Longitudinal Changes in Depressive Symptoms and Risks of Cardiovascular Disease and All-Cause Mortality: A Nationwide Population-Based Cohort Study

Effectiveness of digital modified behavioral activation treatment program for rural older adults with depressive symptoms in Western Hunan: study protocol for a multi-center randomized controlled trial

BACKGROUND

Rural older adults experience a high burden of depressive symptoms and significant barriers to accessing mental health services. The Modified Behavioral Activation Treatment (MBAT) has been verified to be effective among rural older adults in China. Due to its structured format and skill-based learning, it is well suited for digital-based delivery. However, only a few studies were from developed countries, and the evidence to support its application in rural China still needs to be provided. Thus, based on the fact that digital health technology has the potential to address the shortage of healthcare resources and the constraints of community mental health services in rural China, the effectiveness of the digital MBAT (D-MBAT) program among rural older adults is worth further evaluation.

METHODS

A multi-center randomized controlled trial will be conducted among 216 rural older adults from Huayuan County and Fenghuang County in Western Hunan. The intervention group will receive the D-MBAT program, while the control group will receive routine care. Depressive and anxiety symptoms, social health, quality of life, and satisfaction will be measured at baseline, one-month, and three-month follow-ups to evaluate the digital MBAT program's effectiveness.

DISCUSSION

Existing digital psychological intervention strategies seldom take into account the needs and preferences of the older adults in low-resource rural areas. Thus, this study aims to develop a D-MBAT program based on person-centered and community-engaged approach to maximize the mental health service of rural older adults with depressive symptoms.A successful D-MBAT program would be a feasible and scalable approach to the management of prevalent mental health conditions of rural older adults in resource-limited Western Hunan.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400091193. Registered on 23 October 2024.

The Impact of Changes in Depression on Cardiovascular Outcomes in Patients With Coronary Heart Disease

Background

Depression is associated with major adverse cardiovascular events (MACE). Whether longitudinal changes in depression affect MACE in patients with coronary heart disease (CHD) remains unknown.

Objectives

The authors evaluated the hypothesis that increasing or persistent depression predicts MACE in patients with CHD.

Methods

At baseline, 3,483 Emory Cardiovascular Biobank participants (median age 65.5 years, 31.6% female) completed the Patient Health Questionnaire 8 (PHQ8) for depression evaluation. At 1 year, 2,639 of these event-free participants repeated the questionnaire. Depression was defined as a PHQ8 score >9 and change in depressive symptoms ( Δ PHQ8) was year 1 score minus baseline PHQ8 scores. We categorized participants into never depression (both PHQ8 <10), new depression (baseline PHQ8 <10; 1-year PHQ8 >9), remitted depression (baseline PHQ8 >9; year 1 PHQ8 <10), and persistent depression (both PHQ8 >9) groups. Fine-Gray models with noncardiovascular death as the competing event and adjusted for demographics, CHD, and depression related factors evaluated how changes in depression affect MACE (cardiovascular death and MI).

Results

Overall, the incidence of MACE was 14%, with 8.7% of those with follow-up PHQ8 having MACE. 2.9% had persistent depression, 4.5% had new depression, 10.8% had remitted depression, and 81.8% never had depression. Increasing depressive symptoms independently predicted MACE ( Δ PHQ8 subdistribution HR: 1.06 [95% CI: 1.02-1.09], P < 0.001). Correspondingly, the incidence of MACE was higher in those with persistent (20.8%) or new depression (11.9%) than in those with remitted (9.4%) or never depression (8%) (P < 0.001). Compared to never depression, persistent depression independently predicted MACE (subdistribution HR: 2.78 [95% CI: 1.2-6.5], P = 0.017).

Conclusions

Increasing or persistent depression predicts MACE in individuals with CHD.

Pathophysiological dynamics of acute myocardial infarction rats under chronic psychological stress at different time points

There is a lack of in-depth research on the impacts and changes in chronic psychological stress (CPS) on the cardiovascular system after acute myocardial infarction (AMI). This study aims to explore the comorbid mechanism and dynamic evolution of AMI exposed to CPS. 120 Wistar rats were randomly divided into Sham Operation group, Sham Operation + Chronic Unpredictable Mild Stress (CUMS) group, AMI group and AMI + CUMS group, with each group further divided into subgroups at days 7, 14, and 28. The AMI model was created by ligating the left anterior descending coronary artery, and CUMS model was used to induce CPS in rats. Behavioral changes were assessed through open field tests and sucrose preference tests. Cardiac function and structure were evaluated via echocardiography. The serum levels of TNFα, IL-6, NO, ET, CK-MB, cTNT, and ANP were measured using assay kits. Pathological changes in cardiac and brain tissues were observed under an optical microscope. Comparative analysis across different models revealed that CUMS significantly reduced behavioral activities in rats, with an interaction between CUMS and AMI affecting total distance (P < 0.05). Both CUMS and AMI significantly reduced cardiac function indicators, with their interaction effects on LVEF, LVFS, and CO (P < 0.05). AMI significantly altered cardiac structural parameters, particularly on day 28 (P < 0.05); while the impact of CUMS on cardiac structure was not significant, except for a notable reduction in LVAW/s on day 7 in AMI + CUMS group (P < 0.05). AMI caused significant changes in the serum biomarkers, while CUMS only significantly increased cTnT on day 7, ANP, TNFα, and IL-6 on day 14, and CK-MB on day 28, with their interaction effects on the three myocardial injury markers and TNFα (P < 0.05). Comparative analysis across different time points demonstrated that behavioral activity, cardiac function, CK-MB, cTnT, ANP, TNFα, and ET levels decreased significantly over time in the AMI model rats, while the left ventricular mass increased significantly (P < 0.05). Pathologically, compared with stress or AMI alone, the AMI + CUMS group exhibited more severe myocardia cellular degeneration and inflammatory infiltration, causing larger infract areas in myocardial tissue, as well as cell number decreases and morphological changes in hippocampal tissue. AMI with CPS exacerbates myocardial injury through sustained inflammation and endothelial dysfunction, leading to heart-brain pathology manifestations characterized by decreased cardiac function and hippocampal tissue damage.

