Integrative Psychopharmacology in Practice: A Clinical Guide to Addressing Cardiovascular Risk in Psychiatric Patients

Why Psychiatrists Should Care About Cardiology

When I present this approach at conferences, I often get the same question from colleagues: “Why should I, as a psychiatrist, be ordering lipid panels and checking inflammatory markers? Isn’t that the cardiologist’s job?”

My answer: Because our patients are dying of cardiovascular disease at rates 2-3 times higher than the general population, often decades prematurely, and we’re missing opportunities to intervene.

Consider these facts:

Depression increases cardiovascular risk by 30-50%, even after controlling for traditional risk factors. This isn’t confounding. This is causation through multiple biological mechanisms.

Patients with severe mental illness die 10-20 years earlier than the general population, primarily from cardiovascular disease. Not suicide. Not accidents. Heart disease.

Major psychiatric medications (particularly second-generation antipsychotics and some mood stabilizers) significantly increase metabolic and cardiovascular risk.

We see these patients regularly, often more frequently than they see primary care. We’re ideally positioned to identify and address cardiovascular risk factors.

Current guidelines from the AHA and ACC explicitly recommend cardiovascular risk assessment and management in patients with depression and other mental health conditions.

This isn’t scope creep. This is comprehensive, evidence-based psychiatric care that acknowledges the inseparability of mental and physical health.

The Evidence Base: Why This Matters

Let me lay out the evidence that should convince any skeptical colleague.

Depression as an Independent Cardiovascular Risk Factor

The EsDEPACS Trial (JAMA, 2018):

• 300 patients post-ACS with depression randomized to escitalopram vs. placebo
• 8-year follow-up showed significantly fewer major adverse cardiac events (MACE) in the escitalopram group
• Effect was strongest in patients with more severe depression who achieved remission
• This is Level 1 evidence that treating depression reduces cardiovascular events

UK Healthcare Records Study (European Heart Journal, 2023):

• Over 600,000 patients with depression
• Those whose depression improved (with medication, therapy, or both) had 30-40% lower risk of incident CVD, CHD, stroke, and all-cause mortality
• Effect was independent of traditional risk factors
• Dose-response relationship: greater improvement in depression = greater reduction in cardiovascular risk

Multiple Meta-Analyses:

• Depression increases MI risk by 30-40%
• Depression increases stroke risk by 30-45%
• Depression increases cardiovascular mortality by 60-80%
• These effects are independent of traditional risk factors

The Biological Mechanisms Are Clear

Chronic Inflammation:

• Patients with MDD have elevated CRP, IL-6, TNF-alpha, and other inflammatory markers
• Inflammation directly promotes atherosclerosis, plaque instability, and thrombosis
• Successful treatment (medication or therapy) reduces inflammatory markers
• The CANTOS trial proved inflammation causally contributes to cardiovascular events

HPA Axis Dysregulation:

• Depression causes chronic cortisol elevation
• Cortisol promotes visceral adiposity, insulin resistance, hypertension, dyslipidemia
• Cortisol has direct effects on vascular endothelium and cardiac function

Autonomic Dysfunction:

• Reduced heart rate variability (HRV) in depression
• Low HRV independently predicts cardiovascular mortality
• Successful depression treatment improves HRV

Endothelial Dysfunction:

• Depression impairs endothelial function (measured by flow-mediated dilation)
• Endothelial dysfunction is an early marker of atherosclerosis
• Antidepressants (particularly SSRIs) improve endothelial function

Platelet Hyperreactivity:

• Depression increases platelet activation and aggregation
• Increases thrombotic risk
• SSRIs have mild antiplatelet effects

Behavioral Factors:

• Poor medication adherence (23% lower in depressed patients)
• Reduced physical activity
• Poor diet quality
• Smoking (higher rates in depression)
• Social isolation

The mechanisms are not speculative. They’re well-established and measurable.

Current Guidelines and Recommendations

This approach isn’t radical. It’s guideline-concordant care.

AHA/ACC Guidelines (2023)

The 2023 AHA/ACC Guideline for Management of Chronic Coronary Disease (CCD) explicitly addresses psychosocial factors:

Class IIa Recommendations:

• Screening for depression in all patients with CCD
• Consideration of depression treatment to improve cardiovascular outcomes
• Coordination between mental health providers and cardiologists

The Scientific Statement (Circulation, 2021) on “Psychological Health, Well-Being, and the Mind-Heart-Body Connection” provides comprehensive evidence review supporting integrated care.

