Mental health disorders and their impact on cardiovascular health disparities

Summary

Mental health disorders are highly prevalent and are associated with significant morbidity, disability, and reduced life expectancy. A key contributor to this disparity is the increased risk of cardiovascular disease (CVD), which is partially driven by inequalities in social determinants of health, healthcare access, and quality of care. To address this challenge, The Lancet Regional Health—Europe convened experts to evaluate the current state of knowledge on inequalities and disparities in cardiovascular health among people with mental health disorders and propose recommendations to address these disparities. This Series paper aims to raise awareness of the disparities in CVD and health-care quality faced by individuals with common mental health conditions such as major depression, anxiety disorders, schizophrenia, bipolar disorder, and posttraumatic stress disorder. There is an urgent need for increased investment, intervention, and research to address the burden of CVD in these populations. Effective management of the comorbidity between mental health disorders and CVD requires an integrated and holistic approach to clinical care that addresses shared risk factors and the complex interactions between physical and mental health.

Introduction

Mental health disorders are highly prevalent in the general population, and their global burden is increasing.¹ These conditions are linked to an elevated risk of cardiovascular disease (CVD), higher CVD mortality, and poorer prognosis, with the risk of adverse outcomes being 50% to two times higher compared to those without mental health disorders.^2,3 The relationship is bidirectional, as CVD can also trigger the onset of new mental health disorders.4, 5, 6, 7 Consequently, the prevalence of mental health conditions among people with CVD is high, exceeding 40%.³ The comorbidity between mental health disorders and CVD is influenced by a combination of biological, behavioural, and healthcare factors. Stressful life events and psychological trauma often precede mental health disorders such as mood and anxiety disorders and posttraumatic stress disorder (PTSD).⁸ Recognizing stressful life events as a shared risk factor for both mental health disorders and CVD underscores the importance of integrating stress management into preventive health care.⁸

It is concerning that mental health disorders are linked to suboptimal cardiovascular health and care, with a significant gap in the diagnosis and management of mental health disorders among individuals with CVD.⁹ This issue is further compounded by the underdiagnosis and undertreatment of mental health disorders in the general population.¹⁰ People with mental health disorders are often excluded from research studies of CVD, or are less likely to participate, which hinders our ability to study them. In part because of these limitations, stress and mental health factors are rarely addressed in routine clinical care, and professional societies have been hesitant to include mental health considerations in guidelines for CVD prevention.

Given the mounting prevalence of mental health disorders, a contemporary review is needed on the status of their comorbidity with CVD. In this Series paper, we focus on common mental health disorders that have been related to CVD risk, including major depression, anxiety disorders, schizophrenia, bipolar disorder and PTSD. Our aims are to draw attention to people with these conditions as an understudied group that is vulnerable to health disparities for CVD, and to highlight the challenges that the comorbidity of mental health disorders and CVD poses today to clinicians and the healthcare sector. We also seek to provide a contemporary summary of strategies to improve cardiovascular outcomes for this population and delineate future research priorities. Our goals align with the World Health Organization 2025 targets of reducing the global burden of cardiovascular disease.

Key messages.

• •Mental health disorders are linked to an elevated risk of CVD, higher CVD mortality, and poorer prognosis, with the risk of adverse outcomes being 50% to two times higher compared to people without these conditions.
• •On average, individuals with mental health disorders such as schizophrenia, bipolar disorder, or major depressive disorder, experience a shortened lifespan by 10–20 years compared to the general population.
• •The relationship is bidirectional, as CVD can also trigger the onset of new mental health disorders.
• •The comorbidity between mental health disorders and CVD is influenced by a combination of biological, behavioural, and healthcare factors.
• •Mental health disorders are linked to suboptimal cardiovascular health and care.
• •There is a significant gap in the diagnosis and management of mental health disorders among individuals with medical conditions, including CVD.
• •At the same time, there is a significant gap in the diagnosis and management of CVD and CVD risk factors among individuals with mental health disorders.
• •Interventions that address social determinants of health, healthcare structural factors, and healthcare access are likely to provide the largest impacts to reduce disparities and improve outcomes of both mental health disorders and CVD.
• •For the best care, an integrated approach is needed to address the complex needs of this vulnerable population. Such approach should offer enhanced support and interdisciplinary care encompassing mental, cardiovascular, and behavioural health, as well as consideration of the social needs and barriers to care of this patient population.

Terminology

Throughout this review, we refer to “mental health disorders” as conditions that imply a clinical psychiatric diagnosis, i.e., that meet accepted clinical criteria, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) criteria, or that are classified as such in clinical registries or patients’ medical records. “Mental health” and mental health symptoms (such as depressive symptoms) are used in a broader, more generic context, and refer to disturbances that not necessarily meet clinical criteria for a disorder. By lifetime prevalence of a mental disorder, we refer to the proportion of a population who ever had the disease throughout their lifetime. By point prevalence of a mental disorder, we refer to the proportion of a population that has the disease at a particular point in time.

Burden of mental health disorders

Mental health disorders are prevalent worldwide and are associated with significant morbidity and mortality.¹ Approximately one in four people experience a mental disorder in their lifetime. On average, individuals with mental health disorders such as schizophrenia, bipolar disorder, or major depressive disorder, can experience a shortened lifespan by 10–20 years compared to the general population. Mental health disorders contribute to 14% of all deaths globally, or 8 million annual deaths,¹¹ and are among the top ten leading causes of disability worldwide.¹ High-income countries in Europe and North America have among the highest prevalence of mental health disorders globally.¹ Current data, however, underestimate the true burden of mental health disorders by more than a third, because of frequent misclassification of these conditions.¹² Furthermore, the coronavirus disease 19 (COVID-19) pandemic may have exacerbated what was already a steady increase in the burden of mental health disorders in the past 20 years. The Global Burden of Disease study estimated more than 25% relative increase in the global prevalence of major depressive disorder and anxiety disorders, which have coincided with severe disruptions to mental health services.¹³ Whether these changes have persisted needs more evaluation.