Prevalence and management of depressive symptoms in coronary heart disease patients and relationship with cardiovascular prognosis: a prospective cohort study

AIMS

Depressive symptoms are comorbid with coronary heart disease (CHD). There is a controversial debate about whether screening and intervention for depressive symptoms could improve cardiovascular prognosis. This study characterizes the prevalence, characteristics, cardiovascular prognosis and management need of depressive symptoms among CHD patients.

METHODS

CHD patients were recruited between November 18, 2020 and November 26, 2021. Depressive symptoms were evaluated with the Patient Health Questionnaire (PHQ-9). During the 12-month follow-up, cardiovascular disease (CVD) was the endpoint. Time-to-event data were estimated by Kaplan-Meier curves and Cox models.

RESULTS

Of 582 patients (25% women), 21.0% had mild depressive symptoms, and 7.5% had moderate-to-severe depressive symptoms during hospitalization. Mild and moderate-to-severe depressive symptoms were risk factor-adjusted predictors of the primary composite endpoints (adjusted HR = 2.20; 95%CI 1.19-4.03, and adjusted HR = 2.70; 95%CI 1.23-5.59, respectively). Platelet count and low-density lipoprotein were higher in mild depressive symptoms compared to no depressive symptoms.

CONCLUSION

Depressive symptoms are prevalent in CHD patients. Mild and moderate-to-severe depressive symptoms are associated with higher risk of further CVD in CHD patients. Platelet function and behavioral mechanisms may contribute to this association.

TRIAL REGISTRATION

This research was registered at https://www.chictr.org.cn . Full data of first registration is 11/09/2020. The registration number is ChiCTR2000038139.

Depressive symptoms are not associated with clinically important levels of digital home blood pressure in the electronic Framingham Heart Study

Background

Depressive symptoms are common and share many biopsychosocial mechanisms with hypertension. Association studies between depressive symptoms and blood pressure (BP) have been inconsistent. Home BP monitoring may provide insight.

Objective

To investigate the association between depressive symptoms and digital home BP.

Methods

Electronic Framingham Heart Study (eFHS) participants were invited to obtain a smartphone app and digital BP cuff at research exam 3 (2016-2019). Participants with ≥3 weeks of home BP measurements within 1 year were included. Depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale (CES-D). Multivariable linear mixed models were used to test the associations of continuous CES-D score and dichotomous depressive symptoms (CES-D ≥16) (independent) with home BP (dependent), adjusting for age, sex, cohort, number of weeks since baseline, lifestyle factors, diabetes, and cardiovascular disease.

Results

Among 883 participants (mean age 54 years, 59% women, 91% White), the median CES-D score was 4. Depressive symptom prevalence was 7.6%. Mean systolic and diastolic BP at exam 3 were 119 and 76 mm Hg; hypertension prevalence was 48%. A 1 SD higher CES-D score was associated with 0.9 (95% CI: 0.18-1.56, P = .01) and 0.6 (95% CI: 0.06-1.07, P = .03) mm Hg higher home systolic BP and diastolic BP, respectively. Dichotomous depressive symptoms were not significantly associated with home BP (P > .2).

Conclusion

Depressive symptoms were not associated with clinically substantive levels of home BP. The association between depression and cardiovascular disease risk factors warrants more data, which may be supported by mobile health measures.

Influencing Factors on Cardiovascular Health in China

The Annual Report on Cardiovascular Health and Diseases in China (2022) intricate landscape of cardiovascular health in China. This is the first section of the report, which dissects influential factors across diverse domains. The investigation identifies tobacco use as a paramount concern, portraying China as the global epicenter of tobacco consumption. Cigarette smoking, exacerbated by second-hand smoke exposure, emerges as a critical and preventable risk factor, contributing to a surge in attributable deaths over the past three decades. In the realm of dietary nutrition, the study discerns an overall improvement, yet discerns worrisome deviations, notably an escalating fat intake surpassing recommended guidelines. The shifting dietary structure reveals diminished consumption of cereals and vegetables juxtaposed with an uptick in animal foods, while excessive intake of cooking oil and salt persists, straying substantially from endorsed levels. The exploration of physical activity patterns unfolds a nuanced narrative. Varied trends are observed among students, with concerns arising from sedentary behaviors and inadequate adherence to recommended guidelines. The analysis spans a trajectory of declining physical activity in Chinese adults, coupled with an alarming surge in sedentary leisure time, ultimately linking these factors to heightened risks of cardiovascular diseases and increased adiposity. An examination of overweight and obesity trends uncovers a relentless upward trajectory, projecting substantial prevalence by 2030. Noteworthy prevalence rates underscore the imperative for targeted interventions to curtail this burgeoning health crisis, with the anticipated prevalence extending to nearly two-thirds of the adult population. Psychological factors, notably depression, constitute an integral facet of cardiovascular health. Prevalence rates among patients with coronary artery disease and acute myocardial infarction underscore the intricate interplay between mental health and cardiovascular outcomes. Additionally, persistent depressive symptoms are shown to significantly elevate the risk of cardiovascular diseases and mortality. This first section underscores the multifaceted challenges facing cardiovascular health in China, emphasizing the imperative for tailored interventions across tobacco control, dietary habits, physical activity, obesity management, and psychological well-being to mitigate the escalating burden of cardiovascular diseases in the population.

