Cardiovascular disease risk and management in people who experience serious mental illness: an evidence review

Publication date: 28 June 2016

This information is summarised from an evidence review by Candace Bagnall, Te Pou o te Whakaaro Nui, Helen Lockett, the Wise Group, Dr Ruth Cunningham, Department of Public Health, University of Otago Wellington, and Kim Arcus, Heart Foundation.

The Ministry of Health is reviewing the guidance provided to primary care on CVD risk assessment and management. The authors investigated the research on mental health and CVD and this research will be included in the evidence review and used to inform the updated guidelines. This work supports the priorities of Equally Well, a group of organisations committed to improving the physical health of people with mental health and/or addiction issues.

Background 

People who experience serious mental illness (SMI)*, particularly schizophrenia, have significantly reduced life expectancy and a premature mortality rate two to three times higher than the general population (1). It is estimated that cardiovascular disease (CVD) accounts for 40 to 50 per cent of this excess mortality (2). However people diagnosed with SMI are not specifically mentioned in New Zealand guidelines for assessing and managing cardiovascular risk.

*The terms ‘serious mental illness’ and ‘severe mental illness’ (SMI) are widely used to include people with a diagnosis of schizophrenia, major depressive disorder, bipolar disorder and schizoaffective disorder. However major depressive disorder is not always included.

Aims

We reviewed the literature to identify:

  1. The relative increase in CVD risk associated with SMI
  2. The recommended assessment and management of CVD and CVD risk in people with SMI.

Methods and resultsTable 1: Pooled estimates of relative risk of CVD in people with SMI

We reviewed systematic reviews, meta-analyses and relevant single studies published since 2000 or of particular relevance to the New Zealand context. 102 articles passed abstract screening, 42 met the inclusion criteria and were assessed in full for relevance. 34 papers were found to be relevant.

Key findings

People who experience SMI have a greater relative risk of CVD than the general population, even after controlling for other risk factors. 

There is strong evidence to indicate that the risk of developing CVD is higher in people diagnosed with SMI (See Table 1). This increased risk is due in part to established risk factors including smoking and diet but is also related to the metabolic effects of psychotropic medication. Studies that controlled for known CVD risk factors still found an increased relative risk. Some studies have identified mental illness as an independent risk factor for CVD (3, 4, 5).

The increased CVD risk is present at an earlier age than in the general population.

For people with psychosis, CVD risk factors are present from a very early age (6, 7, 8, 9). This evidence of increased risk and at an earlier age is reflected in the National Institute for Health and Care Excellence (NICE) 2015 Quality Outcomes Framework Recommendations (NM129), that all people over 18 years of age on anti-psychotic medication should have annual recording of total cholesterol: hdl ratio.

Current CVD risk assessment tools are likely to underestimate the risk for this population.

Studies have found that CVD risk assessment tools underestimate cardiovascular risk for this group (9, 10). One study has looked at modifying risk assessment protocols specifically for this population (11).

There are inequities in assessment and management of CVD risk and CVD for people diagnosed with SMI.

Several studies point to inequities in assessment and management of CVD risk and CVD in people who experience SMI (12, 13). The evidence for specific interventions to reduce CVD risk among people with SMI is limited, although there is evidence to support behavioural and pharmacological interventions particularly in the area of weight loss (14, 15).

People who experience SMI have a significantly higher risk of dying from CVD than their general population counterparts.

In the only New Zealand study, the standardised mortality ratio (SMR) from CVD for people using mental health services compared to the general population was 1.69 (1). This is consistent with international studies which have found SMR for people with SMI from 1.6 to 2.5 (2). A large UK study (19) found that people with SMI aged 18-49 were three times more likely to die from heart disease as those without SMI, while in people aged 50-75 the risk was doubled.

Conclusions

People who experience SMI have a greater risk of CVD than their counterparts in the general population. The causal pathways are complex (See Figure 1). Established risk factors such as smoking and diet do not fully account for this increased risk. Inequities in assessment and management of CVD risk are likely contributors along with the cardio metabolic effects of psychotropic  medications. 