The global burden of mental health disorders is summarised in Table 1, demonstrating a high prevalence especially for depression and anxiety disorders. Rates of mental health disorders are elevated more than threefold among combat military personnel or civilians in post-conflict settings.¹⁷

Table 1.

Prevalence of major mental disorders in the general adult population and estimates of association with incident cardiovascular disease from published meta-analyses of prospective studies.

	Global lifetime prevalencea	Association with incidence of cardiovascular disease
		Pooled hazards ratio (95% CI)	N. of studies in meta-analysis and bibliographic reference
Major depression	20%	1.72 (1.48–2.00)	1814
Anxiety disorders	30%	1.41 (1.13–1.73)b	815
Schizophrenia	0.3%	1.95 (1.41–2.70)	1414
Bipolar disorder	1%	1.57 (1.28–1.93)	1014
Posttraumatic stress disorder	3.9%	1.61 (1.47–1.76)c	916

^aLifetime prevalence refers to the proportion of the population that has experienced the condition at any point in their life. Prevalence data are mostly from the World Health Organization (https://www.who.int/news-room/fact-sheets/detail/mental-disorders).

^bCardiovascular mortality only.

^cCoronary heart disease only.

Major risk factors for mental health disorders include exposure to adversity like poverty, violence, and psychological trauma, especially starting in childhood; substance abuse, and genetic and familial factors.^1,10 Physical health problems such as CVD and disability can also contribute to mental health problems. In turn, mental health disorders worsen many of these predisposing factors creating a vicious cycle, as they contribute to disability, chronic physical illness (especially CVD, obesity, and diabetes), unfavourable health behaviours and social disadvantage like poverty and homelessness (Fig. 1). High-risk populations for mental health disorders are those that are more likely to have risk factors for mental health disorders; many of these groups are also more vulnerable to the consequences of mental health disorders on CVD risk (Fig. 1). The lifetime risk of mood and anxiety disorders is about two times as high in women as in men, but men have a 40% higher lifetime risk of schizophrenia. Other high-risk groups include sexual minorities, refugees and asylum seekers, incarcerated people, military personnel and others exposed to war conflicts, and those who provide informal care to critically ill or disabled persons. Patients with CVD represent another high-risk group, which is addressed later in this Series paper.

Fig. 1.

Mental health disorders: risk factors, consequences and high-risk groups. The main risk factors for mental health disorders are rooted in the social environment and in adverse exposures, especially those occurring early in life. Childhood abuse and other traumatic events are powerful predictors of mental health disorders. Poverty, social disadvantage and other chronic social/psychological stressors are also linked with poor mental health. Physical health problems like disability can also contribute to mental health disorders, especially depression. Substance use can induce mental health disorders, and genetic and familial factors are also implicated. There are high-risk populations, i.e., groups that are more likely to have risk factors for mental health disorders or are more vulnerable to their consequences on CVD risk. These include adolescents and young adults, women, combat veterans, sexual minorities, refugees and asylum seekers, incarcerated people, and caregivers of critically ill people. Patients with CVD represent another high-risk group for mental health disorders, especially for depression, anxiety disorders and PTSD. In turn, mental health disorders are leading contributors to disability, chronic physical illness (especially cardiovascular disease, obesity and diabetes) and premature mortality, as well as to unfavourable health behaviours and social problems like poverty and homelessness. Thus, several consequences are also risk factors for mental health disorders, creating a vicious cycle.

Mental health disorders and cardiovascular disease

Mental health disorders and CVD frequently coexist and influence each other in a bidirectional fashion. In a meta-analysis of 92 studies including over 3 million individuals with mental health disorders, close to 10% of them also had CVD.¹⁴

Mental health disorders as risk factors for CVD incidence

The mental health disorders considered in this Series paper, including major depression, anxiety disorders, schizophrenia, bipolar disorder and PTSD, are all associated with increased CVD incidence and mortality.^2,14,16,18, 19, 20, 21, 22, 23 In fact, the leading cause of death for people with these conditions is CVD, including ischemic heart disease, hypertensive heart disease, cerebrovascular disease, heart failure, and thromboembolic events.^20,24,25 Not only is the incidence and mortality of CVD increased in these mental health disorders, but CVD occurs earlier in life and the relative increase is higher in younger than in older people.19, 20, 21^,26 The risk is also highest among new cases or in the first year after the initial diagnosis of the mental disorder,^2,20,22,23 although the excess risk persists for many years.²⁰

The risk of CVD associated with mental health disorders from meta-analyses of prospective studies is summarised in Table 1. Major depression is the most extensively studied mental disorder in connection with CVD,^18,27 and in a meta-analysis of 18 prospective studies, it was associated with a pooled 72% increase in CVD risk.¹⁴ Schizophrenia is associated with an approximately twofold higher risk of CVD compared with the general population or non-affected controls.^14,22 For incident (or new-onset) schizophrenia the risk is almost threefold, and the risk of sudden cardiac death is about four times higher in schizophrenia than in the general population.²² There is also a pooled 57% increased CVD risk for bipolar disorder, mostly driven by CVD-related death and heart failure.¹⁴ While few prospective studies are available for PTSD, a meta-analysis reported a pooled estimate of 61% increased risk of coronary heart disease for PTSD, which was only slightly attenuated in studies that adjusted for depression.¹⁶ The association of anxiety disorders with CVD is less clear, because studies have used different definitions, for example aggregating anxiety disorders with PTSD and with simple anxiety and worry symptoms, and results have been heterogeneous.¹⁵ However phobic anxiety, one of the most common anxiety disorders, has been associated with approximately 70%¹⁵ and panic disorder with 50%^15,28 increased risk of coronary heart disease.