Comparison of Imputation Strategies for Incomplete Longitudinal Data in Life-Course Epidemiology

Incomplete longitudinal data are common in life-course epidemiology and may induce bias leading to incorrect inference. Multiple imputation (MI) is increasingly preferred for handling missing data, but few studies explore MI-method performance and feasibility in real-data settings. We compared 3 MI methods using real data under 9 missing-data scenarios, representing combinations of 10%, 20%, and 30% missingness and missing completely at random, at random, and not at random. Using data from Health and Retirement Study (HRS) participants, we introduced record-level missingness to a sample of participants with complete data on depressive symptoms (1998-2008), mortality (2008-2018), and relevant covariates. We then imputed missing data using 3 MI methods (normal linear regression, predictive mean matching, variable-tailored specification), and fitted Cox proportional hazards models to estimate effects of 4 operationalizations of longitudinal depressive symptoms on mortality. We compared bias in hazard ratios, root mean square error, and computation time for each method. Bias was similar across MI methods, and results were consistent across operationalizations of the longitudinal exposure variable. However, our results suggest that predictive mean matching may be an appealing strategy for imputing life-course exposure data, given consistently low root mean square error, competitive computation times, and few implementation challenges.

The association between the Short Physical Performance Battery and longitudinal trajectories of depressive symptoms among Chinese older adults

BACKGROUND

In this study, the long-term trajectories of depressive symptoms in a 7-year prospective survey cohort of Chinese older adults were explored. Additionally, the study examined whether there was an independent association between scores on the Short Physical Performance Battery (SPPB) and the different trajectories of depressive symptoms.

METHODS

A total of 2177 elderly individuals had their depressive symptoms assessed based on the Center for Epidemiological Studies-Depression (CES-D) scale in the years 2011, 2013, 2015, and 2018. In addition, their demographic characteristics, chronic diseases, and lifestyle factors were also assessed. The trajectories of depressive symptoms were analysed using the group-based trajectories analysis model. Furthermore, the relationship between the objectively measured SPPB scores and the long-term trajectory of depressive symptoms was explored using multinomial logistic regression.

RESULTS

The group-based trajectory analysis model categorized the trajectories of depressive symptoms across four waves into four groups: persistent low depressive symptoms, increasing depressive symptoms, decreased depressive symptoms, and persistent high depressive symptoms. After controlling for confounding factors, it was observed that a higher baseline SPPB score was associated with an increased likelihood of persistent high depressive symptoms, OR (95% CI) = 0.724 (0.644, 0.814), for the persistent high depressive symptoms versus the persistent low depressive symptoms.

CONCLUSIONS

Low levels of SPPB score are associated with persistent high depressive symptoms in older adults. Conversely, improving physical performance as measured by the SPPB can help reduce the risk of major depressive disorder and persistent depressive disorder in the elderly.

Predictors of Psychological Distress among Post-Operative Cardiac Patients: A Narrative Review

Following surgery, over 50% of cardiac surgery patients report anxiety, stress and/or depression, with at least 10% meeting clinical diagnoses, which can persist for more than a year. Psychological distress predicts post-surgery health outcomes for cardiac patients. Therefore, post-operative distress represents a critical recovery challenge affecting both physical and psychological health. Despite some research identifying key personal, social, and health service correlates of patient distress, a review or synthesis of this evidence remains unavailable. Understanding these factors can facilitate the identification of high-risk patients, develop tailored support resources and interventions to support optimum recovery. This narrative review synthesises evidence from 39 studies that investigate personal, social, and health service predictors of post-surgery psychological distress among cardiac patients. The following factors predicted lower post-operative distress: participation in pre-operative education, cardiac rehabilitation, having a partner, happier marriages, increased physical activity, and greater social interaction. Conversely, increased pain and functional impairment predicted greater distress. The role of age, and sex in predicting distress is inconclusive. Understanding several factors is limited by the inability to carry out experimental manipulations for ethical reasons (e.g., pain). Future research would profit from addressing key methodological limitations and exploring the role of self-efficacy, pre-operative distress, and pre-operative physical activity. It is recommended that cardiac patients be educated pre-surgery and attend cardiac rehabilitation to decrease distress.

Hearing loss increases all-cause and cardiovascular mortality in middle-aged and older Chinese adults: the Dongfeng-Tongji Cohort Study

We aimed to investigate the association between hearing loss and all-cause and cardiovascular disease (CVD) mortality, and whether the relationship could be modified by chronic conditions in middle-aged and older Chinese adults. We selected 18,625 participants who underwent audiometry in 2013 from the Dongfeng-Tongji Cohort conducted in China, and followed them until December 2018. Hearing loss was grouped as normal, mild, and moderate or severe by pure-tone hearing threshold at speech (0.5, 1, and 2 kHz) and high frequency (4 and 8 kHz). We applied Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and CVD mortality. Among the 18,625 participants, the mean age was 64.6 (range: 36.7-93.0) years, and 56.2% were women. A total of 1185 died, with 420 CVD deaths during a mean follow-up period of 5.5 years. The adjusted HR for all-cause and CVD mortality increased gradually with the increasing hearing threshold (All p for trend < 0.05). Compared to participants with normal hearing at speech frequency, the adjusted HRs (95% CIs) of moderate or severe hearing loss were 1.42 (1.21-1.67), 1.44 (1.10-1.89), and 1.92 (1.21-3.04) for all-cause, CVD, and stroke mortality, respectively. While moderate or severe hearing loss at high frequency was only related to an increased risk of all-cause mortality (HR, 1.60; 95% CI, 1.18-2.17). The associations were generally consistent across subgroups (All p for interaction > 0.05). Additionally, individuals with a combination of moderate or severe hearing loss and occupational noise exposure, diabetes, or hypertension had higher risk of all-cause or CVD mortality, ranging from 1.45 to 2.78. In conclusion, hearing loss was independently associated with an increased risk of all-cause and CVD mortality, in a dose-response manner. Meanwhile, hearing loss and diabetes or hypertension could jointly increase the risk of all-cause and CVD mortality.

