The influence of psychiatric disorders on heart failure

Introduction

The number of people suffering from chronic heart failure amounts to 37.7 million people worldwide, which is a public health problem⁽¹⁾.

Life expectancy for people with severe mental illnesses is almost 20 years shorter than that of the general population, due to the high burden of cardiovascular disease. These patients have a 50% higher risk of cardiovascular disease and an 85% higher risk of cardiovascular mortality compared to the general population⁽²⁾.

Mental illnesses affect one billion people worldwide. Depression and anxiety are the most common such illnesses, with a prevalence of 280 and 300 million, respectively. Women are more affected than man, being 1.5-2 times more affected⁽³⁾. Personality disorders are correlated with a high cardiovascular and metabolic risk, not only with psychiatric comorbidities⁽⁴⁾.

Worldwide, there are 64 million patients suffering from heart failure, and the costs amount to $346 billion⁽⁵⁾.

Over the past years, important advances have been made in cardiac rehabilitation, but the psychosocial risk factors and the mental health problems have remained underdiagnosed and, therefore, untreated⁽⁶⁾.

Severe mental illnesses affect between 5% and 10% of people in the United States of America. A severe mental illness is represented by primary psychotic disorders, such as schizophrenia, bipolar disorder, schizoaffective disorder and major depression⁽⁷⁾.

The basic mechanisms of psychiatric disorders in the development of heart failure

The basic mechanisms of psychiatric disorders that contribute to the development of heart failure are biological, behavioral, psychological and genetic.

Among the biological mechanisms, the most notable are the autonomic nervous system dysfunction (a decreased heart rate variability, hypertension, an increased QT interval variability, and an increased QT and P wave dispersion), hyperactivity of the hypothalamic-pituitary-adrenal axis (increased levels of cortisol), inflammation and increased platelet reactivity⁽⁷⁾.

Among the behavioral mechanisms, the most notable are the reduction of treatment adherence, of functional status, of self-care skills, social support and of the quality of life due to severe mental illness⁽⁵⁾.

There are slight genetic correlations between severe mental illnesses and cardiometabolic abnormalities or cardiovascular diseases⁽⁷⁾.

Severe mental illness and cardiovascular risk

Cardiovascular risk factors have an earlier onset in patients with severe mental illnesses, such as schizophrenia, bipolar disorder and severe depression, which makes the patients more prone to future heart failure compared to the general population⁽²⁾.

People with schizophrenia have a higher rate of traditional cardiovascular risk factors, such as smoking, obesity, obstructive sleep apnea, a sedentary lifestyle and a poor diet. They also have a two to four times higher rate of diabetes, dyslipidemia, metabolic syndrome and hypertension, and the 10-year risk of a cardiac event is higher compared to the general population. The burden of cardiovascular risk factors is higher from the very first episode of schizophrenia, with hypertension being present in 80% of the cases or obesity also being associated. The risk factors accumulate rapidly in people with schizophrenia⁽⁷⁾.

Severe mental illness and heart failure have
a two-way relationship

Severe mental illness is a risk factor for heart failure

Depressive and anxiety disorders are present to a significant degree among patients with heart failure, and they lead to increased morbidity and mortality rates, as well as the occurrence of heart failure in older patients⁽³⁾.

Heart failure occurs seven years earlier in patients with severe mental illnesses, compared to those free of severe mental illnesses. It has been noted that there is excess mortality in men with severe mental illnesses compared to those not suffering from severe mental illnesses⁽²⁾.

Heart failure leads to mental health disorders

The primary cause for depression in heart failure is represented by functional limitations, biological correlations and psychological reactions related to the threat to one’s life, coming from the cardiovascular disease. Day-to-day activities are restricted during the progression of heart failure, and becoming aware of one’s decreased life expectancy leads to despair and hopelessness. This reduces adherence to treatment, thus leading to refractory depression⁽⁶⁾.

Depression is very common among heart failure patients, with a percentage of 41.9%, 28.1% of which being represented by severe depression. Depression has a different prevalence depending on the severity of the heart failure: 32% in stages I and II NYHA, and 54.7% in stages III and IV NYHA. Depression also represents an important risk factor for increased morbidity and mortality among patients with heart failure⁽⁵⁾.

Severe mental illnesses and adverse cardiovascular outcomes in chronic heart failure

Women are more affected than men by depressive and anxiety disorders. Women showing depressive symptoms face a higher risk of cardiovascular disease than men suffering from depression. The age-adjusted risk of coronary heart disease is higher in older depressed women. Compared with men, women with heart failure are more likely to suffer from depression, and women suffering from depression are more likely to develop heart failure. The relationship between depression, anxiety and heart disease is influenced by sex⁽³⁾.

Among men suffering from severe mental illnesses, the absolute risk for all-cause mortality is 10% higher compared to those not suffering from severe mental illnesses or compared to women with or without severe mental illnesses. Furthermore, the increased risk of reduced left ventricular ejection fraction is more common in men with severe mental illnesses than in women with severe mental illnesses or in the general population⁽²⁾.

