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When we think of mental health disorders like depression, anxiety, and bipolar disorder, we most often focus on the psychological symptoms, and rarely consider the idea that a mental health disorder might be associated with physical pathologies like heart disease, which can lead to premature mortality, i.e., early death.

Most of understand the mind-body connection, too. We understand that anxiety includes physical symptoms like a racing heart, trembling hands, nausea, and other uncomfortable symptoms. We also understand we can feel depression in our bodies: aches and pains can feel worse, we may have an empty sensation in the chest, and our stomach and digestive system does, at times, mirror our emotional discomfort and turbulence.

Not long ago – around Y2K – the paradigm began to shift. The mind-body connection wasn’t new, but the early ideas in the 60s and 70s took decades to gain acceptance in mainstream circles. But by the year 2000, even skeptics accepted the reality of the mind-body connection: our emotions influence our bodily sensations, and vice versa.

Now, in 2023, we’re at another point of transformation. We not only understand and accept the basics of the mind-body connection, but we also recognize the relationship between mental illness and physical pathology. We don’t fully understand this relationship – yet – but we can identify it and begin to formulate hypotheses that hint at a physical mechanism underlying these relationships.

The first step in exploring these relationships is by confirming their existence through evidence-based research on nationally representative sample sets, with rigid statistical analyses that allow us to eliminate other possible explanations – known as mediating factors – and establish the role those mediating factors play in the relationship between mental health disorders and physical disease. Of primary importance is understanding how these factors may contribute to diseases that lead to premature mortality.

Is Depression Associated With Heart Disease and Early Death?

In the study “Depressive Symptoms and Mortality Among US Adults,” published in October 2023 in the Journal of the American Medical Association (JAMA), researcher posed this question:

What is the association between depressive symptoms and death from all causes, cardiovascular disease, and ischemic heart disease?

To find an answer, they used data from a nationally representation sample collected from the National Health and Nutrition Examination Survey between 2005 and 2018, cross-referenced to data from the National Death Index for the same time period.

The total sample included 23,694 people. As we mention above, part of the challenge in establishing a connection between depression, heart disease, and death is analyzing enough data to make large-scale generalizations, and this sample set meets and exceeds the threshold. Let’s take a look at the basic information on the patients in this sample set.

Gender:

  • Male: 49.8%, Female: 50.2%

Average Age:

  • 45

Race/Ethnicity:

  • Non-Hispanic Black: 11%, Hispanic: 15%, Non-Hispanic White: 66%, Other: 8.0%

Physical Health Metrics (Mean LE-8 Score):

[ LE-8 Score developed by the American Heart Association: 0-50= low, 51-79=moderate, 80+=high, with higher scores associated with decreased risk of all-cause and cardiovascular mortality.]

  • BMI: 60.5
  • Smoking: 71.7
  • Physical Activity: 53.0
  • Hypertension: 70.7
  • Diabetes: 80.5
  • Non-HDL Cholesterol: 64.4
  • Diet: 39.3
  • Sleep: 83.4
  • Summarized Mean Scores: 65.4, moderate
  • Summarized Mean Scores by Category: 16% low, 64% moderate, 20% high

Alcohol Use:

  • None: 49%
  • Moderate: 40%
  • Heavy: 11%

We spend time sharing this basic data because part of this study examined the influence of factors other than depression on mortality, in order understand the impact of depression alone on mortality or premature mortality. Let’s look at the presence of depression in the sample set:

  • No depression: 78%
  • Mild depression: 15%
  • Moderate/Severe depression: 7%

Now let’s look at the results of the statistical examination of the relationship between depression and all-cause mortality, depression, mortality and cardiovascular disease, and depression, mortality, and ischemic heart disease.

Depressive Symptoms and Mortality: The Results

First, the research team identified the overall associations between depression, heart disease, and death by reporting hazard ratios (HRs) associated with mild or moderate/severe depression. We’ll share the data on the relationship between all-cause mortality, cardiovascular disease-related mortality, ischemic heart disease-associated mortality, and mild and moderate/severe depression.

Depression and Mortality

(by Hazard Ratio: HR of 1 means no increased risk, 1.5 means 50% increased risk, 2.0 means 100% increased risk)

All-Cause Mortality

  • Mild depression: HR 1.35, 35% increased risk
  • Moderate/Severe Depression: HR 1.62, 62% increased risk

Cardiovascular Disease Mortality

  • Mild depression: HR 1.49, 49% increased risk
  • Moderate/Severe Depression: HR 1.79, 79% increased risk

Ischemic Heart Disease Mortality

  • Mild depression: HR 0.96, 0.4% decreased risk
  • Moderate/Severe Depression: HR 2.21, 121% increased risk

Those results are clear. The statistics show increased risk of all-cause premature mortality, cardiovascular disease-related mortality, and ischemic heart disease-related mortality among patients diagnosed with mild depression and moderate/severe depression.

