A psychiatric reading of ESC consensus and EPA “Whole Person Health”

The 2025 ESC consensus on mental health and cardiovascular diseases highlights that mental disorders play a critical role in CV outcomes. [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1]. The paper emphasizes the strong evidence that SMI and common mental disorders are associated with an increased risk of CV disease and worsen prognosis once CV disease is present [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1, Reference Shen, Mikkelsen, Luitva, Song, Kasela and Aspelund2].

At the same time, the EPA Presidential Action Plan has set out a roadmap for better and personalized mental-health care in Europe, including a dedicated task force on lifestyle, multimorbidity and “Whole Person Health” [Reference Fiorillo, Firth, Misiak, Rojnic Kuzman, Samochowiec and Sampogna3, Reference Fiorillo4]. This task force aims to integrate physical and mental health, strengthen collaboration with other medical specialties (including cardiology), promote lifestyle-based interventions, and reduce premature mortality among people with SMI.

Our Viewpoint can be seen as a cardiovascular test case of this agenda. We ask: what would it mean, in practical terms, for psychiatrists to implement the ESC Consensus on mental health and CV disease within a Whole Person Health framework? We propose three priorities: treating SMI and CDI‑PTSD as high-risk conditions that trigger CV assessment; adopting a pragmatic psychotropic safety bundle; and using cardiac rehabilitation, structured physical activity, and social prescribing as psychiatric treatment platforms.

Severe mental illness and CDI‑PTSD as cardiovascular high-risk conditions

People with SMI, including schizophrenia spectrum disorders, bipolar disorder, and recurrent major depression with marked functional impairment, die 10–15 years earlier than the general population, largely because of preventable somatic conditions, especially CV disease [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1, Reference Shen, Mikkelsen, Luitva, Song, Kasela and Aspelund2, Reference Correll, Solmi, Veronese, Bortolato, Rosson and Santonastaso5]. This mortality gap is driven by modifiable factors: tobacco use, physical inactivity, poor diet, psychotropic side‑effects, diagnostic overshadowing, and barriers to guideline-concordant somatic care.

The ESC Consensus calls for systematic mental-health screening in cardiology settings [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1]. From the psychiatric point of view, an equally strong commitment is needed in the opposite direction: SMI should itself trigger basic CV risk assessment and, when indicated, referral to primary care or cardiology.

Psychiatrists and community mental health teams play an important role in monitoring patients with severe mental illness (SMI) by checking vital health metrics like blood pressure, smoking habits, weight, waist circumference, and essential lab markers such as lipid levels and glucose/HbA1c. They can gain important information about a patient’s health by incorporating simple cardiovascular risk assessment tools into their routine care. However, it’s important to remember that these tools might not fully capture the risk for patients with SMI, so clinicians should approach the results with that understanding.

Additionally, it is important to establish clear referral pathways for somatic care when any abnormalities are detected.

Key “sentinel” moments for such screening include first-episode psychosis, initiation or escalation of antipsychotics with high metabolic risk, mood stabilizer titration, and discharge after psychiatric hospitalization. At each of these points, a brief CV assessment can be embedded into standard psychiatric workflows, with agreed feedback loops from primary care and cardiology.

The ESC document also devotes substantial attention to post-traumatic stress disorder (PTSD) as both a risk factor and a consequence of CV disease [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1]. A growing literature describes CDI‑PTSD, in which PTSD symptoms follow a life-threatening cardiac event such as myocardial infarction, cardiac arrest, spontaneous coronary artery dissection, heart transplantation, or device shocks [Reference Edmondson and Cohen6].

Clinically, CDI‑PTSD is characterized by re-experiencing of the event and its bodily sensations (palpitations, chest pain, dyspnea), avoidance of exertion and medical settings, hyperarousal with cardiac-focused anxiety, and behavioral patterns that undermine adherence to medication, lifestyle change, and rehabilitation [Reference Edmondson and Cohen6, Reference Maurus, Wagner, Spaeth, Vogel, Muenz and Seitz7]. Physiologically, PTSD contributes to CV risk through autonomic imbalance, systemic inflammation, and unhealthy coping behaviors [Reference Maurus, Wagner, Spaeth, Vogel, Muenz and Seitz7]. Behaviorally, CDI‑PTSD is marked by persistent avoidance of physical activity, which the ESC Consensus highlights as a major driver of adverse prognosis [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1].

We suggest that CDI‑PTSD should be explicitly recognized in psychiatric training and local protocols. One of the approach’s practical implications is the implementation of systematic PTSD screenings for patients who have had acute cardiovascular events, whether in emergency rooms, outpatient settings, or through liaison services. It recommends establishing cooperative channels between cardiology and psychology (psycho-cardio teams) to deliver quick trauma-focused therapies. Additionally, it highlights the importance of integrating graded exposure to physical activity into cardiac rehabilitation programs. This aims to help patients manage their fear of exertion, addressing this psychological aspect as an important part of their recovery.

