Psychoses and cardiovascular disease: The heart and mind of the matter

Abstract

Cardiovascular disease and its risk factors are markedly overrepresented in people suffering with psychotic disorders such as schizophrenia. Adverse sequelae of this association include heightened mortality, worsened quality of life, and course of mental illness. Of further concern are that cardiovascular disease is underreported and neglected in this population as well as low rate of metabolic screening. The relationship of cardiovascular disease to psychosis is a complex one, with core symptoms of psychosis, poor diet, smoking, sedentary lifestyle, and socioeconomic factors predisposing to cardiovascular risk. These factors act in combination with iatrogenically induced risk factors attributed to antipsychotic medication, in particular weight gain. There are also syndromes that predispose to both psychosis and cardiovascular disease, including velocardiofacial syndrome, homocystinuria, and Cushing's syndrome and possibly pro-inflammatory mechanisms. Psychotic symptoms are also independently associated with coronary artery bypass and valve surgery. Stress plays a role in the negative impact on both psychosis and cardiovascular disease via the hypothalamic-pituitary-adrenal axis. Regular metabolic monitoring and intervention for identified cardiovascular risk factors in psychosis are mandatory. The latter includes education about diet, exercise, and cardiac risk factors, as well as minimization of weight gain and sedation associated with antipsychotic medication, with switching to more weight-neutral and tolerable medication options. Metformin appears to have a role in ameliorating antipsychotic-related weight gain. While there is a limited evidence base about psychological and psychotherapeutic interventions for primary or secondary prevention of cardiac disease in people with psychoses, behavioral and lifestyle interventions have emerged as showing benefit. Varenicline, a medication not without its propsychotic risks, may also complement these lifestyle interventions via facilitation of smoking cessation.