Mental Health and Arrhythmia Care: Insights From the ESC Consensus

Interview With Christi Deaton

© 2025 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates. 

EP LAB DIGEST. 2025;25(12):22.

Interview by Jodie Elrod

The 2025 European Society of Cardiology (ESC) Clinical Consensus Statement on Mental Health and Cardiovascular Disease calls for a rethinking of how cardiovascular care and mental health care intersect. To explore the implications for arrhythmia care, EP Lab Digest sat down with Professor Christi Deaton, one of the co-chairs of the consensus statement, to discuss the concept of the “Psycho-Cardio” team, the management of severe mental illness, and the pressing gaps that remain.

This is the first ESC Clinical Consensus Statement on mental health and cardiovascular disease developed under the auspices of the ESC Clinical Practice Guidelines Committee. Could you share the background on how and why this document was initiated, and what gaps or unmet needs it was designed to address within cardiovascular practice?

The Clinical Practice Guidelines Committee made the decision to develop this consensus statement to increase awareness of the interaction between mental health and cardiovascular disease. There is growing emphasis being placed on integrated and holistic management, and there is a clear need to better understand this relationship, including the risk factors and how they increase risk for one another. Although we do not yet have sufficient evidence to develop formal guidelines, we hope this statement will stimulate much-needed research and encourage the implementation and testing of some of the suggestions in the consensus statement to see if improvements can be made in patient care. The issue is too important to ignore.

The consensus statement emphasizes the importance of collaboration between cardiovascular and mental health professionals. What practical first steps can cardiac electrophysiology (EP) teams take to build meaningful partnerships with mental health professionals to better support patients with arrhythmias and their caregivers?

Yes, we generally operate through multidisciplinary teams. While these may not always be people you meet with regularly, these multidisciplinary teams usually include a broad group of primary care providers, social workers, nurses, and physiologists. The key is to add a psychological or mental health professional. The first step is finding out what resources are available in your area, which will vary depending on the service or system, and may include psychologists or psychiatrists based in the community or within the hospital team, sometimes interacting with other groups. In hospitals that perform heart transplants or use left ventricular assist devices, psychological support is usually part of care. What can we learn from those groups? With growing emphasis on integrated, multidisciplinary management—highlighted, for example, in the 2024 ESC Guidelines for the Management of Atrial Fibrillation (AF), there was considerable discussion about including psychologists as part of the wider team.

We know that lifestyle, along with the management of comorbidities and risk factors, is incredibly important to treatment success. Mental health represents another comorbid condition that must be identified, acknowledged, and managed. The first step is to determine who in your system is a mental health professional you can collaborate with. Talk with them about what can be done, and the best approaches for screening, referral, and patient management.

The document introduces the idea of a multidisciplinary “Psycho-Cardio” team. What would an ideal Psycho-Cardio team look like in an EP setting, and what are some of the ways that mental health screening can be integrated into routine arrhythmia care without overwhelming clinic workflows?

We gave this careful thought and found a pragmatic approach. The Psycho-Cardio team is about having a collaborative relationship with a mental health professional, who can become part of your regular multidisciplinary team meetings. 

For screening, the initial steps involve simple tools that take only a minute to complete: the 2-item Generalized Anxiety Disorder (GAD)-2 questionnaire and the Patient Health Questionnaire (PHQ)-2. These require minimal time and can be given to patients at reception when they arrive for a clinic visit. Screening can be performed by any member of the Psycho-Cardio team—whether that is a nurse, physiologist, or another staff member with interest in taking this forward.

Many systems are also beginning to use electronic questionnaires as part of clinic visits, and screening can be incorporated into that process. If the initial screen is positive, a more comprehensive validated tool should be used, such as the GAD-7 or PHQ-9. They do not take a long time. If we do identify an issue, we must respond and manage it. It might be a mild, normal reaction to a new diagnosis or cardiac event, but it is essential to have a plan in place. That is where collaboration with a mental health professional can be particularly helpful. 

What options are available for our patients? Initial screening does not have to take long, nor does it need to be conducted by the electrophysiologist or cardiologist—it can be performed by any part of the team. The key is to incorporate screening, whether through an electronic questionnaire sent ahead of time or completed at the visit. For example, when I go to the dentist, I must complete a questionnaire before my teeth are checked, and I think patients are beginning to expect this approach. While it may not work for everyone, a growing number of patients are comfortable completing these forms on their smartphones, so it is a practical option for many.

Sex and gender influence both mental health and cardiovascular outcomes. How should EP clinicians adapt their approach when addressing anxiety, depression, or stress in men versus women with arrhythmias, and what role can gender-sensitive screening and treatment play in improving rhythm control and quality of life?