Role of endocrine PACAP in age-related diseases

Pituitary adenylate cyclase activating polypeptide (PACAP) is a conserved neuropeptide, which confers diverse anti-aging endocrine and paracrine/autocrine effects, including anti-apoptotic, anti-inflammatory and antioxidant action. The results of the in vivo and in vitro experiments show that increasing emphasis is being placed on the diagnostic/prognostic biomarker potential of this neuropeptide in a wide array of age-related diseases. After the initial findings regarding the presence and alteration of PACAP in different body fluids in physiological processes, an increasing number of studies have focused on the changes of its levels in various pathological conditions associated with advanced aging. Until 2016 - when the results of previous human studies were reviewed - a vast majority of the studies had dealt with age-related neurological diseases, like cerebrovascular and neurodegenerative diseases, multiple sclerosis, as well as some other common diseases in elderly such as migraine, traumatic brain injury and post-traumatic stress disorder, chronic hepatitis and nephrotic syndrome. The aim of this review is to summarize the old and the new results and highlight those 'classical' and emerging clinical fields in which PACAP may become subject to further investigation as a diagnostic and/or prognostic biomarker in age-related diseases.

Estimated glucose disposal rate and risk of cardiovascular disease: evidence from the China Health and Retirement Longitudinal Study

OBJECTIVES

Previous studies had reported that insulin resistance (assessed by estimated glucose disposal rate; eGDR) was associated with higher risk of cardiovascular events (CVD) in diabetes patients. The aim of present study was to investigate the potential association between eGDR and CVD in general population.

METHODS

The China Health and Retirement Longitudinal Study with 8,267 individuals were included in analysis. Participants were divided into four subgroups according to eGDR quartile. Cox proportional hazards regression models were used to examine the associations of eGDR with CVD (stroke or cardiac events).

RESULTS

During 6 years of follow-up, a total of 1,476 respondents experienced a CVD (494 stroke and 1,110 cardiac events). In multivariable-adjusted analyses, the corresponding hazard ratio (95% confidence intervals) for the highest eGDR versus lowest quartile of eGDR was 0.58(0.49-0.67) for CVD. Each 1-SD increase of eGDR was associated with 16% (HRs = 0.84; 0.79-0.88) decreased risk of CVD. There was also a significant linear association between eGDR and CVD (P for linearity < 0.001). Similar associations were also found between eGDR and stroke and cardiac events.

CONCLUSION

A higher eGDR (a measure of insulin resistance) was associated with a decreased risk of CVD, stroke and cardiac events in general Chinese population, suggesting that eGDR could be considered as a preferential predictor and treatment target of CVD. Future well-designed prospective clinical studies are needed to verify our findings and to assess the effect of eGDR interventions in CVD prevention and therapy.

Acupuncture in treating cardiovascular disease complicated with depression: A systematic review and meta-analysis

Background

Depression is a serious risk for cardiovascular disease (CVD). Improving depression can alleviate cardiac symptoms and improve quality of life. Studies have shown that acupuncture has a positive effect on depression and CVD. This systematic review and meta-analysis will evaluate the efficacy and safety of acupuncture in the treatment of depression complicated with CVD.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and China Biomedical Literature databases. Randomized controlled trials of acupuncture vs. standard care or sham acupuncture or antidepressants were included. The retrieval time is from database construction to 07 April 2022. We used the "risk of bias" tool of Cochrane Collaboration, and the Review Manager (RevMan.) Version 5.4.1 for statistics analysis. Primary outcomes included Hamilton scale for depression (HAMD), self-rating depression scale (SDS), and the effective rate of depression. Secondary outcomes included frequency of angina pectoris and visual analogue scale (VAS) scores for angina pain.

Results

A total of 2,366 studies were screened based on the search strategy. Twelve eligible studies with a total of 1,203 participants have been identified. The result showed that acupuncture reduced the HAMD score [weighted mean difference (WMD): -3.23; 95% confidence interval (CI): -5.38 to -1.09; P = 0.003] and the SDS score (WMD: -1.85; 95% CI: -2.14 to -1.56; P < 0.00001) in patients with depression complicated with CVD. Acupuncture also improved the effective rate of depression (risk ratio: 1.15; 95% CI: 1.03 to 1.29; P = 0.01). The result also showed that acupuncture reduced the attack frequency of angina pectoris (WMD: -4.54; 95% CI: -5.96 to -3.11; P < 0.00001) and the VAS score for angina pain (WMD: -0.72; 95% CI: -1.06 to -0.38; P < 0.0001). This article reviewed the significant advantages of acupuncture for depression and the superiority of acupuncture over no-intervention therapy, antidepressant therapy, and psychotherapy in reducing angina frequency and pain intensity in patients with CVD.

Conclusion

This systematic review suggested that acupuncture was a good complementary and alternative therapy for CVD complicated with depression. Considering the limitations of the included research literature, it is still necessary to perform multi-center, large-sample, and double-blind high-quality studies to provide higher-level evidence in the later stage.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022304957].

Loneliness, social network size and mortality in older adults: a meta-analysis

Loneliness and social network size have been found to be predictors of mortality in older adults. The objective of this study was to investigate whether loneliness and small social network size are associated with an increased mortality risk and to review the evidence for either network size, or loneliness that constitutes the higher mortality risk. A systematic literature search was performed in PubMed, EMBASE and PsychInfo in January/February 2018 and March/April 2021. Studies that mentioned outcome data were included in the meta-analysis and coded using the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. The meta-analysis showed that both loneliness and small social network size are associated with mortality risk in older adults (Hazard Ratio 1.10 (95% Confidence Interval 1.06-1.14) for loneliness and 0.96 (95% Confidence Interval 0.93-0.99) for larger network size). Sensitivity analyses according to the Newcastle-Ottawa Quality Assessment Scale yielded varying results. Heterogeneity was large. In conclusion, both loneliness and small social network size in older adults are associated with increased mortality, although the effect size is small. Targeting subjective and objective aspects of older adults' social contacts should be on the agenda of preventive as well as personalized medicine. In order to be able to compare the association between loneliness and network size and mortality, more studies are needed that include both these risk factors.

