Clinical Heart Failure Among Patients With and Without Severe Mental Illness and the Association With Long-Term Outcomes

Abstract

Background: Patients with severe mental illness (SMI) including schizophrenia, bipolar disorder, and severe depression have earlier onset of cardiovascular risk factors, predisposing to worse future heart failure (HF) compared with the general population. We investigated associations between the presence/absence of SMI and long-term HF outcomes. Methods: We identified patients with HF with and without SMI in the Duke University Health System from 2002 to 2017. Using multivariable Cox regression, we examined the primary outcome of all-cause mortality. Secondary outcomes included rates of implantable cardioverter defibrillator use, cardiac resynchronization therapy, left ventricular assist device implantation, and heart transplantation. Results: We included 20 906 patients with HF (SMI, n=898; non-SMI, n=20 008). Patients with SMI presented clinically 7 years earlier than those without SMI. We observed an interaction between SMI and sex on all-cause mortality ( P =0.002). Excess mortality was observed among men with SMI compared with men without SMI (hazard ratio, 1.36 [95% CI, 1.17–1.59]). No association was observed among women with and without SMI (hazard ratio, 0.97 [95% CI, 0.84–1.12]). Rates of implantable cardioverter defibrillator use, cardiac resynchronization therapy, left ventricular assist device implantation, and heart transplantation were similar between patients with and without SMI (6.1% versus 7.9%, P =0.095). Patients with SMI receiving these procedures for HF experienced poorer prognosis than those without SMI (hazard ratio, 2.12 [95% CI, 1.08–4.15]). Conclusions: SMI was associated with adverse HF outcome among men and not women. Despite equal access to procedures for HF between patients with and without SMI, those with SMI experienced excess postprocedural mortality. Our data highlight concurrent sex- and mental health-related disparities in HF prognosis, suggesting that patients with SMI, especially men, merit closer follow-up.

Disparities in heart transplantation

“…Women were judged more harshly if they had underlying depression and were given worse Stanford Integrate Psychosocial Assessment for Transplant (SIPAT) scores and more likely to be excluded from heart transplant candidacy as a result [6 ▪ ]. However, severe mental illness was associated with worse outcomes in men after transplant not women [44 ▪ ]. Other subjective perceptions also influence healthcare providers, particularly when it comes to minority populations.…”

Echocardiographic evaluation of myocardial strain in bipolar disorder across different phases: A comparative study with healthy controls

“…[8] In particular, the manic phase of bipolar disorder exhibited the highest GLS values, in contrast to the conventional understanding of myocardial function in psychiatric conditions. [9] This deviation from expected norms raises questions about the underlying cardiac adaptations or stressors in bipolar disorder during its different phases. Such findings highlight the need for cardiac monitoring in bipolar patients, as these variations may have significant clinical implications.…”

Scoping Review of Measures of Comorbidities in Heart Failure

“…bipolar disorder, and substance abuse) and adverse clinical outcomes in HF. 70,71 Thus, more studies are needed to evaluate the relationship between mental disorders and clinical outcomes in HF. Second, few studies in our review explored the effect of comorbid diseases on quality of life and self-care.…”

“…As a result, mental disorders in our review may have been underreported. However, many studies have indicated a negative impact of psychological disturbance on outcomes in HF, 69 and some studies have suggested that there may be a significant relationship between mental disorders other than depression (eg, schizophrenia, bipolar disorder, and substance abuse) and adverse clinical outcomes in HF 70,71 . Thus, more studies are needed to evaluate the relationship between mental disorders and clinical outcomes in HF.…”