Association of Symptoms of Depression With Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries | Cardiology | JAMA Psychiatry | JAMA Network
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1.
Griggs  D, Stafford-Smith  M, Gaffney  O,  et al.  Policy: Sustainable development goals for people and planet.   Nature. 2013;495(7441):305-307. doi:10.1038/495305aPubMedGoogle ScholarCrossref
2.
Correll  CU, Solmi  M, Veronese  N,  et al.  Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls.   World Psychiatry. 2017;16(2):163-180. doi:10.1002/wps.20420PubMedGoogle ScholarCrossref
3.
Chida  Y, Hamer  M, Wardle  J, Steptoe  A.  Do stress-related psychosocial factors contribute to cancer incidence and survival?   Nat Clin Pract Oncol. 2008;5(8):466-475. doi:10.1038/ncponc1134PubMedGoogle Scholar
4.
Jia  Y, Li  F, Liu  YF, Zhao  JP, Leng  MM, Chen  L.  Depression and cancer risk: a systematic review and meta-analysis.   Public Health. 2017;149:138-148. doi:10.1016/j.puhe.2017.04.026PubMedGoogle Scholar
5.
Walker  ER, McGee  RE, Druss  BG.  Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis.   JAMA Psychiatry. 2015;72(4):334-341. doi:10.1001/jamapsychiatry.2014.2502PubMedGoogle Scholar
6.
Charlson  FJ, Moran  AE, Freedman  G,  et al.  The contribution of major depression to the global burden of ischemic heart disease: a comparative risk assessment.   BMC Med. 2013;11(1):250. doi:10.1186/1741-7015-11-250PubMedGoogle Scholar
7.
Liu  N, Pan  XF, Yu  C,  et al; China Kadoorie Biobank Collaborative Group.  Association of major depression with risk of ischemic heart disease in a mega-cohort of Chinese adults: the China Kadoorie Biobank Study.   J Am Heart Assoc. 2016;5(12):1-9. doi:10.1161/JAHA.116.004687PubMedGoogle Scholar
8.
Sun  J, Ma  H, Yu  C,  et al; China Kadoorie Biobank Collaborative Group.  Association of major depressive episodes with stroke risk in a prospective study of 0.5 million Chinese adults.   Stroke. 2016;47(9):2203-2208. doi:10.1161/STROKEAHA.116.013512PubMedGoogle Scholar
9.
Patel  V, Saxena  S, Lund  C,  et al.  The Lancet Commission on global mental health and sustainable development.   Lancet. 2018;392(10157):1553-1598. doi:10.1016/S0140-6736(18)31612-XPubMedGoogle Scholar
10.
Global Health Data Exchange. GBD results tool. Accessed February 3, 2019. http://ghdx.healthdata.org/gbd-results-tool
11.
Stapelberg  NJC, Neumann  DL, Shum  DHK, McConnell  H, Hamilton-Craig  I.  A topographical map of the causal network of mechanisms underlying the relationship between major depressive disorder and coronary heart disease.   Aust N Z J Psychiatry. 2011;45(5):351-369. doi:10.3109/00048674.2011.570427PubMedGoogle Scholar
12.
Demyttenaere  K, Bruffaerts  R, Posada-Villa  J,  et al; WHO World Mental Health Survey Consortium.  Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.   JAMA. 2004;291(21):2581-2590. doi:10.1001/jama.291.21.2581PubMedGoogle Scholar
13.
World Health Organization.  Mental Health Action Plan 2013-2020. World Health Organization; 2015.
14.
World Health Organization, WONCA.  Integrating Mental Health Into Primary Care: a Global Perspective. WHO ; 2008.
15.
Lund  C, Tomlinson  M, De Silva  M,  et al.  PRIME: a programme to reduce the treatment gap for mental disorders in five low- and middle-income countries.   PLoS Med. 2012;9(12):e1001359. doi:10.1371/journal.pmed.1001359PubMedGoogle Scholar
16.
World Health Organization.  MhGAP Mental Health Gap Action Programme. World Health Organization; 2013.
17.