Persistence of Depressive Symptoms and Risk of Incident Cardiovascular Disease With and Without Diabetes: Results from the REGARDS Study

BACKGROUND

Baseline depressive symptoms are associated with subsequent adverse cardiovascular (CV) events in subjects with and without diabetes but the impact of persistent symptoms vs. improvement remains controversial.

OBJECTIVE

Examine long-term changes in depressive symptoms in individuals with and without diabetes and the associated risk for adverse CV events.

DESIGN

REGARDS is a prospective cohort study of CV risk factors in 30,000 participants aged 45 years and older.

PARTICIPANTS

N = 16,368 (16.5% with diabetes mellitus) who remained in the cohort an average of 11.1 years later and who had complete data.

MAIN MEASURES

Depressive symptoms were measured using the 4-item Centers for Epidemiologic Study of Depression (CES-D) questionnaire at baseline and again at a mean follow-up of 5.07 (SD = 1.66) years. Adjudicated incident stroke, coronary heart disease (CHD), CV mortality, and a composite outcome were assessed in a subsequent follow-up period of 6.1 (SD = 2.6) years.

METHODS

The association of changes in depressive symptoms (CES-D scores) across 5 years with incident CV events was assessed using Cox proportional hazards modeling.

KEY RESULTS

Compared to participants with no depressive symptoms at either time point, participants without diabetes but with persistently elevated depressive symptoms at both baseline and follow-up demonstrated a significantly increased risk of incident stroke (HR (95% CI) = 1.84 (1.03, 3.30)), a pattern which was substantially more prevalent in blacks (HR (95% CI) = 2.64 (1.48, 4.72)) compared to whites (HR (95% CI) = 1.06 (0.50, 2.25)) and in those not taking anti-depressants (HR (95% CI) = 2.01 (1.21, 3.35)) in fully adjusted models.

CONCLUSIONS

The persistence of depressive symptoms across 5 years of follow-up in participants without diabetes identifies individuals at increased risk for incident stroke. This was particularly evident in black participants and among those not taking anti-depressants.

Screening for Psychological Distress and Risk of Cardiovascular Disease and Related Mortality: A SYSTEMATIZED REVIEW, META-ANALYSIS, AND CASE FOR PREVENTION

BACKGROUND

Psychological distress-elevated symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), or psychosocial stress-has been associated with risk for cardiovascular disease (CVD). Despite increasing attention to the importance of these factors for CVD prevention, the state of this science requires updated synthesis to enable practice recommendations. Moreover, it is unknown whether psychological distress based on screeners, validated self-report instruments that efficiently identify those who may require mental health services or additional support, is associated with incident CVD.

METHODS

MEDLINE, Embase, and PsycInfo were searched for studies published 2017-2022, including adults without a past psychiatric diagnosis, who were screened at baseline for depression, anxiety, PTSD, stress, or general mental health symptoms, and followed for >6 mo to determine their risk for incident CVD (ie, atrial fibrillation, acute coronary syndrome, coronary heart disease, peripheral vascular disease, heart failure, or a composite). A meta-analysis was used to aggregate results to determine whether clinically significant levels of psychological distress were associated with CVD onset.

RESULTS

The search identified 28 investigations that represented 658 331 participants (58% women). Fifteen studies had adequate data for the primary meta-analysis, which indicated that those reporting high psychological distress showed a 28% greater risk of incident CVD compared with those with low or no distress.

CONCLUSIONS

Rapid screening for psychological distress is a helpful and efficient approach to understanding the CVD risk profile of an individual. Additional investigations are needed to improve prospective evidence concerning psychosocial stress. Conducting analyses by sex may better elucidate the benefits of psychological distress screening for men and women, respectively, and encourage more widespread adoption in CVD prevention.

Frailty Index and Cardiovascular Disease among Middle-Aged and Older Chinese Adults: A Nationally Representative Cross-Sectional and Follow-Up Study

Evidence for the association between the frailty index and cardiovascular disease (CVD) is inconclusive, and this association has not been evaluated in Chinese adults. We aim to examine the association between the frailty index and CVD among middle-aged and older Chinese adults. We conducted cross-sectional and cohort analyses using nationally representative data from the China Health and Retirement Longitudinal Study (CHARLS). From 2011 to 2018, 17,708 participants aged 45 years and older were included in the CHARLS. The primary outcome was CVD events (composite of heart disease and stroke). Multivariable adjusted logistic regression and Cox proportional hazards models were used to estimate the association between the frailty index and CVD in cross-sectional and follow-up studies, respectively. A restricted cubic spline model was used to characterize dose−response relationships. A total of 16,293 and 13,580 participants aged 45 years and older were included in the cross-sectional and cohort analyses, respectively. In the cross-sectional study, the prevalence of CVD in robust, pre-frailty and frailty was 7.83%, 18.70% and 32.39%, respectively. After multivariable adjustment, pre-frailty and frailty were associated with CVD; ORs were 2.54 (95% confidence interval [CI], 2.28−2.84) and 4.76 (95% CI, 4.10−5.52), respectively. During the 7 years of follow-up, 2122 participants without previous CVD developed incident CVD; pre-frailty and frailty were associated with increased risk of CVD events; HRs were 1.53 (95% CI, 1.39−1.68) and 2.17 (95% CI, 1.88−2.50), respectively. Furthermore, a stronger association of the frailty index with CVD was observed in participants aged <55, men, rural community-dwellers, BMI ≥ 25, without hypertension, diabetes or dyslipidemia. A clear nonlinear dose−response pattern between the frailty index and CVD was widely observed (p < 0.001 for nonlinearity), the frailty index was above 0.08, and the hazard ratio per standard deviation was 1.18 (95% CI 1.13−1.25). We observed the association between the frailty index and CVD among middle-aged and elderly adults in China, independent of chronological age and other CVD risk factors. Our findings are important for prevention strategies aimed at reducing the growing burden of CVD in older adults.

