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Medical and Psychological Interactions

Feb 24, 20254 min read

INTERHEART Study (EPIDEMIOLOGY, Stress & CHD)

Case control study of:
n > 29000 in 52 countries.

Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Yusef S et al. Lancet 2004

  • Percent
  • The Population attributable risk for MI %
    • Stress
    • Smoking
    • Obesity
    • Hypertension

Chronic Psychological Stress

  • Work-related stress
  • Marital/relationship discord
  • Financial crisis
  • Social isolation

Detrimental Lifestyle

  • Smoking
  • Unhealthy eating
  • Decreased exercise
  • Inadequate sleep
  • Poor medication compliance
  • Inconsistent medical follow-up

Obesity, Hypertension, Metabolic syndrome

Atherosclerosis

  • Coronary artery disease
  • Myocardial infarction, LV dysfunction

Acute Psychological Stress

  • Climate change/weather-related disasters
  • Political rancor
  • COVID

Increased Effects

  • Increased hypothalamic-pituitary-adrenocortical axis (HPA) activity
  • Increased peripheral sympathetic nervous system (SNS) activity
  • Increased sympathetic-adrenal-medullary (SAM) activity
  • Inflammation

Increased SNS Activity

  • Increased HPA activity
  • Increased SAM activity
  • Increased circulating and local catecholamines
  • Inflammation
  • Platelet activation and aggregation
  • Increased prothrombotic milieu
  • Increased oxygen demand
  • Epicardial artery vasoconstriction
  • Impaired microvascular function

Acute myocardial ischemia, Myocardial infarction, Arrhythmia

Levine GN. Psychological Stress and Heart Disease: Fact or Folklore?. The American Journal of Medicine. 2022

Global Burden of Disease Attributable to Mental and Substance Use Disorders

  • As part of the GBD 2010, epidemiological data was collected for 20 mental and substance abuse disorders in 187 countries.
  • In 2010, mental and substance use disorders accounted for 183·9 million DALYs or 7·4% of all DALYs worldwide.
  • Mental and substance abuse disorders were the leading cause of non-fatal illness worldwide in 2010 (22.8%).
  • The burden of mental and substance use disorders increased by 37·6% between 1990 and 2010.
  • Depressive disorders were responsible for 40% of the burden of illness due to mental and substance abuse disorders.

Findings from the Global Burden of Disease Study 2010 (Whiteford, The Lancet, 2013)

The Burden of Disease in Saudi Arabia 1990–2017: Results from the Global Burden of Disease Study 2017, (Lancet Planet Health, 2020)

Top causes of DALYs in Saudi Arabia for the periods 2010-2017

  1. Cardiovascular diseases
  2. Musculoskeletal disorders
  3. Transport injuries
  4. Neoplasms
  5. Neurological disorders
  6. Mental disorders
  7. Diabetes and kidney diseases
  8. Other non-communicable diseases
  9. Maternal and neonatal disorders
  10. Unintentional injuries
  11. Respiratory infections and tuberculosis
  12. Chronic respiratory disorders
  13. Digestive diseases
  14. Sense organ diseases
  15. Substance use
  16. Skin and subcutaneous diseases
  17. Enteric infections
  18. Self-harm and interpersonal violence
  19. Nutritional deficiencies
  20. Other infectious diseases
  21. HIV/AIDS and sexually transmitted infections
  22. Neglected tropical diseases and malaria
  • Years lived with disability (YLDs) in SA due to mental disorders and substance use disorders consistently increased over the periods 1990–2010 and 2010–17.
  • In 2017, low back pain, migraines, opioid use disorders, MDD, DM II, and anxiety disorders were major challenges for SA.

Likelihood of Depression Increases with Number of Physical Symptoms at Presentation

  • Depression Likelihood / Percent
    • 0-1
    • 2 to 3
    • 4 to 5
    • 6 to 8

    • 9

Kroenke K, et al. Arch Fam Med 1994

Epidemiology of Depression in Some Medical Illnesses

  • % Prevalence

    • General
    • Ischemic stroke
    • Parkinson’s Disease
    • CHD
    • Diabetes Mellitus II
    • Cancer

  • Prevalence of Depression

Depression as a Risk Factor for the Development of Medical Illness

(CANMAT, ANNALS OF CLINICAL PSYCHIATRY 2012;24(1):82-90)

  • Odds Ratio

    • 0
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6

  • CHD

  • Ischemic stroke

  • Epilepsy

  • Alzheimer’s Disease

  • Diabetes Mellitus II

  • Cancer

  • Depression as a Risk Factor

Association Between MDD and Physical Diseases According to Mendelian Randomization Studies

  • Conditions whose increased risk is unidirectionally associated with genetically predicted MDD

    • Alzheimer’s disease*
    • Asthma*
    • Breast cancer
    • Coronary artery disease
    • Epilepsy
    • Gastritis and duodenitis
    • Heart failure*
    • Menstruation disorders
    • Myocardial infarction
    • Non-infectious gastroenteritis
    • Osteoarthritis
    • Parkinson’s disease
    • Sleep disorders
    • Stroke*
    • Type 2 diabetes mellitus
    • Urinary system disorders

  • Genetically predicted conditions unidirectionally associated with increased risk of MDD

    • Atopic dermatitis*
    • Insomnia*
    • Osteoarthritis

  • Conditions with reported bidirectional associations

  • Conditions where no association was identified

    • Atrial fibrillation
    • Bladder cancer
    • Colorectal cancer
    • Glioma cancer
    • Hay fever
    • Kidney cancer
    • Lung cancer
    • Lymphoma
    • Multiple sclerosis
    • Osteoporosis
    • Ovarian cancer
    • Pancreatic cancer
    • Periodontitis
    • Prostate cancer
    • Thyroid cancer

Berk M, et al. Comorbidity between major depressive disorder and physical diseases, World Psychiatry. 2023

Pathophysiology: Mediating Factors Between Depression/Stress & Medical Illnesses

  • Physiological:

    • Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis.
    • Immune activation with release of proinflammatory cytokines.
    • Activation of the sympathetic nervous system.

  • Behavioural:

    • Physical inactivity.
    • Smoking.
    • High carbohydrate & high fat diet.
    • Poor adherence to medications.
    • Social isolation.

Environmental and Biological Factors Influencing the Comorbidity Between Major Depressive Disorder and Physical Diseases

  • Shared Environmental Risk Factors

    • Lifestyle
      • Exercise and physical activity
      • Nutrition
      • Sleep
    • Social
      • Socioeconomic disadvantage
      • Discrimination
      • Marginalization
      • Victimization
    • Stressful Life Events
      • Early life adversity
      • Stress and trauma

  • Shared Biological Pathways

    • Inflammation
    • HPA Axis
    • Gut Microbiome
    • Major Depressive Disorder
    • Somatoprogression
    • Mitochondrial Dysfunction
    • Brain Structure and Function
    • Genetics

  • Outcomes

    • Health-related Outcomes
      • Symptom severity
      • Mortality
      • Morbidity
      • Quality of life
      • Misdiagnosis
    • Treatment-related Outcomes
      • Treatment adherence
      • Polypharmacy
      • Drug-drug interaction

Berk M, et al. Comorbidity between major depressive disorder and physical diseases, World Psychiatry. 2023

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