Purtle  J, Nelson  KL, Yang  Y, Langellier  B, Stankov  I, Diez Roux  AV.  Urban-rural differences in older adult depression: a systematic review and meta-analysis of comparative studies.   Am J Prev Med. 2019;56(4):603-613. doi:10.1016/j.amepre.2018.11.008PubMedGoogle Scholar
18.
Pridmore  P, Thomas  L, Havemann  K, Sapag  J, Wood  L.  Social capital and healthy urbanization in a globalized world.   J Urban Health. 2007;84(3)(suppl):i130-i143. doi:10.1007/s11524-007-9172-8PubMedGoogle Scholar
19.
Reddy  KS.  Cardiovascular diseases in the developing countries: dimensions, determinants, dynamics and directions for public health action.   Public Health Nutr. 2002;5(1A):231-237. doi:10.1079/PHN2001298PubMedGoogle Scholar
20.
Teo  K, Chow  CK, Vaz  M, Rangarajan  S, Yusuf  S; PURE Investigators-Writing Group.  The Prospective Urban Rural Epidemiology (PURE) study: examining the impact of societal influences on chronic noncommunicable diseases in low-, middle-, and high-income countries.   Am Heart J. 2009;158(1):1-7.e1. doi:10.1016/j.ahj.2009.04.019PubMedGoogle Scholar
21.
Yusuf  S, Joseph  P, Rangarajan  S,  et al.  Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.  Lancet. 2020;395(10226):795-808. doi:10.1016/S0140-6736(19)32008-2Google Scholar
22.
Kessler  RC, Ustün  TB.  The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI).   Int J Methods Psychiatr Res. 2004;13(2):93-121. doi:10.1002/mpr.168PubMedGoogle Scholar
23.
Rosengren  A, Hawken  S, Ounpuu  S,  et al; INTERHEART investigators.  Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study.   Lancet. 2004;364(9438):953-962. doi:10.1016/S0140-6736(04)17019-0PubMedGoogle Scholar
24.
World Health Organization. Composite International Diagnostic Interview, Version 1.0. Geneva: World Health Organization, 1990.
25.
Kessler  RC, Andrews  G, Mroczek  D, Ustun  B, Wittchen  H-U.  The World Health Organization Composite International Diagnostic Interview short-form (CIDI-SF).   Int J Methods Psychiatr Res. 1998;7:171-185. doi:10.1002/mpr.47Google Scholar
26.
Patten  SB, Brandon-Christie  J, Devji  J, Sedmak  B.  Performance of the composite international diagnostic interview short form for major depression in a community sample.   Chronic Dis Can. 2000;21(2):68-72.PubMedGoogle Scholar
27.
Berkman  LF, Syme  SL.  Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents.   Am J Epidemiol. 1979;109(2):186-204. doi:10.1093/oxfordjournals.aje.a112674PubMedGoogle Scholar
28.
McCullough  ML, Feskanich  D, Stampfer  MJ,  et al.  Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance.   Am J Clin Nutr. 2002;76(6):1261-1271. doi:10.1093/ajcn/76.6.1261PubMedGoogle Scholar
29.
Gupta  R, Islam  S, Mony  P,  et al.  Socioeconomic factors and use of secondary preventive therapies for cardiovascular diseases in South Asia: The PURE study.   Eur J Prev Cardiol. 2015;22(10):1261-1271. doi:10.1177/2047487314540386PubMedGoogle Scholar
30.
Bromet  E, Andrade  LH, Hwang  I,  et al.  Cross-national epidemiology of DSM-IV major depressive episode.   BMC Med. 2011;9(1):90. doi:10.1186/1741-7015-9-90PubMedGoogle Scholar
31.
Moise  N, Khodneva  Y, Jannat-Khah  DP,  et al.  Observational study of the differential impact of time-varying depressive symptoms on all-cause and cause-specific mortality by health status in community-dwelling adults: the REGARDS study.   BMJ Open. 2018;8(1):e017385. doi:10.1136/bmjopen-2017-017385PubMedGoogle Scholar
32.
