Excess heart-disease-related mortality in a national study of patients with mental disorders: identifying modifiable risk factors

Abstract

Objective: People with mental disorders are estimated to die 25 years younger than the general population, and heart disease (HD) is a major contributor to their mortality. We assessed whether Veterans Affairs (VA) health system patients with mental disorders were more likely to die from HD than patients without these disorders, and whether modifiable factors may explain differential mortality risks.

Methods: Subjects included VA patients who completed the 1999 Large Health Survey of Veteran Enrollees (LHSV) and were either diagnosed with schizophrenia, bipolar disorder, other psychotic disorders, major depressive disorder or other depression diagnosis or diagnosed with none of these disorders. LHSV data on patient sociodemographic, clinical and behavioral factors (e.g., physical activity, smoking) were linked to mortality data from the National Death Index of the Centers for Disease Control and Prevention. Hierarchical multivariable Cox proportional hazards models were used to assess 8-year HD-related mortality risk by diagnosis, adding patient sociodemographic, clinical and behavioral factors.

Results: Of 147,193 respondents, 11,809 (8%) died from HD. After controlling for sociodemographic and clinical factors, we found that those with schizophrenia [hazard ratio (HR)=1.25; 95% confidence interval (95% CI): 1.15-1.36; P<.001] or other psychotic disorders (HR=1.41; 95% CI: 1.27-1.55; P<.001) were more likely to die from HD than those without mental disorders. Controlling for behavioral factors diminished, but did not eliminate, the impact of psychosis on mortality. Smoking (HR=1.32; 95% CI: 1.26-1.39; P<.001) and inadequate physical activity (HR=1.66; 95% CI: 1.59-1.74; P<.001) were also associated with HD-related mortality.

Conclusions: Patients with psychosis were more likely to die from HD. For reduction of HD-related mortality, early interventions that promote smoking cessation and physical activity among veterans with psychotic disorders are warranted.

Fig. 1

(A–C) Survival curves for the Cox proportional hazards models assessing HD mortality risk by mental disorder diagnosis. (A) represents the analysis controlling for sociodemographic factors (gender, age, race, education, marital status, support, financial hardship, non-VA use, living alone and service connection). (B) adds clinical factors (Charlson score, cardiovascular disease, diabetes, hypertension, hyperlipidemia, cerebrovascular disease, any hospitalization and other psychiatric diagnoses, including dementia, PTSD and substance use diagnosis). (C) adds health behaviors (smoking, alcohol use and physical activity).