Study Examines Depression-Heart Disease Link
-Even mild symptoms were associated with incident CVD, according to meta-analysis
by Zeena Nackerdien PhD, CME Writer, MedPage Today 2020-12-29
Study Authors: Eric L. Harshfield, Lisa Pennells, et al.
Target Audience and Goal Statement: Psychiatrists, cardiologists, primary care physicians
The goal of this study was to characterize the association between depressive symptoms and incidence of cardiovascular disease (CVD).
- What was the association between depressive symptoms and CVD incidence?
Study Synopsis and Perspective:
The World Health Organization (WHO) lists depression as a leading cause of disability worldwide and a major contributor to the overall global burden of disease.
Previous studies have noted a potential association between depressive disorders and CVD. Professional societies such as the American Heart Association and the European Society of Cardiology have recognized that depression can be a modifiable risk factor for coronary heart disease (CHD) and have encouraged improving its recognition and management.
- Among more than half a million participants across 22 cohorts, baseline depressive symptoms were associated with incidence of cardiovascular disease, according to a meta-analysis.
- Note that even depressive symptoms at levels lower than the threshold indicative of a potential depressive disorder were associated with risk of incident cardiovascular disease.
Nevertheless, it was uncertain whether depressive symptoms were independently associated with subsequent risk of CVD.
According to a recent meta-analysis, baseline depressive symptoms were associated with CVD incidence.
Using pooled data on 162,036 participants in 21 cohorts from the Emerging Risk Factors Collaboration (ERFC), each one standard deviation higher that people scored on a depression scale was tied to a 6% increased risk for a composite of CHD and stroke (HR 1.06, 95% CI 1.04-1.08).
Each standard deviation higher in the depression score was associated with a 7% increased risk for fatal or nonfatal CHD and a 5% increased risk for stroke during a median 9.5-year follow-up, reported Lisa Pennells, PhD, of the University of Cambridge in England, and colleagues in JAMA.
Pennells and team further analyzed data on 401,219 participants from a single cohort in the U.K. Biobank, which showed very similar findings. Over a median 8.1-year follow-up, these participants saw a 10% (95% CI 1.08-1.13) higher risk for any cardiovascular event per each standard deviation higher in depression score.
Similar to the data on the 21 cohorts, this was driven by slightly more fatal or nonfatal CHD risk. Each standard deviation higher in depression score was tied to an 11% and 10% higher risk for CHD and stroke, respectively.
Participants in this meta-analysis did not have a known baseline history of CVD, defined as CHD, other heart disease, stroke, transient ischemic attack, peripheral vascular disease, or cardiovascular surgery.
Of the ERFC participants, 73% were women and the mean age at baseline was 63. Of the participants from the U.K. Biobank, 55% were women and the mean age at baseline was 56. Both groups were followed through March 2020.
The Center for Epidemiological Studies Depression scale (score of 16-plus indicates possible depressive disorder) was used for the 21 cohorts from the ERFC. Incidence rates for heart events were far higher among people who fell into the highest quintile for depressive symptoms (average score of 19) versus the lowest quintile (average score of 1):
- Total events: 62.8 (highest quintile) vs 53.5 events (lowest quintile) per 10,000 person-years of follow-up
- CHD events: 36.3 vs 29.0 events per 10,000 person-years of follow-up
- Stroke events: 28 vs 24.7 events per 10,000 person-years of follow-up
The U.K. Biobank utilized the two-item Patient Health Questionnaire-2 to measure depressive symptoms, scored on a scale of 0-6, with a score of 3 or higher indicating a possible depressive disorder. Incidence rates for heart events during follow-up were higher for those who scored 4 or higher on this scale versus those who scored zero:
- Total events: 36.2 vs 24.5 events per 10,000 person-years
- CHD events: 20.9 vs 14.2 events per 10,000 person-years
- Stroke events: 15.3 vs 10.2 events per 10,000 person-years
« Depressive symptoms, even at levels lower than what is typically indicative of potential clinical depression, were associated with risk of incident cardiovascular disease although the magnitude of the association was modest, » Pennells and colleagues wrote.
They acknowledged that their study did not constitute a comprehensive synthesis of available evidence, as it was not a systematic review. Because the study focused on depressive symptoms captured at a single baseline examination, it prevented investigation of cumulative depression burden, of incident depression, or of time-varying associations with outcomes. In addition, they could not exclude inadequate adjustment for unmeasured or imprecisely measured confounding factors, including various baseline comorbidities.
Source Reference: JAMA 2020; DOI: 10.1001/jama.2020.23068
Study Highlights and Explanation of Findings:
A meta-analysis that included more than half a million participants across 22 cohorts showed that baseline depressive symptoms were associated with CVD incidence, including at symptom levels lower than the threshold indicative of a potential depressive disorder. These results remained consistent after adjustment for cardiovascular risk factors and efforts to limit the effects of reverse causality.
Pennells and team noted ways in which their study extended evidence from the literature:
- Log-linear associations of depressive symptoms with CVD incidence suggested no clear evidence of a threshold below which depressive symptoms were not associated with CVD risk
- Observations support the hypothesis that CVD prevention via addressing depressive symptoms could, in principle, be amenable to population-wide approaches
- Observed associations could not be chiefly attributed to other cardiovascular risk factors, such as systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, body mass index, diabetes, alcohol consumption, or C-reactive protein levels
- Depressive symptoms were associated with a wide range of causes of death, including cancer, as well as non-CVD and non-cancer causes
« These findings reinforce previous observations, highlighting the potential need to investigate the presence of depression and depressive symptoms including among people who would not usually come to the attention of mental health services, and to monitor those expressing symptoms with increased vigilance, » the researchers wrote.
They noted that it is uncertain if treatment of depression could reduce CVD risk.
Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco
Source Reference: Monaco K « Depression: Here’s How Bad It Is for Heart Health » 2020.