We know that prevalence is higher among women, and in some conditions, rates of depression or anxiety are twice as high in women compared to men. There may be several reasons for this, and we must be aware of the stressors that women may experience that are different from men. For example, a young woman may not consider heart disease as something to worry about, while an older woman may face multiple comorbid conditions but not have a lot of support. So, being aware of these issues is important. Some of the difference may also reflect underreporting in men, underscoring the need to make conversations about mental health more acceptable, emphasizing that it is not shameful to feel depressed or anxious about AF or other arrhythmias.

It begins with communication. Whether the patient is a man, woman, or transgender, acceptance and openness are key to making it clear that it is okay to talk about these concerns. Patients may assume their cardiologist is only focused on heart rhythm, but when a team creates an environment where it feels acceptable to say, “I know you are telling me this is under control, but I am still very anxious,” that communication becomes vital. If a patient is hesitant to share their feelings, it may be necessary to speak with a caregiver or family member who can provide insight—for example, noting if the patient appears anxious, depressed, or is not eating or sleeping.

Meta-analyses have shown that depression increases the risk of new-onset and recurrent AF, that 38% of people with AF meet Beck Depression Inventory criteria for significant depression, and depressive symptoms are independently associated with an increased risk of AF recurrence after ablation. How should EP teams respond to these findings? In particular, how can screening for depression and targeted psychosocial interventions be meaningfully integrated into AF management pathways to reduce recurrence?

It goes back to the importance of not only managing the arrhythmia but also having a more integrated approach to the AF patient and their follow-up care. AF management can be complex, and whether patients undergo ablation or receive medical therapy, there is a need for ongoing follow-up. A multidisciplinary approach aligns with the AF care model in the 2024 ESC guidelines, which emphasize the management of comorbid conditions, including depression and anxiety. This concept is not entirely new, but historically the focus has been on more physical aspects such as diabetes and lifestyle measures, with less attention on depression and anxiety. We would never think of not measuring kidney function or electrolytes. This is a potent risk factor and important comorbidity, so we should be screening in the same way that we would check a patient’s blood glucose or lipid levels for treatment. It requires a shift in thinking, acknowledging the impact on prognosis and on adherence to treatment.

That is a significant part of the effect. It makes sense, then, to include this as part of patient management—whether through integrated care, rehabilitation, or lifestyle measures. We have suggested pragmatic processes that involve collaboration with mental health professionals in a stepped-care approach. It depends on the patient's severity, local resources, available services, initial screening followed by more comprehensive assessment, patient preferences, and referral to a mental health professional if needed. These steps can be incorporated if we are mindful of available services and resources. The challenge is that we lack strong evidence on what works best.

We have made decisions based on the expertise of the task force and the available evidence, but the challenge now lies with EP teams to test these approaches or conduct research that will provide the evidence needed to change clinical practice. There are small steps that can be taken immediately, but broader implementation will take time. As much as we would like to see these strategies implemented and tested in practice, we also need research to inform future guidelines on how best to proceed.

The consensus highlights the challenges of managing cardiovascular disease in people with severe mental illness. For patients with conditions such as schizophrenia or bipolar disorder who also suffer from arrhythmias, what are the unique risks EP specialists should anticipate, and how can care be better coordinated to balance arrhythmia management with psychiatric treatment?

This was a particularly important section, as there is not enough cardiovascular risk assessment in patients with severe mental illness, leaving them at very high risk. Many antipsychotic drugs have metabolic effects, are arrhythmogenic, and can prolong the QT interval. We included detailed information on specific drugs as well as an algorithm for managing patients with increasing QT intervals, offering practical suggestions. In general, patients should be managed according to established guidelines for that particular arrhythmia, but for patients with severe mental illness, it is essential to also consider the antipsychotic medication they are taking.

Some of the older antipsychotic drugs are more arrhythmogenic than many of the newer ones, so it is essential to discuss risk-benefit considerations with a psychiatrist. If a drug is changed or the dose is reduced, will the patient’s mental illness symptoms remain controlled? Collaboration and consultation are critical in weighing the risks of stopping or changing a drug due to QT prolongation. It is also important to look for other contributing factors that might prolong the QT interval. Along with collaborating with our mental health professionals, it is about opening the door to a clear consultation with a psychiatrist—sharing what we see from a cardiology standpoint and hearing their psychiatric perspective—so that together we can decide what is in the patient’s best interest regarding medication changes. While newer drugs are available, changing a medication always carries the challenge of predicting how the patient will respond. In practice, the short answer is to work closely with the psychiatrist while offering your expertise. Ideally, a protocol should be followed in which a 12-lead electrocardiogram is performed before starting antipsychotic therapy, then repeated at 6 weeks and at regular intervals to monitor the QT interval. 

The transcripts were edited for clarity and length.

 Reference

1. Bueno H, Deaton C, Farrero M, et al. 2025 ESC Clinical Consensus Statement on mental health and cardiovascular disease: developed under the auspices of the ESC Clinical Practice Guidelines Committee. Eur Heart J. 2025 Aug 29:ehaf191. doi:10.1093/eurheartj/ehaf191