American Heart Association Scientific Statement: "Psychological Health, Well-Being, and the Mind-Heart-Body Connection" (January 2021)
Psychological health can positively or negatively impact a person’s health and risk factors for heart disease and stroke, according to “Psychological Health, Well-Being, and the Mind-Heart-Body Connection,” a new American Heart Association Scientific Statement.
The statement evaluates the relationship between psychological health and heart health, summarizing ways to help improve psychological health for people with and at risk for heart disease.
“A person’s mind, heart and body are all interconnected and interdependent in what can be termed ‘the mind-heart-body-connection,’” said Glenn N. Levine, M.D., FAHA, master clinician and professor of medicine at Baylor College of Medicine, chief of the cardiology section at the Michael E. DeBakey VA Medical Center, both in Houston, and chair of the writing committee for the Scientific Statement. “Research has clearly demonstrated that negative psychological factors, personality traits and mental health disorders can negatively impact cardiovascular health. On the other hand, studies have found positive psychological attributes are associated with lower risk of cardiovascular disease and mortality.”
Negative psychological health conditions include depression, chronic stress, anxiety, anger, pessimism and dissatisfaction with one’s current life. These conditions are associated with potentially harmful biological responses, such as:
Negative psychological health is also associated with health behaviors that are linked to an increased risk for heart disease and stroke, such as smoking, lower levels of physical activity, unhealthy diet, being overweight and not taking medications as prescribed.
Due to evidence that connects negative psychological health to heart disease, the statement suggests regular mental health screening for people with or at risk for cardiovascular disease. The authors note that psychological therapy and mind-body programs can lead to better cardiovascular health. Programs that improve psychological health include cognitive behavioral therapy, psychotherapy, collaborative care management approaches, stress reduction therapy and meditation.
The Statement highlights research showing that both the cumulative effect of daily stressors and exposure to traumatic events can also increase the risk of heart disease and stroke. Patients’ self-report of general stress as well as work-related stress have been associated with an up to 40% increased risk of developing or dying from heart disease.
“Most studies of psychological health are observational, with many involving self-reporting from patients, which presents challenges to establishing specific cause and effect relationships,” said Levine. “However, a preponderance of such studies is highly suggestive and allows one to make reasonable conclusions about an association between negative psychological health and cardiovascular risk.”
On the other hand, studies have found positive psychological health associated with a lower risk of cardiovascular disease and death. Positive psychological health characteristics include happiness, optimism, gratitude, sense of purpose, life satisfaction and mindfulness.
“The data is consistent, suggesting that positive psychological traits play a part in better cardiovascular health,” said Levine.
People with positive psychological health were also more likely to have health factors linked to a lower risk of developing cardiovascular disease:
Positive psychological health is also associated with beneficial health behaviors such as smoking cessation, increased physical activity, heart-healthy eating, increased medication adherence and regular check-ups and health screenings.
Also, said Levine, social factors may further influence cardiovascular health. People with better mental health tend to have positive social relationships, support and connections, which can facilitate healthier adaptation to life’s challenges.
Levine adds, “Wellness is more than simply the absence of disease. It is an active process directed toward a healthier, happier and more fulfilling life, and we must strive to reduce negative aspects of psychological health and promote an overall positive and healthy state of being. In patients with or at risk for heart disease, health care professionals need to address the mental wellness of the patient in tandem with the physical conditions affecting the body, such as blood pressure, cholesterol levels, chest pain, etc.”
This Scientific Statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Council on Clinical Cardiology; the Council on Arteriosclerosis, Thrombosis and Vascular Biology; the Council on Cardiovascular and Stroke Nursing; and the Council on Lifestyle and Metabolic Health.
Co-authors are Beth E. Cohen, M.D., M.A.S.; Yvonne Commodore-Mensah, Ph.D., M.H.S., R.N.; Julie Fleury, B.S.N., M.S., Ph.D.; Jeff Huffman, M.D.; Mirza U. Khalid, M.D.; Darwin R. Labarthe, M.D., M.P.H., Ph.D., FAHA; Helen Lavretsky, M.D.; Erin D. Michos, M.D., M.H.S.; Erica S. Spatz, M.D., M.H.S.; and Laura D. Kubzansky, Ph.D., M.P.H. Author disclosures are in the manuscript.
Quotes from the Statement
"The World Health Organization defines mental health as “a state of well-being in which an individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Negative psychological health encompasses depression, chronic stress, anxiety, anger, pessimism, and dissatisfaction with one’s current life. Positive psychological health is also multifaceted and may be characterized by a sense of optimism, sense of purpose, gratitude, resilience, positive affect (ie, positive emotion), and happiness."
