Heart Disease and Mental Health Disorders
Mental health is an important part of overall health and refers to a person’s emotional, psychological, and social well-being. Mental health involves how we think, feel, act, and make choices.
Mental health disorders can be short- or long-term and can interfere with a person’s mood, behavior, thinking, and ability to relate to others. Various studies have shown the impact of trauma, depression, anxiety, and stress on the body, including stress on the heart.1-3
Mood Disorders: People living with mood disorders, such as major depression or bipolar disorder, find that their mood affects both psychological and mental well-being nearly every day for most of the day.
Anxiety Disorders: People respond to certain objects or situations with fear, dread, or terror. Anxiety disorders include generalized anxiety, social anxiety, panic disorders, and phobias.
Post-Traumatic Stress Disorder (PTSD): People can experience PTSD after undergoing a traumatic life experience, such as war, natural disaster, or any other serious incident.
Chronic Stress: People are in a state of uncomfortable emotional stress—accompanied by predictable biochemical, physiological, and behavioral changes—that is constant and persists over an extended period of time.
*There may be other behavioral health disorders, such as substance use disorders, that are connected to heart disease.
A large and growing body of research shows that mental health is associated with risk factors for heart disease before a diagnosis of a mental health disorder and during treatment. These effects can arise both directly, through biological pathways, and indirectly, through risky health behaviors.5
People experiencing depression, anxiety, stress, and even PTSD over a long period of time may experience certain physiologic effects on the body, such as increased cardiac reactivity (e.g., increased heart rate and blood pressure), reduced blood flow to the heart, and heightened levels of cortisol. Over time, these physiologic effects can lead to calcium buildup in the arteries, metabolic disease, and heart disease.1,6-11
Evidence shows that mental health disorders—such as depression, anxiety, and PTSD—can develop after cardiac events, including heart failure, stroke, and heart attack.5,12-20 These disorders can be brought on after an acute heart disease event from factors including pain, fear of death or disability, and financial problems associated with the event.5,16
Some literature notes the impact of medicines used to treat mental health disorders on cardiometabolic disease risk. The use of some antipsychotic medications has been associated with obesity, insulin resistance, diabetes, heart attacks, atrial fibrillation, stroke, and death.21
Mental health disorders such as anxiety and depression may increase the chance of adopting behaviors such as smoking, inactive lifestyle, or failure to take prescribed medications.5 This is because people experiencing a mental health disorder may have fewer healthy coping strategies for stressful situations, making it difficult for them to make healthy lifestyle choices to reduce their risk for heart disease.5
Specific populations, such as the following, show higher rates of heart disease as a result of pre-existing mental health disorders:
Veterans. Studies found that veterans are at a higher risk for heart disease, mainly due to PTSD as a result of combat.22-26
Women. Studies exclusively focused on women found that PTSD and depression may have damaging effects on physical health, particularly with increased risk for coronary heart disease (CHD)–related morbidity and mortality.27,28
Couples with someone who has PTSD. Comparative studies found that couples where one or both partners had PTSD experienced more severe conflict, greater anger, and increased cardiovascular reactivity to conflict discussions than couples where neither partner had PTSD. Anger and physiological stress responses to couple discord might contribute to CHD and heart disease risk within these relationships.29,30
Racial and ethnic minorities. Lastly, studies focused on racial or ethnic minority groups found that depression, stress, and anxiety due to disparities in social determinants of health,31 adverse childhood experiences,32 and racism/discrimination33-35 could place certain subpopulations at a higher risk for hypertension,32,33,35,36 cardiovascular reactivity,35 heart disease,31,34 and poor heart health outcomes.37
Addressing mental health disorders early by providing access to appropriate services and support to increase healthy behaviors (e.g., increased physical activity, improved diet quality, and reduced smoking) can reduce someone’s risk of experiencing a heart disease event.13,15,17,19,28,38-40
Below are some actions that health care systems, health care professionals, individuals, and researchers can take to promote heart disease prevention and support mental health.
Actions for Health Care Systems
- Set up multidisciplinary teams that include both mental health and heart disease professionals.41-44
- Employ clinical decision support or electronic health record systems to coordinate care among the multidisciplinary teams.42,43
Actions for Health Care Professionals
- Learn more about the link between mental health and heart disease19 with the following resources:
- Talk to your patients about the relationship between mental health and heart disease.1,28,39,45,46
- Incorporate mental health screening and treatment into care surrounding a major heart disease event and chronic disease.2,6,8,17,21,25,32,40,45,47
- Involve individuals and their family members in communication and decision making regarding treatment following a heart disease event.15
- For patients with severe mental health disorders and pre-existing heart disease or its risk factors:21
- Consider prescribing or switching a patient to a psychotropic medication with lower risk for heart disease, while weighing any clinical benefits and potential for adverse events.
