Cardiologists Call for Collaboration on Mental Health of Patients with Cardiovascular Disease

With psychosocial stress and mental illness linked to exacerbation of cardiovascular disease (CVD) and compromised cardiovascular function a risk factor in deterioration of mental health, the European Society of Cardiology (ESC) has issued a clinical consensus statement urging collaboration with mental health professionals in treating individuals with cardiovascular disease.^1,2

“The high burden of concomitant CVD and mental health conditions requires a new integrated approach to caring for people with CVD. Cardiovascular health professionals need to develop collaborations with mental health professionals to provide guidance for practice and appropriate support for people with CVD and their caregivers,” declared ESC task force cochair and lead author Héctor Bueno, MD, PhD, of the Multidisciplinary Translational Cardiovascular Research Group, and colleagues.

The ESC clinical consensus statement is endorsed by the European Federation of Psychologists’ Associations, the European Psychiatric Association, and the International Society of Behavioral Medicine. The statement is intended for a global audience, with acknowledgement that implementing the recommended changes in models of care will require both health center- and country-specific measures.

A principal recommendation of the consensus statement is application of multidisciplinary psychocardio teams to provide “a holistic approach to health promotion and management in people with CVD and mental health conditions.” The task force envisions these teams applying measures that correspond to the acronym, ACTIVE:

1. Acknowledge the links between mental and cardiovascular health and determinants, bias, disparities and stigma associated with mental health.
2. Check for symptoms or mental health conditions at cardiovascular visits regularly and cardiovascular risk factors during mental care.
3. Tools: use validated tools to screen and diagnose mental health symptoms and conditions.
4. Implement person-centered management using shared decision-making and stepped care approaches.
5. Venture to change cardiovascular care by implementing the structural and functional changes needed to integrate mental health care within cardiovascular practice.
6. Evaluate needs for educational support and changes in management and progress in cardiovascular and mental health outcomes.

Recognizing Mental Health Conditions Occurring with CVD

The ESC task force recognizes that conditions such as depression and anxiety are often overlooked in the routine care of people with CVD, and even dismissed as normal reaction to the diagnosis. It also notes the difficulty in recognizing comorbid conditions when symptoms overlap, such as fatigue, apathy, lack of energy, and disrupted sleep manifested by heart failure or by depression.

With the high prevalence of comorbid CVD and mental health conditions, the task force recommends that obtaining clinical history from patients presenting with CVD should include inquiry about potential mental health symptoms.It recommends quick, 2-item mental health screening instruments in evaluating patients with CVD, such as the Whooley Questions, the Patient Health Questionnaire-2, and the Generalized Anxiety Disorder-2.

“Ideally, screening for anxiety and depression should be conducted following a new diagnosis of CVD or acute CV event, at least once during follow-up and periodically—eg, annually or when clinically indicated,” Bueno and colleagues advise.

Bueno and colleagues also emphasize that screening is not treatment, “but includes responsibility to address and provide referral and treatment options.”

Referral to the psychocardio team or mental health professional is recommended for CVD patients with positive initial screening and those with conditions such as depression, anxiety, post-traumatic stress disorders, and severe mental illness. The consensus statement offers a referral algorithm, which distinguishes between those in remission or with mild symptoms from those with moderate or severe mental health symptoms according to ICD-11 criteria.

The algorithm suggests referral for psychological support if patients are not receiving psychotropic therapy, and for psychiatric consultation with possible medication reassessment if the medication is associated with weight gain, diabetes, QTc prolongation, or dyslipidemia. Although the statement refers to an array of possible psychosocial treatments which may follow referral, including cognitive-behavioral therapy, mindfulness-based treatments and psychoeducation, it goes into greater detail about treatment with psychiatric medications which may interact with cardiovascular conditions and related medications.

Managing Psychiatric Medications with Comorbid CVD

The ESC task force notes inconsistent findings across studies of psychiatric medications and CVD, and calls for additional research and larger randomized clinical trials. From the available data, however, the consensus statement does identify several areas of concern.

It cautions that some antidepressants can exert weight gain, QTc prolongation, and variability of heart rate and blood pressure.In addition, it identifies several antidepressants which affect the cytochrome P450 (CYP) metabolizing enzymes to interact with such cardiovascular medications as beta-blockers and calcium channel blockers. The selective serotonin reuptake inhibitor (SSRI) antidepressant interaction with warfarin at this site is also highlighted, with advice to closely monitor those at risk for bleeding.

The task force advises against tricyclic antidepressants as well as citalopram and escitalopram for patients with ventricular arrhythmias, for increasing risk of QTc prolongation. It identifies SSRIs as relatively safe in patients with heart failure, with fewer adverse cardiovascular side such as orthostatic hypotension and tachycardia than some other classes.

Although risk of adverse effect and interaction can be mitigated by choice of antidepressant, the consensus statement suggests that antidepressants for persons with heart failure should be reserved for treatment of severe depression, "where the risk of untreated depression outweighs the risk of taking antidepressants."

Antipsychotic are also found to vary in their potential for risk in the presence of CVD, particularly in relative propensity for weight gain. The task force noted that current reports do not associate antipsychotics with increased risk of myocardial infarction or stroke (with exception of possible clozapine-associated myocarditis), despite this possibility raised in some meta-analyses.In addition, the consensus statement cites evidence that use of long-acting antipsychotic medication and second-generations antipsychotics can be protective against all-cause mortality in populations with schizophrenia.

The ESC consensus statement concludes with a call for integrating CV care models with a holistic view of health. "These should be codesigned together with people with lived experience of CVD and their caregivers, and adapted to the local conditions and availability, individual characteristics and needs," Bueno and colleagues advise.

References

1. Bueno H, Deaton C, Farrero M, et al. 2025 ESC clinical consensus statement on mental health and cardiovascular disease: developed under the auspices of the ESC Clinical Practice Guidelines Committee. Eur Hear J. 2025; 46(41):4156-4225.

2. Dimsdale JE. Psychological stress and cardiovascular disease. J Am Coll Cardiol. 2008;51(13):1237-1246.