Cardiometabolic Monitoring in Psychiatry

Multiple guidelines recommend metabolic and cardiovascular monitoring for patients on psychiatric medications:

ADA/APA Consensus Statement (updated regularly):

• Baseline and periodic monitoring of weight, BMI, waist circumference
• Fasting glucose and lipids at baseline and periodically
• Blood pressure monitoring

European Psychiatric Association Guidance (2024):

• Comprehensive cardiometabolic risk assessment
• Proactive intervention for identified risk factors
• Integration with primary care and cardiology

This is standard of care, not experimental medicine.

Comprehensive Assessment: What to Order and Why

Here’s my practical approach to cardiovascular risk assessment in psychiatric patients.

Who Needs Comprehensive Assessment?

High Priority:

• Any patient with depression or anxiety (given the independent cardiovascular risk)
• Family history of premature CVD (men <55, women <65)
• Personal history of cardiovascular events
• Multiple traditional risk factors (hypertension, diabetes, smoking, obesity)
• Metabolic syndrome or insulin resistance
• Chronic inflammatory conditions
• On medications increasing metabolic risk (SGAs, certain mood stabilizers)

Moderate Priority:

• All patients over 40
• Treatment-resistant depression (inflammation may be contributing)
• Significant chronic stress or trauma history

Consider for Everyone:

• At least once as part of comprehensive evaluation
• Establishes baseline, identifies hidden risk factors

The Lab Panel I Order

Standard Psychiatric Labs:

• TSH, Free T4 (consider Free T3 if subclinical hypothyroidism suspected)
• CBC with differential
• CMP (electrolytes, kidney function, liver function, glucose)
• Vitamin B12, Folate
• Vitamin D 25-OH
• Iron panel if indicated by symptoms

Advanced Cardiovascular Labs:

Lipid Assessment:

• Standard lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides)
• Lipoprotein(a) – Critical to check at least once (genetic, doesn’t change)
• Apolipoprotein B – Better marker of atherogenic particle number than LDL-C
• Consider LDL particle number and size if standard panel discordant with risk

Inflammatory Markers:

• hs-CRP – Most validated inflammatory marker for cardiovascular risk
• Consider IL-6 if hs-CRP very elevated or if research/treatment decisions warrant

Metabolic Markers:

• Hemoglobin A1c – 3-month glucose average, catches prediabetes
• Fasting insulin – Identifies insulin resistance before glucose elevates
• Fasting glucose (included in CMP)

Other:

• Homocysteine – If family history suggests, or if MTHFR variants known
• Omega-3 Index – Identifies deficiency, guides supplementation
• Consider fibrinogen, MPO, oxidized LDL if very high risk

When to Recheck:

• Inflammatory markers: 3-6 months after intervention to assess response
• Lipids: 8-12 weeks after starting lipid-lowering therapy
• Metabolic markers: 3-6 months if prediabetic or insulin resistant
• Lp(a): Once (it’s genetic and stable)

What Each Test Tells You

Lp(a) >50 mg/dL (or >125 nmol/L):

• Significantly increased CVD risk (equivalent to LDL-C >190)
• Inform patient and PCP/cardiologist
• More aggressive management of other risk factors
• Consider PCSK9 inhibitor if very high risk (reduces Lp(a) by 20-30%)
• New antisense oligonucleotide therapies showing 80-90% reduction (in trials)

hs-CRP >3.0 mg/L:

• High cardiovascular risk independent of cholesterol
• Suggests inflammation may be driving both depression and CVD risk
• Consider anti-inflammatory interventions (SSRIs, omega-3s, lifestyle)
• Investigate sources of inflammation (infections, autoimmune conditions, metabolic syndrome)

HbA1c 5.7-6.4%:

• Prediabetes – strong predictor of future diabetes and CVD
• Intensive lifestyle intervention can reverse
• Consider metformin if multiple risk factors
• Avoid or minimize metabolic-worsening psychiatric medications

Fasting insulin >10-12 μIU/mL:

• Insulin resistance (may precede HbA1c elevation by years)
• Associated with increased inflammation, CVD risk
• Lifestyle intervention, consider metformin or berberine
• Choose metabolically neutral or favorable psychiatric medications

