Heart Disease Risk Following Mental Disorders

This is the second in a series looking at the recent study of physical illness in those with a diagnosis of a mental disorder.

Today, I am published a chart of the mental disorders associated with increased risk for report of heart disease at a later time.

Alcohol and drug dependence diagnoses are associated with the highest risk of later heart disease. The odds ratio estimates this increase at better two and three times higher than those without an alcohol or drug dependence diagnosis.

Two specific anxiety disorder conditions also show association with later heart disease, panic disorder and PTSD.

Additionally, bulimia nervosa and bipolar disorder also show greater rates of heart disease although these associations are at around 60% to 80% higher rates.

These associations do not prove causality. For example heart disease may share susceptibility genes with some mental disorders.

Nevertheless, these associations should prompt rigorous medical heart disease surveillance in those with substance abuse and anxiety disorders. 

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Chart is an original figure created using data from the manuscript cited below.

Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, de Girolamo G, Hu C, de Jonge P, Kawakami N, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, O'Neill S, Piazza M, Posada-Villa J, Torres Y, & Kessler RC (2015). Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries. JAMA psychiatry, 1-9 PMID: 26719969

Stroke Risk Following Mental Disorders

An important recent manuscript published in JAMA Psychiatry looked at medical illnesses rates following diagnosis of a brain (mental) disorder.

This very large international study examined over 47,000 subjects followed between 2001 and 2011.

Baseline psychiatric assessment was completed using the Composite International Diagnostic Interview. Physical illness was assessed using a self-report of physician's diagnosis.

The manuscript is not free but I was able to obtain a professional courtesy copy of the manuscript from the lead author. 

The study found that a diagnosis of a mental disorder increased rates for a variety of later physical conditions.

I have put together a graph of the mental disorders associated with higher rates of later stroke (above).

Bulimia nervosa showed a three fold increase in later stroke. I am not aware of this association previously being noted. Alcohol and drug use disorders are known to increase stroke risk and this was found in the study lending face validity support.

Additional mental disorders associated with later stroke were bipolar disorder and panic/agoraphobia. 

Bipolar disorder has been linked to higher risk of hypertension and smoking.

The implications of these findings include need for enhanced medical illness screening and risk factor reduction in those with a mental disorder diagnosis. 

I will look at some the other individual medical conditions in future posts.

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Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, de Girolamo G, Hu C, de Jonge P, Kawakami N, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, O'Neill S, Piazza M, Posada-Villa J, Torres Y, & Kessler RC (2015). Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries. JAMA psychiatry, 1-9 PMID: 26719969

Economic Distress and Suicide: Japan and U.S.

My colleagues and I are presenting a new research poster presentation this week at the 2011 American Psychiatric Association meeting in Honolulu. I wanted to use this post to summarize some of the current research related to our presentation as well as highlight the findings from our poster.

Over the last few years, I have had the opportunity to meet yearly with a group of Japanese and American researchers and psychiatrists in a retreat setting in Itasca State Park in Minnesota. This group has recently been named the Itasca Brain and Behavior Association. The goal of the group is to promote international research collaboration in clinical neuroscience and areas of psychosomatic medicine.

I learned from my Japanese colleagues last year that suicide rates in Japan increased significantly around 1998--a increase that has continued now for the last 12 years. The figure below documents the trend in suicide rates in Japan as well as the U.S.   Suicide rates increased to a larger percent in males (47%) compared to females (23%) in this period. My Japanese colleagues reported that psychological autopsy information suggested unemployment and divorce as common factors felt to be contributing to this increased rate of suicide.

Epidemiological work has now supported a link between regional unemployment in Japan and increased rates of suicides.

Japan has experience a prolonged economic malaise since 1998. Several sources have suggested the U.S. and Japanese economic cycles may be similar with the U.S. trailing the pattern in Japan by 10 to 15 years. Unemployment began increasing in Japan in 1998 and jumped dramatically in the U.S. beginning in 2008. The housing bubble in Japan peaked in 1996 and in the U.S. peaked in 2008. The possibility that the U.S. is entering a prolonged economic downturn similar to Japan raises the question of the mental health and suicide rate response. Is the U.S. vulnerable to an increased rate of suicides similar to that found in Japan? If so, what would a similar response look like and could mental health clinicians and public health officials do anything to reduce of minimize this type of risk.

Our research focused on looking at the age and gender distribution of increased rates of suicide in Japan and applying those rates to the U.S. population based on the 2010 Census. The baseline number of suicides in the U.S. average around 33,000 per year. If suicide rates were to increase to the magnitude found in Japan, the number of increased suicides in the U.S. would be about 14,000 per year. Interestingly, our model found that approximately 90% of the increased number of suicides would occur in men as men have higher baseline rates and experienced a greater increase in Japan after 1998.

