- Women with depression have an increased risk of developing cardiovascular disease than men.
- Women may be more vulnerable to the physiological effects of depression. Also, women experience hormonal changes later in life, and the cardioprotective effects of estrogen begin to diminish, putting them at a heightened risk for cardiovascular disease.
- There are several limitations of this study. Further research is needed.
A new study shows people with depression have a greater risk of developing cardiovascular disease, but more women experience heart disease due to depression compared to men.
The findings were published March 12 in JACC: Asia.
Researchers examined the relationship between depression and cardiovascular outcomes by analyzing data from the JMDC Claims Database between 2005 and 2022. They found 4,125,720 eligible participants. The median age was 44 years, and 2,370,986 participants were men.
The study found that men with depression were at a 39% increased risk for heart disease whereas women with depression had a 64% increased risk of heart disease.
“This is an interesting study of sex-specific associations between depression and risk for cardiovascular disease in a large sample of Japanese adults,” said Dr. Allison Gaffey, assistant professor of cardiovascular medicine at Yale School of Medicine. “Managing depression seems essential for heart disease prevention. Results add to the evidence in favor of addressing depression—through screening, referral, and treatment—to reduce the risk for heart disease in men and women.”
Gaffey was not involved in the study.
The connection between depression and heart health
There are three main ways that depression and heart disease are connected, according to Dr. Roy C. Ziegelstein, MACP, Professor of Medicine and Vice Dean for Education at Johns Hopkins University School of Medicine.
Ziegelstein was not involved in the study.
First, depression is a risk factor for the development of heart disease, and this study highlights that relationship. Some consider depression a “non-traditional” cardiovascular risk factor, with other, perhaps better known, risk factors being considered “traditional” (e.g., high blood pressure, diabetes, high cholesterol, and cigarette smoking).
Second, heart disease is associated with an increased likelihood of developing or being diagnosed with depression. These two aspects together lead to the description of the relationship between depression and heart disease as “bidirectional”.
Third, individuals with depression after a cardiovascular event (e.g., a heart attack) are at greater risk of poor outcomes, including death, than individuals who have a cardiovascular event and who are not depressed.
“There are several reasons for the existence of this relationship, however one thing to note in particular is that individuals with depression find it more challenging to attend to many activities in life – including many of the activities that are important to prevent and/or treat heart disease – since many things seem to require extra effort and energy that individuals with depression feel they don’t have,” said Ziegelstein.
Ziegelstein also pointed out that people with depression may have more difficulty exercising, eating healthy or taking medications as prescribed.
Also, “there is some evidence that individuals with mental illness – including depression – receive needed treatments for heart disease less frequently than individuals without mental illness, even for heart conditions of similar severity,” Ziegelstein added.
Depression and heart health disparities between men and women
As this study highlights, there are sex-based differences between cardiovascular disease risk and depression. Experts explain potential reasons for this association.
“As women progress to later stages of life (post-menopausal), their cardioprotective effects of estrogen begin to wane and coupled with higher rates of inflammation and stress hormones from depression, leads to the disparity between men and women,” said Dr. Hosam Hmoud, a cardiology fellow at Northwell Lenox Hill Hospital.
Hmoud was not involved in the study.
Gaffey explained, “In general, women are more likely to be depressed than men, and this pattern is seen throughout the lifespan. Women may be more vulnerable to the physiological effects of depression.”
Heart disease is the leading cause of death for both men and women in the U.S., but many people are not aware of this fact.
“Much of the traditional teaching has emphasized that women may be ‘protected’ from heart disease, and for this reason, the actual risk of heart disease may be underestimated by women and health care providers,” Ziegelstein stated.
For example, studies show that many people are unaware that heart disease is the #1 cause of death in women in the United States.
“As a result of this ‘double whammy’ (women and health care providers both underestimating risk), risk factors for heart disease may not receive enough attention in women compared to men, and women may seek medical attention for symptoms later than men,” said Ziegelstein. “This is important because the severity of a heart attack, for example, is directly related to the time from the onset of symptoms to the time the individual seeks medical attention, so if women seek medical attention later, they will be at increased risk.”
Limitations of this study
While this study sheds light on an important health concern, further research is needed. Other factors need to be taken into consideration.
“This sample was based on medical claims information only, so subclinical symptoms of depression were not accounted for, and may be associated with a unique risk for depression. There was no data presented on which individuals received treatment for depression or other psychological conditions. Women-specific factors such as history of pregnancy, [were] not accounted for,” said Gaffey.
Ziegelstein explained several of the study limitations:
Perhaps most importantly, the group of individuals in this study are very different from the typical U.S. adult population. Although racial, ethnic and socioeconomic diversity are not described in this observational study, the claims database “mainly includes employees working for relatively large companies in Japan” and this is likely a much less diverse group of individuals than the typical U.S. adult population. Moreover, there are important differences in the prevalence of traditional risk factors in the population studied here compared to the U.S. adult population.
In addition, the definition of obesity in this study includes many individuals who would be considered overweight but not obese in the United States; despite this, the prevalence of obesity in this study is far less than in the U.S. adult population. Along with the lower prevalence of traditional cardiovascular risk factors compared to the U.S., these traditional risk factors were nearly twice as common in men in this study than in women, raising the possibility that the relative contribution of a non-traditional risk factor like depression might have been more important among the women.
Finally, because this study is observational, it must be remembered that “depression” here is based on a diagnostic code in the database, with no indication of whether the condition is currently affecting the individual, how severe it is, or how long the individual has had that diagnosis. This is important because women are more likely than men to be diagnosed with depression in the United States, however, the prevalence of diagnosed depression was about the same in men and women in this study. That may suggest that the women in this study may have had more severe depression than the men, and that possibility affects the interpretation of these results as well.
Takeaway
A new study shows women with depression have a greater risk of developing cardiovascular disease than men.
According to experts, there are a few potential reasons for the sex-based differences between cardiovascular disease risk and depression. Women may be more vulnerable to the physiological effects of depression. Also, during post-menopausal years, women experience hormonal changes, and the cardioprotective effects of estrogen begin to decrease.
There are numerous limitations of this study. Further research is required.