It should be noted that these estimates are from meta-analyses and registry studies that inconsistently adjusted confounding factors. Although some studies adjusted for CVD risk factors, these could be mediators of risk rather than confounding factors. Potential confounders such as family history, income, education, and comorbidities, were not considered in several studies. A sibling-matched cohort adjusted for sex, birth year, education, individualised family income, and history of somatic diseases, in addition to controlling by design for familial confounding.²⁰ The hazards ratios for incident CVD in the first year of diagnosis were 3.6 for schizophrenia, 2.0 for non-affective psychotic disorders other than schizophrenia, 1.6 for bipolar disorder, 1.6 for non-psychotic mood disorders like major depression, 2.1 for anxiety disorder, and 1.7 for PTSD.²⁰

Cardiovascular disease as a trigger of mental health disorders and impact on prognosis

Individuals with CVD have rates of depression, PTSD and anxiety disorders that are up to four times those in the general population, suggesting that acute CVD events can serve as triggers for mental disturbances. Systematic reviews and meta-analyses (summarised in Table 2) have provided a pooled point prevalence of depression of 18% among people with CVD (24% in women and 17% in men).²⁹ Point prevalence estimates are even higher in the setting of an acute event: 28% after acute coronary syndromes⁴ and 27% after a stroke.⁵ The point prevalence of generalised anxiety disorder is 11% in stable coronary disease patients.³¹ Acute, life-threatening cardiovascular conditions, like a myocardial infarction or a stroke, can precipitate the onset of PTSD, which has a pooled point prevalence of 12% after an acute coronary syndrome,^6,7 and 23% after a stroke.³³

Table 2.

Point prevalence of major mental disorders in people with cardiovascular disease and estimates of association with recurrence of cardiovascular disease events and mortality from published meta-analyses.

	Point prevalence in populations with cardiovascular diseasea		Association with recurrent events and mortality from cardiovascular disease
	Pooled estimate of prevalence (95% CI)	N. of studies in meta-analysis and bibliographic reference	Pooled estimate of association (95% CI)	N. of studies in meta-analysis and bibliographic reference
Major depression	18% (15%–22%)	5229	Odds ratio, 1.59 (1.37–1.85) (coronary heart disease events) Odds ratio, 2.71 (1.68–4.36) (coronary heart disease mortality)	18 (coronary heart disease events)30 6 (coronary heart disease mortality)30
Anxiety disorders	11% (8%–14)b	1231	Odds ratio, 1.59 (1.29–1.97)	1332
Posttraumatic stress disorder	12% (9%–16%) (acute coronary syndromes) 23% (16%–33%) (stroke)	246 (acute coronary syndromes) 833 (stroke)	Relative risk, 2.00 (1.69–2.37)c	36

^aPoint prevalence refers to the proportion of the population that has the condition at a specific moment in time.

^bGeneralised anxiety disorder.

^cCoronary heart disease events or mortality only.

Patients with a history of CVD who have major depression, anxiety disorders and PTSD have more unfavourable outcomes than patients without these conditions (Table 2). Depression is associated with an increased likelihood of recurrent cardiac events and mortality that is about 60% to over twofold higher, with larger effects for cardiac death than for nonfatal coronary events.³⁰ In patients with heart failure, major depression more than doubles the risk of mortality and subsequent readmission rates.³⁴ For anxiety, the relationship is not as strong as for depression, with a pooled estimate of 59% increased odds of CVD events, which is weaker in studies that adjusted for covariates.³² On the other hand, developing clinically significant PTSD symptoms after an acute coronary syndrome doubles the risk of subsequent coronary events or death.⁶

Pathophysiological aspects

There are many behavioural and biological pathways that can explain the comorbidity of mental health disorders and CVD (Fig. 2). An unhealthy lifestyle is a common consequence of mental health problems and can lead to adverse cardiovascular risk factors such as obesity, diabetes, dyslipidaemia, poor diet and sedentarism. Biological risk pathways include, among others, inflammation, autonomic nervous system dysregulation, thrombogenesis, insulin resistance, high blood pressure and vascular dysfunction. Reverse pathways are also at play, in that CVD could trigger mental problems such as depressive symptoms, anxiety and PTSD. Finally, there could be shared aetiology involving risk factors for both mental and cardiovascular diseases. These include health behaviours like smoking and physical inactivity, inflammation, and psychosocial stress.

Fig. 2.

Behavioural and biological pathways linking mental health and cardiovascular health. There are many behavioural and biological pathways that can explain the comorbidity of mental health disorders and CVD. An unhealthy lifestyle is a common consequence of mental health problems and can lead to adverse cardiovascular risk factors such as obesity, diabetes, and dyslipidaemia. Biological factors include, among others, inflammation, autonomic nervous system dysregulation, thrombogenesis, insulin resistance, high blood pressure and vascular dysfunction. Opposite pathways can also be at play, such that CVD could trigger mental problems such as depression, anxiety and PTSD, and inflammation and autonomic dysfunction can contribute to the aetiology of mental health disorders. Finally, there could be common aetiology, involving risk factors that are shared between mental health disorders and CVD. These include social determinants of health, health behaviours like smoking and physical inactivity, inflammation, psychosocial stress, and familial and genetic influences.

