Major Mental Illness Linked to Higher CVD Risk, Even in Young

Serious mental illnesses such as bipolar disorder and schizophrenia are associated with a significant increase in cardiovascular risk, particularly among younger age groups, a new observational study suggests.    

Prior research has shown that people with schizophrenia and bipolar disorder die 10 to 20 years earlier than those without serious mental illness and that the leading cause of death for these patients is cardiovascular disease (CVD), said lead author Rebecca C. Rossom, MD, MS, an associate professor at the University of Minnesota Medical School, Minneapolis.

Their work adds to the literature by demonstrating that people with serious mental illness have increased cardiovascular risk even as young adults, she said.

“Our data highlight the potential utility of using 30-year (lifetime) cardiovascular risk equations to estimate elevated cardiovascular risk in young adults,” said Rossom in an email.

“When doctors use these 30-year risk equations, they can start estimating and addressing risk for people as young as 20 years old, rather than waiting until age 40, which is when the more commonly used 10-year risk estimates can be used,” she added.

Their results were published online March 9 in the Journal of the American Heart Association.

These data demonstrate “the need to evaluate cardiac risk in individuals with severe mental illness with particular attention to preventing diabetes, obesity and smoking cessation,” noted Nieca Goldberg, MD, a clinical associate professor in the department of medicine at New York University Grossman School of Medicine, New York City.

A team approach is needed to do so, with input from a psychiatrist, primary care physicians, patients, and family members, Goldberg noted. More research on best practices to address cardiovascular risk in individuals with bipolar disorder and schizophrenia is also needed, she added.

For this analysis, the researchers assessed 579,924 patients without and 11,333 patients with serious mental illness as part of a cluster randomized trial of clinical decision support in primary care aimed at reducing cardiovascular risk in patients with serious mental illness.

The mean age of participants was about 45 years. Females comprised 57.8% of the group with serious mental illness, and 54% of the group without serious mental illness.  

Study participants were between the ages of 18 and 75 years and saw a primary care provider between January 2016 and September 2018 at one of two healthcare organizations in Minnesota and Wisconsin. Patients were classified as having or not having serious mental illness based on diagnosis codes.

For individuals aged 40 to 75 years who did not have CVD, 10-year cardiovascular risk was calculated using atherosclerotic CVD scores. For patients aged 18 to 59 years without CVD, the research team calculated their 30-year cardiovascular risk using the Framingham Risk Score.

Vital sign, diagnosis, prescription drug, health insurance, and demographic information were gathered from electronic health records using a clinical decision support system.

After adjusting for ethnicity, sex, insurance type, age, and race, patients with serious mental illness who were 40 to 75 years of age and did not have CVD had a substantially greater average 10-year cardiovascular risk of 8.31, compared to 7.95 in individuals without serious mental illness. Notably, the difference in risk declined with age.

“This observation might be related to increased treatment and control of cardiovascular risk factors in older patients with serious mental illness,” the researchers write. “Alternatively, it may reflect survival bias, with patients with serious mental illness dying at younger ages than those without serious mental illness.”

When calculating 30-year risk for those aged 18 to 59 years without known CVD, patients with serious mental illness were significantly more likely to be in the highest tier of risk (with two or more major risk factors) than those without serious mental illness (18.8% vs 10.8%; P < .0001).

This increased 30-year risk in serious mental illness patients could be linked to higher rates of smoking and obesity among young individuals with serious mental illness, as well as delayed detection or management of heightened cardiovascular risk factors in this cohort, the study authors noted.

However, other factors also contribute to this excess burden of disease in this group, they add, including increased alcohol use, lower physical activity, poorer socio-economic status, and suboptimal diet. There is also genetic evidence for overlap in genetic risk for serious mental illness and hypertension, cardiac dysrhythmia, nonrheumatic heart disease, and type 1 diabetes, they add, and many medications used to treat mental illness also may increase CVD risk, “largely through cardiometabolic side effects.”

Other study results looked at individual cardiovascular risk factors and found:

  • Those with serious mental illness had a rate of diagnosed diabetes that was nearly double that of patients without serious mental illness (13.7% vs 6.5%; P < .0001).

  • About 15% of patients with serious mental illness had hypertension vs 13.2% of those without.

  • About 69% of patients without and 80% of patients with serious mental illness had a body mass index (BMI) of > 24.9, and 50% of patients with serious mental illness met obesity criterion (BMI of 30 or more), compared to 36% of patients without serious mental illness.

  • About 36% of patients with serious mental illness were current smokers vs only 12% of those without serious mental illness.  

As well as being observational, other limitations of the study include that it did not take into consideration prescription drug use, lack of information on select social determinants of health, and that the study was carried out in an integrated healthcare system, the researchers acknowledged.  

Taking into consideration the shortened life span of people with serious mental illness and the substantial contribution of CVD to earlier mortality, this report supports more evaluation and effective treatment of major cardiovascular risk factors for patients with serious mental illness beginning at a younger age, the researcher noted.

“Use of 30-year cardiovascular risk estimates to help guide decisions about cardiovascular risk factor management and prevention in young adults with serious mental illness may be important to decreasing rates of cardiovascular morbidity and mortality,” the study authors concluded.

Rossom reports no relevant financial relationships.

Journal of the American Heart Association 2022. Published online March 9. Full text.

Ashley Lyles is an award-winning medical journalist. She is a graduate of New York University’s Science, Health, and Environmental Reporting Program, New York City. Previously, she studied professional writing at Michigan State University, East Lansing, where she also took premedical classes. Her work has taken her to Honduras, Cambodia, France, and Ghana and has appeared in outlets like The New York Times Daily 360, PBS NewsHour, The Huffington Post, Undark, The Root, Psychology Today, Insider, and Tonic (Health by Vice), among other publications.

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