Temporal trends in associations between severe mental illness and risk of cardiovascular disease: A systematic review and meta-analysis

Abstract

Background Severe mental illness (SMI; schizophrenia, bipolar disorders (BDs), and other nonorganic psychoses) is associated with increased risk of cardiovascular disease (CVD) and CVD-related mortality. To date, no systematic review has investigated changes in population level CVD-related mortality over calendar time. It is unclear if this relationship has changed over time in higher-income countries with changing treatments. Methods and findings To address this gap, a systematic review was conducted, to assess the association between SMI and CVD including temporal change. Seven databases were searched (last: November 30, 2021) for cohort or case–control studies lasting ≥1 year, comparing frequency of CVD mortality or incidence in high-income countries between people with versus without SMI. No language restrictions were applied. Random effects meta-analyses were conducted to compute pooled hazard ratios (HRs) and rate ratios, pooled standardised mortality ratios (SMRs), pooled odds ratios (ORs), and pooled risk ratios (RRs) of CVD in those with versus without SMI. Temporal trends were explored by decade. Subgroup analyses by age, sex, setting, world region, and study quality (Newcastle–Ottawa scale (NOS) score) were conducted. The narrative synthesis included 108 studies, and the quantitative synthesis 59 mortality studies (with (≥1,841,356 cases and 29,321,409 controls) and 28 incidence studies (≥401,909 cases and 14,372,146 controls). The risk of CVD-related mortality for people with SMI was higher than controls across most comparisons, except for total CVD-related mortality for BD and cerebrovascular accident (CVA) for mixed SMI. Estimated risks were larger for schizophrenia than BD. Pooled results ranged from SMR = 1.55 (95% confidence interval (CI): 1.33 to 1.81, p Conclusions In this study, we found that SMI was associated with an approximate doubling in the rate ratio of CVD-related mortality, particularly since the 1990s, and in younger groups. SMI was also associated with increased incidence of CVA and CHD relative to control participants since the 1990s. More research is needed to clarify the association between SMI and CHD and ways to mitigate this risk. Amanda Lambert and co-workers study associations between severe mental illness and cardiovascular disease outcomes over time. Author summary Why was this study done? Previous research has identified higher incidence and mortality from cardiovascular disease (CVD) in people with severe mental illness (SMI) than those without SMI. It is not known whether the gap has changed over time. What did the researchers do and find? We conducted a comprehensive systematic review and meta-analysis of 108 cohort and case–control studies, including over 30 million participants. Compared to the general population, people with SMI, particularly schizophrenia, generally had higher levels of cardiovascular-related mortality and a higher incidence of CVD. For schizophrenia and bipolar disorder (BD), the rate ratios for coronary heart disease (CHD) mortality and cardiovascular mortality were larger in the 1990s and 2000s than in earlier studies, and the rate ratios were larger in younger people. What do these findings mean? We confirmed a strong association between SMI and incidence of and mortality from CVD. This association became stronger in the 1990s and 2000s.