Next, we’ll assess the evidence on the potential mediators of these risks, to determine whether those factors increased risk, decreased risk, or explained the increased risk associated with depression alone.

Mediators: Factors – Aside from Depression – That Affected All-Cause Mortality Risk

  • Alcohol use:
    • Mild depression: 42% increased risk
    • Moderate/Severe Depression: 78% increased risk
  • Smoking:
    • Mild depression: 36% increased risk
    • Moderate/Severe Depression: 65% increased risk
  • Low Physical Activity:
    • Mild depression: 37% increased risk
    • Moderate/Severe Depression: 67% increased risk
  • Poor Diet:
    • Mild depression: 42% increased risk
    • Moderate/Severe Depression: 75% increased risk
  • High BMI:
    • Mild depression: 43% increased risk
    • Moderate/Severe Depression: 78% increased risk
  • Hypertension:
    • Mild depression: 42% increased risk
    • Moderate/Severe Depression: 80% increased risk
  • High non-LDL Cholesterol:
    • Mild depression: 43% increased risk
    • Moderate/Severe Depression: 78% increased risk
  • Diabetes:
    • Mild depression: 41% increased risk
    • Moderate/Severe Depression: 73% increased risk
  • Poor Sleep:
    • Mild depression: 38% increased risk
    • Moderate/Severe Depression: 67% increased risk
  • High Alcohol use + Low SE-8 Scores:
    • Mild depression: 37% increased risk
    • Moderate/Severe Depression: 65% increased risk

In the above data set, the factors that contributed the largest percentage of risk to premature mortality included alcohol use (3.27% of increase for mild depression/2.88% of increase for moderate/severe depression), smoking (13.67%/12.96%), low physical activity (10.95%/10.64%), poor sleep (8.32%/11.24%), and diabetes (8.32%/11.24%). In addition, researchers the combination of high alcohol use and high scores on the AHA SE-8 scales accounted for 14.17% of increased risk for people with moderate depression, and 16.08% of increased risk for people with moderate to severe depression.

Now let’s look at the of those mediating factors on mortality associated with cardiovascular disease.

Cardiovascular Disease, Depression, and Mortality

  • Alcohol use:
    • Mild depression: 57% increased risk
    • Moderate/Severe Depression: 94% increased risk
  • Smoking:
    • Mild depression: 54% increased risk
    • Moderate/Severe Depression: 89% increased risk
  • Low Physical Activity:
    • Mild depression: 51% increased risk
    • Moderate/Severe Depression: 84% increased risk
  • Poor Diet:
    • Mild depression: 56% increased risk
    • Moderate/Severe Depression: 91% increased risk
  • High BMI:
    • Mild depression: 55% increased risk
    • Moderate/Severe Depression: 90% increased risk
  • Hypertension:
    • Mild depression: 56% increased risk
    • Moderate/Severe Depression: 98% increased risk
  • High non-LDL Cholesterol:
    • Mild depression: 56% increased risk
    • Moderate/Severe Depression: 94% increased risk
  • Diabetes:
    • Mild depression: 55% increased risk
    • Moderate/Severe Depression: 89% increased risk
  • Poor Sleep:
    • Mild depression: 91% increased risk
    • Moderate/Severe Depression: 27% increased risk
  • High Alcohol use + Low SE-8 Scores:
    • Mild depression: 50% increased risk
    • Moderate/Severe Depression: 80% increased risk

In that data set, the factors that contributed the largest percentage of risk to premature mortality included smoking (4.27%/3.67%), low physical activity (8.22%/7.69%). For this cardiovascular disease related mortality, the combination of high alcohol use and high scores on the AHA SE-8 scales accounted for 10.9% of increased risk for people with moderate depression, and 11.98% of increased risk for people with moderate to severe depression.

Next, the data on the relationship between these mediating factors, ischemic heart disease, and mortality risk.

Ischemic Heart Disease, Depression, and Mortality

  • Alcohol use:
    • Mild depression: 5% increased risk
    • Moderate/Severe Depression: 151% increased risk
  • Smoking:
    • Mild depression: 0% increased risk
    • Moderate/Severe Depression: 138% increased risk
  • Low Physical Activity:
    • Mild depression: 0% increased risk
    • Moderate/Severe Depression: 135% increased risk
  • Poor Diet:
    • Mild depression: 4% increased risk
    • Moderate/Severe Depression: 148% increased risk
  • High BMI:
    • Mild depression: 5% increased risk
    • Moderate/Severe Depression: 148% increased risk
  • Hypertension:
    • Mild depression: 5% increased risk
    • Moderate/Severe Depression: 154% increased risk
  • High non-LDL Cholesterol:
    • Mild depression: 4% increased risk
    • Moderate/Severe Depression: 151% increased risk
  • Diabetes:
    • Mild depression: 4% increased risk
    • Moderate/Severe Depression: 147% increased risk
  • Poor Sleep:
    • Mild depression: 6% increased risk
    • Moderate/Severe Depression: 155% increased risk
  • High Alcohol use + Low SE-8 Scores:
    • Mild depression: 0% increased risk
    • Moderate/Severe Depression: 125% increased risk

