Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1255 (Published 10 April 2019) Cite this as: BMJ 2019;365:l1255Linked Editorial
Stress, psychiatric disorders, and cardiovascular disease
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We read with great interests the paper by Huan Song and colleagues,1 which examined the associations between stress-induced disorders, including but not restricted to post-traumatic stress disorder (PTSD) as well as acute stress reaction, and the risks of cardiovascular diseases. The results strongly suggest that psychiatric disorders primarily due to acute stress are associated with several cardiovascular diseases, after adjusting for potential confounders (by both study design and modeling). In the article, the authors very well addressed the effects of “acute stressors” on the risk of cardiovascular diseases. Nonetheless, it is also relevant for the general population to understand how “chronic and stable stressors” across the lifespan may affect cardiovascular disease risks, In fact, many people are frequently exposed to increased stress during everyday social interaction with others.
Genetically, anxiety and stress-related disorders share high genetic correlations with subjective well-being (genetic correlation=-0.46) and neuroticism (genetic correlation=0.49),2 which seems to imply a common genetic basis between acute stress-induced disorders and “a general susceptibility to psychological distress”.3 People may experience depressive and anxious episodes during the lifespan and recover spontaneously or after interventions, but the intrinsic tendency to experience psychological distress may easily lead to recurrent episodic distress. The “distressed” or Type D personality was specifically defined to delineate the broad and stable tendency to experience negative emotions and to inhibit the expression of emotion and behavior. This personality profile has been shown to associate with the risk of coronary heart disease in cross-sectional studies.4 Further evidence from high-quality observational studies, like the article presented here, is undoubtedly warranted to disentangle the effects of acute distress and a chronic, general propensity to psychological distress on the risk of cardiovascular diseases.
Reference:
1. Song H, Fang F, Arnberg FK, et al. Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study. BMJ 2019;365:l1255. doi: 10.1136/bmj.l1255 [published Online First: 2019/04/12]
2. Mattheisen M. Genome-wide association study of anxiety and stress-related disorders in the iPSYCH cohort. Behav Genet 2018;48(6):494-94.
3. Denollet J, Schiffer AA, Spek V. A general propensity to psychological distress affects cardiovascular outcomes: evidence from research on the type D (distressed) personality profile. Circ Cardiovasc Qual Outcomes 2010;3(5):546-57. doi: 10.1161/CIRCOUTCOMES.109.934406 [published Online First: 2010/09/16]
4. Beutel ME, Wiltink J, Till Y, et al. Type D Personality as a Cardiovascular Risk Marker in the General Population: Results from the Gutenberg Health Study. Psychother Psychosom 2012;81(2):108-17. doi: 10.1159/000331776
Competing interests: No competing interests
An Association Between LDL-C and Cardiovascular Disease Does Not Mean Causation
The interesting finding by Song et al.1 that various types of mental stress are associated with all kinds of cardiovascular disease (CVD) raises a relevant question. Already in 1958 Friedman et al. found that mental stress results in a rise of serum cholesterol,2 and since then similar findings have been documented by other researchers.3-5 Therefore our question is whether the cause of CVD is high LDL-C or it is mental stress. The question is relevant because mental stress may increase the risk of CVD by numerous other ways6 and because in a review of 19 studies where the authors had followed elderly people for several years after having measured their LDL-cholesterol, we found that those with the highest values lived the longest.7 Our finding is not an exception; multiple observations and experiments have contradicted the idea that high lipid values are the major cause of CVD,8 not even in people with familial hypercholesterolemia.9 Our findings are obviously difficult to accept, but as Karl Popper noted: ´The growth of knowledge depends entirely on disagreement`.
1. Song H, Fang F, Arnberg FK et al. Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study. BMJ 2019;365:l1255.
2. Friedman M, Rosenman RH, Carroll V. Changes in the serum cholesterol and blood-clotting time in men subjected to cyclic variation of occupational stress. Circulation 1958;17:852-61.
3. Thomas PD, Goodwin JM, Goodwin JS. Effect of social support on stress-related changes in cholesterol level, uric acid level, and immune function in an elderly sample. Am J Psychiatry 1985;142:735-7.
4. Grundy SM, Griffin AC: Effects of periodic mental stress on serum cholesterol levels. Circulation 1959;19:496-8.
5. Muldoon MF, Bachen EA, Manuck SB et al. Acute cholesterol responses to mental stress and change in posture. Arch Intern Med 1992;152:775-80.
6. Thrall G, Lane D, Carroll D, Lip GY. A systematic review of the effects of acute psychological stress and physical activity on haemorheology, coagulation, fibrinolysis and platelet reactivity: Implications for the pathogenesis of acute coronary syndromes. Thromb Res 2007;120:819-47.
7. Ravnskov U, Diamond DM, Hama R, et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review. BMJ Open 2016;6:e010401. doi: 10.1136/bmjopen-2015-010401.
8. Ravnskov U, de Lorgeril M, Diamond DM et al. LDL-C does not cause cardiovascular disease: a comprehensive review of current literature. Exp Rev Clin Pharmacol 2018;11:959-70. doi: 10.1080/17512433.2018.1519391.
9. Ravnskov U, de Lorgeril M, Kendrick M, Diamond DM. Inborn coagulation factors are more important cardiovascular risk factors than high LDL-cholesterol in familial hypercholesterolemia. Med Hypotheses 2018;121:60-3. doi:10.1016/j.mehy.2018.09.019.
Competing interests: No competing interests
The conclusion of population based, sibling-controlled cohort study by Huan Song and colleagues is that stress related disorders are robustly associated with multiple types of cardiovascular disease, independently of familial background, history of somatic/psychiatric diseases, and psychiatric comorbidity.
However, in their study almost twice as many people exposed to stress related disorders were women (63%) while their unaffected siblings had an equal sex distribution.1
Further studies should include information on smoking, alcohol use, weight gain, use of contraceptive or HRT progestogens and/or oestrogens and the use of antidepressant or anxiolytic medications which are all known to increase the risk of cardiovascular diseases.
1 Song H, Fang F, Arnberg FK, Mataix-Cols D, et al. Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study. BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1255 (Published 10 April 2019) Cite this as: BMJ 2019;365:l1255
Competing interests: No competing interests
Re: Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study
The article about stress related disorders and their correlation with cardiovascular disease was interesting to read.
The authors mention absence of data from primary care as a limitation.
In Sweden, where the study was conducted, stress related disorders are mostly taken care of in primary care. Thus, the majority of patients with these symptoms or disorders are missed in the study.
Whether or not patients are treated in secondary care does not necessarily depend on the severity of their problems, but often it depens on whether their GPs persevere in referring despite referrals often being rejected.
Specialised surgeries for refugees with war-related psychological trauma, often PTSD, exist. They belong to primary care; PTSD is mainly regarded as a diagnosis which primary care is responsible for.
At present, primary care does not always code for diagnoses in the ICD-system, but uses for example KSH, which might make it even more difficult to have a complete register.
Foreign-born patients do not always search for help because of the stigma which can come with psychiatric illnesses. Also, psychiatry sometimes refuses these patients with the explanation that care is not possible due to language limitations and the idea that translators would impair the therapeutic relationship.
With these limitations, the calculations about correlation between stress and cardiovascular disease only show a fraction of cases and the main result of the study does not apply to stress related disorders in general.
Competing interests: No competing interests