Association of symptoms of depression with cardiovascular disease and mortality in low, middle, and high-Income countries

1. Depressive symptoms were associated with increased incident cardiovascular disease and all-cause mortality across multiple countries and communities at varying stages of economic development.

2. The strength of the association was highest in populations living in urban areas.

Evidence Rating Level: 2 (Good)

Depression has been shown to be associated with increased risks of cardiovascular disease (CVD), cancers, and mortality. As these studies have nearly exclusively been carried out in high-income countries however, it is not clear if those findings are transferrable to resource-poor populations. This multicenter, population-based cohort study involved 145,862 participants from 370 urban and 341 rural communities across 5 low-, 5 lower-middle-, 7 upper-middle-, and 4 high-income countries. Individuals with 4 or more self-reported depressive symptoms (n = 15,983, M [SD] age = 49.2 [9.3] years) were compared with those reporting less than 4 (n = 129,879, M [SD] age = 50.2 [9.7] years) for incident CVD, all-cause mortality, and a combined measure of either incident CVD or all-cause mortality. Incidence of CVD (HR 1.17, 95% CI 1.08 to 1.27, p <0.001), mortality (HR 1.18, 95% CI 1.11 to 1.26, p <0.001), and combined CVD and all-cause mortality (HR 1.20, 95% CI 1.13 to 1.27, p<0.001) were shown to be significantly increased among participants reporting 4 or more depressive symptoms, increasing overall risk of incident CVD and all-cause mortality by 14% and 17%, respectively. Relative risk for all primary outcomes was shown to significantly (p <0.001) trend upward with more self-reported depressive symptoms, from HR 1.05 (95% CI, -0.92 to 1.19) among those reporting 1 symptom to HR 1.24 (95% CI 1.12 to 1.37) among those reporting 7 symptoms. HRs for depression were similar in the different geographical regions studied (p = 0.56) and in both income cohorts (p = 0.52); however, the risk doubled in urban communities (HR 1.23, 95% CI 1.13 to 1.34) compared with rural communities (HR 1.10, 95% CI 1.02 to 1.19, p = 0.001). Finally, among men (HR 1.27, 95% CI 1.17 to 1.38) the association between depressive symptoms and all primary outcomes compared with women (HR 1.14, 95% CI 1.06 to 1.23) was significantly stronger (p <0.001). Overall, this study demonstrates the association between depressive symptoms and CVD and mortality that exist in countries across various stages of development and geographical context. Given that strength of the association was highest in urban areas, government and healthcare policy must be directed to address this relationship as the majority of the global population is projected to live in urban areas by the mid-century.

Click to read the study in JAMA Psychiatry

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