Gan  Y, Gong  Y, Tong  X,  et al.  Depression and the risk of coronary heart disease: a meta-analysis of prospective cohort studies.   BMC Psychiatry. 2014;14(1):371. doi:10.1186/s12888-014-0371-zPubMedGoogle Scholar
33.
Pan  A, Sun  Q, Okereke  OI, Rexrode  KM, Hu  FB.  Depression and risk of stroke morbidity and mortality: a meta-analysis and systematic review.   JAMA. 2011;306(11):1241-1249. doi:10.1001/jama.2011.1282PubMedGoogle Scholar
34.
Gustad  LT, Laugsand  LE, Janszky  I, Dalen  H, Bjerkeset  O.  Symptoms of anxiety and depression and risk of acute myocardial infarction: the HUNT 2 study.   Eur Heart J. 2014;35(21):1394-1403. doi:10.1093/eurheartj/eht387PubMedGoogle Scholar
35.
Gustad  LT, Laugsand  LE, Janszky  I, Dalen  H, Bjerkeset  O.  Symptoms of anxiety and depression and risk of heart failure: the HUNT Study.   Eur J Heart Fail. 2014;16(8):861-870. doi:10.1002/ejhf.133PubMedGoogle Scholar
36.
Nabi  H, Kivimäki  M, Suominen  S, Koskenvuo  M, Singh-Manoux  A, Vahtera  J.  Does depression predict coronary heart disease and cerebrovascular disease equally well? the Health and Social Support Prospective Cohort Study.   Int J Epidemiol. 2010;39(4):1016-1024. doi:10.1093/ije/dyq050PubMedGoogle Scholar
37.
Patel  RB, Burke  TF.  Urbanization: an emerging humanitarian disaster.   N Engl J Med. 2009;361(8):741-743. doi:10.1056/NEJMp0810878PubMedGoogle Scholar
38.
Maas  J, Verheij  RA, Groenewegen  PP, de Vries  S, Spreeuwenberg  P.  Green space, urbanity, and health: how strong is the relation?   J Epidemiol Community Health. 2006;60(7):587-592. doi:10.1136/jech.2005.043125PubMedGoogle Scholar
39.
Cuijpers  P, Vogelzangs  N, Twisk  J, Kleiboer  A, Li  J, Penninx  BW.  Is excess mortality higher in depressed men than in depressed women? a meta-analytic comparison.   J Affect Disord. 2014;161:47-54. doi:10.1016/j.jad.2014.03.003PubMedGoogle Scholar
40.
Penninx  BWJH, Geerlings  SW, Deeg  DJH, van Eijk  JTM, van Tilburg  W, Beekman  ATF.  Minor and major depression and the risk of death in older persons.   Arch Gen Psychiatry. 1999;56(10):889-895. doi:10.1001/archpsyc.56.10.889PubMedGoogle Scholar
41.
Sun  WJ, Xu  L, Chan  WM, Lam  TH, Schooling  CM.  Are depressive symptoms associated with cardiovascular mortality among older Chinese: a cohort study of 64,000 people in Hong Kong?   Am J Geriatr Psychiatry. 2013;21(11):1107-1115. doi:10.1016/j.jagp.2013.01.048PubMedGoogle Scholar
42.
Vogt  T, Pope  C, Mullooly  J, Hollis  J.  Mental health status as a predictor of morbidity and mortality: a 15-year follow-up of members of a health maintenance organization.   Am J Public Health. 1994;84(2):227-231. doi:10.2105/AJPH.84.2.227PubMedGoogle Scholar
43.
Adelborg  K, Schmidt  M, Sundbøll  J,  et al.  Mortality risk among heart failure patients with depression: a nationwide population-based cohort study.   J Am Heart Assoc. 2016;5(9):e004137. doi:10.1161/JAHA.116.004137PubMedGoogle Scholar
44.
Aromaa  A, Raitasalo  R, Reunanen  A,  et al.  Depression and cardiovascular diseases.   Acta Psychiatr Scand Suppl. 1994;377(377)(suppl):77-82. doi:10.1111/j.1600-0447.1994.tb05807.xPubMedGoogle Scholar
45.
Ryan  J, Carriere  I, Ritchie  K,  et al.  Late-life depression and mortality: influence of gender and antidepressant use.   Br J Psychiatry. 2008;192(1):12-18. doi:10.1192/bjp.bp.107.039164PubMedGoogle Scholar
46.
Kovess-Masfety  V, Boyd  A, van de Velde  S,  et al; EU-WMH investigators.  Are there gender differences in service use for mental disorders across countries in the European Union? results from the EU-World Mental Health survey.   J Epidemiol Community Health. 2014;68(7):649-656. doi:10.1136/jech-2013-202962PubMedGoogle Scholar
