A growing body of research shows good mental health can improve heart health and reduce cardiovascular risks, while poor mental health can increase the risk of heart disease, according to a new scientific report.
Because of the clear link emerging between psychological health and heart health, doctors should assess the mental well-being of heart patients as part of their routine care, concluded a panel of experts in a new scientific statement from the American Heart Association. The statement, published Monday in the journal Circulation, summarizes evidence of biological, behavioral and psychological pathways that link mental health to heart disease.
"When treating heart disease, we have traditionally focused on factors that we can easily measure, such as high blood pressure and cholesterol levels," said Dr. Glenn Levine, chair of the writing committee for the new statement. He is a professor of medicine at Baylor College of Medicine and chief of the cardiology section at Michael E. DeBakey VA Medical Center in Houston.
"It is harder to quantitatively assess psychological health and try to measure its impact on heart health. However, recently more and more studies have been able to do this."
For example, studies show people with depression are at greater risk for heart attacks and strokes, whereas people who report feeling optimistic have a lower risk of heart disease and stroke. Adults who report having a greater sense of purpose in life engage in lifestyle behaviors that reduce heart health risks, such as smoking less, staying more physically active and maintaining better blood glucose control, according to research cited in the statement.
"These relationships between the mind, heart and body are important for both patients and doctors to be aware of," Levine said. "As doctors and health care providers, we need to not only treat the disease state, we need to treat the patient and the person as a whole."
The statement notes there is no universal definition of positive psychological health but describes it as a multi-faceted state characterized by optimism, a sense of purpose, gratitude, resilience, positive emotion and happiness, mindfulness, and the capacity to regulate emotions effectively. Negative psychological health includes depression, chronic stress, anxiety, anger and hostility, pessimism and dissatisfaction with one's life.
The statement recommends doctors use simple screening tools for depression and anxiety during routine visits to assess the psychological health of patients who have or are at risk for heart disease. It also discusses possible interventions – such as antidepressants or psychotherapy – that can be prescribed for people who show signs of mental health disorders.
"Clinicians often don't do a good job of thinking about the impact of psychological factors on our patients," said Dr. Erin Michos, one of the statement's co-authors and a practicing cardiologist. "But you won't know there's a problem unless you look for it."
Doctors have limited time with each patient and a lot to cover at each visit, said Michos, who also is an associate professor of medicine in the division of cardiology and director of Women's Cardiovascular Health at Johns Hopkins School of Medicine in Baltimore. But making time for mental health screenings "could reduce high-risk behavior, increase medication adherence and lead to fewer complications down the line. I think it's worth the time."
Poor mental health doesn't just affect behavior. Chronic stress can affect the body.
"Stress activates the body's fight-or-flight response, raises blood pressure and triggers an inflammatory response," Michos said. "It creates low-grade inflammation. Emotional distress can make the body more vulnerable to a plaque rupture event, such as a heart attack or a stroke."
For example, she pointed to a 2017 Lancet study that found high levels of stress predicted the development of heart disease, independent of other risk factors. Researchers associated increased activity in the amygdala, the part of the brain that registers stress, with the development of inflammation in the arteries and changes in bone marrow.
Raising awareness of the impact chronic stress and other mental health issues can have on heart health is particularly important during the COVID-19 pandemic, Michos and Levine said.
But "COVID will not be the last stressor of our lifetimes," Michos said. "In general, we need to cultivate coping mechanisms and strategies to survive future stressors. The advice we give people is to try to take care of themselves: eat healthy, exercise, get enough sleep, minimize alcohol use and spend time with others, even if it's socially distant. Make time to unwind."
And don't hesitate to seek help, Levine said. "People who feel significantly depressed or extremely anxious should discuss this with their primary doctor or a mental health specialist."
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