Skip to main content Accessibility help

Depressive symptoms and sleep problems as risk factors for heart disease: a prospective community study

  • S. S. Deschênes (a1) (a2), R. J. Burns (a3), E. Graham (a2) (a4) and N. Schmitz (a1) (a2) (a4)



The goals of the present study were to examine the associations between depressive symptoms, sleep problems and the risk of developing heart disease in a Canadian community sample.


Baseline data were from the CARTaGENE study, a community health survey of adults aged 40–69 years in Quebec, Canada. Incidence of heart disease was examined in N = 33 455 participants by linking survey data with administrative health insurance data. Incident heart disease was identified using the World Health Organization's International Classification of Diseases, 9th or 10th edition (ICD-9 and ICD-10) diagnostic codes for heart disease. Sleep problems were assessed with diagnostic codes for sleep disorders within the 2 years preceding the baseline assessment. Average sleep duration was assessed by self-report. Depressive symptoms were assessed with the nine-item Patient Health Questionnaire.


In total, 2448 (7.3%) participants developed heart disease over an average follow-up period of 4.6 years. Compared to those without depressive symptoms and with no sleep disorders, those with elevated depressive symptoms and a sleep disorder (HR = 2.60, 95% CI 1.83–3.69), those with depressive symptoms alone (HR = 1.40, 95% CI 1.25–1.57) and those with sleep disorders alone (HR = 1.33, 95% CI 1.03–1.73) were more likely to develop heart disease. Test of additive interaction suggested a synergistic interaction between depressive symptoms and sleep disorders (synergy index = 2.17 [95% CI 1.01–4.64]). When sleep duration was considered, those with long sleep duration and elevated depressive symptoms were more likely to develop heart disease than those with long sleep alone (HR = 1.77, 95% CI 1.37–2.28; and HR = 1.16, 95% CI 0.99–1.36, respectively).


Depression and diagnosed sleep disorders or long sleep duration are independent risk factors for heart disease and are associated with a stronger risk of heart disease when occurring together.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Depressive symptoms and sleep problems as risk factors for heart disease: a prospective community study
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Depressive symptoms and sleep problems as risk factors for heart disease: a prospective community study
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Depressive symptoms and sleep problems as risk factors for heart disease: a prospective community study
      Available formats


This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Author for correspondence: Sonya Deschênes, E-mail:


Hide All
Alvaro, PK, Roberts, RM and Harris, JK (2013) A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep 36, 10591068.
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Washington, DC: American Psychiatric Association.
Andersson, T, Alfredsson, L, Kallberg, H, Zdravkovic, S and Ahlbom, A (2005) Calculating measures of biological interaction. European Journal of Epidemiology 20, 575579.
Antonijevic, I (2008) HPA axis and sleep: identifying subtypes of major depression. Stress 11, 1527.
Awadalla, P, Boileau, C, Payette, Y, Idaghdour, Y, Goulet, JP, Knoppers, B, Hamet, P and Laberge, C (2013) Cohort profile of the CARTaGENE study: Quebec's population-based biobank for public health and personalized genomics. International Journal of Epidemiology 42, 12851299.
Bogers, RP, Bemelmans, WJ, Hoogenveen, RT, Boshuizen, HC, Woodward, M, Knekt, P, van Dam, RM, Hu, FB, Visscher, TL, Menotti, A, Thorpe, RJ Jr, Jamrozik, K, Calling, S, Strand, BH and Shipley, MJ (2007) Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons. Archives of Internal Medicine 167, 17201728.
Bradley, TD and Floras, JS (2009) Obstructive sleep apnoea and its cardiovascular consequences. Lancet 373, 8293.
Canivet, C, Nilsson, PM, Lindeberg, SI, Karasek, R and Östergren, P-O (2014) Insomnia increases risk for cardiovascular events in women and in men with low socioeconomic status: a longitudinal, register-based study. Journal of Psychosomatic Research 76, 292299.
Cappuccio, FP, Cooper, D, D'Elia, L, Strazzullo, P and Miller, MA (2011) Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. European Heart Journal 32, 14841492.
Corrao, G, Rubbiati, L, Bagnardi, V, Zambon, A and Poikolainen, K (2000) Alcohol and coronary heart disease: a meta-analysis. Addiction 95, 15051523.
D'Agostino, RB Sr, Vasan, RS, Pencina, MJ, Wolf, PA, Cobain, M, Massaro, JM and Kannel, WB (2008) General cardiovascular risk profile for use in primary care: the Framingham heart study. Circulation 117, 743753.
Dikeos, D and Georgantopoulos, G (2011) Medical comorbidity of sleep disorders. Current Opinion in Psychiatry 24, 346354.
Ettehad, D, Emdin, CA, Kiran, A, Anderson, SG, Callender, T, Emberson, J, Chalmers, J, Rodgers, A and Rahimi, K (2016) Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 387, 957967.
Fried, EI and Nesse, RM (2015) Depression is not a consistent syndrome: an investigation of unique symptom patterns in the STAR*D study. Journal of Affective Disorders 172, 96102.
Gan, Y, Gong, Y, Tong, X, Sun, H, Cong, Y, Dong, X, Wang, Y, Xu, X, Yin, X, Deng, J, Li, L, Cao, S and Lu, Z (2014) Depression and the risk of coronary heart disease: a meta-analysis of prospective cohort studies. BMC Psychiatry 14, 371.
Gianfagna, F, Veronesi, G, Bertu, L, Cesana, G, Grassi, G, Stranges, S, Callegari, C and Ferrario, MM (2016) Influence of sleep disturbances on age at onset and long-term incidence of major cardiovascular events: the Monica-Brianza and Pamela cohort studies. Sleep Medicine 21, 126132.
Grandner, MA and Drummond, SP (2007) Who are the long sleepers? Towards an understanding of the mortality relationship. Sleep Medicine Reviews 11, 341360.
Holt, A, Bjerre, J, Zareini, B, Koch, H, Tønnesen, P, Gislason, GH, Nielsen, OW, Schou, M and Lamberts, M (2018) Sleep apnea, the risk of developing heart failure, and potential benefits of continuous positive airway pressure (CPAP) therapy. Journal of the American Heart Association 7, e008684.
Howren, MB, Lamkin, DM and Suls, J (2009) Associations of depression with C-reactive protein, IL-1, and IL-6: a meta-analysis. Psychosomatic Medicine 71, 171186.
Huxley, R, Barzi, F and Woodward, M (2006) Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. British Medical Journal 332, 7378.
Itani, O, Jike, M, Watanabe, N and Kaneita, Y (2017) Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression. Sleep Medicine 32, 246256.
Javaheri, S and Redline, S (2017) Insomnia and risk of cardiovascular disease. Chest 152, 435444.
Jiang, W, Krishnan, RRK and O'Connor, CM (2002) Depression and heart disease – evidence of a link, and its therapeutic implications. CNS Drugs 16, 111127.
Jike, M, Itani, O, Watanabe, N, Buysse, DJ and Kaneita, Y (2018) Long sleep duration and health outcomes: a systematic review, meta-analysis and meta-regression. Sleep Medicine Reviews 39, 2536.
Joynt, KE, Whellan, DJ and O'Connor, CM (2003) Depression and cardiovascular disease: mechanisms of interaction. Biological Psychiatry 54, 248261.