ApoB >100 mg/dL or high LDL-P:

• High atherogenic particle number despite “normal” LDL-C
• Increased CVD risk
• More aggressive lipid management warranted

Homocysteine >10-12 μmol/L:

• Independently increases CVD risk
• Often due to B vitamin deficiencies (B12, folate, B6) or MTHFR variants
• Easily treatable with B vitamin supplementation
• Check methylmalonic acid if B12 borderline to confirm deficiency

Omega-3 Index <4%:

• Deficiency state, increased CVD risk and inflammation
• Associated with worse depression outcomes
• Supplementation (2-4g EPA+DHA daily) improves both mood and cardiovascular risk

Medication Selection: Cardiovascular Considerations

Not all antidepressants are equal regarding cardiovascular effects. Here’s how I think about medication selection.

SSRIs: The Cardiovascular-Friendly Antidepressants

Escitalopram (Lexapro):

• Strongest outcome data from EsDEPACS trial
• Reduces MACE in post-MI patients with depression
• Reduces inflammatory markers
• Generally well-tolerated
• My first choice for patients with depression + CVD risk
• Dosing: 10-20mg daily

Sertraline (Zoloft):

• Studied in SADHART trial (safe post-MI)
• Long track record of cardiovascular safety
• Also reduces inflammation
• Good alternative to escitalopram
• Dosing: 50-200mg daily

Citalopram (Celexa):

• Similar to escitalopram (escitalopram is the active enantiomer)
• Dose-dependent QT prolongation above 40mg (20mg if >60 years old or other risk factors)
• Max dose limitations in cardiac patients
• Still useful, just need to respect dose limits
• Dosing: 20-40mg daily (lower for elderly/cardiac patients)

Fluoxetine (Prozac):

• Long half-life (less withdrawal)
• More activating (can help with fatigue, may worsen anxiety)
• More drug interactions (potent CYP2D6 inhibitor)
• Safe cardiovascular profile
• Less specific CVD outcome data than escitalopram/sertraline
• Dosing: 20-60mg daily

Why SSRIs are cardiovascular-protective:

• Direct anti-inflammatory effects (reduce CRP, IL-6, TNF-alpha)
• Improve HRV
• Improve endothelial function
• Mild antiplatelet effects
• Don’t cause QT prolongation (except citalopram at high doses)
• Safe post-MI

SNRIs: Use with Caution in Hypertension

Venlafaxine, Duloxetine, Desvenlafaxine:

• Can increase blood pressure (dose-dependent)
• Monitor BP closely, especially at higher doses
• If BP increases, consider dose reduction or alternative
• Otherwise cardiovascularly safe
• May be better choice if comorbid chronic pain
• Use if SSRIs ineffective, but monitor BP

Bupropion: Generally Safe But Monitor

Bupropion (Wellbutrin):

• Can increase BP and HR in some patients (usually modest)
• No weight gain (may cause weight loss)
• No sexual side effects (major advantage)
• Safe post-MI in most patients
• Good alternative if SSRI side effects intolerable
• Monitor BP, especially at higher doses
• Dosing: 150-450mg daily (extended release formulations preferred)

Mirtazapine: Safe but Metabolically Unfavorable

Mirtazapine (Remeron):

• Cardiovascularly safe (no BP effects, no QT prolongation)
• Excellent for insomnia and anxiety
• Major disadvantage: weight gain and increased appetite
• Increases metabolic risk
• Use judiciously in metabolic syndrome or obesity
• May be good choice for underweight patient with insomnia
• Dosing: 15-45mg nightly

Tricyclics: Generally Avoid in CVD

TCAs (amitriptyline, nortriptyline, etc.):

• Anticholinergic effects
• Orthostatic hypotension
• QT prolongation
• Dangerous in overdose
• Can cause arrhythmias
• Generally avoid in patients with known CVD or significant risk factors
• If absolutely necessary (e.g., nortriptyline for neuropathic pain), use low doses with careful monitoring and ECG

MAOIs: Specialty Use Only

MAOIs:

• Hypertensive crises with tyramine
• Orthostatic hypotension
• Drug and food interactions
• Reserved for treatment-resistant depression by specialists
• Not first-line for patients with CVD concerns