47.
Penninx  BWJH.  Depression and cardiovascular disease: Epidemiological evidence on their linking mechanisms.   Neurosci Biobehav Rev. 2017;74(Pt B):277-286. doi:10.1016/j.neubiorev.2016.07.003PubMedGoogle Scholar
48.
Spiegel  D, Giese-Davis  J.  Depression and cancer: mechanisms and disease progression.   Biol Psychiatry. 2003;54(3):269-282. doi:10.1016/S0006-3223(03)00566-3PubMedGoogle Scholar
49.
Richards  SH, Anderson  L, Jenkinson  CE,  et al.  Psychological interventions for coronary heart disease.   Cochrane Database Syst Rev. 2017;4(April):CD002902. doi:10.1002/14651858.CD002902.pub4PubMedGoogle Scholar
50.
Gallo  JJ, Morales  KH, Bogner  HR,  et al.  Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care.   BMJ. 2013;346:f2570. doi:10.1136/bmj.f2570PubMedGoogle Scholar
51.
Katon  WJ, Lin  EHBB, Von Korff  M,  et al.  Collaborative care for patients with depression and chronic illnesses.   N Engl J Med. 2010;363(27):2611-2620. doi:10.1056/NEJMoa1003955PubMedGoogle Scholar
52.
Lichtman  J, Froelicher  E, Blumenthal  JA,  et al.  Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association.   Circulation. 2014;129(12):1350-1369. doi:10.1161/CIR.0000000000000019Google Scholar
53.
Piepoli  MF, Hoes  AW, Agewall  S,  et al; ESC Scientific Document Group.  2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).   Eur Heart J. 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106PubMedGoogle Scholar
54.
Charlson  FJ, Stapelberg  NJC, Baxter  AJ, Whiteford  HA.  Should global burden of disease estimates include depression as a risk factor for coronary heart disease?   BMC Med. 2011;9:47. doi:10.1186/1741-7015-9-47PubMedGoogle Scholar
55.
Simon  GE, VonKorff  M, Piccinelli  M, Fullerton  C, Ormel  J.  An international study of the relation between somatic symptoms and depression.   N Engl J Med. 1999;341(18):1329-1335. doi:10.1056/NEJM199910283411801PubMedGoogle Scholar
56.
World Health Organization.  Depression and Other Common Mental Disorders: Global Health Estimates. World Health Organization; 2017.
57.
Dalton  SO, Schüz  J, Engholm  G,  et al.  Social inequality in incidence of and survival from cancer in a population-based study in Denmark, 1994-2003: summary of findings.   Eur J Cancer. 2008;44(14):2074-2085. doi:10.1016/j.ejca.2008.06.018PubMedGoogle Scholar
58.
Gross  AL, Gallo  JJ, Eaton  WW.  Depression and cancer risk: 24 years of follow-up of the Baltimore Epidemiologic Catchment Area sample.   Cancer Causes Control. 2010;21(2):191-199. doi:10.1007/s10552-009-9449-1PubMedGoogle Scholar
59.
United Nations Department of Economic and Social Affairs.  World Urbanization Prospects: The 2018 Revision, Highlights. United Nations; 2018.
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    1 Comment for this article
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    Depression, incident cardiovascular disease, and all-cause mortality
    Tomoyuki Kawada, MD | Nippon Medical School
    Rajan et al. conducted a prospective study to investigate the association between depression and incident cardiovascular disease (CVD) and all-cause mortality in countries with different levels of economic developments (1). Adults with depressive symptoms were significantly associated with the increased risk of incident CVD and mortality, especially in urban areas and in men. I have some comments about their study.

