• Teresa Tseng - the US & Sean Lybrand - Switzerland

Healthy minds for healthier hearts

Supporting mental health and wellbeing and its impact on heart disease

Chronic illnesses often lead to poor mental health, and in the case of heart disease it can worsen the condition. Depression and heart disease share many symptoms such as tiredness and low energy levels, heightening the risk of a missed diagnosis and suboptimal care.


Health is more than just the absence of disease, and the link between mental and physical health is well known. The World Health Organization has noted since 1948 that ‘health is a state of complete physical, mental and social wellbeing…’. Arguably, that definition could be extended to include many other factors, as our social and physical environment, our workplaces and our upbringing all contribute to our overall health.


While the link between mental wellbeing and health may be clearly understood, the ways of managing that interaction may be less clear. Mental health is a continuum of wellbeing—at one end it is a positive state and at the other often severe and debilitating. Various factors can influence where a person may be on that continuum, and particular health or life conditions may have an influence on how healthy an individual feels overall.


Acute injuries and illnesses can be unpleasant and stressful, but the sole silver lining here is that they generally have a finite duration. Chronic conditions, on the other hand, last more than a year, often cause functional restrictions, and require ongoing management. Besides being stressful, over time, such conditions can lead to other health consequences. Evidence suggests that people with chronic illnesses may be more likely to have or develop poor mental health.


In the case of heart disease, poor mental health and negative perceptions of disease may worsen the condition. Depression can directly impair quality of life and the evaluation and treatment of cardiovascular disease (CVD) after a cardiac episode. While the precise pathophysiological relationships between factors impacting heart health remain incompletely understood, chronic repeated exposure to psychosocial stress is a well-established factor in the pathogenesis of heart disease.


In the case of heart disease, poor mental health and negative perceptions of disease may worsen the condition. Depression can directly impair quality of life and the evaluation and treatment of cardiovascular disease (CVD) after a cardiac episode.

Diagnosing depression in people with heart disease may not be easy, because symptoms of depression such as tiredness and low energy levels are shared with heart disease. The challenges faced by care providers in detecting and addressing underlying mental health disorders suggests an underestimation of overall CVD risk and can lead to suboptimal care.


Impact of mental health on cardiovascular health management


Health has climbed on the agenda of many governments, and not solely due to covid-19. For instance, the European Commission recently launched the Healthier Together – EU Non-Communicable Diseases Initiative to support EU countries in identifying and implementing effective policies and actions to reduce the burden of major non-communicable diseases and improve citizens’ health and wellbeing.


In support of the EU initiative, the European Alliance for Cardiovascular Health extends the framing of cardiovascular health into the mental health domain, suggesting that the European Commission should:


“…convene a series of multi-stakeholder workshops to examine the key conclusions from the covid-19 pandemic in a structured way, including mental health implications and the fear and specific vulnerability of patients living with CVD. Both physical and mental health must be addressed through a common set of guidelines, that specifically addresses longer term CV health management, including physical and mental health.”


Adherence to medical orders and the impact on health outcomes


Understanding the underlying factors that contribute to a person’s mental health and empowerment can support treatment adherence. Treatment plans can be disruptive and negatively impact quality of life. People with depression are three times more likely to be non-compliant with medical treatment than people without depression, and the presence of clinically diagnosed depression can predict an increased risk of death.


Similarly, when it comes to people who survive a heart attack, it has been demonstrated that among those with depressive symptoms non-adherence occurred along a gradient, increasing with severity of depression. Furthermore, mental health disorders such as anxiety and depression may increase the chance of adopting behaviours such as smoking, inactive lifestyle, or failure to take prescribed medications.


The health consequences arising specifically from non-adherence to prescribed medication are substantial:

  • non-adherence reduces the effectiveness of treatments and contributes to poor health

  • non-adherence to medication is associated with almost 200,000 deaths annually in Europe

  • non-adherence to medication affects up to 50% of people who use medication for chronic diseases

  • the annual cost of non-adherence to medication ranges from US$100-290 billion in the USA, €125 billion in Europe and approximately AU$7 billion in Australia.

  • 10% of hospitalisations among older people are attributed to non-adherence

  • the typical non-adherent person requires three extra medical visits per year

While the relationship between poor mental health and CVD is influenced by several factors, simply initiating treatment for depression, for instance, does not fully eliminate the relationship between depressive symptoms and mortality in CVD. Because of the many determinants of mental and physical health, interventions to prevent untimely readmission of people with heart disease may require combined approaches that include behavioural, clinical, educational, and psychosocial components.

Keeping the whole person in the picture


Chronic conditions are complicated—they are multifactorial and often occur with related conditions. If a person’s health is an intertwined state of complete physical, mental and social wellbeing, it is a lot for a healthcare professional to manage in a routine consultation. Many forms of CVD have preventable aspects, but much of the preventability occurs earlier in a person’s life, when routine visits to the doctor or other healthcare professionals may be less frequent.


By acknowledging the importance of mental health and well-being to the overall consideration of heart health, governments can ensure that appropriate recognition of individual needs and predictors of health outcomes can be identified and addressed.

In order to address the preventability of heart disease, governments can implement broader campaigns among at-risk populations early on to support healthy life choices. For instance, in 2019 the Australian Government introduced a heart health check for people aged 45 or more, or 30 or more for indigenous Australians, to assess risk factors and, if required, plan a course of action to improve heart health. Mental health and well-being assessments are not a specific investigation, but referral to other healthcare professionals is possible for those who need further support.


More recently, the European Alliance for Cardiovascular Health’s ‘Cardiovascular Health Plan for Europe’ has a specific recommendation to implement a similar programme. Within that plan, the Alliance has more explicitly acknowledged the importance of psychosocial aspects of care and shared decision-making, and, more broadly, that anxiety, depression and stress are among the most important psychological risk factors related to heart disease. Following a cardiac event, the plan also acknowledges the importance of psychological well-being in a comprehensive rehabilitation plan.


By acknowledging the importance of mental health and well-being to the overall consideration of heart health, governments can ensure that appropriate recognition of individual needs and predictors of health outcomes can be identified and addressed.


Furthermore, such acknowledgements may also help create incentive systems for healthcare professionals to adequately take into account not just a person’s primary health condition, but also other factors that contribute to a state of complete physical, mental and social well-being.

 

The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.


Amgen is one of the world’s leading biotechnology companies. Amgen is a values-based company, deeply rooted in science and innovation to transform new ideas and discoveries into medicines for patients with serious illnesses.