The trauma of a heart attack is more than just physical—it’s a life-changing event that leaves many people feeling overwhelmed, depressed, and stressed out. And just how well a person manages those emotions may make a major impact on their recovery and the future of their heart health, new research shows.

An American College of Cardiology study, which is set to be presented at the organization’s 70th Annual Scientific Session later this month, evaluated the health outcomes of nearly 300 young adult and middle-aged heart attack survivors. The results showed that those with high distress levels experienced more than double the risk of another serious heart problem within five years, compared with participants with lower distress.1

Here’s what the research showed about the role of mental health in heart attack recovery, along with ways survivors can reduce their stress levels.

The Study

In a study led by Mariana Garcia, MD, a cardiology fellow at Emory University in Atlanta, a team of researchers recruited 283 heart attack survivors to figure out how their mental health may affect future cardiovascular problems.

The group consisted of adults younger than people typically are at the time of their first heart attack. They ranged in age from 18 to 61 years old, with an average age of 51.1 For comparison, the first heart attack in men tends to occur around age 66, and for women, it happens at about 72 years old, according to the American Heart Association.2

Half of the participants were women, and nearly two-thirds were Black.

Within six months of their heart attack, the survivors answered a series of questionnaires about their symptoms of anxiety, anger, depression, perceived stress, and post-traumatic stress disorder (PTSD). That allowed the researchers to determine whether participants had mild, moderate, or high distress.

The data showed that women, Black participants, those from disadvantaged socioeconomic backgrounds, smokers, and people with diabetes or high blood pressure were more likely to have high distress.

Researchers also ran blood tests on participants and found that those with high distress also tended to have increased levels of two inflammatory markers that have been linked to a build-up of plaque in the arteries and heart problems.

The researchers then tracked serious heart problems that occurred within the next five years. Eighty of the participants experienced a second heart attack, stroke, hospitalization for heart failure, or death from another cardiovascular issue.

The researchers found that 47% of the participants with high distress levels after their first heart attack experienced another major heart issue during the study period, compared with just 22% of the participants who had mild distress.1

“Psychological distress, like any distress, diverts the energy needed for healing the heart and recovering from heart attack,” explains Russell Kennedy, MD, a neuroscientist, anxiety and trauma specialist, and author of “Anxiety Rx.” “The mind and body are intimately connected, so if your mind is troubled, it makes perfect sense your body will also be at the effect of that stress.”

According to the study authors, this research is the first of its kind “to comprehensively assess how mental health influences the outlook for younger heart attack survivors.”1

The Link Between Stress and Heart Health 

More research may be needed to determine whether the high levels of distress were the direct cause of subsequent cardiovascular issues in young heart attack survivors, or whether other factors were involved, says Jennifer Wong, MD, cardiologist and medical director of non-invasive cardiology at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in Fountain Valley, California.

“These findings are similar to prior studies with older adults. However, this is an observational study and thus does not prove causation,” she says.

Dr. Wong adds: “Given that the degree of psychological distress was based on a self-reported survey, there may have been unintentional bias. For instance, participants may have reported more severe psychological distress among those with worse cardiovascular disease and higher likelihood of another cardiovascular event.”

With that said, a large body of research has found consistent links between stress and heart disease.

According to the Centers for Disease Control and Prevention (CDC), long periods of stress, anxiety, depression, and other mental health problems can take a toll on heart health.

People with those conditions may experience an increase in their heart rate and blood pressure, a boost in levels of the stress hormone cortisol, and a reduction in blood circulation to the heart. That, in turn, can often lead to heart disease and other health problems.3

“Stress interferes with hormonal pathways, leading to elevated levels of adrenaline and cortisol, higher blood pressure, faster heart rates, poorer sleep,” says Luiza Petre, MD, assistant clinical professor of cardiology at The Mount Sinai School of Medicine in New York.

Stress may also make it more difficult for people to follow through with healthy behaviors, like eating nutritious foods and exercising consistently, which may further increase their risk of heart problems.4

Reducing Stress After a Heart Attack

The latest research highlights the importance of incorporating mental healthcare and stress-reductions strategies into a heart attack recovery plan. Ideally, the healthcare system could provide interventions to improve the emotional wellbeing of heart attack survivors, says Dr. Petre.

“Screening for depression should be mandatory, as many patients suffer from [it after] their first heart attack,” she says. “For many, this might be their first health scare. From brushing with mortality to understanding one’s fragile existence, it can be a traumatic event, mostly for someone who never had medical history before.”

But there are also other ways that people can work to improve their mental health and reduce their stress levels on their own after a major heart issue. That may include meditating, gentle exercise, getting plenty of rest, and spending time in nature, experts say.

It may also be helpful to tap into external sources of support, such as a support group for heart attack survivors, or simply connecting with loved ones.

