About Heart Disease and Mental Health

The Costs section provides information about the significant costs that heart disease has on individuals and society as a whole. It also underscores the undeniable connection between heart disease and mental health. This section focuses on defining heart disease and exploring its connection with mental health. We will also review risk and preventive factors, as well as issues associated with coping with a diagnosis of heart disease.

What is heart disease? 

Heart disease is a general term that refers to any disease or condition of the heart, including:

• coronary heart disease (CHD), also known as coronary artery disease (CAD)
• congenital heart disease (abnormalities of the heart’s structure and function caused by abnormal or disordered heart development before birth)
• hypertension
• heart infections
• heart failure (a disorder in which the heart loses its ability to pump blood efficiently)
• disorders of the heart valves
• heart arrhythmia's (irregular rhythms of the heart beat)
• cardiomyopathy (a group of diseases that affect the myocardium, the muscle of the heart)¹

Here we will focus on CHD—a condition in which the heart has difficulty circulating blood because the arteries have become clogged with deposits made up of “bad” cholesterol, plaque, scar tissue or calcium. This clogging causes a myriad of heart problems and serious illnesses by reducing the flow of blood to major systems of the body, such as the kidneys, legs and intestines.

The heart and mind connection

Many studies have provided evidence of a link between negative emotional states and heart disease. Although our current understanding of this relationship is incomplete, it must be considered in developing a comprehensive cardiovascular/behavioral health program. For example, how does being depressed impact one’s ability to maintain compliance with the doctor’s recommendations regarding diet, exercise, smoking and use of medications? How does the experience of being diagnosed with heart disease impact one’s emotional health? What impact does chronic stress have on one’s heart health? How can one change unhealthy lifestyle behaviors for good in order to prevent heart disease? An integrated program should help individuals address cardiovascular issues holistically, so that an individual’s emotions, behaviors and coping strategies can help promote a healthy heart.

Risk factors

The primary risk factors for the development of heart disease include:

Smoking—Many studies provide evidence that cigarette smoking is a major cause of heart disease.²

Sedentary lifestyle—The relative risk of heart disease associated with physical inactivity is comparable to the risk observed for high cholesterol, high blood pressure or cigarette smoking.³

Hypertension—Hypertension, or high blood pressure, is often called the “silent killer,” because there are no symptoms and people often don’t know they have it. It can lead to stroke, heart attack, heart failure or kidney failure.⁴

High blood cholesterol—The higher one’s blood cholesterol level, the greater the risk for developing heart disease or for having a heart attack. Age, gender and heredity can impact cholesterol levels, as can modifiable risk factors such as diet, weight and physical activity.⁵

Overweight and obesity—Being overweight or obese increases the risk of many diseases, including heart disease.⁶

Diabetes—Two out of 3 people with diabetes die from heart disease or stroke. With diabetes, heart attacks occur earlier in life and often result in death.⁷

Genetic predisposition—Having a family history of heart disease increases one’s chance of developing heart conditions. This is defined as having heart disease diagnosed before age 55 in one’s father or brother, or before age 65 in one’s mother or sister.⁸

Depression and other behavioral health disorders— There is abundant evidence to support the “heart and mind” connection. Consider the following:

• Depression, anxiety, hopelessness, pessimism, hostility and anger have all been linked with heart disease.^{9, 10, 11}
• Depression and anxiety disorders are suspected to affect heart rhythms, increase blood pressure, alter blood clotting and lead to elevated insulin and cholesterol levels. These risk factors often predict, and are a response to, heart disease.¹²
• People with heart disease are more likely to suffer from depression than otherwise healthy people; conversely, people with depression are at greater risk for developing heart disease.¹³
• One in 5 people who have survived a heart attack experiences major depression.¹⁴
• Individuals who have heart disease and who are depressed have an increased risk of death after a heart attack compared with those with heart disease who are not depressed.¹⁵
• Anxiety is strongly associated with the onset of heart disease.¹⁶
• Anger doubles one’s risk of having a heart attack for 2 hours after the episode of anger.¹⁷

Protective factors

The following preventive factors are within one’s control—they can be impacted by behavior change.

