‘Take the extra time’: Assess mental health at every cardiology visit
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Recent data from the American Heart Association show social isolation and loneliness are associated with a 29% increased risk for MI and/or CV death and a 32% increased risk for stroke and stroke death.
Isolation and loneliness are often closely linked to mental health disorders such as anxiety or depression, and can be brought on by sudden life events like the death of a spouse or a job loss. In addition, mental health stressors can put direct stress on the heart, according to Fidelis Mkparu, MD, FACC, professor of medicine at Northeast Ohio Medical University and senior attending cardiologist at Aultman Hospital and Mercy Medical Center.
Healio spoke with Mkparu about the connection between mental health and CVD, who may be at increased CV risk and why, and simple steps cardiologists can take to reduce risk associated with mental health comorbidities.
Healio: What led to you get into this type of research and why is it so important to stress this connection between mental health and CV risk?
Mkparu: It has to do with my patient base. Many of my patients are in their 80s and 90s; my oldest is aged 107 years. She still comes into the office, walks in with her family. The problem is many of my older patients have experienced the death of a spouse or partner. These patients are much more dependent on their family. I have seen them experiencing loneliness, depression, anxiety, stress. As they age, memory issues can compound this. It can be difficult to ascertain if they are taking their medications as prescribed.
I find myself spending more time with these patients. I’ve known many of them for 25 to 30 years. I’ve conducted a lot of clinical research to know what goes on in their family, what resources they have and how to best help them. When you ask them a question, you must have patience for the answers. Time is so important.
Healio: How does loneliness, anxiety or depression impact CVD risk?
Mkparu: There are direct connections and there are indirect connections. Direct connections are anxiety raises heart rate and BP. If that persists, it can increase the risk for heart attack and possibly stroke in patients with underlying CVD. We must identify those patients at increased risk for having an acute cardiac event. Sometimes when patients come to my clinic, they are anxious, and their BP and heart rate are high. You must be careful not to increase their medications each time the BP goes up because when they get home, those things often return to normal. You don’t want to be part of the problem by increasing their medications inappropriately and causing their BP to be too low at home. Lower than normal BP may cause dizziness and sometimes passing out.
Healio: You mentioned older adults and the loss of a spouse causing loneliness or depression. Who else should receive a mental health screening during a cardiology visit?
Mkparu: I screen every patient. Age does not matter. Other life events cause stress that impact CVD risk. Divorce can be a problem. Losing a child, losing a job. Moving to a new home. Financial difficulties. During the COVID-19 pandemic, some of these issues were exacerbated. During the early phase of the pandemic, there were limited interactions between many of my patients and their families. The isolation led to depression and anxiety. For people with PTSD, whether they are members of the military or people who were victims of physical abuse, I see some of them with cardiac issues even decades later, because they carry that experience with them.
Healio: How should cardiologists screen for mental health concerns?
Mkparu: The most important thing is time. You can design any kind of questionnaire that you want, but will it be implemented? That is the issue. I have the benefit of knowing many of my patients for decades, so I designed some basic questions. We ask them to communicate with our office when they experience the death of a spouse, when they retire, move or lose a job, or can no longer take care of themselves and their children could not step in to help, or any time there is any change in their lives. Then I know the things going on in their lives. Any time a patient loses a spouse, I call them. I learn so much from these calls. Communication is very important. It does not have to take place during the office visit. My staff helps with this also. The day before the patient comes in, we always make a phone call. We ask them if anything is new: any financial issues, major life changes, the loss of loved ones. You cannot accomplish everything in a 20-minute office visit. We make those calls ahead.
Healio: Apart from medications, what are some other interventions cardiologists should be aware of to reduce risk associated with mental health conditions?
Mkparu: Know what resources are available. Some of my patients cannot cook anymore. For them, services like Meals on Wheels can take that worry off of their plate. As we get closer to the holidays, I check in with my older patients about their holiday plans. Some of these patients have no family, are unable to travel or do not have the capability to prepare holiday meals for themselves. I used to set a fund aside during Thanksgiving to have meals delivered. It makes patients feel special and it helps a great deal. Talk with social workers aligned with your hospitals to see what other resources are available. All of those things make a big difference.
Healio: Anything else you would like to mention about mental health and heart health?
Mkparu: Reimbursement and time issues are always a concern, but that is not the patient’s fault. I tell my colleagues, every time you walk into a patient’s room, imagine that patient is your mother, father, brother or you. How would you like them to be treated? You have to take the extra time just to talk to them. Medicare may not reimburse for that conversation, but it is so important. Patience, reassurance and caring matter for mental health and for cardiovascular health. Make sure you are giving them your best and treat them like family.
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