Physician's Weekly Article - The Link Between CVD & Mental Illness

       A collaborative effort from primary care clinicians, endocrinologists, cardiologists, and psychiatrists is critical to reducing the burden of avoidable premature mortality from CVD in patients with severe mental illness.

      During the past several decades, mortality from cardiovascular diseases (CVD) has markedly declined in the United States, but recent data suggest that this trend is largely due to improved diagnosis and treatments rather than to successes in primary prevention efforts. Patients with severe mental illnesses—most notably schizophrenia, bipolar disorder, and depression—lose 25 or more years of life expectancy, according to recent investigations. John W. Newcomer, MD, says the majority of deaths in mentally ill patients are attributed to CVD, not suicide. “Significant disparities in CVD mortality and prevention efforts are more prevalent for individuals with severe mental illnesses when compared with the general population. In patients with severe mental illness, we’re now seeing the average age of death occurring much earlier in life than in other patients. Emerging data are helping us gain a better understanding as to why this is happening, but it’s clear that there’s an urgent need for new CVD diagnosis and treatment paradigms in this patient population.”

      Understanding the Link

      Recent research has demonstrated that there is a significant relationship between mental illness and CVD (Table 1). Patients suffering with severe mental illness are twice as likely to have diabetes, dyslipidemia, hypertension, obesity, and/or metabolic syndrome. The problem, Dr. Newcomer says, is that these patients are significantly less likely to receive CVD risk-lowering drugs, including thrombolytics, aspirin, β-blockers, and ACE inhibitors or to undergo cardiac catheterizations and receive emergency angioplasties or CABG surgery. “We need to get the message out beyond the psychiatric community and to primary and specialty care physicians that many patients with mental-health problems are also likely to have diabetes or CVD. Historically, these patients do not get primary or secondary CVD prevention treatments in an appropriate or timely manner.”

      The current healthcare system in the United States is another factor that plays a role in the way mentally ill patients are handled. “Patients with serious psychiatric disorders are typically treated at outpatient mental health centers, but these facilities may be located far away from general hospitals,” Dr. Newcomer says. “These outpatient centers may work well for targeting issues related to mental health, but their distance away from other medical care facilities may contribute to under recognition and treatment of CVD risk factors.”

      Mentally ill patients typically develop CVD risk factors earlier in life than those without these illnesses. Several medical associations are now recognizing that some mental health illnesses increase the risk for CVD. As a result, physicians are now more likely to see references to the goal of metabolic risk reduction in professional guidelines and treatment recommendations. “It’s critical that physicians practicing in primary care, cardiology, endocrinology, and psychiatry settings make efforts to screen for and manage cardiometabolic risk factors in individuals with mental illness,” says Dr. Newcomer. “Greater attention needs to be paid to existing problems and potential solutions.”

      Presenting Potential Solutions

      Dr. Newcomer says that psychiatrists need to change their thinking if they believe that CVD prevention is not, to some degree, within their scope of practice. He adds that there are several possible approaches to better manage CVD risk in patients with mental illness (Table 2). “One approach,” he says, “may be to have a primary care physician on staff at mental health centers to improve CVD risk-factor screening as well as primary and secondary prevention efforts. Partnering psychiatry with primary care, cardiology, endocrinology, and/or other health professionals may help lower CVD risk in these patients. Another approach may be to reallocate existing resources to coordinate screening, interventions (including needed referrals), and required follow-up monitoring. For example, it may make sense to have the responsibilities of psychiatric case managers or related personnel extend beyond mental health goals to the broader goal of general health. While the practicality of these approaches may vary across practice settings, they all represent an opportunity to make a substantial impact.”

      Improving primary prevention efforts—such as modifying diet and exercise, quitting smoking, and controlling blood pressure and cholesterol—may offer the greatest potential to reduce CVD mortality in people with severe mental illness, according to Dr. Newcomer. “Physicians need to carefully evaluate the risks and benefits of individual antipsychotic and other psychotropic drug regimens as they relate to cardiometabolic risk. Difficult decisions may arise with respect to choosing psychotropic therapies less likely to adversely affect cardiometabolic risk versus the less-tested approach of staying on psychotropics with higher risk but adding adjunctive pharmacotherapies to target obesity, dyslipidemia, hypertension, or hyperglycemia. Having non-psychiatric physicians evaluate more patients with severe mental illness will require access to supportive services and collaborative psychiatric consultations to appropriately implement recommendations. However, without this collaboration among primary care doctors, endocrinologists, and cardiologists with psychiatrists, the burden of avoidable premature mortality from CVD in mentally ill patients will continue in the future and increase in severity.”

      John W. Newcomer, MD, has disclosed to Physician’s Weekly that he has received research grant support from the National Institute of Mental Health, the National Alliance for Research on Schizophrenia and Depression, the Sidney R. Baer Jr. Foundation, Janssen, Pfizer, Bristol-Myers Squibb, and Wyeth. He has served as a consultant for Janssen, Pfizer, Bristol-Myers Squibb, AstraZeneca, GlaxoSmithKline, Solvay, and Wyeth. He is also a member of a data and safety monitoring board for Organon, has served as a legal consultant regarding medication effects, and has received royalties for a metabolic screening form from Compact Clinicals.