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Young adults with depression or overall poor mental health report more heart attacks, strokes and risk factors for cardiovascular disease than their peers without mental health issues, new research shows.

The findings, published recently in the , add to a large body of evidence linking cardiovascular disease risk and death with depression, but leave unanswered questions about how one may lead to the other.

"While the relationship between heart disease and depression is likely to be bidirectional, it's important to prioritize mental health among younger adults as this may be beneficial in reducing heart disease and improving overall heart health," said the study's lead author, Dr. Yaa Adoma Kwapong, a postdoctoral research fellow at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore.

Kwapong and her colleagues wanted to better understand how mental health may affect cardiovascular disease and its risk factors earlier in life. They analyzed data for 593,616 adults who were 35 years old on average and took part in the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, a self-reported nationally representative survey, between 2017 and 2020.

Survey participants reported whether they had ever been told they had a depressive disorder and the number of days they experienced poor mental health during the past month. They also reported whether they had experienced a heart attack, stroke or chest pain, a condition known as angina, or have had cardiovascular disease risk factors including high blood pressure, high cholesterol, being overweight or having obesity, smoking, diabetes, physical inactivity and not eating enough fruits and vegetables. People who had two or more of these risk factors were considered to have suboptimal cardiovascular health.

The researchers, Kwapong said, found "a particularly high prevalence of depression in this group" – 19.6%, a rate she said may be due to the overall rise in depression in 2020, the last year of the study and the first year of the COVID-19 pandemic. A different survey cited in the study found 8.4% of U.S. adults overall reported at least one major depressive episode in 2020.

The new research found that young adults who reported having depression had more than double the odds of cardiovascular disease compared to those without depression, the new research showed. For people without established cardiovascular disease, those who reported depression had 1.8 times higher odds of suboptimal cardiovascular health than those without depression.

Likewise, the greater the number of poor mental health days they reported, the more likely they were to have cardiovascular disease. Compared to people who reported no poor mental health days in the past month, those who reported up to 13 poor mental health days had 1.5 times higher odds of cardiovascular disease, while participants with two weeks to a full month of poor mental health days had double the odds.

"Clinicians need to be better at recognizing and referring patients with poor mental health for aggressive risk factor control and vice versa," said Dr. Garima Sharma, the study's senior author and an associate professor of medicine at Johns Hopkins University School of Medicine. "The COVID-19 pandemic has exposed many disparities and inequities in care, and we need more data to see the change in trends post-pandemic."

Previous research suggests at least one-fourth of people with heart conditions and a third of stroke survivors develop symptoms of depression. But whether depression leads to cardiovascular disease or cardiovascular disease leads to depression has long been a subject of investigation, said Dr. Helen Lavretsky, a professor in residence in the department of psychiatry at the University of California, Los Angeles. Both appear to be true, she said.

Depression produces greater levels of stress hormones and creates inflammation – both risk factors for cardiovascular disease, said Lavretsky, who was not involved in the new research. "And, people who are depressed don't take care of their bodies or see doctors regularly and their sleep can be disrupted," adding to heart disease and stroke risks.

In a Lavretsky coauthored, the ľ¹ÏÖ±²¥ recognized the link between psychological health and cardiovascular health and recommended health care professionals assess the mental health of people with or at risk for heart disease and stroke.

But health care professionals also need to follow up by referring patients for mental health services, Lavretsky said. "Just diagnosing depression does not help. You have to treat it."

Psychotherapy, group therapy, acupuncture, reducing stress and, if needed, medication can be used to successfully treat depression, she said.

Skills for coping with stress should be taught beginning in childhood, Lavretsky said. "You have to train them to manage their anxiety. Kids are so super anxious because they don't have the tools for self-regulation and stress reduction."

While the new study provides a snapshot of cardiovascular health among young people with depression, future studies need to look at how depression impacts cardiovascular health over time, Kwapong said.

In the meantime, she said, greater collaboration is needed between mental health professionals and those who treat people for heart disease and stroke, as well as increased screening and monitoring for heart disease in people with mental health conditions.

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