Q&A: Assess mental health to reduce CVD risk for women
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Research suggests that women are more vulnerable to common mental health conditions compared with men at all stages of the life course, which can also have important implications for CVD risk.
A woman’s vulnerability to , including depression, anxiety, PTSD and even relationship stress, can raise CVD risk and also complicate recovery after a CV event, according to Nieca Goldberg, MD, medical director of Atria New York City, clinical associate professor at NYU Grossman School of Medicine and a member of the HealthyWomen Women’s Health Advisory Council. Stigma surrounding mental health, on the part of patients and sometimes providers, can also complicate diagnosis and referrals that can help women reduce their CV risk, Goldberg said.
Healio spoke with Goldberg about how mental health impacts CVD in women, how cardiologists should assess mental health during clinic encounters, and the need for more research on what connects mental health and CVD.
Healio: What does the research tell us about women vs. men and mental health disorders?
Goldberg: Mental health disorders are twice as likely in women compared with men. Women are more likely to experience depression, stress and anxiety, and all of that takes a toll on their physical health. Additionally, we are more likely to see depression in younger women with heart disease. In data from the VIRGO study presented at the American Heart Association Scientific Sessions in November, researchers reported that severe marital stress was associated with reduced physical and mental health and increased all-cause readmission in the 1 year following an acute MI, with the associations persisting even after adjustment for socioeconomic factors. Both women and men had worse outcomes after an MI, but women carried the greater burden.
Healio: What might be some of the mechanisms that drive those associations?
Goldberg: This is an emerging area. We have much more to learn and more research is needed. For a long time, the head was separate from the rest of the body in medicine. During the pandemic, when we all saw a much greater interest in mental health, our eyes were more open to the impact of mental health on physical health. Isolation or lack of social support is also associated with higher morbidity and mortality. Loneliness is a mental health issue. During the pandemic, we were all isolated. For people who are depressed, it is difficult to reach out to others. They can feel isolated. Those who are stressed and anxious often do not have the bandwidth to follow a lifestyle program. They may also engage in behaviors that are bad for their heart, such as cigarette smoking, increased drinking or a poor diet or sedentary lifestyle.
Healio: What should clinicians do to better assess mental health in their patients?
Goldberg: Until we learn more about the exact mechanisms linking mental health and heart health, what this comes down to is how are we going to care for people? Yes, we must evaluate a person’s mental health in addition to their physical health, and there are different ways of doing that. We have validated depression and anxiety inventories and validated scales for things like marital stress. These scales can help in a clinical practice setting to identify people who may need mental health support. You can also assess for drug and alcohol use. But it does not end there.
We need to get people help. For people with mild depression, cognitive behavior therapy or other forms of psychotherapy can help. For moderate to severe depression, treatment can also include medical therapy. For many patients with a CV condition or at CV risk, antidepressants can safely be used in consultation with a treating clinician.
Healio: How often should a clinician assess mental health?
Goldberg: These issues do not go away. Depression, for example, is a chronic disease. People should think about depression the way we do heart disease. It is a medical condition, and we need to evaluate it and find the best method of treating it.
It is key to check in with patients at every visit. Ask, ‘how are you feeling?’ And really try to understand how that patient is feeling. Another question I commonly ask is if a patient lives alone and, if so, how often they see family or friends who can help them if needed. Who is in your network? That is a key question.
We must refocus the way we deliver health care as a system. This information should not only be in the realm of cardiology. We must work with primary care, family care doctors and OB/GYNs. We have to widen our net to better care for women. Mental health and physical health are connected.
What else must be done to improve the connection between mental and CV health?
Goldberg: One of the problems we have to fix is difficulty getting access to mental health professionals. Oftentimes, they are not in network for our patients. But there are some online programs and telehealth therapy options. These are other resources, and clinicians should educate themselves on this so they can recommend these options.
We must respect mental health as a medical condition and break the stigma.
For more information:
Nieca Goldberg, MD, can be reached at nieca.goldberg@atria.org.
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