Prospective bidirectional associations between depression and chronic kidney diseases

Previous studies had reported the mutual relation between depression and chronic kidney diseases (CKD). This study aimed to investigate potential bidirectional relationships between depression and CKD. Participants more than 45 years from the China Health and Retirement Longitudinal Study (CHARLS) were included in present study. In study I, we tended to assess the association between baseline depression with the risk of subsequent CKD. In study II, we aimed to examine whether the onset of CKD could predict the development of depression. Multivariate logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) in study I and study II, respectively. In study I, 301 (6.16%) respondents experienced CKD in participants without depression, and 233 (8.48%) respondents experienced CKD in participants with depression. Participants with depression had higher risk of developing CKD with the corresponding ORs (95% CIs) was 1.38(1.08-1.76). In study II, 1333 (22.29%) subjects in the non-CKD group and 97 (27.17%) in CKD group developed depressive symptoms. Individuals with CKD had higher risk of developing depression than those without CKD, with the multivariate ORs (95% CIs) was 1.48(1.23-1.78). Significant bidirectional relationships remained in both sensitivity and subgroup analyses. Findings demonstrate bidirectional relationships between depression and CKD. Individuals with depression were associated with increasing risk of CKD; in addition, CKD patients had higher risk of developing depression.

Association Between Depression and Risk of Incident Cardiovascular Diseases and Its Sex and Age Modifications: A Prospective Cohort Study in Southwest China

To examine possible associations between depression and cardiovascular disease (CVD) incidence and whether demographic factors modified those associations in the Chinese population. This prospective cohort study comprised 7,735 adults aged 18 years or older in Guizhou, China from 2010 to 2020. The Patient Health Questionnaire-9 (PHQ-9) was used to measure the prevalence of depression. Cox proportional hazard models were used to estimated hazard ratios (HRs) and 95% confidence intervals (95%CIs) of depression and incident CVD. We identified 215 CVD cases (including 28 acute myocardial infarction (AMI) and 197 stroke cases) during an average follow-up of 7.07 years. In the multivariable-adjusted model, baseline PHQ-9 score was associated with incident CVD, AMI, and stroke. The HR per 1-SD increase for PHQ-9 score was 1.14 (95%CI: 1.03, 1.26) for CVD, 1.26 (95%CI: 1.01, 1.57) for AMI, and 1.12 (95%CI: 1.01, 1.25) for stroke. Compared with participants without depression, those with any mild or more advanced depression had a higher risk of incident CVD (HR: 1.69, 95%CI: 1.08, 2.64) and AMI (HR: 3.36, 95%CI: 1.17, 10.56). Associations between depression with CVD and stroke were suggested to be even stronger among women and participants aged <65 years (P for interaction <0.05). The effect of depression on stroke tended to be preserved in non-smokers. Depression was associated with a higher risk of incident CVD, AMI, and stroke in adults of Southwest, China, particularly in women, participants aged <65 years, and non-smokers. These findings highlighted the importance and urgency of depression healthcare.

Longitudinal association between muscle strength and depression in middle-aged and older adults: A 7-year prospective cohort study in China

BACKGROUND

Evidence regarding the associations between muscle strength in different parts of the body and depression is lacking. This study examined whether poor muscle strength is associated with a higher incidence of depression in a large cohort of middle-aged and older adults.

METHODS

In total, 5,228 middle-aged and older adults from the China Health and Retirement Longitudinal Study without depression at baseline were followed for 7 years. Their demographic characteristics, chronic diseases and lifestyle behaviors were assessed. After adjusting for relevant variables, a Cox regression was used to determine the relationship between muscle strength and incident depression.

RESULTS

Over 32,544 person-years of follow-up, 1,490 participants developed depression. Low muscle strength at baseline was associated with a higher 7-year incident of depression, even after excluding those who developed depression within 2 years. After adjusting for confounding factors, it was found that a higher baseline relative handgrip strength was a protective factor against depression (HR [95% CI]=0.575 [0.430-0.768] for the lowest quartile vs. the highest quartile; p<0.001). Longer times on the 5TSTS test were a risk factor for depression (HR [95% CI]=1.321 [1.077-1.621] for the lowest quartile vs. the highest quartile; p = 0.007). When the strengths of the upper and lower limbs were considered together, the hazard ratio for depression in people with relatively greater muscle strength was 0.463 (95% CI=0.307-0.699; p<0.001).

CONCLUSIONS

Muscle strength could be predictive of depression, and the combined measurement of upper and lower limb muscle strength can improve the predictive ability.

The association between pulmonary function and depression in middle-aged and elderly people in China: The role of cognitive ability and sleep time

BACKGROUND

Depression is a common mental disorder in middle-aged and elderly people, which seriously affects their physical health and life quality.So far, whether pulmonary function is a factor in depression has not been tested.The purpose of this study was to test whether pulmonary function was independently associated with depression and to assess the effects of cognitive ability and sleep time on this association.

METHODS

In this analysis, 5,235 participants from the Chinese Longitudinal Study of Health and Retirement were included. Participants were registered in 2015 and followed up in 2018. The relationship between pulmonary function and depression was estimated by binary logistic regression model. The mediated role of cognitive ability was examined by intermediary analysis, and the interaction between pulmonary function and sleep time on depression was discussed.

RESULTS

After adjusting for confounding factors, it was found that higher baseline pulmonary function was the protective factor of depression (OR [95%CI]=0.524 [0.394-0.697] for the lowest quantile vs the highest quantile). Cognitive ability explained 14.55% of the association between pulmonary function and depression, pulmonary function and sleep time on the effects of depression have a combined interaction, RERI (95%CI) = 0.545 (0.053-1.038).

CONCLUSIONS

High baseline pulmonary function is independently associated with a lower risk of depression, which is partly mediated by cognitive ability. Pulmonary function and sleep time have synergy with the effects of depression. These findings show that pulmonary function, cognitive ability and sleep time are reliable predictors of depression.