Not smoking—Anyone can benefit from quitting smoking—regardless of his or her age, smoking history or whether he or she already has a smoking-related disease. One year after quitting, the excess risk of coronary heart disease is half that of a smoker’s.¹⁸

Exercise—Regular exercise can increase the heart’s pumping efficiency, benefit circulation, increase overall strength and endurance and can help reduce the risk for heart disease.  Exercise can help efforts to control cholesterol levels, diabetes and obesity; it also may favorably affect cigarette smoking, hypertension and emotional stress. Enhanced physical activity often can prevent or significantly reduce the emotional and physical consequences of heart disease.¹⁹

Regular checkups with doctor—Physical exams should include having blood pressure and blood cholesterol checked. The level of cholesterol in one’s blood is a good indicator of the health of one’s heart.²⁰

Maintaining a healthy weight—Excess weight increases stress on the heart. Maintaining an appropriate weight helps the heart function as effectively as it can.

A healthy diet—Diet and physical activity help to lower and maintain weight and also improve cholesterol levels.²¹ Reducing the amount of saturated fat and cholesterol in the diet also helps lower blood cholesterol levels. Also recommended is increased consumption of vegetables, fresh fruits, low-fat milk and other dairy products, whole grains, fish and poultry.²²

Carefully monitoring diabetes—By managing diabetes, high blood pressure and cholesterol, people with diabetes can reduce their risk for heart disease and stroke.²³

Emotional factors—Individuals who are at risk for or have been diagnosed with heart disease need to be aware of the connection between emotional factors and heart disease, and they should discuss any distress they may be having with their physician. Likewise, medical professionals should routinely screen patients for emotional factors that could put them at risk for heart disease. In addition, heart patients are advised to:

• use a support system of friends, family and life partner
• adjust life expectations to be more realistic
• celebrate the smallest successes
• pursue more activities that are pleasurable and less of those that are displeasing
• stay informed about the disease and its treatment
• work closely with the treating physician
• be alert to the signs of depression

Supporting healthy lifestyle change

Now armed with an awareness of risk factors and protective factors associated with heart disease, what is the best way to support individuals in making lifestyle changes in order to minimize their risk? Quitting smoking, maintaining a healthy diet, following an exercise regimen and managing stress are changes that don’t occur overnight. The “Stages of Change” model recognizes that, for many, behavior change is a gradual process:

1. Pre-contemplation—unaware of the need or unwilling to make a change
2. Contemplation—aware of the need for change and considering it
3. Preparation—preparing to make a change
4. Action—actively working to change the behavior
5. Maintenance—trying to maintain the new behavior without reverting back to the old one; relapses are common and become part of the process of working toward established change

An effective prevention program incorporates elements to support individuals at each stage of change—from providing accurate information to those in the pre-contemplation stage, to providing support, encouragement and tools in the maintenance stage. 

The need for an integrated cardiovascular/behavioral health program is clear. Please review the section, “Helping Individuals,” to see how ValueOptions can help support your employees or members. The section, “Support,” offers suggested next steps in building a program.

1 HeartInfo.org
2 American Heart Association
3 Journal of the American Medical Association, 1995; 273:402-7.
4 American Heart Association
5 National Heart, Lung and Blood Institute
6 Centers for Disease Control and Prevention
7 American Diabetes Association
8 National Heart, Lung and Blood Institute
9 Williams R.B. Neurobiology, cellular and molecular biology, and psychosomatic medicine. Psychosom Med. 1994;56:308-315.
10 Denollet J., Brutsaert D.L. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Circulation. 1998;97:167-173.
11 L.D. Kuzansky, K.W. Davidson, and A. Rozanski. The Clinical Impact of Negative Psychological States: Expanding the Spectrum of Risk for Coronary Artery Disease. Psychosom Med, May 1, 2005; 67(Supplement_1):S10-S14.
12 National Heart, Lung and Blood Institute
13 Nemeroff CB, Musselman DL, Evans DL. Depression and cardiac disease. Depression and Anxiety, 1998; 8(Suppl 1): 71-9.
14 Johns Hopkins University
15 Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation, 1995; 91(4): 999-1005.
16 Kubzansky L.D., Kawachi I. Going to the heart of the matter: Do negative emotions cause coronary heart disease? J Psychosom Res 2000;48:323-37.
17 Thriving With Heart Disease: A Unique Program for You and Your Family/Live Happier, Healthier, Longer by Wayne M. Sotile, PhD. Free Press, 2003, p. 139.
18 U.S. Surgeon General
19 Statement on exercise. A position statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association, Circulation 1990;81;396-398.
20 HeartInfo.org
21 National Heart, Lung and Blood Institute
22 HeartInfo.org
23 American Diabetes Association