A psychotropic safety bundle for people with cardiovascular disease

Psychotropic medications remain essential for treating many mental disorders, but their cardiometabolic and electrophysiological side‑effect profiles vary widely [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1, Reference Correll, Solmi, Veronese, Bortolato, Rosson and Santonastaso5]. Antipsychotics such as clozapine and olanzapine are strongly associated with weight gain, dyslipidemia, and dysglycaemia; several antidepressants and antipsychotics can prolong the QT interval, especially in combination with antiarrhythmics or other QT-prolonging drugs [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1, Reference Correll, Solmi, Veronese, Bortolato, Rosson and Santonastaso5].

Evidence-based recommendations exist, yet implementation is patchy. We propose that psychiatric services adopt a simple safety bundle whenever patients have, or are at high risk of, CV disease:

Baseline and follow-up cardiometabolic assessment

• ○ Measure weight, body‑mass index, waist circumference, blood pressure, fasting glucose or HbA1c, and lipid profile at baseline when initiating or switching higher-risk psychotropics.

• ○ Repeat at 3 and 6 months, then at least annually, with more frequent monitoring in high-risk patients.

ECG and interaction checks for QT-prolonging or arrhythmogenic drugs

• ○ Obtain baseline and early follow-up ECGs for psychotropics known to prolong QTc or interact with CV medications. Depending on the patient’s cardiovascular risk of developing torsade de pointes and QT prolongation, the rate of QTc monitoring should be modified. While patients at lower risk may be monitored at longer intervals, those at higher risk need more frequent ECG surveillance. [Reference Zolezzi and Cheung8].

• ○ Routinely check for drug–drug interactions and consult cardiology when combining multiple QT-prolonging drugs or antiarrhythmics.

Shared decision-making and early switching

• ○ Discuss benefits and risks, including CV risk, when choosing antipsychotics or antidepressants.

• ○ Be prepared to switch to agents with lower metabolic or arrhythmic risk when clinically feasible, rather than accepting substantial weight gain or QTc changes as inevitable.

This bundle can be implemented by psychiatrists and mental-health nurses, with cardiology input as needed, and fits squarely within the Whole Person Health task force’s call to embed cardiometabolic monitoring and lifestyle-related practices into psychiatric care [Reference Fiorillo, Firth, Misiak, Rojnic Kuzman, Samochowiec and Sampogna3, Reference Fiorillo4].

Cardiac rehabilitation, physical activity, and social prescribing as psychiatric interventions

Cardiac rehabilitation and long‑term CV follow-up are usually seen as cardiology domains, but they are also under‑used psychiatric treatment settings. The ESC Consensus calls for systematic mental-health assessment in cardiac rehabilitation [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1]. EPA guidance on physical activity for SMI goes further, showing that structured physical activity is an effective treatment for depressive symptoms, negative symptoms, and functional impairment in schizophrenia, major depression, and bipolar disorder [Reference Stubbs, Vancampfort, Hallgren, Firth, Veronese and Solmi9]. EPA recommends at least 150 minutes of moderate‑intensity or 75 minutes of vigorous‑intensity activity per week, plus resistance training on 2 days per week, adapted to individual capacity [Reference Stubbs, Vancampfort, Hallgren, Firth, Veronese and Solmi9].

An EPA meta‑review confirms that multi-component lifestyle interventions combining exercise, diet, and smoking cessation can improve cardiometabolic outcomes in adults with SMI [Reference Maurus, Wagner, Spaeth, Vogel, Muenz and Seitz7]. These findings underpin the EPA Whole Person Health task force, which explicitly prioritizes physical activity, nutrition, sleep, and social connectedness as levers to reduce premature mortality [Reference Fiorillo, Firth, Misiak, Rojnic Kuzman, Samochowiec and Sampogna3, Reference Fiorillo4]. Within this framework, psychiatrists should regard physical activity not merely as a “healthy habit” but as a core psychiatric intervention with robust evidence.

Working with cardiology and rehabilitation teams, psychiatrists can ensure that people with SMI are actively referred to, and supported in, accessing cardiac rehabilitation when indicated; contribute psychological input focusing on motivation, adherence and fear of exertion; and use rehabilitation as a supervised environment to deliver EPA-concordant physical‑activity prescriptions, including graded exposure for patients with CDI‑PTSD.

The ESC consensus also highlights social prescribing – referrals to community-based activities such as walking groups, arts and music programs, gardening, green exercise, and peer‑support groups [Reference Bueno, Deaton, Farrero, Forsyth, Braunschweig and Buccheri1]. Systematic reviews show that social prescribing can improve depressive and anxiety symptoms, well-being, and quality of life, especially when link workers coordinate care [Reference Nguyen, AstellBurt, RahimiArdabili and Feng10], while nature-based prescriptions may additionally reduce blood pressure and improve cardiometabolic indicators [Reference Nguyen, AstellBurt, RahimiArdabili and Feng10].

Psychiatry has a long tradition of community-based psychosocial interventions; social prescribing offers a practical framework to reconnect this tradition with CV prevention. In collaboration with primary care and social‑care services, psychiatrists can identify patients with SMI, CDI-PTSD, or cardiac anxiety who may benefit from community activities, work with link workers to match people to programs, and monitor mental‑health outcomes as part of routine follow-up. Digital platforms can support social prescribing and activity monitoring, but should always be complemented by non-digital options and active support to avoid excluding older or disadvantaged groups [Reference Nguyen, AstellBurt, RahimiArdabili and Feng10].