Association of Depression With 10-Year and Lifetime Cardiovascular Disease Risk Among US Adults, National Health and Nutrition Examination Survey, 2005–2018

Steven D. Barger, PhD; Gabrielle C. Struve, MA


Prev Chronic Dis. 2022;19(5):e28 

In This Article

Abstract and Introduction


Introduction: Although an association between depression and incident cardiovascular disease (CVD) risk has been established, no US studies have quantified this association using standard primary care assessments or among younger adults who are not routinely screened for CVD risk. We estimated the association of mild and major depression with 1) 10-year atherosclerotic CVD (ASCVD) risk for people aged 40 to 79 years and 2) high lifetime CVD risk prevalence for people aged 20 to 39 years.

Methods: We conducted a cross-sectional analysis of data from the 2005–2018 National Health and Nutrition Examination Survey for adults aged 20 to 39 years (n = 10,588) and adults aged 40 to 79 years (n = 16,848). We used the Patient Health Questionnaire-9 [PHQ-9] to classify no depression (PHQ-9 score, 0–4), mild depression (PHQ-9 score, 5–9) and major depression (PHQ-9 score ≥10).

Results: Among women aged 40 to 79, ASCVD absolute risk was 6.0% for no depression, 6.9% for mild depression, and 7.6% for major depression (P < .001 vs no depression). Among men aged 40 to 79, the corresponding absolute ASCVD risks were 9.9%, 11.1%, and 11.3%, respectively (P < .001 vs no depression). High lifetime CVD risk prevalence for women aged 20 to 39 was 41.9% for no depression, 53.2% for mild depression, and 66.5% for major depression (P < .001 vs no depression). For men aged 20–39 the corresponding high lifetime risk percentages were 53.3%, 64.8%, and 74.4% respectively (P < .001 vs no depression).

Conclusion: Mild and major depression are associated with elevated 10-year ASCVD risk and substantially elevated lifetime CVD risk among younger people ineligible for ASCVD risk assessment. Jointly addressing depression and CVD risk and extending prevention efforts to younger adults are warranted.


Unipolar depression is observed in 7% of the US adult population,[1] is a leading cause of disability,[2] and in 2018 was noted in more than 10 million office visits in the US.[3] Depression is also an established marker of incident cardiovascular disease (CVD) risk,[4,5] the leading cause of death worldwide. Together, depression and CVD are associated with premature death, and both are principal contributors to the rise in disability-adjusted life years observed from 1990 to 2019.[2] Alleviating depression and reducing CVD risk are therefore paramount for public health, and the prevalence and comorbidity of these conditions underscore the importance of considering them together. This consideration can be facilitated by characterizing the association of depression with CVD risk while risk modification is possible (ie, among people free of clinical CVD).

Although primary care depression screening is recommended in the US,[6] heterogeneous depression screening assessments are a barrier to reliably characterizing the magnitude of the depression–CVD risk association and to establishing a harmonized clinical and public health infrastructure to treat and prevent these conditions.[7] Many different depression assessments exist, and these differences create uncertainty regarding the association of depression with CVD risk. For example, some popular depression assessments do not align with clinical diagnostic criteria (eg, loneliness is an item in the Center for Epidemiological Studies Depression scale). Standardized, validated assessments, particularly those widely used in research and practice,[8] reduce uncertainty and permit harmonization of depression assessments in patient registries and clinical care.[7,9] The recommended depression assessment standard is the Patient Health Questionnaire (PHQ-9).[10] The PHQ-9 is brief, is self-administered, has excellent congruence with diagnostic interviews, and is widely used in clinical settings and in public health surveillance. Similarly, the pooled cohort equations[11] represent the current US standard for assessing 10-year atherosclerotic cardiovascular disease (ASCVD) risk among people aged 40 to 79 years who are free of clinical CVD.[11] Describing the depression–CVD association using these 2 assessment standards can provide risk benchmarks relevant for both public health and clinical practice. To date, no studies have quantified the association between depression and CVD risk using these 2 US assessment standards. The first objective of this study was to estimate the association of 10-year ASCVD risk with PHQ-9 depression in a probability sample of US adults aged 40 to 79 years.

Adults aged 20 to 39 years represent 27% of the US population[12] and have a substantial prevalence of depression.[13] However, because of the low risk of a clinical CVD event in people aged 20 to 39, there is no 10-year ASCVD risk algorithm for this group.[11] However, lifetime CVD risk can be assessed among people aged 20 to 39 and can therefore provide a valid index of CVD risk at different levels of depression for adults otherwise overlooked by ASCVD-based primary prevention.[14] The second objective of the study was to estimate the association between depression and high lifetime risk of CVD death for adults aged 20 to 39. Because depression below clinical thresholds is prognostic for incident CVD,[5] we compared CVD risk for both mild and major depression relative to people without depression. Consistent with similar work,[15] we hypothesized that mild and moderate depression are associated with higher 10-year and lifetime CVD risk relative to no depression.