Atypical Antipsychotics: High Metabolic Risk

SGAs (quetiapine, olanzapine, risperidone, etc.):

• Significant metabolic risk (weight gain, diabetes, dyslipidemia)
• Increased cardiovascular mortality in some studies
• Use judiciously for augmentation in treatment-resistant depression
• When necessary, choose lower-risk options (aripiprazole, ziprasidone, lurasidone)
• Intensive metabolic monitoring required
• Consider metformin prophylaxis if using metabolically risky SGA

The Bottom Line on Medication Selection

For patients with depression and CVD risk:

1. First choice: Escitalopram or sertraline
2. Second choice: Bupropion (if no hypertension) or another SSRI
3. Avoid: TCAs, high-dose citalopram
4. Use cautiously: SNRIs (monitor BP), mirtazapine (metabolic risk), SGAs (metabolic risk)

Consider medication as one part of comprehensive treatment, not the only intervention.

Non-Pharmacological Interventions: Essential Components

Medication alone is not enough. Evidence-based non-pharmacological interventions are critical.

Psychotherapy: Not Optional

Cognitive Behavioral Therapy (CBT):

• Reduces depression as effectively as medication for mild-moderate depression
• Reduces cardiovascular events when depression improves (UK study)
• Teaches skills that prevent relapse
• Referral should be routine, not afterthought
• 12-20 sessions typically adequate

Mindfulness-Based Cognitive Therapy (MBCT):

• Combines CBT with mindfulness practice
• Reduces relapse better than medication alone in some studies
• Improves HRV, reduces BP, lowers inflammatory markers
• Particularly good for anxious depression
• 8-week structured program

Other Evidence-Based Therapies:

• Acceptance and Commitment Therapy (ACT)
• Interpersonal Therapy (IPT)
• Behavioral Activation

The Evidence:

• Therapy + medication > either alone for moderate-severe depression
• Therapy reduces cardiovascular risk independent of medication
• Skills learned in therapy provide lasting benefit

Omega-3 Fatty Acids: The Supplement with Best Evidence

The Data:

• Reduces cardiovascular mortality by 7-15% (multiple meta-analyses)
• Reduces triglycerides 20-30%
• Anti-inflammatory effects (reduces CRP, IL-6)
• Modest antidepressant effects (especially EPA)
• Enhances antidepressant response when added to medication
• Safe, well-tolerated

Clinical Recommendations:

• Dose: 2-4 grams EPA+DHA daily (therapeutic dose, not the 300mg in grocery store fish oil)
• Higher EPA:DHA ratio may be better for depression (e.g., 2:1)
• Quality matters: third-party tested, triglyceride or phospholipid form
• Takes 2-3 months to see full effect
• Monitor with Omega-3 Index if available (target >8%)

Who Should Take It:

• All patients with depression + CVD risk (which is most of them)
• Elevated triglycerides
• High inflammatory markers
• Treatment-resistant depression (as augmentation)

This is the supplement with the strongest evidence base for both cardiovascular and psychiatric benefits.

Lifestyle Interventions: Specific, Not Generic

Exercise:

• As effective as medication for mild-moderate depression
• Reduces cardiovascular risk through multiple mechanisms
• Problem: depressed patients can’t exercise until depression improves
• Strategy: treat depression first, then add exercise as tolerated
• Even moderate intensity (walking 30 min/day) provides significant benefit
• Refer to cardiac rehab if post-MI or other cardiac event

Diet:

• Mediterranean diet has best evidence for both depression and CVD
• Reduces inflammatory markers
• Improves lipids, BP, insulin sensitivity
• Anti-inflammatory eating pattern, not restrictive diet
• Specific referral to dietitian more effective than generic advice

Sleep:

• Poor sleep increases inflammation, worsens depression, increases CVD risk
• Screen for sleep apnea (high prevalence in depression and obesity)
• Address insomnia aggressively (CBT-I, medications if needed)
• Sleep optimization is foundational, not optional

Stress Management:

• Chronic stress drives both depression and CVD
• Specific techniques: breathing exercises, progressive relaxation, mindfulness
• Heart rate variability biofeedback particularly effective
• Can teach in clinic or refer to psychologist trained in these techniques

Coordination with Other Providers

Primary Care:

• Share assessment findings
• Coordinate lipid management
• Co-manage metabolic issues
• Ensure appropriate preventive care

Cardiology:

• Refer high-risk patients for cardiovascular assessment
• Coordinate care for patients with established CVD
• Share psychiatric medication plans (some drug interactions)

Endocrinology:

• For complex metabolic issues or diabetes
• For medication-induced metabolic syndrome

Integrated care produces better outcomes than siloed care.

