Takeaway
Smoking, uncontrolled blood pressure, or rising A1c may be signs of psychological distress—particularly in young women. Screening for anxiety and depression can help identify treatable mental and physical conditions.
Lifelong learning in clinical excellence | July 31, 2026 | 2 min read
By Ateh Ketum, MD, MPH, and Faith Metlock, PhD, RN, Johns Hopkins Medicine
A woman in her late 20s came in for a routine visit. She was tired, but so is almost everyone these days. Her blood pressure was a little high but not alarming, just a number to “keep an eye on.” She mentioned in passing that she’d been smoking again since a stressful move last year. It was noted, with a plan to circle back to smoking cessation at the next visit and move on to the next concern on the list.
It’s a familiar scene. And it’s exactly the kind of visit where something important can slip through.
What the data shows
In our recent SAFE HEART study analysis, published in “JACC: Advances,” we found that among 361 women of reproductive age, psychological distress, depressive symptoms, anxiety, and perceived stress were strongly linked to several cardiovascular risk factors: diabetes, hypertension, hyperlipidemia, and especially smoking. Women with high depressive symptoms were nearly five times more likely to smoke than those without. These associations held even after accounting for social disadvantages like housing instability, food insecurity, and financial strain.
What struck us most wasn’t just that psychological distress and cardiovascular risk travel together—it was that they do so quietly. Sleep, diet, and physical activity didn’t show the same pattern. It was specifically the mental-health-to-smoking, mental-health-to-hypertension links that stood out. In other words, distress doesn’t always show up as a patient saying “I’m struggling.” Sometimes it shows up as a pack of cigarettes, a blood pressure reading, or an A1c that has crept up since last year.
Why this matters at the bedside
Women of reproductive age are often seen as “too young” for cardiovascular concern, and their visits are often organized around reproductive health rather than heart health. That framing can mean psychological distress and its downstream cardiovascular effects go unasked-about and unaddressed until symptoms are harder to reverse.
Practical tips for clinicians in any specialty:
1. Ask.
A two-question depression screen (PHQ-2) or anxiety screen (GAD-2) takes under a minute and can surface distress that a routine review of systems misses.
2. Connect the dots out loud.
If a patient mentions stress, ask specifically about smoking, sleep, and blood pressure. Don’t assume these are separate conversations.
3. Don’t wait for “true” psychiatric symptoms.
Perceived stress alone without meeting criteria for anxiety or depression was still associated with adverse cardiovascular risk in our data. You don’t need a diagnosis to justify addressing it.
4. Loop in support.
An open conversation and a warm handoff to behavioral health, a community resource, or even a peer support group can matter more than trying to solve it all in one visit.
5. Remember—this isn’t just a mental health issue.
It’s a cardiovascular one, too and increasingly, a maternal health issue too.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.