A recent manuscript published in the American Journal of Public Health looked at suicide rates in relation to economic cycles between 1929 and 2007. This analysis suggested that suicide rates in the U.S. do vary with economic cycles and need to be consider in public health planning.

The presence of a primary psychiatric disorder (major depression, bipolar disorder, schizophrenia, substance dependence) is the primary determinant of risk for suicide. Our research does not predict a dramatic increase in suicide rates but rather is a warning to U.S. clinicians and public health officials. The take home messages from our collaborative research would be:

The U.S. should be alert for the potential for economic crisis and unemployment to increase risk of suicide deaths

Elevated risk for suicide related to unemployment appears highest in middle to older aged men

Adults with pre-existing mental disorders losing there job may also lose prescription benefits as well as re-imbursement for mental health services. Efforts should be made to identify these individuals and provide alternate pathways to mental health care

Employers should examine the support services provided those involved in layoffs with an effort to provide psychiatric and psychological services to these vulnerable populations

Link to Copy of APA Poster is Here.


Chang SS, Gunnell D, Sterne JA, Lu TH, & Cheng AT (2009). Was the economic crisis 1997-1998 responsible for rising suicide rates in East/Southeast Asia? A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Social science & medicine (1982), 68 (7), 1322-31 PMID: 19200631

Luo F, Florence C, Quispe-Agnoli M, Ouyang L, & Crosby A (2011). Impact of Business Cycles on US Suicide Rates, 1928-2007. American journal of public health PMID: 21493938

Stressful Live Events and Suicide

The role of stressful life events in suicide attempts and completed suicides has been a key area of study in the epidemiology of mental disorders.  Although suicidal behavior often occurs in the context of acute and chronic stressor, this does not prove a causal link.  We all could probably report serious life stressors throughout out lives and these could be interpreted as a reason for suicidal behavior.  So these associations could simply be a coincidence and not have anything to do with suicidal behavior.

A recent analysis of the WHO (World Health Organization) World Mental Health Surveys attempts to shed some light on this issue.  This study focussed on traumatic life events, a subset of life stressors that are associated with the development of PTSD.  The traumatic events studied included:

1. natural and man-made disasters
2. combat, war and refugee experiences
3. sexual and interpersonal violence
4. witnessing or perpetrating violence
5. death or trauma to a loved one

These more serious stressful life events provide a opportunity focus on events everyone would agree as significant.  The authors then looked at five lifetime categories related to suicide:

1. suicide ideation
2. suicide attempt
3. suicide planning in those with ideation
4. suicide attempt in those with a suicide plan
5. suicide attempt in those without a plan

The most common traumatic events reported by respondents across the 20 country survey included: death of a loved one (30.5%), followed by witnessing violence (21.8%), interpersonal violence (18.8%), accidents (17.7%), exposure to war (16.2%) and trauma to a loved one (12.5%).

The authors of the study perform complex analysis of the individual and cumulative effects of traumatic events.  The key findings summarized by these analyses include:

• experiencing interpersonal or sexual violence appeared to have the strongest effect on suicidal ideation and suicide attempt
• suicidal ideation and attempts had a dose-response effect with traumatic experiences--the more number of experiences, the higher the risk although this effect plateaued after experiencing about 4 events
• traumatic effects had limited effect on the progression from suicidal ideation to a suicide attempt
• effects of traumatic events occurred across low-, middle- and high income countries
• it was estimated that elimination of traumatic life events could reduce population suicide ideation by 15% and suicide attempts by 22%

The study was not able to analyze the effect on the most important variable--completed suicide.  This would add significant weight to attributing a link between traumatic life events.  Nevertheless, this study provides additional insight into stressful life events and suicide ideation and plan.  Traumatic events appear to be important although playing a relatively minor role.  Presence of a serious mental disorder, i.e. major depression, bipolar disorder, substance abuse, schizophrenia, severe personality disorder continues to be the most important risk factor for suicide.

Photo of Baby Duck in Grass Courtesy of Yates Photography

Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, Borges G, Bromet E, Bruffaerts R, de Girolamo G, Florescu S, Gureje O, He Y, Kovess-Masfety V, Levinson D, Matschinger H, Mneimneh Z, Nakamura Y, Ormel J, Posada-Villa J, Sagar R, Scott KM, Tomov T, Viana MC, Williams DR, & Nock MK (2010). Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO World Mental Health Surveys. PloS one, 5 (5) PMID: 20485530