“Engaging family in the recovery process can help,” says Dr. Petre. “Emotional support is a cornerstone in the process of recovering from a heart attack.”

You don’t have to wait for a heart attack to actively try to reduce your stress levels, though. Managing your mental wellbeing and taking care of your body now can protect your heart health—and help you feel your best throughout your life.

This pandemic has meant a great deal more uncertainty for most people, which will likely have far-reaching consequences as time progresses. A recently published study in the Journal of Child Psychology and Psychiatry is particularly relevant as it found that untreated health anxiety in children and adolescents may contribute to challenges in adulthood.1

Prior to this study, no research had explored how health anxiety may continue from childhood to adolescence, which is especially relevant as individuals navigate worry regarding physical and mental health with COVID-19. While this study was conducted prior to the pandemic in Denmark, its insights may apply to many challenges Americans face with health anxiety in the U.S.

Understanding the Research

For this study, health anxiety was assessed among 1,278 children and adolescents at the ages of 11 and 16 in a general population‐based birth cohort in Denmark.1 The large sample size and longitudinal design are strengths of this research. The data on healthcare costs through public services limited bias in terms of the socioeconomic factors of participants.

Although only 1.3% of youth reported persistent challenges with health anxiety, they found it debilitating, and it resulted in the use of resources with their healthcare providers at rates that were two to three times the average.1

Given how many Americans find it difficult to afford healthcare, such persistent severe health anxiety may feel particularly overwhelming in terms of costs for adults if left untreated in childhood and adolescence.

In terms of limitations, the 5‐year period between the two data points means that it cannot be considered continuous, as assessments between the ages of 11 and 16 may have provided further insights into these trajectories whereby severe persistent health anxiety was developed, as would have reports of health anxiety from the parents of the participants and a baseline measure of their Adverse Childhood Experiences (ACE) at age 11.1

How Health Anxiety Can Develop

Clinical psychologist Dr. Diante Fuchs says, “Anxiety is a tricky state. It is supposed to be a helpful human response designed to keep us safe by alerting us to danger. Our anxiety spikes in relation to situations we need to pay attention to in order to promote our survival.”

Despite how anxiety is meant to keep folx safe, it can be triggered in response to a traumatic event, such as the illness of a loved one, which can have long-term impacts on the perception of illness for the individual.

While health anxiety may persist into adulthood, Alton Bozeman, PsyD, cautions, “The researchers’ findings did not support chronic health anxiety after controlling for other variables (17 out of 2000 kids). Per the original study, gender and somatic illness were the primary predictors. Fear of illness did not persist in the children and they did not utilize health care resources.”

With these insights in mind, it is important to take the health concerns of marginalized genders seriously, as there is a long history of reports of women’s pain being dismissed by healthcare providers with misogyny, just as transphobia often impacts the experiences of gender diverse folx.

In addition to the exacerbated healthcare costs associated with persistent severe health anxiety when left untreated, navigating such debilitating worry may make it difficult for folx to function well in their daily lives.

Getting people the care they need after a stint in the intensive care unit (ICU) is of increasing importance, given the severity of the COVID-19 pandemic. While the recovery period is known to include a range of lingering symptoms, like muscle weakness, fatigue, and pain, it may also be linked to an increased risk of suicide and self-harm, according to new research. 

A study recently published in The BMJ on May 5, 2021, looked at data on more than 3.5 million people who were admitted to the hospital and found that ICU survivors had a 22% higher risk of suicide than patients who spent time in other hospital departments. Their risk of self-harm also increased by 15% and remained elevated for years after their discharge.1

Here’s what the research shows about mental health outcomes after a stay in the ICU, along with suggestions from experts on improving care.

The Study

For the study, a team of researchers from the U.S. and Canada gathered health records on adults admitted to hospitals in Ontario through the single payer healthcare system between January 1, 2009, and December 31, 2017.

The data included information on 423,060 ICU survivors, 39% of whom were women. People in this group were about 62 years old on average. The median length of their stay in the ICU was 7 days.

The data also included records on nearly 3.1 million people who survived after being admitted to other areas of the hospital (not the ICU). This group skewed younger, with an average age of about 54 years old. Roughly two-thirds of the non-ICU survivors were women.

The ICU group tended to have higher rates of other health conditions prior to their hospitalization, compared with those who were admitted elsewhere in the hospital. Around 15% of those in the ICU had at least one mental health condition prior to their hospital stay.

Researchers then gathered information on death by suicide or hospital visits related to intentional self-harm during the time period between the participants’ discharge from the hospital and the end of the study period.

