Depression, Bipolar Disorder in Teens Are CVD Risk Factors: AHA

Deborah Brauser

August 10, 2015

TORONTO, ON — Both major depressive disorder (MDD) and bipolar disorder are widely prevalent in youth in the US and should be recognized as tier 2 moderate risk factors for atherosclerosis and early cardiovascular disease (CVD), according to a new American Heart Association (AHA) scientific statement[1].

This means clinicians should closely monitor all young patients with mood disorders regardless of medication use, notes the statement. It was published online August 10, 2015 in Circulation and is an update to 2011 recommendations from an AHA panel on CV health and various pediatric conditions.

The new paper outlines several "risk-stratification and management strategies" for adolescents with either MDD or bipolar disorder, which together affect more than 10% of the young population and are "at least 10 times greater than the prevalence of the existing moderate-risk conditions combined," note the authors.

"A transformational change is required in the management of MDD and [bipolar disorder] among youth to meaningfully integrate cardiovascular risk assessment and management into day-to-day treatment," write Dr Benjamin I Goldstein (University of Toronto, ON) and colleagues.

Tier 2 Status

In 2006, AHA released a scientific statement listing eight pediatric conditions linked to increased CV risk: familial hypercholesterolemia, diabetes mellitus, chronic kidney disease, heart transplant, Kawasaki disease, chronic inflammatory disease, congenital heart disease, and cancer survival—with all given tier 1 to tier 3 designations[2].

Tier 2 moderate risk status meant there was "pathophysiological evidence for arterial dysfunction indicative of accelerated atherosclerosis before 30 years of age," explain the current authors.

In 2011, AHA released the "Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents," which focused on risk stratification for the tier 2 conditions.

Based on several recent studies, adolescent mood disorders should now also be included on the list of tier 2 diagnoses, note the authors, especially because a link between CVD and depression in adults "is well known." In addition, "the association between [bipolar disorder] and CVD appears to be at least as strong."

Time for "Meaningful Change"

The new scientific statement was created by the AHA Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on [CVD] in the Young in order to raise awareness of these associations, to summarize past evidence, and to discuss new strategies "in accordance with expert panel recommendations."

Studies cited showed evidence of a link between pediatric depression and/or bipolar disorder with premature CV mortality and with endothelial dysfunction. CV risk factors for these teens, vs teens without a mood disorder, include obesity, insulin resistance and diabetes, dyslipidemia, and hypertension.

Although several mechanisms have been implicated in these associations, the authors cite inflammation, oxidative stress, and autonomic dysfunction as processes having the strongest evidence to date.

Some behavioral and environmental factors, including childhood maltreatment, sleep problems, bad nutrition, and use of tobacco and other substances, may also be contributors. However, these particular factors "do not fully explain the link between mood disorders and cardiovascular risk," write the authors. Nor did the use of mood-stabilizing medications, although many of these can cause increased weight gain and other metabolic problems.

Still, the committee members write that metabolic monitoring is crucial in these young patients, whether or not they are taking medications. Because current guidelines for both bipolar and MDD "do not adequately incorporate" CV risk factors, future guidelines should, they note.

"To meaningfully change the cardiovascular risk associated with [these] youth, a concerted effort across stakeholder groups will be required, including pediatricians and other primary-care providers, psychiatrists, patients and their families, research-funding agencies, and policy makers," they write.

Until youth-specific guidelines are developed, it's important that these groups work together to ensure that the earlier expert panel guidelines, with consideration of MDD and bipolar added in, be consistently applied to these young patients, conclude the authors.

Goldstein reports receiving research grants from the Depressive and Bipolar Disorder Alternative Treatment Foundation, the Canadian Institutes for Health Research, the Heart and Stroke Foundation, the National Institute of Mental Health, and the Ontario Mental Health Foundation. Disclosures for the coauthors are listed in the article.

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