Dietary Intake of Flavonoids and Carotenoids Is Associated with Anti-Depressive Symptoms: Epidemiological Study and In Silico-Mechanism Analysis

Flavonoids and carotenoids are bioactive compounds that have protective effects against depressive symptoms. Flavonoids and carotenoids are the two main types of antioxidant phytochemicals. This study investigated the association between flavonoid and carotenoid intake and depressive symptoms in middle-aged Korean females. We analyzed the mechanism of these associations using an in silico method. Depressive symptoms were screened using the Beck Depression Inventory-II (BDI-II), and flavonoid and carotenoid intake were assessed using a semi-quantitative food frequency questionnaire. Using a multivariate logistic regression model, we found that flavones, anthocyanins, individual phenolic compounds, lycopene, and zeaxanthin were negatively associated with depressive symptoms. In silico analysis showed that most flavonoids have high docking scores for monoamine oxidase A (MAOA) and monoamine oxidase B (MAOB), which are two important drug targets in depression. The results of the docking of brain-derived neurotrophic factor (BDNF) and carotenoids suggested the possibility of allosteric activation of BDNF by carotenoids. These results suggest that dietary flavonoids and carotenoids can be utilized in the treatment of depressive symptoms.

Trajectories of depressive symptoms and risk of cardiovascular disease: Evidence from the China Health and Retirement Longitudinal Study

BACKGROUND

Previous studies have reported that depression is associated with higher risk of cardiovascular disease (CVD). However, the association between long-term depressive symptom patterns and the risk of CVD was not well characterized.

METHODS

A total of 8621 participants with three Center for Epidemiological Studies Depression Scale (CES-D) measurements from the China Health and Retirement Longitudinal Study were included. Trajectories of depressive symptoms were identified by latent mixture modeling. Cox proportional hazards regression models were used to examine the association of depressive symptom trajectories with CVD (stroke or cardiac events), and accounting for mortality as a competing risk for CVD.

RESULTS

We identified four distinct depressive symptoms trajectories, characterized by maintaining low CES-D score throughout the follow-up (no depressive symptoms; 5642 participants [65.44%]); high starting CES-D scores but then decreasing scores (decreasing depressive symptoms; 1329 participants [14.91%]); low starting CES-D scores then increasing scores (increasing depressive symptoms; 1154 participants [13.39%]) and maintained high CES-D scores throughout the follow-up (persistent depressive symptoms; 496 participants [6.26%]). During the follow-up period, 853 CVD events (including 362 strokes and 535 cardiac events) were recorded. Compared to participants in the no depressive symptom trajectory, those in the increasing depressive symptoms and persistent depressive symptom trajectories had an increased risk of CVD, with multiple-adjusted hazard ratios (95% confidence intervals) of 1.53 (1.28-1.82) and 1.68 (1.34-2.12), respectively. Individuals with increasing and persistent depressive symptoms trajectories also had higher risks of stroke and cardiac events.

CONCLUSIONS

Individuals with increasing and persistent depressive symptom over time were associated with increased risk of incident CVD.

Prospective increases in depression symptoms and markers of inflammation increase coronary heart disease risk - The Whitehall II cohort study

OBJECTIVE

Stress, inflammation, and depression are associated to coronary heart disease (CHD). However, how these constructs collectively contribute to CHD incidence is not well understood. For the first time, this study explored the concurrent relationship between workplace stress, depression symptomology and levels of low-grade inflammation with future CHD incidence.

METHODS

Data from the 5-year intervals at phase 5, 7, and 9 of the Whitehall II study (N = 8348, M_age = 56) provided measures of workplace stress, depression symptomology, inflammation (interleukin-6, C-reactive protein, fibrinogen), and CHD incidence. The proposed stress-inflammation-depression-CHD pathway was assessed with a longitudinal design incorporating a structural equation model (SEM) that measured if changes in stress, depression, and inflammation between phase 5 to phase 7 predicted first-time CHD events between phases 7 and 9.

RESULTS

The SEM empirically supported this proposed pathway and demonstrated excellent model fit, χ (72) = 3582.959, p < .001, CFI = 0.896, RMSEA = 0.076 (CI₉₀ = 0.074, 0.079), while depression symptoms mediated the association between workplace stress and CHD incidence, B = 0.003 (CI₉₀ = 0.001, 0.004). Further, survival analysis indicated that individuals with higher mean scores (across phases) of depression symptoms or fibrinogen levels were more likely to experience a first time CHD event.

CONCLUSIONS

Increases in depression symptoms and fibrinogen levels may be good indicators of future CHD morbidity among older employees. Future research is encouraged to monitor negative affective states and the potential use of biobehavioural options to reduce depression and inflammation that may mitigate CHD risk.

Loneliness, social network size, and mortality in older adults and the role of cortisol

BACKGROUND

Loneliness and social isolation have both been found to be associated with increased mortality in previous studies. One potential underlying mechanism is via the hypothalamic-pituitary-adrenal axis.

OBJECTIVE

This study aimed to examine the association between social network size and cortisol, to analyze the associations between both loneliness and social network size and mortality, and to examine to what extent the association between network size and/or loneliness and mortality is mediated by cortisol.

DESIGN

The study group consisted of 443 depressed and non-depressed participants of the Netherlands Study of Depression in the Elderly (NESDO). Cross-sectional analysis of the association between social network size and cortisol measures was followed by a survival analysis of the associations between both social network size and loneliness and mortality.

RESULTS

There were no significant associations between social network size and cortisol measures. Loneliness and small social network size were not associated with mortality. Age and partner status were more important predictors of mortality.

CONCLUSION

As people grow older the variety of factors that influence mortality risk increases, diminishing the effect of a single factor. Prevention of early morbidity and mortality in older adults should be tailored to specific needs and risks, instead of aiming at one specific factor.