Practical Implementation: How to Start

Colleagues often say: “This sounds great, but I don’t have time for all this.”

Here’s how to implement this practically without doubling your appointment times.

Start Simple: Tier Your Approach

Tier 1 (All Patients):

• Screen for cardiovascular risk factors in initial evaluation
• Check basic metabolic labs (already standard of care)
• Add hs-CRP and HbA1c to your standard panel (minimal additional cost)
• Document family history of CVD
• Prescribe omega-3s liberally

Tier 2 (High-Risk Patients):

• Anyone with multiple risk factors or strong family history
• Add advanced lipid testing (including Lp(a), ApoB)
• More intensive lifestyle intervention
• Closer coordination with PCP/cardiology

Tier 3 (Very High-Risk or Treatment-Resistant):

• Comprehensive assessment with all markers
• Functional medicine-style deep dive
• Complex cases needing extensive workup

Most patients need Tier 1 or 2. Tier 3 is reserved for complex cases.

Use Standing Orders

Create a “Depression + CVD Risk” lab panel that includes:

• TSH, CBC, CMP (standard)
• HbA1c, lipid panel including Lp(a), hs-CRP (added)
• B12, Folate, Vitamin D (standard)
• Omega-3 Index (if available, helpful but optional)

Order this panel for high-risk patients at intake. Results ready by second visit.

Partner with Lab Companies

Many reference labs now offer cardiovascular risk panels that include advanced markers. Quest, LabCorp, and specialty labs like Boston Heart Diagnostics have comprehensive panels.

Price point: comprehensive panel costs $200-500 if self-pay, much less with insurance.

Use Templates

Create documentation templates that include:

• Cardiovascular risk assessment section
• Family history of CVD
• Lifestyle factors affecting both mental and cardiovascular health
• Treatment plan addressing both domains

This makes documentation efficient and ensures you don’t forget components.

Delegate When Appropriate

You don’t have to do everything:

• Medical assistants can collect family history, vital signs
• Use health coaches or care coordinators for lifestyle intervention support
• Refer to dietitians, exercise physiologists for intensive lifestyle work
• Therapists can address stress management and behavioral change

Your role: assessment, medication management, coordination, and oversight.

Educate Your Patients

Provide patient education materials explaining the heart-mind connection. When patients understand why you’re checking these labs and recommending these interventions, compliance improves dramatically.

Common Objections and How to Address Them

When presenting this approach to colleagues, I hear predictable objections. Here’s how I respond.

“That’s not my job. That’s what primary care is for.”

Response: Our patients often don’t have good primary care, see us more regularly, and we’re prescribing medications that worsen metabolic health. We have a responsibility to monitor and mitigate the risks we create. Plus, we’re treating depression, which is itself a major cardiovascular risk factor. This is comprehensive psychiatric care, not scope creep.

“I don’t have time for this.”

Response: You don’t need to do everything in every appointment. Comprehensive assessment happens once. Ongoing monitoring is minimal. Standing lab orders at intake make this efficient. And catching prediabetes or high Lp(a) early prevents future complications that will take far more time to manage.

“Insurance won’t cover these labs.”

Response: Most of these labs are increasingly covered, especially with appropriate diagnosis codes (depression, family history of CVD, metabolic syndrome, etc.). Even if some aren’t covered, the out-of-pocket cost is modest compared to the value of information. And it’s often less than patients spend on supplements of questionable benefit.

“I’m not comfortable managing cardiovascular risk.”

Response: You’re not managing it alone. You’re identifying it and coordinating with PCP/cardiology. But you should be comfortable enough to know when to be concerned and when to refer. And choosing SSRIs over TCAs is cardiovascular risk management. You’re already doing this, just not explicitly.

“The evidence isn’t strong enough.”

Response: We have Level 1 evidence from RCTs that treating depression reduces cardiovascular events. We have multiple meta-analyses showing depression independently increases CVD risk by 30-50%. We have mechanistic studies showing how depression damages the cardiovascular system. AHA/ACC guidelines recommend this approach. What more evidence do you need?