Behavioural and traditional CVD risk factors

Patients with mental health disorders have an elevated rate of preventable metabolic risk factors for CVD, which are heavily influenced by lifestyle behaviours.³⁵ Nearly all mental health disorders have been linked to unhealthy lifestyle, including poorer dietary and sleeping patterns, low levels of physical activity, and higher rates of tobacco and substance use compared to healthy controls.³⁶ Adverse behaviours and CVD risk factors are present early in the course of mental health disorders, even at the time of the initial psychiatric diagnosis. These risk factors accumulate more rapidly than in the general population and their prevalence and severity correlate with the duration of the mental disorder.²⁵

Lifestyle behaviours such as physical inactivity, smoking and obesity act dually to increase the risk for both mental health disorders and CVD. The higher rate of smoking among people with mental health disorders could result, in part, from positive subjective effects of tobacco, although data are not consistent.³⁷ Smoking and lack of physical activity have also been implicated in the development of mental health disorders, especially schizophrenia and major depression.³⁶ Part of this evidence comes from Mendelian randomization studies suggesting a causal effect of physical activity in reducing the risk of depression,³⁸ and a bidirectional relationship linking smoking behaviour to both depression and schizophrenia.³⁶ Several indices of unhealthy diet and sleep disturbance are also associated with a higher incidence of depression.³⁶ One potentially shared biological mechanism is inflammation, which has been implicated in mental health disorders,³⁹ and healthy behaviours have an anti-inflammatory effect. Psychiatric medications may also contribute to CVD risk factors among people with mental health disorders. Antipsychotic therapies, lithium and other psychiatric medications have all been linked to weight gain, dyslipidaemia and insulin resistance.⁴⁰ Despite the high prevalence of CVD risk factors among people with mental health disorders, these factors alone do not explain the higher rates of CVD in this population.^14,41

Additionally, people with mental health disorders may have difficulties with access to care and medications to control CVD risk factors. Financial limitations experienced by this group, poor health literacy, substance use, cognitive impairment, stigma toward mental health disorders and social isolation all contribute to poor access to care and poor self-care, which can interfere with management of CVD risk factors (addressed later in this Series paper).^35,42 Furthermore, people with mental health disorders have a lower ability to motivate themselves to engage in healthy lifestyle and to seek care because of an impaired ability for self-care. These same factors can affect adherence to medical therapies in patients with mental health disorders, which is reduced compared to patients without these conditions.^43,44

Overall, evidence supports multifactorial interconnections of mental health disorders with modifiable adverse behaviours and risk factors for CVD, therefore providing strong rationale for lifestyle interventions in people with mental health disorders which can help decrease their risk of CVD.⁴⁵

Biological factors

Major mental health disorders are associated with dysregulation of stress response systems, including the autonomic nervous system and the hypothalamic-pituitary adrenal axis. Dysfunction of these regulatory systems results in adverse downstream effects that can affect cardiovascular risk chronically, including increased inflammation, metabolic abnormalities, high blood pressure, enhanced systemic vascular resistance, and autonomic inflexibility.⁸ In particular, there is extensive evidence of autonomic dysfunction in people with depression, PTSD and schizophrenia,46, 47, 48 as well as increased inflammation and immune dysregulation^39,49,50 and reduced microcirculatory function.^49,51,52

Among people with mental health disorders, autonomic, inflammatory, and vascular abnormalities could play a larger role as risk pathways for CVD than increased atherosclerotic plaque burden. Although few studies are available, no association has been reported for mental health disorders or psychosocial symptom scales with coronary artery calcium, a measure of atherosclerotic plaque,^53,54 and with myocardial perfusion defects, which are indicative of coronary stenoses.⁵¹

Role of psychosocial stress and other shared pathways

Individuals with mental health disorders are vulnerable to socioeconomic stressors like unemployment, poverty, living in disadvantaged neighbourhoods and social isolation, all factors that can contribute to dysregulation of stress response systems and to CVD risk.⁸ However, psychosocial stressors can also serve as shared aetiology connecting mental health disorders and CVD. Consistent evidence has linked exposure to acute or chronic stressors with an elevated risk of CVD.⁸ At the same time, severe loss or trauma, particularly when it occurs in childhood, represents the single most important risk factor for mental health disorders, especially major depression and PTSD. Childhood adversity can cause enduring changes in the nervous, endocrine, and immune regulatory systems that may affect the risk of both mental health disorders and cardiometabolic conditions in adult life.⁵⁵ Shared genetic factors can also contribute, since there are genetic correlations between these mental health disorders and CVD.⁵⁶ Yet, a large matched sibling-controlled study has disproved the idea that the comorbidity between mental health disorders and CVD can be attributed even partially to unmeasured environmental and genetic factors shared within families.²⁰ Thus, a causal pathway linking mental health disorders to CVD is likely, therefore highlighting the importance of recognition and treatment of mental health disorders for the prevention of CVD.

Disparities and challenges in the prevention and treatment of CVD for people with mental health disorders

Given the high rate of CVD and CVD risk factors in people with mental health disorders, it is essential to adopt strategies to reduce cardiovascular risk in this population. Individuals with mental health disorders, however, often receive lower-quality care for their physical health. Despite having more interactions with the healthcare system, they undergo fewer physical checkups and screenings, and receive fewer diagnoses and treatments for CVD and its risk factors, even though these health issues are more common in this population.⁹ Even in setting of universal health care, many people with mental health disorders do not receive recommended treatments for CVD, including medications, cardiovascular procedures and follow-up care.⁹

There is also a significant gap in the diagnosis and management of mental health disorders among individuals seeking care for medical conditions including CVD. It is difficult to estimate the proportion of people with undiagnosed mental health disorders, because many studies have focused on clinical populations undergoing psychiatric care identified through billing codes. These approaches do not account for individuals who are undiagnosed and untreated for mental health problems. According to 2023 survey data from the U.S. Substance Abuse and Mental Health Services Administration, slightly more than half (54%) of the US population who met the survey criteria for mental health disorders in the past year were not receiving any treatment, suggesting that they were unrecognised or untreated.¹⁰ Rates were even lower for non-White people (less than 45% received any treatment). The large proportion of untreated mental health disorders in the population is likely a combination of system, provider, and patient factors (such as limited access to care, stigma, poor health literacy, lack of social support), calling for better strategies towards outreach, screening, treatment referral and access to care for mental health problems in primary care and cardiology settings.

