People With Mental Health Conditions Should Be Screened for Heart Disease Earlier

People with serious mental illness die on average 10–20 years earlier than their peers. The leading cause of this premature death is heart disease. 

Because of this, psychiatrist Rebecca Rossom, MD, MS, and colleagues at the HealthPartners Institute in Minnesota, wondered if these patients’ heart disease risk could be predicted earlier than the standard screening age of 40. If it could, it meant that healthcare providers and patients could take steps to prevent cardiovascular disease sooner.

After reviewing medical records of almost 600,000 adults in the United States, they found that those who had schizophrenia, bipolar disorder, or schizoaffective disorder showed an elevated risk of cardiovascular disease as soon as young adulthood—more than a decade before the standard screening age could detect it.

Rossom added that even though physicians already have tools to assess heart disease risk, they’re not always used—and to an even lesser extent in people with serious mental illness. These findings underline the importance of tapping into these tools earlier.

“Part of the reason for our work was to raise awareness on the part of clinicians—primary care and mental health clinicians alike—that this increased risk of [cardiovascular] events is real and is evident even in young adults with serious mental illness,” she told Verywell.

The link between serious mental illness and heart disease risk is complex. Factors like smoking, obesity, and diabetes contribute to risk, the study found. But McWelling Todman, PhD, co-chair of psychology at The New School in New York, who was not involved with the study, noted that these risk factors are also emblematic of larger social justice issues, especially disparities related to income and access to care.

“For example, the zip code that you reside in will influence the quality of food you have access to, the kind of smoking prevention and cessation information that you are exposed to, and the quality of primary medical care you have access to,” he told Verywell.

The study was published in the Journal of the American Heart Association in early March.

Heart Disease Risk Detectable Earlier

Rather than look at data from hospitalized patients, Rossom and colleagues sought to sample the general community. They collected medical records from people who visited a primary care clinic in Minnesota and Wisconsin between January 2016 and September 2018.

Of the hundreds of thousands of individual medical records analyzed, about 11,000 were from people with serious mental health conditions—specifically, bipolar disorder, schizophrenia, and schizoaffective disorder.

Individuals with these diagnoses were more likely to have cardiovascular disease than people without. Researchers also found that these individuals were also more likely to identify as female, Black, Native American/Alaskan Native, or of multiple races, and be insured by Medicaid or Medicare.

“We thought it important to compare risk factors for heart disease in young people with and without serious mental illness to look for early opportunities to intervene on this risk,” Rossom said.

To do so, Rossom and colleagues ran analyses to compare cardiovascular disease risk in young adult patients with serious mental illness compared with their counterparts without related diagnoses. They also controlled for age, sex, race, ethnicity, and insurance type.

Between those with and without serious mental illness, there were significant differences. Young adults with schizophrenia, bipolar disorder, or schizoaffective disorder were significantly more likely to be at high risk for cardiovascular disease (25%) compared to their peers without serious mental illness (11%).

Limitations

The study is notable for the size of the sample, Todman said, and the fact that the people included are not inpatient, but rather everyday people not in a medical emergency. This offers a look into general community health.

However, Todman added, their statistical models did not control for income/social class, employment, education level, compliance with prescribed psychiatric services and medications, and family medical history. These factors could have all contributed to the risk differences observed.

Rossom agreed. “In our study, we were limited to risk factors that are documented in the electronic health record, but there are of course many more contributors to [cardiovascular] health,” she said.

Need for Earlier Screening

The data underlines the importance of assessing heart disease risk earlier. Ideally, Rossom said, risk would be assessed as early as 18—especially in individuals with serious mental illness.

It’d be as simple as making these risk estimates part of the check-up routine. “I think this is particularly compelling for young people who may see that their risk of having a heart attack or stroke could be 50% in the next 30 years,” Rossom added.

To Rossom, these risk estimates have a way of “hitting home the importance of smoking cessation or adequately treating high blood pressure in a way that just talking about the individual risk factor may not.”

Although implementing these questionnaires is simple, it might not be all that easy.

“While the guidelines recommend frequent measurement, especially when people are taking antipsychotics and other medications for serious mental illness, these recommendations are frequently not followed,” Rossom said.

Better integration between health care systems and reducing stigma around mental illness may help encourage that these recommendations be followed.

Mental Illness and Cardiovascular Health

Researchers have previously found that patients with serious mental illness are also at increased risk for cardiovascular disease, morbidity, and mortality. This link is more sociopolitical than medical, Todman said.

Even though the study cited smoking and elevated body mass index as the factors most linked to disease risk in people with serious mental illness, many socioeconomic factors lie underneath.

Take the well-documented inverse relationship between schizophrenia and income/class, Todman said. Because the lower socioeconomic status of one’s own family and neighborhood are both risk factors for schizophrenia, the individuals with serious mental illness in the study likely over-represented all the health risks that come with lower income. “This makes the cardiovascular risk-mental illness association part of a larger social justice issue,” he said.

Rossom agreed. “The contributors to elevated cardiovascular risk in people with serious mental illness are likely complex and often interrelated,” she said. “These include the chronic elevated stress of living with a serious and persistent mental illness, food insecurity, housing instability, poor diet and exercise perhaps related to food deserts and neighborhoods where people may not feel safe going out for walks or otherwise exercising, poor sleep, or social isolation, to name a few.”

What’s more, she added, some of the medications used to treat symptoms of serious mental illness can also increase risk. “All of these factors and others may differentially contribute to the variances in cardiovascular risk we see among people with different types of serious mental illness,” she said.

“Almost all of us, under the right circumstances, are capable of exhibiting and experiencing some of the signs and symptoms that are associated with mental illness,” Todman added. “And many individuals who at some point in their lives receive a formal psychiatric diagnosis are capable of functioning quite normally for extended periods of time, even in the absence of medical intervention.”

Earlier screening for heart disease, then, can support everyone.