“This seems like functional medicine woo.”

Response: Everything I’m recommending is in mainstream medical literature and clinical guidelines. Advanced lipid testing is standard in cardiology. Checking inflammatory markers for cardiovascular risk has AHA support. SSRIs for depression in cardiac patients is guideline-recommended. Nothing here is alternative medicine. It’s comprehensive, evidence-based care.

Clinical Pearls and Practical Tips

Pearl 1: Lp(a) Testing is Low-Hanging Fruit

Check it once in everyone with depression + family history of CVD. It’s genetic, doesn’t change, and identifies ~20% of patients with significantly elevated risk that standard testing misses. When you find high Lp(a), you’ve identified a patient who needs aggressive risk factor management and close monitoring.

Pearl 2: hs-CRP Guides Treatment Decisions

hs-CRP >3 mg/L suggests inflammation is driving both depression and CVD risk. These patients often respond particularly well to:

• SSRIs (anti-inflammatory)
• High-dose omega-3s (anti-inflammatory)
• Anti-inflammatory diet
• Aggressive stress management

Track hs-CRP with treatment. When it drops, you know your interventions are working on a biological level.

Pearl 3: Insulin Resistance is Common and Treatable

Many depressed patients have insulin resistance even with normal glucose. Fasting insulin >10-12 μIU/mL is a red flag. Address it with:

• Metformin (off-label but effective)
• Berberine (natural supplement, similar efficacy to metformin)
• Low-glycemic diet
• Exercise
• Avoid metabolic-worsening psychiatric medications

Pearl 4: Omega-3s Should Be Your Default Supplement

This is the supplement with the strongest evidence for both depression and cardiovascular protection. Prescribe it liberally. Dose matters: 2-4g EPA+DHA daily, not the 300mg in grocery store fish oil. Quality matters: third-party tested products.

Pearl 5: Choose Your Battles with Lifestyle

Don’t overwhelm patients with “lose weight, exercise daily, eat perfectly, quit smoking, manage stress.” Prioritize:

1. Sleep (foundational for everything else)
2. Movement (even minimal increase helps)
3. Anti-inflammatory eating pattern (Mediterranean diet)
4. One stress management technique they’ll actually use

Small consistent changes beat grand plans that get abandoned.

Pearl 6: Document Cardiovascular Risk in Your Notes

When you identify cardiovascular risk factors, document them clearly. This:

• Justifies your lab orders to insurance
• Communicates risk to other providers
• Protects you legally
• Ensures continuity of care if patient sees other psychiatrists

Pearl 7: Use Depression Itself as Diagnosis Code for Advanced Testing

ICD-10 codes for depression (F32.x, F33.x) plus family history of CVD (Z82.49) or personal history of CVD (Z86.7x) justify most advanced testing. Insurance coverage is increasingly good for this work.

Pearl 8: Medication Selection Should Consider Cardiovascular Risk Profile

High CVD risk + depression = SSRI (preferably escitalopram or sertraline) Metabolic syndrome + depression = avoid mirtazapine, choose bupropion or SSRI Hypertension + depression = avoid SNRIs, choose SSRI or bupropion Post-MI + depression = escitalopram or sertraline (evidence-based)

Let cardiovascular risk profile guide psychopharmacology.

Building Your Practice Around This Model

If you want to truly integrate this approach, here’s how to structure your practice.

Intake Process

First appointment (60-90 minutes):

• Comprehensive psychiatric evaluation
• Detailed family history (psychiatric and cardiovascular)
• Cardiovascular risk assessment
• Physical exam with vital signs
• Order comprehensive labs (use standing order set)

Second appointment (30-45 minutes, ~2 weeks later):

• Review lab results in detail
• Discuss cardiovascular and metabolic findings
• Create comprehensive treatment plan
• Initiate medication if appropriate
• Provide psychotherapy referral
• Discuss supplements (omega-3s at minimum)
• Specific lifestyle recommendations

Ongoing appointments:

• First month: weekly or biweekly (titrating medication, close monitoring)
• Months 2-3: every 2-3 weeks
• Months 4-6: monthly
• Beyond 6 months: every 2-3 months once stable

Care Coordination

Establish relationships with:

• Preventive cardiologists interested in this population
• Primary care physicians who appreciate psychiatric collaboration
• Psychologists offering evidence-based therapy (CBT, MBCT)
• Dietitians who understand anti-inflammatory eating
• Exercise physiologists or cardiac rehab programs

Create a referral network of providers who understand integrated care.