Social determinants of health, healthcare structural factors, and healthcare access and quality are highly interconnected and together play an upstream role in cardiovascular health disparities among people with mental health disorders (Fig. 3). Thus, interventions that address these aspects are likely to provide the largest impacts to reduce disparities and improve outcomes of both mental health disorders and CVD.

Fig. 3.

Multilevel model of cardiovascular disease disparities in persons with mental health disorders. Social determinants of health, healthcare systems and healthcare access and quality are highly interconnected and play a driving role in cardiovascular health disparities based on mental health at multiple levels. Interventions at the policy level to address social determinants of health and the structure of systems of care, and interventions at the clinical level to enhance access and quality of care tailored to the complex needs of people with mental health disorders are likely to provide the largest impacts to reduce disparities and improve outcomes of both mental health disorders and cardiovascular disease.

Social determinants of health and access to care

Social determinants of health, which include an array of social, economic, environmental, and psychological factors that influence health, play an important part in CVD outcomes.⁵⁷ Decreased earning potential in people with mental health disorders can limit access to care due to inadequate health insurance coverage. Poor health education, cognitive impairment, low self-efficacy, and the effect of psychosis and mania on effective interfacing with medical caretakers can exacerbate this problem. These factors make it less likely that individuals with mental health disorders receive guideline-recommended screening and treatments for CVD prevention. Implicit bias from providers and stigma associated with mental health disorders, which is characterised by negative stereotypes, prejudice, and discrimination, may further limit effectiveness of care among marginalised populations such as those with mental health disorders.⁴²

Healthcare structural factors

Primary care clinicians, cardiologists and healthcare systems face challenges in implementing care needs for patients with mental health disorders. Even if access to care is available in countries with universal health care systems, barriers exist for the recognition and treatment of both the mental condition itself and cardiovascular problems. Lack of resources in the clinical setting and providers’ negative beliefs and attitudes towards mental health disorders can further contribute to inadequate screening for CVD risk and insufficient management of the burden of adverse behaviours among people with mental health problems. Fragmented healthcare systems, where physical and mental health care are separated, also pose significant challenges to addressing the complex clinical needs of individuals with mental health disorders. A possible contributing factor is the limited expertise of mental health providers in addressing physical health needs, and conversely, the limited capacity of primary care or cardiology providers to manage the full range of health concerns in those with mental health disorders. Another challenge is insufficient evidence for effective interventions in persons with mental health disorders to guide clinical management and prevention of non-psychiatric diseases in this population.

Inadequate research among people with mental health disorders

In addition to inequalities in access to quality care, successful CVD prevention in people with mental health disorders is diminished by the fact that these individuals were often excluded from randomised trials of CVD prevention and from the development of CVD risk prediction equations. In fact, commonly employed CVD risk prediction models underestimate the risk of CVD in people with mental health disorders.⁴¹ To obviate this problem a risk prediction model for CVD was developed that was specific for people with schizophrenia and bipolar disorder, called the PRIMROSE model.⁵⁸ In addition to traditional CVD risk factors, the model included social deprivation, use of anti-depressants, use two different classes of antipsychotics, and history of heavy drinking. This model performed better in this population than models which only included established CVD risk factors. However, further work is needed to demonstrate its effectiveness in improving clinical care and prevention of CVD.

Strategies for improving cardiovascular risk and care in people with mental health disorders

Standard interventions for mental health disorders

Standard management strategies include psychotherapies and medications. Commonly used medications are antidepressants for major depression and PTSD, mood stabilisers for bipolar disorder, and antipsychotic medications for schizophrenia. Among antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs) are commonly prescribed.

Several randomised clinical trials have tested the effect of psychotherapeutic interventions alone or in combination with medications on CVD outcomes, with varying results. Most of these were interventions for depression in coronary heart disease patients. The largest was the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, including 2481 participants who had depression, low perceived social support, or both and were recruited within one month of acute myocardial infarction.⁵⁹ Participants were randomly assigned to receive cognitive behavioural therapy or usual care. Concomitant medications included SSRIs, which were the most frequently prescribed antidepressant class in both groups. At baseline, SSRI use rates were 3.8% in the usual care arm and 6.9% in the intervention arm. These rates increased to 14.6% and 21.0% by the end of follow-up. Cognitive behavioural therapy modestly improved symptoms of depression compared with usual care, but there was no difference in cardiac event-free survival. Other smaller trials of psychotherapy or medications for depression in patients with CVD have shown modest and inconsistent effects on improving depressive symptoms, but were not powered to examine cardiac events.60, 61, 62, 63, 64 The 2018 Escitalopram for Depression in Acute Coronary Syndrome Trial (ESDEPACS) conducted in South Korea in 300 patients with depression after acute coronary syndrome is the only randomised controlled trial to date to show a beneficial effect of an SSRI (escitalopram) on major adverse cardiac events compared with placebo, with a relative risk reduction of 31%.⁶⁵ These results need replication in a larger trial.

A meta-analysis of psychological intervention trials in the management of coronary heart disease showed a reduction of 21% in cardiovascular mortality, but no effects on total mortality or nonfatal myocardial infarction.⁶⁶ Notably, this meta-analysis focused on psychological interventions in patients with coronary disease regardless of comorbidity with mental health disorders. Thus, intervening on all patients may be a fruitful strategy rather than targeting only those with a certain threshold of psychological morbidity.

Exercise and other lifestyle interventions

Exercise is an intervention that can be beneficial both for mental health and cardiovascular health. Meta-analyses of randomised clinical trials have reported moderate to large effects of exercise on depression, with a clinically significant improvement of similar or larger magnitude than psychotherapy or drug treatment.⁶⁷ Exercise is equally effective for people with and without comorbidities and with different levels of depression,⁶⁷ and improves mental health even among people without a psychiatric diagnosis.⁶⁸ Thus, exercise should be considered alongside psychotherapy and antidepressants as core treatment for depression.⁶⁷ The beneficial effects of exercise on mental health may be explained by stimulation of the production of endorphins, which are natural painkillers and mood enhancers.⁶⁹ It also promotes neurogenesis and prefrontal cortex activation, which is important for emotion regulation.⁶⁹ Increased physical activity also enhances the parasympathetic nervous system, which helps to reduce inflammation.