    First, Many factors can be considered as risk factors of CVD incidence, and depression is one of the psychological risk factors. Furthermore, there exist many mortality risks in patients with depression, including suicide and physical commodities. Epidemiological risk assessment
    of CVD incidence and all-cause mortality should be conducted comprehensively by considering sociodemographic and socioeconomic status. Causal mechanism regarding urbanization and increased risk of CVD or mortality should be specified by further studies.

    Second, Harshfield et al. conducted a pooled prospective analysis to investigate the association between depressive symptoms and CVD incidence (2). Baseline depressive symptoms were significantly associated with subsequent CVD incidence, even symptoms lower than the threshold of clinical depressive disorder. This study presented minimum risk of depressive symptom on subsequent CVD incidence. As the type of CVD and causality of depressive symptoms might be various, stratified analysis by classifying clinical outcomes and cause of depression might be needed.

    Finally, Kabutoya et al. reported that CVD incidence in men was higher in the depression group than in the non-depression group, although there was no difference in women (3). The frequency and severity of depression differ in women and men, and the association between depression and CVD incidence should be considered in each sex. I speculate that difference in working environment and hormonal factors in women and men might influence the association. In any case, further studies are needed.

    References
    1. Rajan S, McKee M, Rangarajan S, et al. Association of Symptoms of Depression With Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries. JAMA Psychiatry 2020;77(10):1052-1063.
    2. Harshfield EL, Pennells L, Schwartz JE, et al. Association Between Depressive Symptoms and Incident Cardiovascular Diseases. JAMA 2020;324(23):2396-2405.
    3. Kabutoya T, Hoshide S, Davidson KW, Kario K. Sex differences and the prognosis of depressive and nondepressive patients with cardiovascular risk factors: the Japan Morning Surge-Home Blood Pressure (J-HOP) study. Hypertens Res 2018;41(11):965-972.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    June 10, 2020

    Association of Symptoms of Depression With Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries

    Author Affiliations
    • 1Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, Tavistock Place, London, United Kingdom
    • 2Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
    • 3Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Sweden
    • 4Eternal Heart Care Centre & Research Institute, Jaipur, India
    • 5Health Action by People, Trivandrum, India
    • 6Department of Medicine, University of Ottawa, Ontario, Canada
    • 7Faculty of Health Sciences, Simon Fraser University, Burnaby, Division of Cardiology, Providence Health Care, Vancouver, British Columbia, Canada
    • 8Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
    • 9University of the Philippines College of Medicine, Manila, Philippines
    • 10Masira Research Institute, Medical School, Universidad de Santander (UDES), FOSCAL, Bucaramanga, Colombia
    • 11Department of Medicine, Universidade de Santo Amaro, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
    • 12Universidad de La Frontera, Temuco, Chile
    • 13Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey
    • 14Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
    • 15Estudios Clínicos Latinoamérica (ECLA), Rosario, Santa Fe, Argentina
    • 16Faculty of Medicine, UiTM, Malaysia
    • 17University of Zimbabwe College of Health Sciences, Department of Physiology, Harare, Zimbabwe
    • 18Department of Medicine, Queen's University, Kingston, Ontario, Canada
    • 19Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
    • 20Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
    • 21Department of Angiology, Wroclaw Medical University, Poland
    • 22Advocate Research Institute, Advocate Health Care, Downers Grove, Illinois
    • 23Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
    • 24Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
    • 25Independent University, Bangladesh, Dhaka, Bangladesh
    • 26National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
    JAMA Psychiatry. 2020;77(10):1052-1063. doi:10.1001/jamapsychiatry.2020.1351
    Key Points

    Question  Does the increased risk of incident cardiovascular disease and mortality in middle-aged adults with depressive symptoms vary across and within countries?

    Findings  In this cohort study from 21 countries and 145 862 participants, cardiovascular events and death increased by 20% in people with 4 or more depressive symptoms compared with people without. The relative risk increased in countries at all economic levels but was more than twice as high in urban than rural areas.

    Meaning  Adults with depressive symptoms experience poor physical health outcomes and increased risk of mortality across the world and in different settings, especially in urban areas.

    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.

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