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Title: Association of symptoms of depression with cardiovascular disease and mortality in low-, middle-, and high-income countries
Authors: Rajan, Selina 
McKee, Martin 
Rangarajan, Sumathy 
Bangdiwala, Shrikant 
Rosengren, Annika 
Gupta, Rajeev 
Kutty, Vellappillil Raman 
Wielgosz, Andreas 
Lear, Scott 
AlHabib, Khalid F. 
Co, Homer U. 
Lopez-Jaramillo, Patricio 
Avezum, Alvaro 
Seron, Pamela 
Oguz, Aytekin 
Kruger, Iolanth√© M. 
Diaz, Rafael 
Nafiza, Mat-Nasir 
Chifamba, Jephat 
Yeates, Karen 
Kelishadi, Roya 
Sharief, Wadeia Mohammed 
Szuba, Andrzej 
Khatib, Rasha 
Rahman, Omar 
Iqbal, Romaina 
Bo, Hu 
Yibing, Zhu 
Wei, Li 
Yusuf, Salim 
Keywords: Depression, Mental - Symptoms;Cardiovascular system - Diseases - Mortality;Depression, Mental - Prevention;Cardiovascular system - Diseases - Prevention
Issue Date: 2020
Publisher: JAMA Psychiatry
Abstract: IMPORTANCE Depression is associated with incidence of and premature death from cardiovascular disease (CVD) and cancer in high-income countries, but it is not known whether this is true in low- and middle-income countries and in urban areas, where most people with depression now live. OBJECTIVE To identify any associations between depressive symptoms and incident CVD and all-cause mortality in countries at different levels of economic development and in urban and rural areas. DESIGN, SETTING, AND PARTICIPANTS This multicenter, population-based cohort study was conducted between January 2005 and June 2019 (median follow-up, 9.3 years) and included 370 urban and 314 rural communities from 21 economically diverse countries on 5 continents. Eligible participants aged 35 to 70 years were enrolled. Analysis began February 2018 and ended September 2019. EXPOSURES Four or more self-reported depressive symptoms from the Short-Form Composite International Diagnostic Interview. MAIN OUTCOMES AND MEASURES Incident CVD, all-cause mortality, and a combined measure of either incident CVD or all-cause mortality. RESULTS Of 145 862 participants, 61 235 (58%) were male and the mean (SD) age was 50.05 (9.7) years. Of those, 15 983 (11%) reported 4 or more depressive symptoms at baseline. Depression was associated with incident CVD (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24), all-cause mortality (HR, 1.17; 95% CI, 1.11-1.25), the combined CVD/mortality outcome (HR, 1.18; 95% CI, 1.11-1.24), myocardial infarction (HR, 1.23; 95% CI, 1.10-1.37), and noncardiovascular death (HR, 1.21; 95% CI, 1.13-1.31) in multivariable models. The risk of the combined outcome increased progressively with number of symptoms, being highest in those with 7 symptoms (HR, 1.24; 95% CI, 1.12-1.37) and lowest with 1 symptom (HR, 1.05; 95% CI, 0.92 -1.19; P for trend < .001). The associations between having 4 or more depressive symptoms and the combined outcome were similar in 7 different geographical regions and in countries at all economic levels but were stronger in urban (HR, 1.23; 95% CI, 1.13-1.34) compared with rural (HR, 1.10; 95% CI, 1.02-1.19) communities (P for interaction = .001) and in men (HR, 1.27; 95% CI, 1.13-1.38) compared with women (HR, 1.14; 95% CI, 1.06-1.23; P for interaction < .001). CONCLUSIONS AND RELEVANCE In this large, population-based cohort study, adults with depressive symptoms were associated with having increased risk of incident CVD and mortality in economically diverse settings, especially in urban areas. Improving understanding and awareness of these physical health risks should be prioritized as part of a comprehensive strategy to reduce the burden of noncommunicable diseases worldwide.
DOI: 10.1001/jamapsychiatry.2020.1351
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