People with any chronic physical health condition are significantly more likely to experience mental health problems. The relationship between physical health and mental health is particularly strong within cardiovascular diseases. For example, depression is two to three times more common in a range of cardiovascular diseases including cardiac disease, coronary artery disease, angina, congestive heart failure, or following a heart attack. Anxiety problems are also common in cardiovascular disease.
There are numerous reasons why it is important to effectively manage mental health problems within cardiac care.
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Co-morbid anxiety and depression in individuals with cardiac disease lead to:
| Heart disease | ↔ | Anxiety and depression |
|---|---|---|
| People are at increased risk of developing a depressed mood after heart attack or heart failure. | Decreased quality of life/functional disability Increased service use and Health Service Costs Changes in Attitude/Mood Uncertainty about the future Lack of confidence in ability to fulfill their roles both at work and home Low self-esteem and increased self-doubt caused by decreased physical capabilities decreased motivation (e.g. to change diet, exercise, take medication, decrease smoking/drinking alcohol). |
People experiencing a clinically depressed mood are at increased risk of developing heart disease. |
Poorer cardiac outcomes
Outcomes from cardiovascular care are poorer for patients with co-morbid mental health problems, even after taking severity of cardiovascular disease and patient age into account. Cardiovascular patients with depression experience 50 per cent more acute exacerbations per year (Whooley et al 2008) and have higher mortality rates (Katon 2003). One meta-analysis suggests that depression leads to a two- to threefold increase in negative outcomes for people with acute coronary syndromes (Barth et al 2004). One study found that depression increases mortality rates after heart attack by 3.5 times (Lesperance et al 2002), while another found a twofold increase in mortality after heart bypass surgery over an average follow-up period of five years (Blumenthal et al 2003). Patients with chronic heart failure are eight times more likely to die within 30 months if they have depression (Junger et al 2005).
Decreased quality of life
There is evidence that quality of life for those with co-morbid mental and physical health problems is considerably worse compared with the quality of life for people with two or more physical health problems. Data from the World Health Survey (based on 245,404 participants in 60 countries; Mossavi et al 2007) reported a lower quality of life score than for two or more long-term physical health conditions. This suggests that the burden of mental health problems, in comparison to the physical health conditions, is greater in terms of impact on day to day living.
There is increasing evidence that co-morbid mental health problems can exacerbate the level of functional disability experienced by people with long-term conditions (Molosankwe et al (2012)). One survey in Canada reported much higher risks of functional disability in people with long-term conditions and depression compared with people with depression or long-term conditions alone (Schmitz et al 2007).
Some studies indicate that the presence of co-morbid psychological problems can have a greater effect on the functional status and quality of life of people with long-term conditions than the level of severity of their physical illness. For example, in cardiovascular diseases, depressive symptoms can have a bigger impact on quality of life than severity of cardiac problems (de Jonge et al 2006).
Increased service use
Given the significant impact on prognosis, it is unsurprising that co-morbid psychological problems also substantially increase patients’ use of health services for their physical problems. Depression, for example, is associated with an increase in rehospitalisation rates in cardiovascular disease. For example, for patients with chronic heart failure the emergency admission rates are two to three times higher (Himelhoch et al 2004; Jiang et al 2001; Fenton and Stover 2006). International studies report similar findings, for example that the presence of mental health problems increases risk of admission by 2.8 times, causes slight increases in length of stay, and doubles the use of outpatient services (Krein et al 2006; Vamos et al 2009). For cardiovascular inpatients in Germany, psychiatric co-morbidity increased average length of stay from 8.9 days to 13.2 days, with total costs increasing by 49 per cent (Hochlehnert et al 2011).
Increased Health Service costs
Increased service use translates into substantial additional costs. There is strong evidence that, by interacting with and exacerbating physical illnesses, co-morbid mental health problems significantly increase the costs of providing care to people with long-term conditions.
An analysis of USA national claims data for more than nine million people showed that patients with long-term conditions, who were also receiving treatment for depression or anxiety, had average monthly medical costs that were between 33 per cent and 169 per cent higher over a range of conditions. Importantly, these costs excluded direct expenditure on mental health services (Melek and Norris 2008).
Similarly, depression has been shown to be associated with increased total annual medical costs for people with congestive heart failure by 37% (Thomas et al 2006).
Pulse point
Despite the potential negative impact of anxiety and depression on the quality of life of people with cardiac disease, studies claim that 92% of panic-like anxiety attacks remain undiagnosed at the time of discharge
- Academia.edu: Unexplained chest pain in the ED: could it be panic? (pdf download),
- with fewer than 25% of cardiac patients with major depression being appropriately assessed and diagnosed as depressed: Medscape (Log in required).
Page last reviewed: 31 Jul 2020
