Psychosocial risk factors of mental disorders and cardiovascular disease.

Mesa Vieira, Cristina (2023). Psychosocial risk factors of mental disorders and cardiovascular disease. (Unpublished). (Dissertation, University of Bern, Faculty of Medicine and the Faculty of Human Sciences)

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Background: Cardiovascular disease (CVD) is the leading cause of morbidity and
mortality worldwide, while mental disorders are the leading cause of disability. Both
mental disorders and CVD share common behavioural, metabolic and psychosocial
risk factors (PSRFs). PSRFs, such as job strain, childhood abuse, or exposure to
traumatic events are examples of factors that can potentially trigger a stress response
and thus, are associated with both mental disorders and CVD. Evidence shows that
PSRFs lead to unhealthy behaviours, cause an inflammatory state or limit the access
to healthcare, all of which can ultimately lead to CVD. Furthermore, some mental
disorders, such as depression and anxiety are independent PSRFs for CVD. Despite
evidence of their association, post-traumatic stress disorder (PTSD) is not yet
considered an independent risk factor for CVD due to methodological limitations in
previous studies.

Aims: The overall aim of this thesis was to enhance the understanding of the PSRFs
for CVD and the association between mental disorders and CVD. In three sections,
the following evidence is provided: 1) Prevalence of major depressive disorder (MDD),
generalized anxiety disorders (GAD) and PTSD in migrants exposed to armed conflict.
2) Causal inference analysis of PTSD as risk factor for major adverse cardiovascular
events (MACE) in a South African population. 3) Screening and prevalence of PSRFs
in patients attending a cardiac rehabilitation (CR) setting. Identifying persons with
PSRFs and contributing to the evidence on the association of PTSD and CVD is crucial
for the prevention and prognosis of CVD.

Methods: In article 1, I conducted a systematic review of 34 studies accounting for 15
549 migrants. I then performed a meta-analysis to estimate the prevalence of MDD,
GAD and PTSD and used meta-regression to evaluate the association of age, time
since displacement, income classification of country of origin and host country and
intensity of the conflict with lifetime and current prevalence. For article 2, in a cohort
of 1 099 199 beneficiaries of a private health insurance provider in South Africa I
calculated the cumulative incidence of PTSD and major adverse cardiovascular events
(MACE). Then, I calculated adjusted hazard ratios (aHR) for associations between
PTSD and MACE using Cox proportional hazard models and estimated the average treatment effect of PTSD on MACE using longitudinal targeted maximum likelihood
estimation (LTMLE) (article 2). In article 3, I included 609 consecutive patients from
Swiss CARE study attending CR in Bern. I used a set of questionnaires to screen for
PSRFs and invited patients with elevated scores to attend counselling. T- and
Spearman X2- tests were performed to assess differences between patients who
participated in psychological counselling and those who did not.

Results: In the meta-analysis (article 1), I found that migrants with pre-migration
exposure to armed conflict have a high prevalence of mental disorders, being PTSD
the most prevalent one. A younger mean age and a low-income level of the host
country were associated with a higher prevalence of anxiety disorders, while a higher
intensity of the conflict of origin and a more recent displacement were associated with
a higher prevalence of MDD. In article 2, I found a higher cumulative incidence of
PTSD among women and of MACE among men with PTSD. After adjusting for
demographic characteristic and HIV, PTSD showed to increase the risk of MACE, but
the association dropped when psychiatric comorbidities were introduced in the model.
Association between PTSD and MACE were confirmed by causal inference analysis.
Article 3 shows that it is possible to screen for a wide array of PSRFs using a set of
questionnaires in the CR setting in under an hour. Type-D personality traits and vital
exhaustion are the most prevalent PSRFs, while low social support and depressive
symptoms the least prevalent. About half of the patients with elevated scores on at
least one PSRF accepted to participate in psychological counselling.

Conclusion: In this thesis, I contributed to the knowledge on PSRFs of mental
disorders and CVD. I showed that some populations, such as migrants exposed to
armed conflict, have a high prevalence of mental disorders that is associated with
sociodemographic characteristics and intensity of the conflict. Then, I provided
evidence of PTSD as a risk factor for MACE in South African beneficiaries of a private
health insurance provider. Finally, I presented an example of how to screen for PSRFs
and prevalence of PSRFs in a population attending cardiac rehabilitation (CR) in
Switzerland. Overall, mental disorders are highly associated to CVD. Therefore, they
should be targeted in strategies aiming at preventing and treatment mental disorders
and CVD.

Item Type:	Thesis (Dissertation)
Division/Institute:	04 Faculty of Medicine > Pre-clinic Human Medicine > Institute of Social and Preventive Medicine (ISPM)
Graduate School:	Graduate School for Health Sciences (GHS)
UniBE Contributor:	Mesa Vieira, Cristina, Franco Duran, Oscar Horacio, Haas, Andreas
Subjects:	600 Technology > 610 Medicine & health 300 Social sciences, sociology & anthropology > 360 Social problems & social services
Language:	English
Submitter:	Doris Kopp Heim
Date Deposited:	11 Jun 2024 14:31
Last Modified:	11 Jun 2024 14:31
Additional Information:	PhD in Health Sciences (Public Health Sciences)
URI:	https://boris.unibe.ch/id/eprint/197748