Everyone knows the growing problem of depression in today’s society, but most people assume that it’s not all that connected to our overall physical health. An alarming new study, however, claims that depression has a devastating impact on a person’s heart, even more so than high cholesterol.

German researchers examined health information from 3,428 between the ages of 45 and 74 and found that among those who died of some form of cardiovascular disease, just as many had depression as had the major heart disease risk factors like diabetes, high blood pressure, smoking, high cholesterol and obesity.

In fact, depression was related to 15 percent of cardiovascular deaths, whereas high cholesterol was connected to 8 to 21 percent of deaths. Diabetes is actually less of a risk to your heart than depression is at 5 to 8 percent, and by a significant margin.

Only smoking and high blood pressure accounted for more such deaths than depression did. Smoking scored about 17 to 20 percent and high blood pressure was 30 and 34 percent. It’s an indication that we underestimate how important mental health is to our physical health.

“We invested a great deal of time in this work, just due to the long observation period,” says study leader Karl-Heinz Ladwig in a statement from Helmholtz Zentrum Munchen. “Our data show that depression has a medium effect size within the range of major, non-congenital risk factors for cardiovascular diseases.” Ladwig accordingly proposes consequences here: “In high risk patients, the diagnostic investigation of co-morbid depression should be standard. This could be registered with simple means.”