Major Depressive and Bipolar Disorders Predispose Youth to Early Cardiovascular Disease

Goldstein BI, Carnethon MR, Matthews KA, et al., on behalf of the American Heart Association Atherosclerosis, Hypertension and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young.
Major Depressive Disorder and Bipolar Disorder Predispose Youth to Accelerated Atherosclerosis and Early Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2015;Aug 10:[Epub ahead of print].

The following are key points to remember from this American Heart Association statement about major depressive (MDD) and bipolar disorders (BD) and accelerated atherosclerosis and early cardiovascular disease (CVD):

  1. Eight pediatric diagnoses are associated with elevated cardiovascular (CV) risk, defined as “pathophysiological evidence for arterial dysfunction indicative of accelerated atherosclerosis before 30 years of age,” including increase in carotid intima-media thickness and endothelial dysfunction. In 2011, special risk conditions were identified as moderate risk including Kawasaki disease with coronary aneurysms, inflammatory diseases including systemic lupus and juvenile inflammatory arthritis, human immunodeficiency virus, and the nephrotic syndrome. Children and adolescents considered moderate risk were moved to high risk if they had two or more of the seven traditional CV risk factors (family history of early CVD, obesity, tobacco, hypertension, insulin resistance, high low-density lipoprotein cholesterol, high triglycerides, and low high-density lipoprotein cholesterol).
  2. The authors of this review concluded that adolescent mood disorders should be added to the list of diagnoses considered moderate-risk for CVD. The prevalence of CVD among adults with MDD is nearly threefold greater, and adults with CVD and MDD were approximately 7.5 years younger than adults with CVD without mood disorders. Adults with BD in the United States have a fivefold increased risk of CVD and manifest CVD 14 years earlier than adults without mood disorders. MDD, attempted suicide, BD, and anxiety in children and young adults increase risk of premature CVD or related deaths controlling for lifestyle and socioeconomic factors.
  3. MDD and BD in adolescence (about 10%) are at least 10 times more prevalent than the four previously identified moderate-risk conditions combined. Putative pathophysiological mechanisms of the increased risk of CVD with mood disorders include hypothalamic-pituitary-adrenal axis and sympathomedullary hyperactivity, increased platelet reactivity, reduced heart rate variability, vascular inflammation, oxidative stress, and endothelial dysfunction. These processes are likely set into motion in part by adverse lifestyle behaviors that are disproportionate in mood disorders.
  4. Antidepressant medications (including SSRIs) and mood-stabilizing medications (particularly SGAs) can cause weight gain, and may also affect other metabolic parameters (diabetes and insulin resistance) among adults and youth. There is no doubt these are undesirable side effects in a population with increased risk of CVD; however, it is important to acknowledge that despite the clear evidence regarding CVD risk factors, evidence that these medications cause increases in CVD or CVD mortality is lacking to date.
  5. As in adults, adolescents with MDD and BD are associated with an increase in prevalence of obesity, metabolic syndrome, and diabetes, which is bidirectional, as well as hypertension, dyslipidemia, sedentary lifestyle, sleep disturbances, tobacco, alcohol, and other substance abuse. Guidelines for children and adolescents for treatment of each of the behavioral, and cardiometabolic risk factors have been published.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Imaging, CHD & Pediatrics and Prevention, CHD & Pediatrics and Quality Improvement, Lipid Metabolism, Nonstatins, Echocardiography/Ultrasound, Hypertension, Chronic Angina

Keywords: Adolescent, Antidepressive Agents, Atherosclerosis, Bipolar Disorder, Carotid Intima-Media Thickness, Cholesterol, Coronary Aneurysm, Coronary Artery Disease, Depressive Disorder, Major, Diabetes Mellitus, Dyslipidemias, Hypertension, Insulin Resistance, Lipoproteins, HDL, Lipoproteins, LDL, Metabolic Syndrome X, Mood Disorders, Obesity, Pediatrics, Risk Factors, Secondary Prevention, Tobacco, Triglycerides

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