The Acute Effects of Aerobic Exercise on Nocturnal and Pre-Sleep Arousal in Patients with Unipolar Depression: Preplanned Secondary Analysis of a Randomized Controlled Trial

Unipolar depression is associated with insomnia and autonomic arousal. The aim of this study was to quantify the effect of a single bout of aerobic exercise on nocturnal heart rate variability and pre-sleep arousal in patients with depression. This study was designed as a two-arm, parallel-group, randomized, outcome assessor-blinded, controlled, superiority trial. Patients with a primary diagnosis of unipolar depression aged 18-65 years were included. The intervention consisted of a single 30 min moderate-intensity aerobic exercise bout. The control group sat and read for 30 min. The primary outcome of interest was RMSSD during the sleep period assessed with polysomnography. Secondary outcomes were additional heart rate variability outcomes during the sleep and pre-sleep period as well as subjective pre-sleep arousal. A total of 92 patients were randomized to either the exercise (N = 46) or the control (N = 46) group. Intent-to-treat analysis ANCOVA of follow-up sleep period RMSSD, adjusted for baseline levels and minimization factors, did not detect a significant effect of the allocation (β = 0.12, p = 0.94). There was no evidence for significant differences between both groups in any other heart rate variability measure nor in measures of cognitive or somatic pre-sleep arousal. As this is the first trial of its kind in this population, the findings need to be confirmed in further studies. Patients with depression should be encouraged to exercise regularly in order to profit from the known benefits on sleep and depressive symptoms, which are supported by extensive literature.

Waist-to-height ratio, waist circumference, body mass index, waist divided by height0.5 and the risk of cardiometabolic multimorbidity: A national longitudinal cohort study

BACKGROUND AND AIMS

Cardiometabolic multimorbidity (CM) is an increasing public health burden. This study aimed to evaluate the association of waist-to-height ratio (WHtR), waist circumference (WC), waist divided by height^0.5 (WHT.5R) and body mass index (BMI) with the risk of CM.

METHODS AND RESULTS

We used data from the China Health and Retirement Longitudinal Study (CHARLS). A total of 10,521 participants aged 45 years and over were recruited, including 8807 individuals with 0 cardiometabolic diseases at baseline (stage I) and 1714 individuals with 1 cardiometabolic disease at baseline (stage II). CM was defined as self-reporting of two or more of the following conditions: stroke, diabetes and heart disease. Logistic regression was conducted to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). The net reclassification index (NRI) and integrated discrimination improvement (IDI) were used to evaluate the incremental predictive value beyond conventional factors. In stage I, an increased risk of CM was observed among participants with WHtR ≥0.5 (OR: 1.76, 95% CI: 1.05-2.97), WC ≥ 90 cm (men) + WC ≥ 80 cm (women) (OR: 2.06, 95% CI: 1.29-3.27), WHT.5R ≥ 6.54 cm^0.5 (OR: 1.81, 95% CI: 1.16-2.83) or BMI ≥24 kg/m² (OR: 1.48, 95% CI: 0.98-2.24). Furthermore, the NRI and IDI of WHtR, WC and WHT.5R were all higher than those of BMI. In stage II, the adjusted ORs (95% CIs) of WHtR, WC, WHT.5R and BMI were 2.04 (1.24-3.35), 1.89 (1.29-2.77), 1.86 (1.24-2.78) and 1.47 (1.06-2.04), respectively. In addition, WC exhibited the highest NRI and IDI.

CONCLUSION

WHtR, WC, WHT.5R and BMI are independent predictors of CM in the middle-aged and older Chinese population. WHtR, WC and WHT.5R show better abilities in predicting CM than BMI.

The longitudinal relation between depressive symptoms and change in self-rated health: A nationwide cohort study

OBJECTIVE

This study aimed to prospectively assess the relationship between depressive symptoms and change in self-rated health (SRH) in middle-aged and elderly Chinese adults.

METHODS

We used data from the China Health and Retirement Longitudinal Study (CHARLS). The final analysis included 8169 participants (≥45 years old) and a multinomial logistic regression model was used to assess the association between baseline depression and follow-up change in SRH.

RESULTS

Taking no change in SRH as the reference, depressive symptoms at baseline were positively associated with a 2-year decline in SRH (OR: 1.38, 95% CI: 1.15-1.65) and negatively associated with a 2-year improvement in SRH (OR: 0.74, 95% CI: 0.63-0.85). Over a 4-year period, the OR (95% CI) values increased to 1.41 (1.19-1.67) and decreased to 0.69 (0.59-0.80) for decline and improvement in SRH, respectively. In stratified analyses, the association between depression and 2- or 4-year decline/improvement in SRH persisted in all sex and age subgroups.

CONCLUSIONS

Baseline depression is an independent predictor of change in SRH among Chinese people aged 45 and above. Early monitoring and management of depressive symptoms may be worthwhile to maintain and improve SRH in the middle-aged and elderly population.

Factors associated with return to work following myocardial infarction: A systematic review of observational studies

OBJECTIVES

To identify and critically synthesise literature on return to work of patients following a myocardial infarction and to identify factors that are associated with this.

BACKGROUND

Understanding when patients return to work after myocardial infarction and what factors are associated with this may be helpful in designing person-centred treatment plans to facilitate patients' rehabilitation and return to work.

DESIGN

A narrative systematic review.

REVIEW METHODS

Six databases, MEDLINE, CINAHL, Academic Search Complete, EMBASE, SCOPUS and ProQuest Health and Medicine, and the search engine Google were searched to retrieve peer-reviewed articles published in English from January 2008-January 2020. In total, 22,217 papers were sourced and screened, with 18 papers retained for quality appraisal using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

The mean time to return to work varied between 46-192 days; about half the participants resumed work by 3 months. Patients who were male, younger, educated, non-manual workers or owned their own business, and those who evaluated their general and mental health highly, and had shorter hospitalisation, fewer comorbidities, complications and mental health issues were more likely to return to work after myocardial infarction.

RELEVANCE TO CLINICAL PRACTICE

Findings may help nurses detect patients at increased risk of failure to return to work and provide appropriate support to facilitate this.