes38 (table 3).
Implementation
Example of a screening questionnaire
Management of suicidal ideation
General recommendations for initiating treatment in CVD settings
Acquire sufficient mental health literacy by continuing interdisciplinary medical education.
Ask for the preference of the patient regarding mental healthcare.
Improving lifestyle has beneficial effects on cardiovascular and mental health. Therefore, unhealthy behaviour should be addressed, especially in patients with mental disorders.
Complex patients (ie, patients with severe mental disorders, interactional difficulties or severe non-compliance, or medical conditions limiting psychopharmacotherapy) should be referred to mental healthcare services.
The treatment of patients with mental disorders needs long-term follow-up monitoring and continuity of care.
CVD, cardiovascular disease.
General recommendations for handling psychopharmacological medications in patients with CVD
The psychopharmacological treatment of cardiac patients with mental disorders needs interdisciplinary cooperation and communication (eg, multidisciplinary case discussions, balancing the pros and cons of medications). Notably, the indication for antipsychotic drugs should carefully balance the pros and cons of the individual patient.
Tricyclic antidepressants and monoamine oxidase inhibitors have a high risk of fatal side-effects and therefore should be avoided.
Intermediate to long-acting benzodiazepines can be used as anxiolytics in acute crisis; however, the development of drug dependency must be avoided. The prescription of benzodiazepines should be accompanied by a referral to a mental health service for further evaluation and treatment.
CVD, cardiovascular disease.
Treatment of mental disorders
Mental disorders often remain undiagnosed, untreated or undertreated despite the availability of effective and stepped treatments in most countries with universal healthcare (box 1). In addition to the improvement of mental health, mental healthcare has also demonstrated beneficial effects on cardiovascular outcomes.5 37 39
Psychotherapy
For the most prevalent mental disorders, there is a first-line recommendation for psychotherapy (cognitive-behavioural, psychodynamic). Cardiac patients prefer talking therapy over drug therapy as do non-cardiac patients.40 Treatment sessions usually last for 50 min. Treatment courses typically range from 1 to 100 and more meetings, usually with one session per week. Psychotherapy compares well with established medical practices. The general response rate is around 50%–70%, the overall effect size is 0.80, which is equivalent to an NNT (number needed to treat) of 3, meaning that three patients need to be treated to achieve success relative to untreated patients. Psychotherapy usually is as effective as pharmacological treatments but more enduring. Psychotherapy aims to be a causal therapy.41 All brands of psychotherapy aim at helping patients to learn adaptive and unlearn maladaptive behaviour on the basis of a trusting relationship. In some countries, psychotherapeutic inpatient or day hospital treatments are available for patients with mental disorders and severe medical diseases.42 43
Recently, e-mental health treatments have been established as psychological self-help therapies with little or no support from therapists (eg, https://moodgym.com.au), which are yielding sound effects in highly motivated patients.44
Psychopharmacological medications
The most common psychopharmacological drugs are antidepressants, anxiolytics/hypnotics and antipsychotics. Especially in cardiac patients, side effects, drug–drug interactions, indications and contraindications must be carefully considered45 (box 2). For example, while in patients with coronary heart disease, selective serotonin reuptake inhibitor antidepressants significantly reduce depression, coronary heart disease readmission rates and all-cause death (0.56, 0.35 to 0.88),46 in heart failure, the same drugs increased mortality without any benefit for the mood.47
Many psychiatric medications are associated with increased risk for sudden cardiac death, as demonstrated by a sizeable case-control study.19 After adjustment for confounding variables, the risk was highest for tricyclic antidepressants (3.41, 1.33 to 8.77), antipsychotic drugs (3.4, 1.8 to 6.5) and exceptionally high for the combined use of phenothiazines and any antidepressants (18.3, 2.5 to 135.3). Common side effects of psychopharmacological drugs concern the impact on blood pressure, heart rate, cardiac conduction and proarrhythmic effects (eg, prolongation of the QT interval). Regarding antidepressants, tricyclics have especially harmful side-effects.45 Antipsychotics are associated with weight gain, dyslipidaemia, hyperglycaemic, QT prolongation, hypotension, tachycardia and generally increased cardiovascular risk.20 Benzodiazepines are not associated with severe cardiovascular side-effects and drug–drug interactions. However, the literature is conflicting concerning the increase or decrease of mortality related to benzodiazepines. Further, prolonged intake of benzodiazepines leads to the development of substance dependency.45
Conclusion
Mental disorders are very prevalent in cardiac patients and have a profound impact on the well-being and prognosis. Professional management of these mental health needs is a major challenge in cardiologic settings. We have provided an algorithm for the identification and management of common mental disorders, which can easily be realised under the time constraint of cardiological settings. The cardiologist may look out for a biopsychosocial understanding and treatment of the patient.
Key messages
Mental health is the basis of personal and emotional well-being for the individual, the family, the community and society.
Mental disorders reflect adverse or traumatic experiences of the individual and his environment. The genetic predisposition plays a subordinate role.
Mental disorders are associated with an increased risk of developing cardiovascular disease (CVD) and reduced life expectancy.
The key to improving outcomes of persons with mental disorders is enabling access to healthcare by proactive identification of mental disorders and treatment initiation.
Screening questionnaires are time-efficient measures for improving recognition rates in time constraint cardiological settings and should be applied to all patients with CVD routinely.
Patients with CVD have an increased risk of committing suicide, particularly in the first months after the onset of the CVD.
Patients with CVD who have mental disorders are at increased risk of non-adherence, denial of critical medical findings and miscommunication.
Personalised patient care needs integrated or multidisciplinary treatment approaches and interdisciplinary medical education. Silo-thinking does not meet the complex healthcare needs of heart patients.
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Ethics statements
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References
Footnotes
Contributors MM wrote the first draft. MM and MB contributed original material to the manuscript and provided revisions. MM finalised the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Author note References which include a * are considered to be key references.