Despite the robust results for depression, much less is known about the effects of exercise in other mental health disorders. For example, few controlled trials have evaluated exercise interventions in reducing PTSD symptoms, but the existing evidence suggests a beneficial effect.⁷⁰

Combined lifestyle interventions including weight loss, exercise, diet and smoking cessation have shown robust benefits in the general population (and to a certain extent, also in patients with mental health disorders) for multiple cardiometabolic risk factors (body weight, blood pressure, blood lipids and glucose).⁴⁵ Simultaneous covering multiple lifestyle factors is preferred, although the effectiveness of these approaches among patients with mental health disorders needs more evaluation. Digital technologies, e.g., through online support platforms, fitness trackers and smartphone apps, may provide an effective, convenient, and accessible avenue to promoting healthy lifestyle and monitoring health among persons with functional impairments such as those with mental health disorders. These approaches, however, vary in quality, and limited research exists on their clinical effectiveness or cost-effectiveness, especially among people with mental health disorders.⁴⁵

Mind-body approaches

Certain forms of exercise, such as Tai chi, qigong, and yoga, are considered mind-body practices, as they combine mental, physical, and spiritual benefits. These various components may contribute to their beneficial effects on mental health.⁶⁹ Tai chi and qigong are ancient self-healing practices that have originated in China and focus on slow, formalised movements such as musculoskeletal relaxation and balanced postures. Yoga combines physical postures, breath control, and meditation. These activities have shown beneficial effects for depression.⁶⁷ Limited studies have found that yoga may be helpful also for PTSD.⁷⁰ Favourable effects of yoga have also been reported on negative symptoms of schizophrenia, but findings are not consistent.⁷¹

Mindfulness-based stress reduction is a meditation practice that has shown beneficial effects in mental health disorders including depression, anxiety disorders and schizophrenia,^71,72 as well as among individuals without a psychiatric diagnosis.⁷³ Mantra-based meditation such as transcendental meditation have also shown potential efficacy, but studies on psychiatric patients are limited.⁷⁴ Biofeedback is another mind-body approach that has promise but has been insufficiently evaluated in psychiatric populations.^75,76

Collectively, mind-body approaches have shown positive effects on psychological health. They can improve cardiovascular risk factors, although it is unknown if these effects translate into a reduction of CVD events.^66,77, 78, 79 In the setting of cardiac rehabilitation, these strategies have improved adherence to rehab and quality of life,^80,81 and reduced hospital admissions.⁸¹ Despite the relatively small sizes of the individual studies and the heterogeneity of effects, the overall evidence supports the value of these interventions as adjunct management strategies, even though more rigorous evaluation is warranted.

Integrated care models and multilevel interventions

An integrated care approach that offers enhanced support systems and interdisciplinary care could be more apt to address the care needs of people with mental health disorders than traditional fragmented care systems. Integrated care models for mental health and cardiac care emphasise interdisciplinary approaches involving cardiologists, psychiatrists, primary care providers, nurses, and care managers. Care coordination should promote comprehensive management of medical, mental, and behavioural health. Access to care and support is improved, facilitating behavioural changes and reducing barriers to care.

Few randomised clinical trials have tested care coordination programmes for cardiometabolic conditions in adults with mental health disorders. Randomised trials of integrated care management or centralised team-care approaches for depression or anxiety in cardiac patients have generally shown improvements in mental health status but no significant reductions in CVD events and mortality.82, 83, 84 These trials, however, were small and not designed to assess major CVD outcomes. Other care programmes for patients with mental health disorders that combined management of lifestyle behaviours, screening and management of physical health conditions, and monitoring and managing adverse cardiometabolic effects of psychotropic drugs have also been implemented but evaluation is needed.⁹

Summary of interventions

Randomised clinical trials have supported the value of psychological interventions for mental health and, to a certain degree, cardiovascular health as well (Panel 1).^66,77, 78, 79 Their value has been demonstrated in the setting of cardiac rehabilitation.^80,81 Evidence for the benefits of medications varies but they are generally well tolerated in patients with coronary heart disease. In general, the benefits on CVD clinical endpoints have not been established for all these interventions.⁸⁵ Most controlled treatment trials have focused on coronary heart disease patients with depression; little is known on the benefit of treating other mental health disorders on CVD outcomes. Robust clinical trials are also needed on the utility of screening modalities and optimal clinical decision support systems for identification and management of mental health disorders in primary care and among patients with CVD. Given the evidence linking modifiable lifestyle factors to both cardiovascular and mental health, a key step in reducing cardiovascular health disparities in people with mental health disorders is to routinely include evidence-based lifestyle interventions as a standard part of mental health care.

Panel 1. Recommendations for clinical management of mental health disorders in order to reduce cardiovascular health disparities.

