Two recently published studies conducted by Rebecca Rossom, MD, senior research investigator at HealthPartners Institute, highlight connections between serious mental illness (SMI) and elevated risk of cardiovascular disease.
In the first study, published in the Journal of the American Heart Association, Rossom and her colleagues analyzed data from nearly 600,000 patients with and without SMI. Their research found that, for patients aged 18-59, the risk of developing heart disease over the next 30 years was significantly higher for individuals with SMI than for those without.
In the second study, recently published in JAMA Network Open, Rossom’s team discovered that patients with SMI who visited primary care clinics that used a clinical decision-support system that alerted providers of patients’ increased risk had a four percent lower heart-health risk over 12 months.
“This shows that interventions can help minimize risk among this patient population,” Rossom said. She recommends that health systems consider heart disease risk assessment among younger patients with SMI and then use interventions to reduce short and long-term risks.
Recently, I spoke to Rossom about her research, and about the intersection between mental and physical health.
MinnPost: What inspired you to work on these studies?
Rebecca Rossom: I wanted to do the first study almost right away when I got to HealthPartners, but we couldn’t get it funded. When we did the second study, we knew we were already collecting all the data, and so that work eventually opened the door for us to do the first study. It gives us evidence for why this approach is important.
MinnPost: Why did you want to do the first study as soon as you got to HealthPartners?
RR: Actually, this issue wasn’t really on my radar before then. Then, when I first got to HealthPartners, Michael Trangle MD, the senior fellow at HealthPartners Institute — he’s now retired — talked to me about why he thought this was a really important issue that people aren’t paying enough attention to. We both thought, “What can we do?”
MinnPost: Why did Trangle think this was an important project for the Institute to tackle?
RR: We are part of this large mental health research network where we can combine a lot of data and look at things like this from a larger scale. Really teasing things out requires you to study a lot of people, and we have that resource at HealthPartners. We wrote a grant for the first study a few times and could not get it funded. What I wanted was to understand with data that there really is a difference between the cardiovascular risk for people with SMI and those without SMI. I wanted to see evidence of what was driving that difference.
MinnPost: Once you finally got your funding, how did you go about your research?
RR: We looked at data from 600,000 patients. All the data from the study comes from electronic health records. At HealthPartners, we have this research tool we use called The Wizard. For the purposes of this work, we called it the Cardiovascular Wizard. For every patient that comes into primary care at HealthPartners, we run the Cardiovascular Wizard. It analyzes health data to assess an individual’s risk of developing cardiovascular disease at some point in their lifetime.
You don’t need a Wizard to see some factors that raise the risk of cardiovascular disease. A person’s weight, for instance, can put them at elevated risk for developing some health conditions. But the Cardiovascular Wizard looks at other, less obvious risk factors and can quickly let a physician know an individual patient’s cardiovascular risk depending on their age. With the Cardiovascular Wizard, it was relatively easy to look at these differences not only in these individual risk factors but also compare individual patients’ 10- and 30-year cardiovascular risk levels to people without SMI.
MinnPost: What makes your study different from other research that has looked into this issue?
RR: Most of the work that had been done with a large data set up until our study was conducted with patients with SMI who were already the hospital. Because of that, the groups tended to be sicker. These studies were also mostly done in Europe. We wanted to do this work with a healthier population of people with SMI who live in the US.
MinnPost: Your research results also stand out because they focus on cardiovascular risk for younger people. Usually doctors don’t start focusing on heart-health issues until a patient nears middle age. Why did you do it differently?
RR: Our work on the second study allowed us to collect all this data with the Cardiovascular Wizard, which helped us to identify patients’ 30-year cardiovascular risks. We hadn’t been using that kind of data before, and we realized that we could target young people with SMI. The 30-year risk equation allowed us to estimate the risk for younger patients. We could use this data in the first study.
We focused on younger people with SMI because we knew if we waited until they reached middle age, it was too late to make a significant difference in the cardiovascular risk for this population of people that die 10-20 years earlier than their peers.
MinnPost: Young people generally don’t worry much about their chances of having a heart attack or a stroke.
RR: When you are 18 you are invincible. You can’t be convinced that something can touch you. But when a health care provider shows you that your risk of having a heart attack or stroke in the next 30 years is at maybe 30 percent that may stimulate you to make some changes.
MinnPost: What kind of changes can a health care provider suggest for their higher-risk patients?
RR: Behavior is a big part of it, especially in young people and in general people with SMI. The biggest drivers of cardiovascular risk are elevated BMI and smoking. There is a fair amount of medical attention paid to both factors, but we also wanted to get clinicians to pay special attention to this connection for people with SMI. For some people, the kind of behavioral change they need is simple, like taking a statin for their lipid profile or an aspirin a day.
MinnPost: People with SMI tend to smoke more than average, too.
RR: The smoking rate for the US general population is 12.5 percent. Forty-six percent of the people with SMI in our study are current smokers. So that adds to their cardiovascular risk.
MinnPost: Your second study illustrates the health benefits of provider-led discussions about cardiovascular risk. Do you think these results will help make more physicians aware of the increased risk profile for patients with SMI?
RR: I hope so. I think at least I’m hoping it will prompt conversation in primary care clinics or behavioral health clinics. I don’t have a good sense of how much awareness or conversation there is about this connection to cardiovascular risk for people with SMI.
MinnPost: It’s interesting to me that many medical professionals aren’t aware of the increased cardiovascular health risks associated with SMI.
RR: I did not learn about this elevated risk of cardiovascular issues with SMI in medical school. That just floors me. We were told that some psychotropic medications can lead to higher lipid levels, weight gain, metabolic syndrome, but we weren’t told that SMI was associated with an increased risk of cardiovascular disease. But it is the leading cause of death for people with SMI.
I came to HealthPartners 11 years ago and honestly it was meeting Michael Trengle, and him saying, “This is an issue we should be working on,” that grabbed my attention. I now do a lot of my work on that intersection between mental health and physical health.
MinnPost: That’s an intersection that a lot of people didn’t pay attention to until just recently.
RR: We’re finally realizing that mental health and physical health are connected. They aren’t separate.
I think some of this works really well with the Make It OK program that HealthPartners has been promoting on mental health issues writ large. Different populations, especially younger people, are so much more open these days about their mental health and talking about the issues, which is fantastic.
MinnPost: Your second study looks at the benefit of health care providers alerting patients with SMI to their increased cardiovascular risks. How does that approach work in everyday interactions between health care providers and patients?
RR: At HealthPartners, when our medical records system identifies a patient with SMI with cardiovascular risk factor that is not at the goal recommended by the American Heart Association, we flag that and bring it to the attention of their clinician.
When a patient is in clinic for a visit, the rooming staff now gets a warning in the record. They print out a sheet that has suggestions for treatment so when clinicians are on their way into the room they can assess the patient’s cardiovascular risk status and prioritize their risk factors.
MinnPost: How do your physicians communicate the significance of this elevated cardiovascular risk to patients with SMI? Is it hard to explain the concept of a 10-year risk vs. 30-year risk?
RR: The physician and the patient both get that piece of paper and it becomes a shared decision-making tool. The patient gets the information and it is presented in a clear way. They can say, “My blood pressure is up. My lipids are up.” They can sit down with their doctor and take on what they are willing to change and how they want to address their cardiovascular risk. There is a lot that can be done to treat reversible cardiovascular risk.