This data shows no significant association between these mediating factors and mortality risk for people with mild depression. However, for people with moderate/severe depression, alcohol use contributed to 2.27% of increased risk of ischemic heart disease-related mortality, smoking contributed to 5.94% of increased risk of ischemic heart disease-related mortality, and low levels of physical activity contributed to 7.50% of increased risk of ischemic heart disease-related mortality. The combination of high alcohol use and high scores on the AHA SE-8 scales accounted for 14.27% of increased risk of ischemic heart disease-related mortality for people with moderate to severe depression.

Takeaways from the Data: Depression, Heart Disease, and Death

This research shows the association between depression, heart disease and death. The takeaway from the big-picture question is that mild depression increases risk of premature mortality by 35 percent, and moderate to severe depression increase risk of premature mortality by 62 percent. People with mild depression show a 49 percent increased risk of cardiovascular disease, while people with moderate to severe depression show 79% increased risk of cardiovascular disease. In addition, data showed no significant increased risk of ischemic heart disease, while people with moderate to severe depression show 121 percent increased risk of ischemic heart disease.

With regard to the impact of the American Heart Association LE-8 metrics on depression and mortality, this data is illuminating – and helpful to everyone. The evidence shows smoking, physical activity, and sleep had a significant negative impact on all-cause mortality. Physical activity, smoking, diabetes, and BMI, on the other hand, had a significant impact on cardiovascular- and ischemic heart-disease related mortality.

How We Can Use This Data: Target Your Depression Treatment

We won’t leave you with this data without offering solutions, or rather, proactive steps anyone – from treatment professionals like us to laypeople reading about depression for the first time – can take to decrease the risks we identify and discuss above.

We’ll start at the beginning: diagnosis of depression increases risk of all-cause mortality, cardiovascular disease related mortality, and ischemic heart-disease-related mortality.

What do we do with this information?

We remind everyone that evidence-based treatment for depression is effective. It can reduce symptoms to the point at which professionals consider depression to be in remission. Here are the primary treatment options for depression in 2023.

Evidence-Based Treatment for Depression

  • Psychotherapy:
    • Cognitive behavioral therapy (CBT)
    • Dialectical behavior therapy (DBT)
    • Acceptance and commitment therapy (ACT)
    • Eye movement desensitization and reprocessing (EMDR) therapy
    • Solution-focused brief therapy (SFBT)
    • Strengths-based therapy
  • Medication:
    • Antidepressants, such as selective serotonin uptake inhibitors (SSRIs)
      • Prozac
      • Zoloft
    • New medications for depression include:
      • Spravato®
      • Ketamine
    • Brain stimulation techniques:
      • Transcranial magnetic stimulation (TMS)
      • Electroconvulsive therapy (ECT)
    • Lifestyle changes:
      • Healthy eating
      • Exercise
      • Stress management
    • Complementary support:
      • Yoga
      • Meditation
      • Expressive therapies, such as music, art, dance, and writing

That’s step one. If you have depression, then, to reduce your likelihood of premature mortality associated with depression, you can engage in evidence-based treatment, which can send depression into remission, thereby decreasing mortality risk associated with depression.

But that’s not everything the data showed us. We also learned that various mediating factors from a list developed by the American Heart Association – the SE-8 Scale – can either increase or decrease risk of depression. The factors that significantly increased mortality among people with depression included:

  • Alcohol consumption
  • Smoking
  • Low levels of physical activity
  • Poor sleep
  • High BMI

Fortunately, evidence-based strategies to mitigate the risks posed by the mediating factors are well-known and well-researched. We’ll list those, beginning with alcohol.

People with Depression: How to Reduce Risk Associated with Health and Lifestyle Factors

While we’re on the topic of alcohol, we encourage everyone to read about the latest research on alcohol consumption, which indicates that many of our assumptions about alcohol consumption over the past generations have been incorrect, and we need to adjust our behavior to account for the new evidence.

