Study suggests treating anxiety and depression significantly reduces ER visits and rehospitalizations among heart disease patients

By Dr. Liji Thomas, MDMar 22 2024Reviewed by Danielle Ellis, B.Sc.

Ischemic heart disease (IHD) is a major cause of illness and death in developed countries. While advanced technology has boosted survival and rehabilitation odds, not much is known about the impact of anxiety or depression on the eventual outcomes. The prevalence of heart failure (HF) is predicted to increase by half in 2030. This will mean that eight million adults with HF, with almost $31 billion being required to treat them.

A new study looks at this area in order to provide evidence for key recommendations in the treatment of such patients.

Mental health and heart disease outcomes

Several previous studies have reported that anxiety and depression are independent risk factors for IHD and HF. Anxiety increases the incidence of IHD and HF by 41% and 35%, respectively, while increasing IHD-related mortality by 41%. Since anxiety and depression may originate in common factors, further research on their cross-linkage with cardiovascular disease and its outcomes is necessary.

Moreover, anxiety and depression both increase the odds of rehospitalizations and Emergency Department (ED) visits, pushing up healthcare costs. However, there is contradictory evidence for the benefits of treating anxiety or depression in IHD or HF, including recent trials like the SADHEART (Sertraline Antidepressant Heart Attack Randomized Trial).

Yet these mental and physical conditions reduce the quality of life, acting synergistically with the others due to their shared pathways. For instance, “coexistence of depression results in perception of symptom severity that exceed measures of actual functional impairment.”

About the study

The aim of the current study, published online in the Journal of the American Heart Association, aimed to examine the effect of treatment for anxiety or depression on the odds of repeated hospital admissions, ED visits, or mortality.

The researchers used a population-based cohort from the Ohio Medicaid database, exploring data retrospectively to assess the link between being treated for these conditions and future outcomes. All participants had ischemic heart disease (IHD) or heart failure, along with anxiety or depression.

There were ~1,500 participants, over 80% being White, with a mean age of 50 years. The upper age limit was 64 since people older than this are not eligible for Medicaid.

Treatment of anxiety and depression in the cohort

Over 92% were diagnosed with anxiety and 56% with depression. About half were disabled, a similar number had a history of substance use, and almost 60% had lung disease.

They were treated medically with antidepressant medication, or with psychotherapy, or both. About a quarter were on both courses of treatment, while ~30% were on antidepressants only and 15% on psychotherapy alone.

Anxiety was diagnosed in 90% of those on both therapies and depression in 70%. In the antidepressant group, 93% were anxious, and 53% were depressed. The corresponding figures in the psychotherapy group were similar.

The majority of those on treatment with antidepressants, alone or in combination with psychotherapy, were on benzodiazepines, antipsychotics, or mood stabilizers. Tricyclic antidepressants were used by a small proportion of patients.

About half the patients were on beta-blockers for their heart conditions, 36% on angiotensin-converting enzyme inhibitors (ACEIs), and 26% on calcium channel blockers. 

How did treatment affect outcomes?

For all outcomes except mortality from IHD, “those who received some form of mental health treatment were significantly less likely to experience the outcome than those who received no mental health treatment.”

Those who received both psychotherapy and antidepressant therapy showed the greatest benefit in all three outcomes compared to no treatment and also when compared to either therapeutic modality alone.

The group treated with both modalities was 75% less likely to require another hospitalization or ED visit. After compensating for all known confounding factors, the risk of all-cause mortality dropped by 65% compared to those not treated for their mental ill-health.

With psychotherapy alone, there was a 40% reduction in mortality from all causes. There was no significant difference in the antidepressant-only group. None of the treatments resulted in a difference in the risk of IHD mortality, perhaps because the study was underpowered to detect this effect.

ED visits were reduced with all treatments. The combination therapy group showed a reduction of 74% compared to the no-treatment group. Psychotherapy alone, or antidepressants alone, was linked to a reduction in risk by 50%.

Hospital readmissions were also lower with combined therapy, at ~75% below the no-treatment group. With psychotherapy alone or antidepressants alone, the risk was approximately 50% and 60% lower, respectively.

Future implications

“This article is the first to show that mental health treatment may be associated with reduced risk for relevant outcomes.”

The unequivocal findings indicate the need to screen heart patients for anxiety and depression. If these conditions are diagnosed, providing appropriate treatment markedly improves the risk of rehospitalization and ED visits. Strategies must be optimized to diagnose and treat anxiety and depression in this group of patients to improve their quality of life.

Sympathetic activation occurs with anxiety and depression, along with heart disease. This results in the release of pro-inflammatory cytokines, promoting the progression of all three conditions. This may explain in part why treatment of mental ill-health improves the incidence of cardiovascular events.

This marks an advance from earlier studies that focused mostly on the safety of administering such medications to patients with IHD or HF and fills this research gap. Treating anxiety and depression in heart patients not only improves their health outcomes but may significantly reduce their healthcare costs, with a positive cost-benefit ratio.