• 1.
  Standard psychiatric interventions

  • •
    Psychotherapies: Psychological interventions such as cognitive behavioural therapy are recommended for depression in patients with cardiovascular disease. Psychological interventions should be considered in all patients, not only those with mental health diagnoses. These interventions may improve psychological and cardiovascular health although they may not affect survival.
  • •
    Medications: Antidepressants, particularly SSRIs, should be considered for treating major depression in patients with cardiovascular disease. To date the benefits on cardiovascular disease clinical endpoints have not been established.
  • •
    Combination approaches: Combining psychotherapies with medications and lifestyle interventions may offer benefits for mental health, though evidence of impact on cardiovascular outcomes is inconsistent.
• 2.
  Exercise and lifestyle interventions

  • •
    Exercise is strongly recommended as a core treatment for depression, with evidence showing moderate to large improvements in depressive symptoms. Its effects are on par with or superior to those of psychotherapy or medication. Further research is needed to determine its effectiveness in other mental health disorders. Exercise also provides direct cardiovascular benefits.
  • •
    Lifestyle interventions combining exercise, diet, sleep hygiene and smoking cessation have in general shown benefits in the general population and, to a certain extent, also in patients with mental health disorders for multiple cardiometabolic risk factors, with a similar efficacy to pharmacological treatment. Simultaneous covering multiple lifestyle factors should be a standard part of mental health care.
• 3.
  Mind-body approaches

  • •
    Tai chi, qigong and yoga: These practices should be considered as complementary treatments for mental health conditions, especially depression and PTSD. They offer a unique blend of physical, mental, and spiritual benefits, though their impact on cardiovascular outcomes requires more robust evidence.
  • •
    Mindfulness stress reduction and meditation: Mindfulness-based stress reduction and mantra-based meditation, such as Transcendental Meditation, have shown potential in improving mental health in conditions like depression and anxiety. These practices may also offer cardiovascular benefits, though studies are limited, and further research is needed to confirm their efficacy.
  • •
    Biofeedback: This technique shows promise in reducing anxiety and managing hypertension, and it should be explored further as an adjunctive treatment in psychiatric populations.
• 4.
  Integrated care models

  • •
    Interdisciplinary approaches: Integrated care models that involve collaboration between cardiologists, psychiatrists, primary care providers, and other healthcare professionals are recommended for managing patients with coexisting mental and cardiovascular conditions. These models have consistently improved mental health outcomes, though they have not yet demonstrated significant reductions in cardiovascular events or mortality.
  • •
    Care coordination: Effective care coordination should be maximised to ensure comprehensive management, improve access to necessary services, and facilitate behavioural changes that could enhance both mental and cardiovascular health outcomes. Further studies should aim to assess the long-term impact of these models on cardiovascular events.

Our recommendations

To tackle the complexity of factors that underlie disparities in CVD based on mental health disorders, multi-level approaches are needed, from social determinants of health to individual behaviours to barriers in the health care system and health care quality. Recommended strategies for research, clinical practice, and policy, are detailed in Panel 2. Sample language that could be used for brief assessments of mental health in primary and secondary prevention is given in Panel 3.

Panel 2. Recommendations for the reduction of cardiovascular health disparities among people with mental health disorders.

• 1.
  Research recommendations

  • •
    Develop and test guidelines for screening and management of mental health disorders in primary care or among patients with cardiovascular disease. Adequately powered randomised clinical trials should be conducted to inform the development of guidelines for screening and management of mental health disorders in order to improve mental health and cardiovascular health in primary care or among patients with CVD. Trials should identify optimal screening modalities, implementation practices and patient support systems. With these data, screening and management of mental health disorders could eventually be adopted as a performance measure to promote adoption into clinical practice.
  • •
    Investigate the benefits of behavioural, mind-body and drug-based management modalities for mental health disorders on cardiovascular disease outcomes. Randomised trials should be adequately powered and expanded to include other mental health disorders in addition to depression. Integrated care coordination programmes should also be evaluated.
  • •
    Investigate biological risk pathways that link mental health disorders to cardiovascular disease. This is warranted since pathways other than atherosclerosis are implicated. The discovery of such pathways could inform successful interventions.
  • •
    Evaluate novel assessment and management tools that may decrease barriers to care and improve communication for people with mental health disorders. Promising tools include mobile health technologies. Examples are smartphone apps to monitor health and behaviours and deliver clinical reminders and interventions.
  • •
    Modify cardiovascular research protocols to allow the inclusion of research participants with mental health disorders by addressing barriers to participation and providing adequate support and resources.
• 2.
  Clinical recommendations

  • •
    Develop strategies for early detection and management of mental health disorders in clinical patient populations. For example, test the effectiveness of brief assessment tools for mental health in primary and secondary prevention programmes for cardiovascular disease. Such assessments may not need to be structured and may be tailored to the specific clinical encounter.
  • •
    Promote screening for cardiovascular disease risk factors in patients with mental health disorders. Practitioners should be vigilant in addressing somatic complaints of these patients and should monitor their lifestyle behaviours and physical health. Evidence-based lifestyle interventions, such as physical activity and tobacco cessation, should be offered and tailored to the needs and abilities of this patient population.
  • •
    Develop and test education programmes for providers towards decreasing implicit bias, stigma and negative stereotypes associated with mental health disorders. The effectiveness of such programmes should be evaluated.
  • •
    Implement clinical support systems to improve patient-provider interactions and communications. These strategies should address potential cognitive and behavioural deficits, for example using reminders and increasing the frequency of contacts and support.
  • •
    Promote the integration of mental health and cardiovascular care by improving communication and coordination across different providers and develop multidisciplinary care teams with complementary expertise in mental health, cardiovascular health, and behaviour change.
• 3.
  Policy recommendations

  • •
    Address barriers towards healthcare access for people with mental health disorders. Expand insurance coverage for mental health treatment. Provide resources to allow the receipt of cardiovascular screening and medical and lifestyle interventions for people who use mental health services.
  • •
    Invest in public health programmes to address social deprivation in people with mental health disorders, such as programmes to facilitate employment and enhance stable housing.
  • •
    Expand medical training to include behavioural medicine and integrated care models. This will enhance the integration of menta health and lifestyle interventions with routine medical care. Medical staff and students should receive training on working in multidisciplinary teams and with allied health professionals.
  • •
    Improve healthcare systems and platforms towards the integration of clinical care, the delivery of guidelines and interventions, and the monitoring of people with mental health disorders and the care they receive. For example, quick tools for lifestyle and behavioural health screening could be deployed across a range of diagnoses and clinical services. Tools could be developed to monitor the quality of health care offered to people with mental health disorders.
  • •
    Enable routine data collection of key indicators of health in people with mental health disorders, for example through the development of databases and surveillance systems at the national and local level to monitor comorbidity, mortality, disability and quality of care.

