Heart Disease Outcomes Better When Anxiety, Depression Are Treated

In people with heart disease and comorbid anxiety or depression, mental health treatment showed strong links to better clinical outcomes in an observational analysis of the Ohio Medicaid database.

Those hospitalized with coronary artery disease (CAD) or heart failure (HF) and a record of both psychotherapy and antidepressant use tended to have fewer subsequent events, when followed for up to 4 years, compared with peers with no mental health treatment:

• All-cause mortality: HR 0.33 (95% CI 0.23-0.46)
• Coronary heart disease mortality: HR 0.47 (95% CI 0.21-1.02)
• Emergency department (ED) visits: HR 0.32 (95% CI 0.26-0.39)
• Hospital readmission: HR 0.30 (95% CI 0.24-0.38)

Results were similar after adjusting for comorbid disorders, medication use, and prior diagnosis of depression or substance use disorder, reported Philip Binkley, MD, MPH, of The Ohio State University Wexner Medical Center in Columbus, and colleagues in the Journal of the American Heart Association.

Psychotherapy or antidepressants alone were also associated with some improved clinical outcomes. Each treatment carried a hazard ratio in the range of 0.48 to 0.70 depending on the specific endpoint analyzed in the population-based cohort study.

“To the authors’ knowledge, this article is the first to show that mental health treatment may be associated with reduced risk for relevant outcomes,” Binkley’s group concluded. “These findings indicate that mental health interventions are essential to reducing hospitalizations and ED visits in patients with HF or coronary disease and concomitant depression or anxiety.”

“While the findings relevant to CAD-related deaths are suggestive, they are not significant. This may be related to a relatively small sample size of patients with this diagnosis and a consequent lack of sufficient statistical power to detect an effect,” the authors noted.

Prior work has shown that depressive symptoms are associated with a higher risk for all-cause and cardiovascular mortality based on the National Health and Nutrition Examination Survey. Additionally, in U.K. and Finnish population studies, people with severe or moderately severe depression were at increased risk of various physical illnesses requiring hospitalization, including ischemic heart disease and diabetes.

Binkley’s team acknowledged that the evidence is not as strong for an anxiety-heart disease link, but maintained that there is evidence for a general heart-brain connection.

“Both heart disease and anxiety are associated with activation of the sympathetic nervous system and the production and release of proinflammatory cytokines. Simultaneous activation of these systems promote the progression of both central nervous system-mediated conditions such as anxiety and depression as well as heart disease,” the group explained.

“Heart disease and anxiety/depression interact such that each promotes the other,” Binkley said in a press release. “There appear to be mental processes that link heart disease with anxiety and depression that are currently under investigation.”

In the meantime, Binkley said he hopes the study’s results will motivate cardiologists and healthcare professionals to screen routinely for depression and anxiety.

“Effective strategies for identifying anxiety and depression in patients with subsequent effective treatment may be an important strategy by which clinicians can improve the quality of life in individuals with HF,” his group wrote.

Beyond medication and psychotherapy, some patients are also turning to transcranial magnetic stimulation (TMS) for the treatment of depression and other neuropsychiatric disorders. Lab experiments suggest a low risk of damage or overheating of cardiac implants during TMS.

The American Heart Association projects that heart disease will continue rising in this decade to reach 43.9% of Americans by 2030, with costs of heart failure alone totaling nearly $70 billion.

“Interventions that can reduce the frequency of readmission and ED care hold the promise of significantly reducing healthcare costs. Considering the cost of hospital and ED visits versus that for mental health professional visits, our results suggest that the cost-benefit ratio for mental healthcare is likely to be important,” wrote Binkley’s group.

For their study, the authors gathered data from Ohio Medicaid claims files and death certificates from 2009 to 2012. Patients hospitalized with CAD or HF, with comorbid anxiety or depression, were followed for up to 4 years, through the end of 2014.

Included were 1,563 people (mean age 50 years, 68% women). Four in five were white. There were 92.2% diagnosed as having anxiety and 55.5% diagnosed with depression. Over 53% were diagnosed with substance abuse as well.

Based on pharmacy records and billing codes, the investigators estimated that 23.2% of participants received antidepressant medications and psychotherapy, 14.8% psychotherapy alone, 29.2% antidepressants alone, and 33% no mental health treatment.

Study authors acknowledged that the study may not be generalizable to a wider or older population, noting that Medicaid only covers people age 21 to 64 years.

“A collaborative care model is essential to manage cardiovascular and mental health,” Binkley maintained. “Hopefully these findings inspire additional research regarding the mechanistic connections between mental health and heart disease.”

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