Patient Education

Provide written materials:

• Explanation of heart-mind connection
• Why you’re checking these labs
• Lifestyle recommendations specific to reducing inflammation
• Supplement recommendations and dosing

Educated patients are compliant patients.

Documentation Templates

Create templates that include:

• Cardiovascular risk factor assessment
• Family history section (organized by disease)
• Current metabolic parameters
• Inflammatory markers
• Treatment plan addressing both mental and physical health

Good templates make this efficient and ensure completeness.

The Future: Where This Field is Heading

This approach will become standard of care. Here’s why I’m confident about that.

Emerging Treatments

Anti-inflammatory medications for depression:

• Trials of IL-6 inhibitors, TNF-alpha inhibitors in treatment-resistant depression
• Minocycline (antibiotic with anti-inflammatory properties) showing promise
• Celecoxib (COX-2 inhibitor) augmentation in some studies

Lp(a)-lowering therapies:

• Antisense oligonucleotides (pelacarsen) in Phase 3 trials
• siRNA therapies in development
• Expected FDA approval within 2-3 years
• Will transform management of this genetic risk factor

Precision medicine approaches:

• Inflammatory biomarkers to predict antidepressant response
• Genetic testing for cardiovascular risk (polygenic risk scores)
• Metabolomic profiling

Changing Guidelines

Future psychiatric guidelines will likely mandate:

• Cardiovascular risk screening in all patients with depression
• Metabolic monitoring as standard of care
• Coordination with primary care/cardiology
• Lifestyle intervention as first-line treatment component

We’re ahead of the curve, but the curve is moving in our direction.

Reimbursement Models

Value-based care models will reward:

• Preventing cardiovascular events in psychiatric patients
• Comprehensive assessment reducing long-term costs
• Coordination between specialties

Fee-for-service disincentivizes comprehensive care. Value-based care incentivizes exactly what we’re advocating.

Frequently Asked Questions from Clinicians

Q: What if primary care says I’m overstepping?

A: Frame it as collaboration, not competition. You’re identifying risk factors they may not have looked for, and you’re coordinating care, not replacing them. Most PCPs appreciate psychiatrists who think about physical health. Share your findings and recommendations, don’t dictate management.

Q: How do I bill for this extra time?

A: Initial evaluations: 90792 (with medical services) or 90791 (without). These codes allow 90+ minutes. Follow-ups: 99214 or 99215 for complexity/time. Document medical decision-making complexity (cardiovascular risk assessment) to justify higher-level codes. Some use prolonged service codes for longer appointments.

Q: What about liability if I miss something?

A: You’re reducing liability by being more comprehensive, not increasing it. Liability comes from not meeting standard of care. As guidelines increasingly recommend cardiovascular risk assessment in depression, not doing it becomes the liability. Document what you find and coordinate with appropriate specialists.

Q: Do patients actually comply with lifestyle recommendations?

A: More than you’d think, especially when you explain the connection between their depression and cardiovascular health. Compliance improves when:

• Recommendations are specific, not generic
• You provide written materials
• You follow up on recommendations at subsequent visits
• Depression improves enough that they have energy for change

Q: What if I don’t have time to learn all this?

A: Start simple. Add hs-CRP and Lp(a) to your standard labs. Prescribe omega-3s. Choose SSRIs for patients with CVD risk. Coordinate with PCP for management. You don’t need to become a cardiologist. You need to recognize cardiovascular risk and act on it appropriately.

Q: Is this worth it financially for my practice?

A: Comprehensive initial evaluations command higher reimbursement. Patients who get better stay with you long-term. Preventing catastrophic events (heart attacks) in your patient panel reduces overall healthcare costs and improves outcomes. In value-based care models, this is financially rewarded. Even in fee-for-service, comprehensive care builds a strong practice.

Recommended Resources for Further Learning

Key Papers to Read

1. Kim JM, et al. (2018). Effect of Escitalopram vs Placebo on Long-term Cardiac Outcomes in Patients With Acute Coronary Syndrome: EsDEPACS Trial. JAMA. 320(4):350-358.
   
