On a typical day inside the ambulatory cardiology clinics at the Yale School of Medicine, conversations about cholesterol and ejection fraction with patients often turn to less measurable concerns: anxiety about another heart attack, fear of exertion, and concern that life may never feel normal again.

For Kim Smolderen, PhD, a clinical psychologist and professor of cardiovascular medicine at Yale School of Medicine in New Haven, Connecticut, those latter conversations, once considered tangential to cardiac care, are now a part of it.

In February 2025, she started the Yale Medicine Heart and Vascular Psychology and Wellbeing Clinic in New Haven — a pilot program that offers mental health services within the cardiology clinic itself.

“I think there’s enough evidence out there that our mental health and medical conditions influence one another,” Smolderen said.

Her clinic reflects a broader, though still uneven, movement to close the long-standing gap between cardiovascular medicine and mental health care.

Link Long Recognized, Not Fully Integrated

Depression, anxiety, and chronic stress are common among patients with coronary artery disease, heart failure, and arrhythmias. The biological and behavioral links are well described.

“There are a variety of ways that depression, emotional stress, and other mental health conditions may be associated with worse outcomes among people with heart disease,” said Roy C. Ziegelstein, MD, a cardiologist at Johns Hopkins Medicine in Baltimore who has long advocated for integrating mental and cardiovascular care.

Some mechanisms are behavioral. Mental health conditions “can make it more difficult for a person to pay attention to their health and health behaviors,” Ziegelstein said.

Depression and anxiety may make it harder to exercise, maintain a heart-healthy diet, sleep well, or sustain social connections.

Other pathways are physiologic.

“Mental health conditions — and depression in particular — are associated with abnormalities in the function of platelets, cells that cause blood to clot,” Ziegelstein said. These abnormalities increase the likelihood of clot-related events, such as myocardial infarction or stroke. They are also linked to activation of inflammatory pathways that can accelerate atherosclerosis.

Once heart disease develops, mental health challenges can complicate recovery, he said.

“Patients with mental health conditions, especially depression, less often follow recommendations to reduce the risk of future cardiac events,” Ziegelstein said. “They adhere to beneficial medical treatments less frequently.”

Yet despite decades of evidence, integration of mental health and cardiac care remains inconsistent.

“I don’t think there is evidence — or at least not evidence I have seen — that there is wide-scale adoption of mental health care in cardiovascular practices,” Ziegelstein said.

While some centers have embedded services or streamlined referrals, he said, “in my view, these practices are few and far between.”

Christina M. Luberto, PhD, founding director of the Women’s Heart Health Mindful Living Center at Massachusetts General Hospital in Boston, said many cardiologists recognize the importance of mental health and can identify patients who could benefit from psychosocial services.

“I think the biggest gap right now is an access issue,” she said. “Most cardiologists do not have clear, easy access to refer patients to mental health services in their hospital and may not have the time or expertise to help patients seek mental health care.”

After the American Heart Association issued a statement in 2009 recommending routine screening, many cardiology clinics implemented them. But, Luberto said, they often had “limited resources to refer patients for treatment.”

She also noted that the field’s focus has evolved from depression to anxiety and now increasingly to trauma.

“More work is needed to identify screening approaches, treatments, and referral pathways for cardiac-related trauma symptoms,” she said.

A Cardiac Event as Psychological Shock

At Yale, Smolderen sees firsthand how a cardiac diagnosis affects more than the myocardium.

“When people have a severe medical condition, it impacts their livelihood,” she said, noting they are confronted with the anxiety over having another event or, in some cases, death.

For some patients, the experience triggers earlier trauma.

“If there’s previous vulnerability in the sense of trauma that they had incurred, the medical trauma might bring that up again,” she said.

At the same time, cardiology visits often become inflection points. Patients are told to modify diet, increase physical activity, and adhere strictly to medications.

“It’s often also a wake-up call for people to change their lifestyle and changing habits is always difficult,” Smolderen said. “So they might benefit from extra support in that regard as well.”

In many clinics, those emotional concerns surface but remain secondary. Programs such as Smolderen’s and Luberto’s in Boston attempt to address them in real time.

How the Model Works

At Yale, the clinic is co-located within the ambulatory cardiology setting.

“People would walk in as they see their cardiologist and I’m located in the same building,” Smolderen said. When cardiologists identify emotional distress, they enter a referral in the medical record; her team contacts the patient to schedule an intake.

At Massachusetts General Hospital, Luberto’s center offers telehealth-delivered mindfulness-based cognitive therapy groups as well as individual therapy for women with co-occurring mental health problems and cardiovascular disease.

By embedding services within a women’s heart health program and making them billable to insurance, she said, “we provide accessible, effective, and comprehensive whole-person care.”

As far as her team knows, “this is the first and only mindfulness-based clinical service embedded into a women’s heart health program nationwide.”

Research supports several psychological approaches for cardiac patients.

“The most widely studied approach is [cognitive-behavioral therapy],” Luberto said. However, there is also growing evidence for mindfulness-based therapies, positive psychology, and trauma-focused treatments.

In 2017, the American Heart Association issued a scientific statement supporting meditation, including mindfulness meditation, for its potential cardiovascular benefits.

Psychological therapies such as cognitive-behavioral therapy, mindfulness, and medications are not novel or unique to cardiac patients.

There is limited head-to-head research comparing therapies in cardiac populations, Luberto said, and treatment choice is often driven by availability, patient preference, or therapist expertise. Some studies suggest benefits beyond mood.

“Recent studies have shown that mindfulness-based interventions show clinically significant reductions in blood pressure as compared to usual care,” Luberto said, though larger trials are still needed.

Evidence for Treating Both Conditions

Mounting evidence suggests that addressing depression and anxiety may influence not only quality of life but also cardiovascular outcomes.

A recent study published in the Journal of the American Heart Association found that patients with coronary artery disease or heart failure who received treatment for both their cardiac conditions and their anxiety or depression were 75% less likely to be rehospitalized, 74% less likely to visit an emergency department, and 66% less likely to die over 4 years of follow-up.

Even in clinics without embedded behavioral health staff, Luberto said cardiologists can make a difference.

“I think cardiologists can make simple statements that can go a long way for patients,” she said. “Often patients hear what their physician doesn’t say.”

Acknowledging and normalizing distress, briefly explaining the link between mental and heart health, and offering referrals, even to outside providers, can help patients feel supported and more willing to seek care.

Through her work with colleagues connected to the American Psychological Association, Smolderen sees similar services emerging at major academic centers, though access remains uneven.

“I don’t think it is the norm yet,” she said.

She expects demand to grow as cardiovascular disease prevalence increases and stigma around mental health declines.

“Cardiovascular disease is not going to go away. It’s going to snowball,” Smolderen said. “I think in the future, it will go hand in hand no matter what.”

And patients are already signaling that need. Some contact her clinic after reading about it, she said.

“People often report they feel lonely, or they feel like they’re an exception with these kinds of issues,” she said.

Knowing that their experience is common and treatable can itself be therapeutic, she added.

Luberto, Smolderen, and Ziegelstein reported having no relevant disclosures.

Lara Salahi is a health journalist based in Boston.