Decreasing the Impact of External Factors on Depression, Heart Disease, and Early Death

Alcohol

  • Emerging evidence indicates that even drinking in levels considered moderate by the National Institute on Alcohol and Alcoholism (NIAA) – 2 drinks per day for men and 2 drink a day for women – can increase risk of cancer and some forms of cardiovascular disease.
  • Therefore, health experts advise reducing alcohol consumption as much as possible, and advise against drinking – even small amounts – every day.
  • If you have depression, reducing alcohol intake reduces risk of premature death

Smoking

  • Evidence shows smoking causes 7 million deaths worldwide, and half a million deaths in the U.S. every year.
  • Smoking increases risk of stroke, coronary heart disease, obstructive pulmonary disease (COPD), emphysema, chronic bronchitis
  • No level of cigarette smoking is safe
  • If you have depression, quitting smoking can reduce your likelihood of premature death

Physical Activity

  • Low levels of physical activity increase mortality risk for people with depression.
  • We advise patients to follow the CDC guidelines for physical activity:
    • 175 minutes of moderate aerobic exercise per week, such as walking, swimming, cycling, or jogging/running
    • 75-150 minutes of vigorous aerobic exercise per week.
    • Exercise is better spread throughout the week, rather than packed into the weekend
    • It’s important to include strength building exercises into any exercise routine, either with free weights, weight machines, or functional strength exercises like pushups, planks, or squats/squat jumps.
  • The CDC stresses that any exercise is better than no exercise.
  • People new to exercising should start where they are, do what they can, and build up to the levels recommended by the CDC.
  • New evidence shows that simply walking around half an hour a day can reduce the likelihood of developing depression

Poor Sleep

  • The study indicates that among people with depression, poor sleep increases risk of premature mortality.
  • To improve sleep, experts recommend:
    • Go to bed and get out of bed at the same time every day, including weekends
    • Make sure your bedroom is dark, quiet, and cool. Consider blackout curtains if needed.
    • Avoid working, watching TV, or hanging out on your phone in bed.
    • Turn off all electronic devices – especially communication and media devices – half an hour before bedtime
    • Create an evening routine that’s relaxing, and helps end the day and prepare you for the next
    • Avoid alcohol, tobacco, and coffee in the evening

High BMI

  • We understand BMI is an imperfect measure of health, and for various reasons, can mislead patients and providers about the actual health of an individual. However, the data in this study shows high BMI is associated with an increase risk of premature mortality among people diagnosed with depression. Therefore, we recommend that our patients with depression follow the CDC guidelines for healthy eating, which align with recommendations from the American Heath Associations for a heart healthy diet.
Note: healthy eating is also the foundation of stress management, sleep hygiene, and physical health.
  • To keep your heart healthy and BMI at a level that promotes overall health, thereby reducing premature mortality associated with depression, the CDC recommends:
    • Fresh Fruits. Consume 2-3 servings of fresh fruit per day. A serving fruit is equivalent to a medium-sized apple.
    • Fresh Vegetables. Eat 5 servings of fresh vegetables per day. One serving of fresh vegetables is about one cup of fresh or frozen vegetables
    • Whole Grains. Processed grains like plain spaghetti or white bread lack the vitamins, minerals, and nutrients in whole grains. Examples of whole grains include brown rice, wild rice, quinoa, rolled or steel-cut oatmeal, and whole wheat, oats, and popcorn. Experts advise that at least 51% of your grain intake should come from whole grains
    • Lean Protein. Health experts recommend 5 ½ ounces of lean protein every day. The healthiest sources of protein include nuts, beans, and seeds. Next, experts advise earing fish or lean beef/chicken. One ounce of protein equals about ¼ cup of cooked beans, and one cup of chicken or beef equals about 8 ounces of protein.
    • Healthy Fats/Oils. Healthy oils mean plant oils such as olive, corn, soybean, corn, safflower, and canola. Lard and butter are less healthy than liquid oils, and partially hydrogenated fats should be avoided. Nutritionists recommend no more than 3 tablespoon of healthy fat/oil every day.
    • Sugar, Salt, and Processed Foods. The advice here is simple: avoid them and/or reduce intake as much as possible. Yes, you can have sugar and salt – just not too much, and optimally, not every day. With regards to processed foods, the recommendation is that occasionally, no problem, but avoid including them as part of your regular diet.

To clarify that last point: anything with additives and preservatives is considered processed food.

Body, Mind, and Total Health

We take a holistic approach to mental health treatment. That means we also take a holistic view toward health. We concur with the World Health Organization (WHO) when they define health this way:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

When we treat our patients for depression, we want more for them than a remission of symptoms. We want that, of course – that’s our first goal – but what we really want is to help them achieve health and happiness in all life domains. That’s how this research helps us: we can share this information with our patients, and teach them how factors in each life domain may or may not contribute to their experience of depression. When they learn these lessons, it increases their likelihood of achieving full remission, and helps them on their journey to holistic, overall health and wellbeing.