Figure 1: Potential causal pathways to increased CVD mortality for people with SMI

Ensuring guideline-concordant cardiovascular risk assessment and management is particularly important for this population. It is also necessary to bear in mind that current risk assessment tools are likely to underestimate the risk. The utility of adapting a general population tool to adjust for mental illness, or of creating a specific tool, should be assessed in a New Zealand context.

For more information on this review please contact Dr Ruth Cunningham at ruth.cunningham@otago.ac.nz.

References

1. Cunningham, R., et al. (2014). Premature mortality in adults using New Zealand psychiatric services. NZMJ, 127(1394), 31-41. 
2. Ringen, P. A., et al. (2014). Increased mortality in schizophrenia. Frontiers in Psychiatry, 5.
3. Ösby, U., et al. (2014). Psychotic disorder is an independent risk factor for increased fasting glucose and waist circumference. Nordic Journal of Psychiatry, 68(4), 251-258.
4. Van der Kooy, K., et al. (2007). Depression and the risk for cardiovascular diseases: systematic review and meta analysis. International Journal of Geriatric Psychiatry, 22(7), 613-626.
5. Wulsin, L. R. (2004). Is depression a major risk factor for coronary disease? Harvard Review of Psychiatry, 12(2), 79-93.
6. Correll, C. U., et al. (2014). Cardiometabolic risk in patients with first-episode schizophrenia spectrum disorders: baseline results from the RAISE-ETP study. JAMA psychiatry, 71(12), 1350-1363.
7. Foley, D. L., et al. (2015). Cardiovascular risk factor associations in adults with psychosis and adults in a national comparator sample. Australian and NZ Journal of Psychiatry, 0004867414565476.
8. Goldstein, B. I., et al. (2015). Excessive and premature new-onset cardiovascular disease among adults with bipolar disorder in the US NESARC cohort. Journal of Clinical Psychiatry, 76(2), 163-169.
9. McLean, G., et al. (2014). Standard CVD risk algorithms underestimate the risk of cardiovascular disease in schizophrenia. Schizophrenia Research, 159(1), 176-181.
10. Rugulies, R. (2002). Depression as a predictor for coronary heart disease. American Journal of Preventive Medicine, 23(1), 51-61.
11. Osborn, D. P., et al. (2015). CVD risk prediction models for people with severe mental illness: results from the PRIMROSE Research Program. JAMA psychiatry, 72(2), 143-151.
12. De Hert, M., et al. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10(1), 52-77.
13. Smith, D. J., et al. (2013). Multimorbidity in bipolar disorder and undertreatment of cardiovascular disease. BMC Medicine, 11(1), 263.
14. Gierisch, J. M., et al. (2014). Interventions to improve cardiovascular risk factors in people with serious mental illness. Journal of Clinical Psychiatry 75(5): 424-440
15. McGinty, E. E., et al. (2015). Interventions to Address Medical Conditions and Health-Risk Behaviors Among Persons With Serious Mental Illness. Schizophrenia Bulletin, sbv101.
16. Fan, Z., et al. (2013). Schizophrenia and the risk of cardiovascular diseases: a meta-analysis of 13 cohort studies. Journal of Psychiatric Research, 47(11), 1549-1556.
17. Charlson, F. J., et al. (2013). The contribution of major depression to the global burden of ischemic heart disease. BMC Medicine, 11(1), 250.
18. Nicholson, A., et al. (2006). Depression as an aetiologic and prognostic factor in coronary heart disease. European Heart Journal, 27(23), 2763-2774.
19. Osborn, D. P., et al. (2007). Relative risk of cardiovascular and cancer mortality in people with SMI. Archives of general psychiatry, 64(2), 242-249.

Competing interests

This review was funded by the Ministry of Health to inform a revision of the CVD risk assessment guidance in primary care. The Heart Foundation coordinated the review process. Te Pou o te Whakaaro Nui and University of Otago, Wellington contributed staff time to this review process.

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