Panel 3. Sample language for addressing psychological factors in clinical encounters.

Many cardiologists and primary care providers may feel ill-equipped to have substantial discussions about mental health with their patients. However, brief, targeted discussions with specific patients, e.g., after screening for mental health problems provided by other staff, can be helpful and are often highly valued by patients. Sample language to address psychological factors during clinical encounters are given below.

Scenario	Sample language
Introduction to mental health discussion	“I want to take a moment to talk about how you’re feeling emotionally, as mental health can impact your heart health.”
Acknowledging the role of mental health in cardiovascular health	“It’s important to understand that stress, anxiety, and depression can affect your heart, just like other physical factors. How have you been feeling lately?”
Normalizing mental health concerns	“Many people with heart conditions experience feelings of anxiety or depression. It’s a common part of dealing with a serious illness.”
Discussing the impact of mental health on recovery	“Addressing mental health is crucial for your overall recovery. Managing stress and emotions can improve your heart health and overall well-being.”
Encouraging open dialogue	“If you’re feeling overwhelmed, anxious, or down, it’s important to talk about it. We can explore ways to help you feel better, both mentally and physically.”
Linking mental health to treatment adherence	“When we’re feeling low or stressed, it can be harder to stick to medications and lifestyle changes. Let’s work together to make sure you’re supported in every way.”
Introducing the role of other team members	“Our team includes professionals who can help with managing stress and emotions. Would you be open to speaking with someone about this?”
Reassurance and support	“You’re not alone in this, and help is available. We can find ways to support you through this challenging time.”
Connecting mental health to quality of life	“Your emotional well-being is just as important as your physical health. By addressing it, we can help improve your quality of life.”
Encouraging follow-up	“Let’s keep this conversation going. We can check in on how you’re feeling during our next visit and make adjustments as needed.”

Conclusions

Large disparities exist in cardiovascular health for people with mental health disorders. Many research questions remain to be tackled, and programmes and policies are needed to ameliorate structural, economic, environmental, and clinical barriers to ensure appropriate mental and cardiovascular health. There are many challenges in achieving equitable care, however, both for patients and clinicians. For the best care, an integrated approach is needed to address the complex needs of this vulnerable population. Such approach should offer enhanced support and interdisciplinary care encompassing mental, cardiovascular, and behavioural health, as well as consideration of the social needs and barriers to care of this patient population. Closing the disparity gap for individuals with mental health disorders would be consistent with the World Health Organization 2025 targets of reducing the global burden of CVD and with the priorities of the United Nations Sustainable Development Goals, calling for reducing health disparities and promoting good health and wellbeing for all. Reducing these disparities would also uphold the rights of people with mental health disorders to achieve the highest possible level of health and to fully participate in society and the workforce.

Contributors

VV and RB conceived the Series paper. VV, EP, AJS, JDB and RB conducted the search and reviewed the literature. VV, EP, AJS, JDB and RB wrote the initial draft the paper. VV and AJS produced the manuscript figures. VV, EP, AJS, JDB, PR, OD, CPG and RB participated in the review and revision of the manuscript for important intellectual content.

Declaration of interests

Dr. Gale received grants and contracts from the Alan Turing Institute, the British Heart Foundation, the National Institute for Health Research, Horizon 2020, Abbott Diabetes, Bristol Myers Squibb, and the European Society of Cardiology; consulting fees or honoraria from AI Nexus, AstraZeneca, Amgen, Bayer, Bristol Myers Squibb, Boehrinher-Ingleheim, CardioMatics, Chiesi, Daiichi Sankyo, GPRI Research B.V., Menarini, Novartis, iRhythm, Organon, The Phoenix Group, Boston Scientific, Raisio Group, Wondr Medical, and Zydus; and participation in advisory boards for the DANBLCOK trial and the TARGET CTCA trial. He received equipment from Kosmos and serves as Deputy Editor of EHJ Quality of Care and Clinical Outcomes; he serves in the NICE Indicator Advisory Committee, and as Chair of the ESC Quality Indicator Committee. Dr. Bugiardini declares participation in advisory board for NCT05758896 (Contrast Induced Acute Kidney Injury, Aptabio Therapeutics, Inc.). Dr. Vaccarino declares participation in Data Safety Monitoring Boards for NIH studies (ARIC and Connect 4R). No specific funding was received for the preparation of this manuscript.

Search strategy and selection criteria.

Data included in this narrative review were from the most recent studies identified by searching academic databases, database inception from Jan 1, 2012 to July 1, 2024, including MEDLINE and Google Scholar, using keywords for mental health disorders (such as “psychiatric disorders”, “mental illness”, “mental disorder”, “depression”, “major depressive disorder”, “major depressive episode”, “anxiety”, “anxiety disorder”, “posttraumatic stress disorder”, “bipolar disorder”, and “schizophrenia”), and for cardiovascular disease (such as “cardiovascular disease”, “coronary heart disease”, “coronary atherosclerosis”, “coronary artery disease”, “ischemic heart disease”, “myocardial infarction”, “stroke”, “cerebrovascular disease”, “heart failure”, “hypertensive heart disease”, “cardiovascular risk factors”, “cardiovascular disease prevention”, “cardiac mortality”, and “cardiovascular mortality”. The search of academic databases was supplemented by reviews of reference lists in publications and Google search engines to search cited articles and ensure that the most recent papers and meta-analyses were not missed. Criteria for being included in the review were peer-reviewed, scientific publications, including empirical studies, systematic reviews, or meta-analyses published in the English language. Only studies of adult populations were considered. Preference was given to meta-analyses, systematic reviews and large registry studies published since 2017. Preference was also given to data for mental health disorders assessed with clinical interviews, but in absence of these, self-reported symptom scales were considered.