February 13, 2017

By Ken Duckworth, M.D.


It has been 50 years since Lyndon Johnson declared February American Heart Month. While we have steadily reduced the rate of heart disease since then, it still remains our number one killer. And those who experience mental health conditions—people like my hero Carrie Fisher—usually have an even higher risk. Her passing due to heart disease is a reminder for us all to attend to this important topic.

Through research like The Framingham Heart Study, we have learned that heart disease has clear risk factors (smoking, diabetes, obesity, high blood pressure, high cholesterol and inactivity). We also know from other research that these risk factors are more common for people who live with mental illness, resulting in potential loss of years of life for some. There are many factors that may be contributing to this including trauma, poverty, and inadequate integration of care. It is also important to note that diverse populations have been studied less overall and may have some different dimensions to their risks (the Framingham Heart Study has worked to add diverse populations to its study in response to this observation).

If you live with a mental health condition, take the time this month—American Heart Month—to talk with your doctor about your risks of heart disease and what you can do to reduce them. If they apply to you, here are a few topics you should bring up at your next visit:

Smoking Cessation

Smoking is a major killer of people who live with serious mental illness and the single greatest risk factor for heart and lung diseases. It isn’t easy for anyone to quit smoking, but research shows it is even harder for people with psychiatric conditions to quit. Many people aren’t asked by their caregivers about smoking so it may be something you want to initiate. There is also new research which may help people adjust their approach to smoking cessation.

One tool that is worth re-examining is a medicine called varenicline. This medication has been around for a while but was first  thought to add too much risk in terms of depression and suicidal thoughts. A recent large scale international research study led by Massachusetts General Hospital’s Eden Evins found that varenicline was shown to be effective in helping people quit smoking with relatively few psychiatric effects, including suicidal thoughts and risk. This led to the FDA removing this “Black Box” warning for   varenicline in December  2016.  There is also a helpful national support line 800 QUIT NOW if you want more information on smoking cessation.

If you are interested in learning more about this topic, Dr. Evins will be attending the 2017 NAMI National Convention to discuss smoking cessation related research. Feel free to attend if you want to ask her detailed questions about this study or other approaches to quitting smoking.

Second-Generation Antipsychotics

Many second-generation antipsychotics (SGAs: antipsychotics developed in the past 20 years) can add to cardiac risk. They may cause a person to lose the feeling of fullness, therefore causing them to eat more and gain weight. I first noticed this in my sister, who was taking an SGA shortly after they came out and hadn’t been told of this risk. She gained 40 pounds in a short time.

We know now that SGAs may have effects on metabolism that contribute to obesity. Yet to this day, I have found that many people don’t know this possible side effect. I once had a patient ask me why she had to pick between “having a mind” and “having a body” due to weight gain side effects of SGAs. To be clear: This is now known to be a real side effect and one we can anticipate and plan for if SGAs are prescribed. It is important to check your numbers (weight, blood pressure, diabetes risk and cholesterol) before and when taking these meds. Not all meds have the same side effects, so be sure to understand which one may be best for you.

How to battle these health risks in a society that is arguably losing its battle with obesity and diabetes remains a difficult and important challenge. We do know that it is possible to lower your risks but it isn’t easy. There is a growing literature on how to evaluate health promotion programs that hope to prevent and minimize these side effects. An excellent summary was published by SAMSHA in 2012. Dr. Steven Bartels of Dartmouth Medical School, the lead author of this report, will also be at the 2017 NAMI National Convention and will be updating this important research.

Access to Cardiac Care

Access to cardiac care once a person has a heart problem is another challenge that people living with mental illnesses face. Dr. Ben Druss and his colleagues have shown that people with mental health conditions receive fewer cardiac procedures than people without a diagnosis (JAMA 2000). Additionally, we know that care is often fragmented, and these risks are not always being identified and tended to.

Unfortunately, this problem may worsen as changes continue to be made to the insurance landscape. The repeal of the Affordable Care Act (ACA) threatens the effort to promote better integration of care. However, NAMI is dedicated to protecting access to Medicaid, which is a part of our policy priorities for 2017. We will advocate for better screening and integration no matter the outcome of the ACA. 

As a nation, our overall approach to heart disease risk has improved steadily. Yet, people with mental illness are often left behind this progress. We as a field were late—forty years behind the rest of society—to fully understand these risks and advocate for improvement. We need to do better in terms of prevention, quality of care, access to treatment and creating a culture of health promotion in our field. The road is long, and we have been on it for a much shorter time than we should have been, but we need to stay with it—together. There is no quality of life without quantity of life.

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