- Consider the potential interactions between prescribed medicines for heart disease and prescribed psychotropic medications.
- Monitor heart health outcomes and risk factors, and adjust doses of heart disease medicines if required.
Actions for Individuals
- Recognize the signs and symptoms of mental health disordersexternal icon and heart disease.
- Talk with your health care professionals about potential heart conditions in relation to your mental health disorder and treatment options.4
- Know that your family history and genetic factors likely play some role in your risk for heart disease.
- Know which conditions increase the risk of heart disease.
- Maintain a healthy lifestyle.
Actions for Researchers
- Address the role of social determinants of health and health disparities in improving the intersection between mental health and heart health outcomes.48,49
- Understand the link and impact of mental health on the prevention and treatment of heart disease and its risk factors.44
- Describe the biological pathway between mental health disorders and heart disease to understand the intermediate and long-term outcomes (e.g., chronic inflammation, cardiac reactivity, heart rate variability, and coronary artery calcification).29,44,47,50-54
- Analyze the impact of emotional well-being (i.e., a state in which people understand and manage their emotions through achievable goals, positive relationships, and responsible decision making) on mental health and physical health.55,56
- Expand traditional heart disease risk assessments, such as the Atherosclerotic Cardiovascular Disease Risk Estimatorexternal icon or Framingham 10-Year Risk of General Cardiovascular Diseaseexternal icon,57 to include mental health disorders.
- Develop valid and reliable screening instruments to help identify vulnerable populations.12
For more information about the link between mental health and heart disease, see the following resources:
- Centers for Disease Control and Prevention: Behavioral Risk Factor Surveillance System
- Centers for Disease Control and Prevention: Interactive Atlas of Heart Disease and Stroke
- Centers for Disease Control and Prevention: Mental Health
- Centers for Disease Control and Prevention: National Health and Nutrition Examination Survey
- Cleveland Clinic: Depression & Heart Diseaseexternal icon
- National Institute of Mental Health: Chronic Illness & Mental Healthexternal icon
- Substance Abuse and Mental Health Services Administration (SAMHSA)–Health Resources and Services Administration (HRSA): Center for Integrated Health Solutionsexternal icon
- World Health Organization: Mental Healthexternal icon
- Bremner JD, Campanella C, Khan Z, Shah M, Hammadah M, Wilmot K, et al. Brain correlates of mental stress-induced myocardial ischemia. Psychosom Med 2018;80(6):515–25.
- Del Gaizo AL, Elhai JD, Weaver TL. Posttraumatic stress disorder, poor physical health and substance use behaviors in a national trauma-exposed sample. Psychiatry Res 2011;188(3):390–5.
- Sowden GL, Huffman JC. The impact of mental illness on cardiac outcomes: a review for the cardiologist. Int J Cardiol 2009;132(1):30–7.
- Chaddha A, Robinson EA, Kline-Rogers E, Alexandris-Souphis T, Rubenfire M. Mental health and cardiovascular disease. Am J Med 2016;129(11):1145–8.
- Abed MA, Kloub MI, Moser DK. Anxiety and adverse health outcomes among cardiac patients: a biobehavioral model. J Cardiovasc Nurs 2014;29(4):354–63.
- Hopkinson NS, Baxter N. Breathing SPACE—a practical approach to the breathless patient. NPJ Prim Care Respir Med 2017;27(1):5.
- Jacob L, Haro JM, Koyanagi A. Post-traumatic stress symptoms are associated with physical multimorbidity: findings from the Adult Psychiatric Morbidity Survey 2007. J Affect Disord 2018;232:385–92.
- Jurek B, Neumann ID. The oxytocin receptor: from intracellular signaling to behavior. Physiol Rev 2018;98(3):1805–908.
- Ning L, Guan S, Liu J. An investigation into psychological stress and its determinants in Xinjiang desert oil workers. Medicine (Baltimore) 2018;97(15):e0323.
- Quensell ML, Taira DA, Seto TB, Braun KL, Sentell TL. “I need my own place to get better”: patient perspectives on the role of housing in potentially preventable hospitalizations. J Health Care Poor Underserved 2017;28(2):784–97.
- Sambamoorthi U, Mitra S, Findley PA, Pogach LM. Decomposing gender differences in low-density lipoprotein cholesterol among veterans with or at risk for cardiovascular illness. Womens Health Issues 2012;22(2):e201–8.
- Alosaimi F, Hawa R. Broken heart: broken mind. J Psychosom Res 2009;67(4):285–7.