"There is no single universal definition of positive psychological health. For the purposes of this scientific statement, positive psychological health includes the presence of positive psychological factors such as happiness, optimism, gratitude, sense of purpose, life satisfaction, eudaimonic (virtuous) well-being, and mindfulness."
"Optimism is characterized by having a sense of hopefulness and confidence that things will work out well in the future and anticipating the best possible outcomes. Multiple studies have found that optimism is associated with healthier behaviors such as more physical activity, not smoking, healthy diet score, better sleep quality, and higher composite cardiovascular health scores. An optimistic frame of mind has been shown to be associated with healthy aging and a lower risk of CVD, including stroke and heart failure, and a lower risk of all-cause mortality.
"One study found that women with higher optimism scores experienced slower progression of atherosclerosis in their carotid arteries. A recent meta-analysis that included 15 observational studies and 220391 individuals found that higher levels of optimism were associated with a 35% decreased risk of incident CVD events (RR, 0.65 [95% CI, 0.51–0.78]) and a 14% decreased risk of all-cause mortality (RR, 0.86 [95% CI, 0.80–0.92]). This association was seen for both men and women and remained significant after adjustment for depression. Of note, this degree of association for optimism was similar to that of traditional CVD risk factors. In 2 epidemiological cohorts of men and women, more optimistic individuals had an ≈10% longer life span and a greater adjusted odds of surviving to ≥85 years of age (OR, 1.5 for women and 1.7 for men).
"In individuals with established CVD, optimism has similarly been linked to more favorable cardiovascular outcomes. In the GRACE study (Gratitude Research in Acute Coronary Events), which assessed degree of optimism in 164 patients with ACS and then followed up these individuals for 6 months, higher optimism was associated with decreased risk of hospital cardiac readmissions (HR, 0.92 [95% CI, 0.86–0.98])."
"Similar to optimistic adults, adults with a greater sense of purpose have more favorable lifestyle and cardiovascular risk factors such as less smoking,70 more physical activity,30 less alcohol and substance abuse, and better glucose control."
"Psychological factors may influence cardiovascular health through direct biological alterations, through indirect effects on behaviors that influence cardiac health, and by promoting or impairing psychosocial resources that protect health or buffer detrimental effects of stressful experiences. Studies have considered a broad array of psychological factors, including negative emotional states (eg, anger, anxiety, depression, general distress) and perceived stress, as well as positive emotions (eg, happiness) and other facets of psychological health (eg, optimism, purpose, life satisfaction). Although some pathways are shared across negative and positive psychological factors,11,53,77,94,95 specific manifestations of psychological health may also have distinct biobehavioral effects. Some studies demonstrate associations of depression with higher concentrations of low-density and very-low-density lipoprotein cholesterols, whereas higher psychological health has been linked to elevated high-density lipoprotein cholesterol levels only. Furthermore, pathways linking psychological factors and CVD may differ depending on whether the population under study is healthy or already has CVD. For example, in healthy populations, preventive screening may serve as a mediator of outcomes, whereas in populations with established CVD, medication adherence is a plausible mechanism."
"Positive psychology–based programs use systematic activities (using personal strengths, recalling positive life events) to improve psychological attributes and experiences (optimism, positive affect) that have been linked to superior cardiac outcomes. Several such programs, either alone or combined with motivational interviewing, have focused on the promotion of physical activity in patients with cardiac disease or cardiac risk conditions in randomized studies, with a majority, but not all, of such studies finding positive psychology–based interventions to be associated with greater improvements in physical activity compared with control conditions. Effects of such programs on cardiac biomarkers (eg, inflammatory markers, heart rate variability) or other disease markers have been mixed, with some observed effects on markers of inflammation in small trials in patients with heart failure or coronary artery disease, modest effects on glycosylated hemoglobin in small studies in diabetes, but minimal effects on other markers. Likewise, a pair of larger studies implementing a positive psychology–based program found no intervention effect on blood pressure at 1 year."
"brief questions about optimism, motivation, and positive affect and their impact on self management, initiated by front-line staff, can lead to important discussions during a clinical encounter."
"Although many studies have examined relationships between general well-being and cardiac health, inquiries about health-related optimism or gratitude flow much more easily in a clinical encounter, and such constructs have been linked to better recovery in cardiac patients."
"Sample statements to support optimism “I have taken care of many patients with this kind of heart problem before, and many of them have done very well. I think you can, too.”
Dr. Jeff Huffman, director of the cardiac psychiatry research program at Massachusetts General Hospital and Harvard Medical School
"An important part of the AHA statement is that it focuses also on the importance of positive psychological well-being, feeling more optimistic, grateful or happy, and how these states actually have protective effects. People who are more optimistic or grateful have superior cardiac outcomes."
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