After analyzing the data, the researchers found that 0.2% of the ICU survivors died by suicide, compared with 0.1% of the non-ICU patients, in the years after they left the hospital. The results also showed that 1.3% of ICU survivors deliberately harmed themselves after their hospital stay, compared with 0.8% of people in the other group.1

“Self-injury is a coping skill we can use when we feel overwhelmed, traumatized, and don’t have other healthier ways to deal with all that’s going on. If we consider the patients in this study, we know they just experienced a life-threatening event, and while they did survive, that event is a lot to process. We can feel scared, hyper-vigilant, possibly be in physical pain as a result, and not know how to cope,” explains Kati Morton, LMFT, a licensed therapist and host of the Ask Kati Anything Podcast.

Overall, the ICU survivors experienced a 22% higher risk of suicide and a 15% higher risk of self-harm. The elevated risk of either mental health problem became prevalent immediately after the person left the hospital and continued to remain high for years.1

“The correlation is not surprising. Medical trauma is trauma and is often overlooked when discussing traumatic events that may impact a person’s mental health,” says Suzanne Galletly, NP, a psychiatric mental health nurse practitioner at the Mind Health Institute in Pasadena, California. “The trauma of being in the intensive care unit is coupled with the physical aftermath (often not regaining full pre-admission functioning) and the financial implications to create a perfect storm of anxiety, depression, and post-traumatic stress disorder (PTSD).”

The risk of suicide and self-harm tended to be highest among ICU survivors who were between 18-34 years old and/or had a pre-existing diagnosis for a mental illness (such as PTSD, depression, or schizophrenia). The risk was also higher among ICU survivors who received invasive mechanical ventilation or renal replacement therapy.1

“For a younger person, the healing journey might seem overwhelming, questioning if they will be able to get back on the track they were on before the hospitalization,” says Galletly. “When a person has a baseline of some psychiatric illness and we add the trauma and stress of a hospitalization, the system is overwhelmed. Suicide may seem like the only solution and self-harm becomes a way to alleviate some pain.”

Strengths and Limitations of the Research

While the findings offer insights into the risks people may face after leaving the ICU, more research is needed. As a data-based study, the research may be missing information on other confounding factors that may further explain the increased risk of suicide and self-harm, says Rashmi Parmar, MD, psychiatrist with Community Psychiatry.

“An ICU stay may represent just the tip of the iceberg of a person’s health concerns. There can be several other underlying risks as well as protective factors that can influence the emotional and physical wellbeing of an individual which have not been considered in this study,” she says.

The data may also be missing information on some suicide attempts and self-harm episodes, which could mean the true rates are even higher, Dr. Parmar adds.

“The actual rate of suicide and self-harm may possibly be higher than that reported in the study given the fact that they only included deaths reported from suicide and self-harm episodes that prompted hospital visits,” she says. “There is a high likelihood of self-harm and suicidal behaviors that may have failed or may not have been severe enough to require medical attention, but nevertheless have a major influence on the study outcome.”

Still, the study is bolstered by a few strengths. It used eight years worth of data, giving the authors a long period of time to evaluate. It also included a huge sample size of more than 3.5 million hospital patients in total, which helps provide a good representation of the population at large.1

Improving Care After ICU Stays

Understanding what a patient goes through after an ICU stay is crucial in improving health outcomes. Many people experience a condition called post-intensive care syndrome (PICS), which can include a range of debilitating physical, cognitive, and mental health challenges.2

While the likelihood of self-harm and suicide are overall quite low after a person leaves the ICU, taking the slightly elevated risk levels into account during follow-up care could help bring those rates down even further—an especially important task, amid the spike in ICU admissions and higher rates of suicide during the pandemic.

“Suicide is a public health emergency which warrants our attention, and it can be potentially prevented with early detection and intervention. Physicians and hospitals should be on high alert with patients admitted to hospitals, especially those with ICU stays,” says Dr. Parmar.

Galletly suggests that hospitals have social workers and discharge coordinators connect patients with mental healthcare resources, such as an appointment with a therapist.

“Post-ICU patients need to have a thorough and consistent follow-up with primary care providers who are adept at asking about mental health and then referring for specialized treatment, if deemed necessary,” she adds.

It would also help if emotional support services were as easy as physical healthcare services to get covered by health insurance policies, Morton says.

“We like to think that mental health and physical health can be treated differently, but they are inextricably linked, and need to be treated simultaneously,” she adds. “If doctors and mental health professionals can work in tandem with patients, we can help people heal both physically and mentally, and see suicide and self-injury rates go down.”

Finally, helping the patient tap into their own support network and learn about ways to access emergency support may also help people during their emotional recovery from the ICU.

“The patient should be educated about coping skills, including seeking out family and friends for support in times of crisis. Suicide prevention hotline numbers should be provided for easy access,” says Dr. Parmar. “An effort should be made to coordinate care with the patient’s family and other levels of support in the community.”