- Copeland LA, Sako EY, Zeber JE, Pugh MJ, Wang CP, MacCarthy AA, et al. Mortality after cardiac or vascular operations by preexisting serious mental illness status in the Veterans Health Administration. Gen Hosp Psychiatry 2014;36(5):502–8.
- Edmondson D, von Känel R. Post-traumatic stress disorder and cardiovascular disease. Lancet Psychiatry 2017;4(4):320–9.
- Hwang B, Moser DK, Dracup K. Knowledge is insufficient for self-care among heart failure patients with psychological distress. Health Psychol 2014;33(7):588–96.
- Lett HS, Blumenthal JA, Babyak MA, Catellier DJ, Carney RM, Berkman LF, et al. Social support and prognosis in patients at increased psychosocial risk recovering from myocardial infarction. Health Psychol 2007;26(4):418–27.
- Morin RT, Galatzer-Levy IR, Maccallum F, Bonanno GA. Do multiple health events reduce resilience when compared with single events? Health Psychol 2017;36(8):721–8.
- Pino EC, Zuo Y, Borba CP, Henderson DC, Kalesan B. Clinical depression and anxiety among ST-elevation myocardial infarction hospitalizations: results from Nationwide Inpatient Sample 2004–2013. Psychiatry Res 2018;266:291–300.
- Spitznagel MB, Potter V, Miller LA, Roberts Miller AN, Hughes J, Rosneck J, et al. Ability to regulate emotion is predicted by depressive symptoms and cognitive function in a cardiac sample. J Cardiovasc Nurs 2013;28(5):453–9.
- Violanti JM, Andrew ME, Burchfiel CM, Dorn J, Hartley T, Miller DB. Posttraumatic stress symptoms and subclinical cardiovascular disease in police officers. Int J Stress Manag 2006;13(4):541–54.
- World Health Organization. WHO Guidelines: Management of Physical Health Conditions in Adults With Severe Mental Disorders. Geneva, Switzerland: World Health Organization; 2018.
- Davis MB, Maddox TM, Langner P, Plomondon ME, Rumsfeld JS, Duvernoy CS. Characteristics and outcomes of women veterans undergoing cardiac catheterization in the Veterans Affairs Healthcare System: insights from the VA CART Program. Circ Cardiovasc Qual Outcomes 2015;8(2 Suppl 1):S39–47.
- Dedert EA, Calhoun PS, Watkins LL, Sherwood A, Beckham JC. Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evidence. Ann Behav Med 2010;39(1):61–78.
- Khazaie H, Saidi MR, Sepehry AA, Knight DC, Ahmadi M, Najafi F, et al. Abnormal ECG patterns in chronic post-war PTSD patients: a pilot study. Int J Behav Med 2013;20(1):1–6.
- Oddone AE, Dennis PA, Calhoun PS, Watkins LL, Sherwood A, Dedert EA, et al. Orthostatic hypotension in young adults with and without posttraumatic stress disorder. Psychol Trauma 2015;7(3):229–33.
- Olff M, Meewisse ML, Kleber RJ, van der Velden PG, Drogendijk AN, van Amsterdam JG, et al. Tobacco usage interacts with postdisaster psychopathology on circadian salivary cortisol. Int J Psychophysiol 2006;59(3):251–8.
- Kubzansky LD, Koenen KC, Jones C, Eaton WW. A prospective study of posttraumatic stress disorder symptoms and coronary heart disease in women. Health Psychol 2009;28(1):125–30.
- Schwartzman JB, Glaus KD. Depression and coronary heart disease in women: implications for clinical practice and research. Prof Psychol Res Pract 2000;31(1):48–57.
- Caska CM, Smith TW, Renshaw KD, Allen SN, Uchino BN, Birmingham W, et al. Posttraumatic stress disorder and responses to couple conflict: implications for cardiovascular risk. Health Psychol 2014;33(11):1273–80.
- Troxel WM, DeSantis A, Germain A, Buysse DJ, Matthews KA. Marital conflict and nocturnal blood pressure dipping in military couples. Health Psychol 2017;36(1):31–4.
- Belgrave FZ, Abrams JA. Reducing disparities and achieving equity in African American women’s health. Am Psychol 2016;71(8):723–33.
- Lehman BJ, Taylor SE, Kiefe CI, Seeman TE. Relationship of early life stress and psychological functioning to blood pressure in the CARDIA study. Health Psychol 2009;28(3):338–46.
- Moody DLB, Chang YF, Pantesco EJ, Darden TM, Lewis TT, Brown C, et al. Everyday discrimination prospectively predicts blood pressure across 10 years in racially/ethnically diverse midlife women: study of women’s health across the nation. Ann Behav Med 2019;53(7):608–20.
- Paradies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 2015;10(9):1–48.
