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Cardiovascular disease in patients with severe mental illness

Abstract

Individuals diagnosed with schizophrenia or bipolar disorder have a life expectancy 15–20 years shorter than that in the general population. The rate of unnatural deaths, such as suicide and accidents, is high for these patients. Despite this increased proportion of unnatural deaths, physical conditions account for approximately 70% of deaths in patients with either schizophrenia or bipolar disorder, with cardiovascular disease contributing 17.4% and 22.0% to the reduction in overall life expectancy in men and women, respectively. Risk factors for cardiovascular disease, such as smoking, unhealthy diet and lack of exercise, are common in these patients, and lifestyle interventions have been shown to have small effects. Pharmacological interventions to reduce risk factors for cardiovascular disease have been proven to be effective. Treatment with antipsychotic drugs is associated with reduced mortality but also with an increased risk of weight gain, dyslipidaemia and diabetes mellitus. These patients have higher risks of both myocardial infarction and stroke but a lower risk of undergoing interventional procedures compared with the general population. Data indicate a negative attitude from clinicians working outside the mental health fields towards patients with severe mental illness. Education might be a possible method to decrease the negative attitudes towards these patients, thereby improving their rates of diagnosis and treatment.

Key points

  • Patients diagnosed with schizophrenia or bipolar disorder, often termed jointly as patients with severe mental illness (SMI), have a life expectancy 15–20 years shorter than that in the general population.

  • Physical conditions account for approximately 70% of all deaths in patients with either schizophrenia or bipolar disorder.

  • Cardiovascular risk prediction models developed specifically for patients with SMI are needed; data indicate an overall positive effect on health-care spending with the use of these scores, albeit with no direct effect on cardiovascular outcomes.

  • Risk factors for cardiovascular disease, such as smoking, unhealthy diet and lack of exercise, are common in patients with SMI, with early onset of these risk factors.

  • Patients with SMI have higher risks of both myocardial infarction and stroke but a lower risk of undergoing interventional procedures compared with the general population.

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Fig. 1: Factors associated with cardiovascular morbidity and mortality in patients with SMI.

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R.E.N. researched data for the article and wrote the initial draft. J.B. and S.E.J. revised the manuscript in collaboration with R.E.N. All authors provided substantial contribution to the discussion of the content and reviewed and/or edited the manuscript before submission.

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Correspondence to René Ernst Nielsen.

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Competing interests

R.E.N. has received research grants from H. Lundbeck and Otsuka Pharmaceuticals for clinical trials, received speaking fees from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen & Cilag, Lundbeck, Otsuka Pharmaceuticals, Servier and Teva A/S, and has acted as an advisor to AstraZeneca, Eli Lilly, Lundbeck, Medivir, Otsuka Pharmaceuticals and Takeda. J.B. and S.E.J. declare no competing interests.

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Glossary

Schizophrenia

A severe mental illness often characterized by hallucinations and delusions as well as impaired cognition and social functioning; symptoms are often to some degree episodic.

Bipolar disorder

A severe mental disorder often characterized by mood swings with either euphoric or irritable increased mood or depressed mood; symptoms are often episodic.

Varenicline

A prescription medication used to minimize the craving for and pleasurable effects of tobacco smoking.

Bupropion

A prescription medication used to support smoking cessation, but also used for the treatment of major depressive disorders.

Lithium

An ion with mood-stabilizing effects used in patients with bipolar disorder and also to minimize depressive episodes in patients with major depressive disorders.

Clozapine

An antipsychotic drug that is mainly used in patients who are resistant to other forms of antipsychotic drug, with a known tendency to cause metabolic adverse effects.

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Nielsen, R.E., Banner, J. & Jensen, S.E. Cardiovascular disease in patients with severe mental illness. Nat Rev Cardiol 18, 136–145 (2021). https://doi.org/10.1038/s41569-020-00463-7

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