People who suffer with severe mental illness (SMI) have a high burden of modifiable cardiovascular risk factors and their rate of cardiovascular mortality is doubled, according to a State-of-the-Art Review published August 22 in JACC. Furthermore, the relationship between SMI and cardiovascular disease seems to be bidirectional, with emerging evidence of shared etiological factors.

SMI, defined as schizophrenia, bipolar disorder and major depression, is present in 5% to 10% of adults in the U.S., and their life expectancy is about 15-25 years shorter than the general population, mostly due to cardiovascular mortality. Factors contributing to this excess premature cardiovascular-related mortality include a high prevalence of nearly all modifiable cardiovascular behaviors and conditions, disparities in access to and quality of care, psychopharmacotherapy, and direct effects of the illness. Yet, this population is less likely to be assessed for cardiovascular risk factors and to receive guideline-concordant treatments.

Michael Goldfarb, MD, MSc, et al., describe the relationship between mental illness and cardiovascular disease, strategies for improving cardiovascular health in people with SMI, psychopharmacology and cardiovascular disease, and care disparities in people with SMI and cardiovascular disease. The review also explores existing knowledge gaps and proposes future directions of investigation.

Regarding the assessment of cardiovascular risk, the authors recommend two tools designed for individuals with SMI: the Prediction and Management of Cardiovascular Risk in People with Severe Mental Illness (PRIMROSE) body mass index and the PRIMROSE lipid model, which have been found to more accurately estimate 10-year risk than conventional tools, because they include risk factors such as SMI diagnosis, antipsychotic/antidepressant use and weight.

In terms of the shared pathophysiology between SMI and cardiovascular disease, plausible pathways include biological, behavioral, psychological and genetic mechanisms. The authors write that the “strong interconnections between cardiovascular disease and psychiatric disorders call for a joint focus. Cardio-psychiatry includes both the perspective of the impact of mental health conditions on cardiovascular disease and the perspective of the impact of cardiovascular disease on mental health conditions.”

Furthermore, “cardio-psychiatry as a conceptual framework may highlight the importance of the field and may have the potential to enable the necessary interdisciplinary approaches,” they write.

There is a strong need to improve care delivery and outcomes for individuals with SMI by educating cardiovascular health professionals and implementing targeted risk reduction strategies. A collaborative multidisciplinary approach is needed.

Note: Help is available 24/7 to anyone experiencing a mental health crisis via the new 9-8-8 Suicide and Crisis Lifeline.

Clinical Topics: Dyslipidemia, Lipid Metabolism

Keywords: Lipids, Psychiatry, Risk Reduction Behavior, Life Expectancy, Antidepressive Agents, Heart Disease Risk Factors, Mental Disorders, Risk Factors, Psychopharmacology, Mental Health, Depressive Disorder, Major, Depression, Prevalence, Body Mass Index, Schizophrenia, Bipolar Disorder, Cardiovascular Diseases, Antipsychotic Agents

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