- Peters RM, Butler K, Gjini K, Yeragani V, Boutros NN. The role of sensory gating in the racism/blood pressure relationship: a pilot study. J Psychophysiol 2011;25(1):40–9.
- Hunter LR, Schmidt NB. Anxiety psychopathology in African American adults: literature review and development of an empirically informed sociocultural model. Psychol Bull 2010;136(2):211–35.
- Brewer LC, Redmond N, Slusser JP, Scott CG, Chamberlain AM, Djousse L, et al. Stress and achievement of cardiovascular health metrics: the American Heart Association Life’s Simple 7 in blacks of the Jackson Heart Study. J Am Heart Assoc 2018;7(11):1–16.
- Stewart JC, Perkins AJ, Callahan CM. Effect of collaborative care for depression on risk of cardiovascular events: data from the IMPACT randomized controlled trial. Psychosom Med 2014;76(1):29–37.
- Appleton AA, Buka SL, Loucks EB, Gilman SE, Kubzansky LD. Divergent associations of adaptive and maladaptive emotion regulation strategies with inflammation. Health Psychol 2013;32(7):748–56.
- van den Berk-Clark C, Secrest S, Walls J, Hallberg E, Lustman PJ, Schneider FD, et al. Association between posttraumatic stress disorder and lack of exercise, poor diet, obesity, and co-occuring smoking: a systematic review and meta-analysis. Health Psychol 2018;37(5):407–16.
- Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363(27):2611–20.
- Community Preventive Services Task Force. Recommendation for use of collaborative care for the management of depressive disorders. Am J Prev Med 2012;42(5):521–4.
- Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight-Eily LR, et al. Collaborative care to improve the management of depressive disorders: a Community Guide systematic review and meta-analysis. Am J Prev Med 2012;42(5):525–38.
- Gerber MR, King MW, Iverson KM, Pineles SL, Haskell SG. Association between mental health burden and coronary artery disease in U.S. women veterans over 45: a national cross-sectional study. J Womens Health 2018;27(3):238–44.
- Hawkley LC, Masi CM, Berry JD, Cacioppo JT. Loneliness is a unique predictor of age-related differences in systolic blood pressure. Psychol Aging 2006;21(1):152–64.
- Zen AL, Whooley MA, Zhao S, Cohen BE. Post-traumatic stress disorder is associated with poor health behaviors: findings from the Heart and Soul Study. Health Psychol 2012;31(2):194–201.
- Kinder LS, Kamarck TW, Baum A, Orchard TJ. Depressive symptomatology and coronary heart disease in type I diabetes mellitus: a study of possible mechanisms. Health Psychol 2002;21(6):542–52.
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2015;132(9):873–98.
- Tawakol A, Osborne MT, Wang Y, Hammed B, Tung B, Patrich T, et al. Stress-associated neurobiological pathway linking socioeconomic disparities to cardiovascular disease. J Am Coll Cardiol 2019;73(25):3243–55.
- Agorastos A, Boel JA, Heppner PS, Hager T, Moeller-Bertram T, Haji U, et al. Diminished vagal activity and blunted diurnal variation of heart rate dynamics in posttraumatic stress disorder. Stress 2013;16(3):300–10.
- Carroll AJ, Carnethon MR, Liu K, Jacobs DR, Colangelo LA, Stewart JC, et al. Interaction between smoking and depressive symptoms with subclinical heart disease in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Health Psychol 2017;36(2):101–11.
- Pizzi C, Manzoli L, Mancini S, Costa GM. Analysis of potential predictors of depression among coronary heart disease risk factors including heart rate variability, markers of inflammation, and endothelial function. Eur Heart J 2008;29(9):1110–7.
- Rohleder N. Stress system regulation of chronic low-grade inflammation. Adv Neuroimmune Biol 2012;3(3):265–76.
- Smith TW, Uchino BN, Berg CA, Florsheim P, Pearce G, Hawkins M, et al. Associations of self-reports versus spouse ratings of negative affectivity, dominance, and affiliation with coronary artery disease: where should we look and who should we ask when studying personality and health? Health Psychol 2008;27(6):676–84.
- Kubzansky LD, Huffman JC, Boehm JK, Hernandez R, Kim ES, Koga HK, et al. Positive psychological well-being and cardiovascular disease: JACC Health Promotion Series. J Am Coll Cardiol 2018;72(12):1382–96.
- Sin NL. The protective role of positive well-being in cardiovascular disease: review of current evidence, mechanisms, and clinical implications. Curr Cardiol Rep 2016;18(11):106.
- Jin H, Folsom D, Sasaki A, Mudaliar S, Henry R, Torres M, et al. Increased Framingham 10-year risk of coronary heart disease in middle-aged and older patients with psychotic symptoms. Schizophr Res 2011;125(2-3):295–9.