2. El Baou C, et al. (2023). Psychological Therapies for Depression and Cardiovascular Risk. European Heart Journal. 44(18):1650-1662.
   
3. Levine GN, et al. (2021). Psychological Health, Well-Being, and the Mind-Heart-Body Connection: AHA Scientific Statement. Circulation. 143(10):e763-e783.
   
4. Virani SS, et al. (2023). 2023 AHA/ACC Guidelines for Chronic Coronary Disease. Journal of the American College of Cardiology. 82(9):833-955. 

Organizations and Guidelines

• American Heart Association (www.heart.org) – guidelines and scientific statements
• American College of Cardiology (www.acc.org) – guidelines and educational resources
• Academy of Integrative Health & Medicine (www.aihm.org) – integrative medicine education
• American Psychiatric Association – Practice Guidelines

Continuing Education

• Consider fellowship or certificate programs in integrative psychiatry
• Attend conferences on psychosomatic medicine or consultation-liaison psychiatry
• Journal clubs focusing on psychoneuroimmunology and cardiovascular psychiatry
• Online courses on functional medicine or integrative approaches

The Bottom Line for Clinicians

Depression is a systemic inflammatory condition that dramatically increases cardiovascular risk through multiple biological mechanisms. Treating depression effectively reduces cardiovascular events by 30-40%.

Current guidelines from the AHA and ACC recommend cardiovascular risk assessment and management in patients with depression. This is evidence-based, guideline-concordant care.

Comprehensive assessment includes advanced lipid testing (particularly Lp(a)), inflammatory markers (hs-CRP), and metabolic markers (HbA1c, fasting insulin). These tests identify hidden risk factors that standard panels miss.

Medication selection should consider cardiovascular risk profile. SSRIs (particularly escitalopram and sertraline) have the best evidence for cardiovascular protection. Evidence-based psychotherapy, omega-3 supplementation, and specific lifestyle interventions are essential components of comprehensive treatment.

This approach is practical to implement using standing lab orders, templates, and care coordination. It improves patient outcomes, reduces long-term complications, and represents the future of psychiatric care.

We have an opportunity and responsibility to address the whole health of our patients, not just their mental health symptoms. The evidence is clear. The guidelines support it. The tools are available.

The question is: will we use them? 

Implementation Checklist for Your Practice

Immediate (This Week):

• [ ] Add hs-CRP and Lp(a) to standard depression intake labs
• [ ] Create template for cardiovascular risk assessment in psychiatric evaluation
• [ ] Start prescribing omega-3s (2-4g EPA+DHA) for depressed patients

Short-term (This Month):

• [ ] Review current antidepressant prescribing patterns; default to SSRIs for patients with CVD risk
• [ ] Establish referral relationship with preventive cardiologist
• [ ] Create patient education handout on depression-heart connection
• [ ] Review and update documentation templates

Medium-term (This Quarter):

• [ ] Develop standing order set for comprehensive cardiovascular/metabolic/inflammatory labs
• [ ] Establish relationships with therapists offering evidence-based treatment (CBT, MBCT)
• [ ] Create protocol for lifestyle recommendations (specific, not generic)
• [ ] Schedule case conferences with PCP colleagues to discuss collaborative care

Long-term (This Year):

• [ ] Track outcomes: depression remission rates, cardiovascular events, metabolic parameters
• [ ] Build comprehensive integrative practice model
• [ ] Consider additional training in integrative psychiatry or functional medicine
• [ ] Publish or present on your experience implementing this approach

Conclusion

The integration of cardiovascular risk assessment and management into psychiatric practice is not optional. It’s the future of comprehensive, evidence-based psychiatric care.

Our patients with depression are dying prematurely from cardiovascular disease. We have the tools to identify their risk, the treatments to reduce it, and the evidence to support our interventions.

The question is not whether we should do this. The question is how quickly we can implement it to save lives.

The time to start is now.

About the Author

Dr. Bliss Lewis is a board-certified psychiatrist specializing in integrative medicine with particular focus on the cardiovascular implications of psychiatric conditions. She practices comprehensive assessment and treatment addressing both mental health and physical health, and teaches other clinicians to implement similar approaches in their practices.

Disclosure: No relevant financial relationships to disclose. This article represents clinical opinion based on current evidence and guidelines.