Depression is a difficult mental health issue that can result in self-harm or even suicide, but the physical health risks go way beyond that according to a new study: it causes just as much damage to your heart as having high cholesterol. The new study, which comes from researchers in Germany, are based on an examination of 3,428 between the ages of 45 and 74 over a decade, and it found that depression is just as much of a risk factor for death from a cardiovascular ailment as common heart disease risk factors.

The study shows that depression should be treated as a much more serious issue than simply feeling low, but something that has serious health consequences, and should be ranked among the five most common factors in cardiovascular death: high cholesterol, obesity, smoking, high blood pressure and diabetes.

Depression was determined to be a factor in 15 percent of cardiovascular deaths, compared to 8 to 21 percent for high cholesterol and just 5 to 8 percent for diabetes. Only smoking and high blood pressure at 17 to 20 percent and 30 to 4 percent respectively ranked higher than depression.

“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.”