The influence of anxiety on heart failure is inconclusive, although anxiety is involved in multiple cardiovascular morbidities, such as coronary atherosclerosis and myocardial infarction. In a recent study, posttraumatic stress disorder turned out to be a risk factor for the development of heart failure and for heart failure-related rehospitalization⁽³⁾.

Comorbid depression and heart failure have been shown to increase healthcare costs by 22-30% due to their increased burden on caregivers and frequent hospitalisations⁽⁵⁾.

Compared to those not suffering from depression, patients with heart failure and depression have shown poorer self-care, more rehospitalizations, a lower quality of life and a higher mortality. That’s why more attention is needed to treat depression in heart failure⁽⁵⁾.

In people with severe mental illnesses, the causes of excess cardiovascular mortality are represented by common modifiable cardiovascular behaviors and conditions, discrepancies in access to and quality of care, psychopharmacotherapy, and the direct effects of the illness⁽⁷⁾.

The influence of severe mental illnesses
on heart failure outcomes

Life expectancy is reduced by an average of 25 years in people with schizophrenia because of their increased rates of cardiovascular morbidity and mortality. The most common cause of death is cardiovascular disease, represented primarily by coronary artery disease (with an incidence of 64%), cerebrovascular disease (64%), congestive heart failure (110%) and cardiovascular death (85%) compared to the general population⁽⁷⁾.

Women suffering from depression show more severe symptoms of heart failure than men, which leads to higher costs of care for women with depression. Studies have revealed that left ventricular function is more affected by depression in women than in men. Besides, somatic and affective-cognitive symptoms, including dyspnea and pain, are more common in women hospitalized for heart disease than in men, requiring complex treatments with inotropic agents, diuretics and pain killers⁽³⁾.

The risk of cardiovascular disease in patients suffering from bipolar disorder is 1.5-2.5 times higher than in the general population. The excess mortality from cardiovascular disease is 35-40% in bipolar disorder patients⁽⁷⁾.

Personality disorders have been frequently encountered in heart failure patients (30% in heart transplantation), and they have been represented by the following types: avoidant (8.2%), borderline (6.8%) and obsessive compulsive (4.1%), other personality disorders (less than 3%). The most common comorbidities of personality disorders are major depression, generalized anxiety disorder, social phobia and abuse or addiction to alcohol⁽⁴⁾.

Interventions

Cardiopsychiatry is the nexus between the perspectives of cardiology and psychiatry on the interconnection between mental health conditions and cardiovascular diseases and their mutual impact⁽⁷⁾.

Patients suffering from mental health disorders are characterized by unhealthy lifestyles, neglect of timely medical care, adverse effects of psychotropic drugs, chronic inflammation, and shared genetic features between the severe mental illness and the cardiovascular disease. These features lead to an excess cardiovascular risk in patients suffering from severe mental illnesses⁽²⁾.

As the impact of psychiatric disorders on heart failure has been recognized in terms of morbidity and mortality, it is necessary for health professionals to address the routine of these psychiatric disorders, in order to increase the quality of life, reduce hospitalizations, improve cost-effectiveness of care, and positively influence the cardiovascular outcomes of patients suffering from heart failure⁽¹⁾.

It is still unclear whether the discrepancies in clinical outcomes coming from patients with severe mental illnesses and heart failure, in terms of poorer prognosis, are due to the severe mental illness and/or the substance abuse, to social deprivation, or to the lack of medical treatment⁽²⁾.

People suffering from personality disorders have significant comorbidities related to anxiety disorders, depression, use of alcohol and suicide, thus leading to high costs of mental healthcare, even in a cardiological context. Their complex needs must be assessed and met so as not to frustrate efforts to integrate psychiatric management into cardiological clinical practice⁽⁴⁾.

The European and American Heart Association guidelines for heart failure recommend the early detection of depression in patients with heart failure, during their hospitalization and during long-term follow-up, but the implementation of this recommendation in clinical practice is poor, among other things, because the sleep disorders, fatigue and loss of appetite that are present in heart failure overlap with the symptoms of depression⁽⁵⁾.

Self-care is a key element in maintaining health in case of chronic heart failure. It consists of adherence to medication, detection, monitoring and management of signs and symptoms of heart failure progression, and the reduction of water and salt intake. Health behaviors should also be promoted by increasing physical activity and giving up alcohol consumption and smoking. Failure to adhere to these health behaviors leads to poor outcomes in chronic heart failure, including the increase of exacerbations, rehospitalization and death⁽⁶⁾.

Lack of autonomy is important in people with severe mental illnesses, because certain psychiatric symptoms can affect judgment, perception and orientation. In case of depression, there may be a lack of motivation to get help due to feelings of diminished personal worth and hopelessness, and a decreased ability to change one’s lifestyle. In cases of schizophrenia, negative symptoms have a similar effect. In cases of hypomania or mania, there is a lack of awareness of danger and the neglect of somatic conditions. Under these conditions, it is necessary to support autonomy by way of motivational interviewing and not using paternalistic instructions that would burden the patient⁽⁷⁾.

Patients suffering from heart failure have a 40% risk of death from their first hospitalization for chronic heart failure. Palliative care is important for this population category in which mental health problems are not recognized⁽⁶⁾.    

Corresponding author: Raluca Pretorian E-mail: pretorianraluca@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.