Medically reviewed by: Rob Philibert MD PhD
In order to be truly effective, coronary heart disease (CHD) risk prevention should start early, perhaps as young adulthood. This is particularly true for patients with mental disorders. However, for many, in particular those with a history of depression or other serious behavioral disorders, preventive care isdelayed, often to the point of futility. According to the World Health Organization, those with severe mental disorders die 10-25 years earlier thanthose without behavioral illness. In large part, this differential mortality is secondary to increased rates of potentially preventable heart disease amongbehaviorally ill patients. Although the reasons for this failure to deliver timelypreventive care to these patients are complex, finger pointing to assign blame is pointless. The solution to the problem is clear. Those clinicians who care for patients with depression, anxiety or psychosis need to grasp the ringof leadership, “look below the shoulders” and treat their patients more holistically.
Why are those with mental disorders more at risk for CHD?
In general, this increased vulnerability arises from two diatheses. The first diathesis or root cause is a consequence of the primary pathology of these disorders. For example, the primary symptoms of depression include apathy,lethargy and increased appetite, all of which can increase risk for heart disease and impede ability to engage in preventive exercise routines. The second diathesis is a consequence of the medical therapies designed to treatthe behavioral symptoms. At the top of that list are antipsychotics which can double the risk for diabetes and increase risk for CHD by 30-75%. However, other medications are not harmless. By both direct and indirect effects, the indiscriminate use of anxiolytics or antidepressants can lead to adverse effects on the cardiovascular system. Therefore, to maximize beneficence to their patients, clinicians need to evaluate risks to their patients and offer only those treatment choices which will truly benefit the patient overall.
Who are these clinicians who need to advocate for more holistic care of those with behavioral illness?
Surprisingly, psychiatrists, who constitute only about 4-5% of the U.S. physician workforce, constitute only a minority of those clinicians. In general,psychiatrists tend to take care of those with the most severe mental disorders. But the majority of mental health care is provided by family practitioners, nurse practitioners or allied health professionals. Often, the interventions provided by these clinicians are non-medical. However, these patients are still at risk for CHD. For example, those with substance use are at markedly elevated risk for CHD. Yet, they rarely receive the type of embracing holistic care that addresses more general risk but also increases the likelihood of a therapeutic response for the behavioral disorder.
What are the major barriers to delivering more holistic care?
Lack of reimbursement is a major factor. Healthcare policymakers consistently favor expensive, low impact, often futile late life treatments instead of relatively inexpensive, more effective preventive care. This is a double whammy to thoughtful providers who also do not receive adequate reimbursement for psychiatric treatments. A second barrier is the difficulty inconducting the screening. Current risk screening protocols require overnight fasting by patients and access to phlebotomy. The former is difficult to assure in many circumstances and the latter hard to come by in many behavioral health practices, in particular, those conducted using telemedicine. A third barrier is the sad fact that current lipid-based methods do not work well. In many studies, they fail to identify the majority of patients who later go on to experience a cardiac event.
Fortunately, there are pioneers who are attempting to hurdle the barriers between these challenges and better preventive care for patients with behavioral disorder. One such visionary is Dr. Christoph Correll of the Feinstein Institutes for Medical Research (New York) and Charite Hospital (Berlin). As early as 2004, Dr. Correll was documenting the relationship between antipsychotic use and increased risk for CHD. In 2013, in a widely cited meta-analysis of prior studies of patients with depression or mania, he and his colleagues extended those prior findings to show that those with depression or bipolar disorder were also at increased risk for CHD. They concluded that those with these common disorders “require regular monitoring and adequate preventive efforts and treatment for cardio-metabolic risk factors.” The results of these and similar studies are so strong that routine screening of high-risk psychiatric patients have been included in standard treatment guidelines. Still, in the vast majority of cases, screening is not performed.
Why isn’t this screening performed?
Well, it turns out that running the gauntlet of clinical obstacles to get this vital screening performed is a formidable challenge. Fortunately, Precision Epigenetics may provide the revolution that Behavioral Medicine requires to surmount these obstacles and provide state of the art cardiac prevention now present in the current COVID-19 healthcare clime. In particular, integrated genetic-epigenetic tests such as Epi+Gen CHD™, which not only outperform standard lipid testing in head-to-head comparisons, provides improved predictive capacity, allow practitioners to avoid the necessity of having patients fast and comes in a convenient at-home testing format compatible with standard telemedicine or phlebotomist free healthcare settings. Our patients should not needlessly die from preventable disease. The technology to prevent CHD in our patients is now here. We realize that
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