Kaptoge, S, Di Angelantonio, E, Lowe, G, Pepys, MB, Thompson, SG, Collins, R, Danesh, J, Tipping, RW, Ford, CE, Pressel, SL, Walldius, G, Jungner, I, Folsom, AR, Chambless, L, Ballantyne, CM, Panagiotakos, D, Pitsavos, C, Chrysohoou, C, Stefanadis, C, Knuiman, MW, Goldbourt, U, Benderly, M, Tanne, D, Whincup, P, Wannamethee, SG, Morris, RW, Kiechl, S, Willeit, J, Mayr, A, Schett, G, Wald, N, Ebrahim, S, Lawlor, D, Yarnell, J, Gallacher, J, Casiglia, E, Tikhonoff, V, Nietert, PJ, Sutherland, SE, Bachman, DL, Keil, JE, Cushman, M, Psaty, BM, Tracy, R, Tybjaerg-Hansen, A, Nordestgaard, BG, Zacho, J, Frikke-Schmidt, R, Giampaoli, S, Palmieri, L, Panico, S, Vanuzzo, D, Pilotto, L, de la Camara, AG, Gerique, JAG, Simons, L, McCallum, J, Friedlander, Y, Fowkes, FGR, Lee, A, Taylor, J, Guralnik, JM, Phillips, CL, Wallace, RB, Blazer, DG, Khaw, KT, Brenner, H, Raum, E, Muller, H, Rothenbacher, D, Jansson, JH, Wennberg, P, Nissinen, A, Donfrancesco, C, Salomaa, V, Harald, K, Jousilahti, P, Vartiainen, E, Woodward, M, D'Agostino, RB, Wolf, PA, Vasan, RS, Benjamin, EJ, Bladbjerg, EM, Jorgensen, T, Moller, L, Jespersen, J, Dankner, R, Chetrit, A, Lubin, F, Rosengren, A, Wilhelmsen, L, Lappas, G, Eriksson, H, Bjorkelund, C, Lissner, L, Bengtsson, C, Cremer, P, Nagel, D, Tilvis, RS, Strandberg, TE, Kiyohara, Y, Arima, H, Doi, Y, Ninomiya, T, Rodriguez, B, Dekker, J, Nijpels, G, Stehouwer, CDA, Rimm, E, Pai, JK, Sato, S, Iso, H, Kitamura, A, Noda, H, Salonen, JT, Nyyssonen, K, Tuomainen, TP, Laukkanen, JA, Deeg, DJH, Bremmer, MA, Meade, TW, Cooper, JA, Hedblad, B, Berglund, G, Engstrom, G, Verschuren, WMM, Blokstra, A, Shea, S, Doring, A, Koenig, W, Meisinger, C, Bueno-De-Mesquita, HB, Kuller, LH, Grandits, G, Selmer, R, Tverdal, A, Nystad, W, Gillum, RF, Mussolino, M, Hankinson, S, Manson, JE, Knottenbelt, C, Bauer, KA, Davidson, K, Kirkland, S, Shaffer, J, Korin, MR, Naito, Y, Holme, I, Nakagawa, H, Miura, K, Ducimetiere, P, Jouven, X, Luc, G, Crespo, J, Garcia-Palmieri, MR, Amouyel, P, Arveiler, D, Evans, A, Ferrieres, J, Schulte, H, Assmann, G, Packard, CJ, Sattar, N, Westendorp, RG, Buckley, BM, Cantin, B, Lamarche, B, Despres, JP, Dagenais, GR, Barrett-Connor, E, Wingard, DL, Bettencourt, RR, Gudnason, V, Aspelund, T, Sigurdsson, G, Thorsson, B, Trevisan, M, Witteman, J, Kardys, I, Breteler, MMB, Hofman, A, Tunstall-Pedoe, H, Tavendale, R, Lowe, G, Howard, BV, Zhang, Y, Bes, L, Umans, J, Ben-Shlomo, Y, Davey-Smith, G, Onat, A, Njostad, I, Mathiesen, EB, Lohen, ML, Wilsgaard, T, Ingelsson, E, Basu, S, Cederholm, T, Byberg, L, Gaziano, JM, Stampfer, M, Ridker, PM, Ulmer, H, Diem, G, Concin, H, Tosetto, A, Rodeghiero, F, Wassertheil-Smoller, S, Marmot, M, Clarke, R, Collins, R, Fletcher, A, Brunner, E, Shipley, M, Buring, J, Shepherd, J, Cobbe, S, Ford, I, Robertson, M, He, Y, Ibanez, AM, Feskens, EJM, Walker, M, Watson, S, Erqou, S, Kaptoge, S, Lewington, S, Pennells, L, Perry, PL, Ray, KK, Sarwar, N, Alexander, M, Thompson, A, Thompson, SG, White, IR, Wood, AM and Danesh, J (2010) C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis. Lancet 375, 132140.
Katz, DA and McHorney, CA (1998) Clinical correlates of insomnia in patients with chronic illness. Archives of Internal Medicine 158, 10991107.
Kleinbaum, DG and Klein, M (2010) Survival Analysis. New York: Springer.
Kroenke, K, Spitzer, RL and Williams, JBW (2001) The PHQ-9 – validity of a brief depression severity measure. Journal of General Internal Medicine 16, 606613.
Lamers, F, Jonkers, CC, Bosma, H, Penninx, BW, Knottnerus, JA and van Eijk, JTM (2008) Summed score of the patient health questionnaire-9 was a reliable and valid method for depression screening in chronically ill elderly patients. Journal of Clinical Epidemiology 61, 679687.
Lasserre, A, Strippoli, MF, Glaus, J, Gholam-Rezaee, M, Vandeleur, C, Castelao, E, Marques-Vidal, P, Waeber, G, Vollenweider, P and Preisig, M (2017) Prospective associations of depression subtypes with cardio-metabolic risk factors in the general population. Molecular Psychiatry 22, 1026.
Laugsand, LE, Vatten, LJ, Platou, C and Janszky, I (2011) Insomnia and the risk of acute myocardial infarction: a population study. Circulation 124, 20732081.
Law, M, Naughton, M, Ho, S, Roebuck, T and Dabscheck, E (2014) Depression may reduce adherence during cpap titration trial. Journal of Clinical Sleep Medicine: JCSM 10, 163169.
Lemogne, C, Meneton, P, Wiernik, E, Quesnot, A, Consoli, SM, Ducimetiere, P, Nabi, H, Empana, JP, Hoertel, N, Limosin, F, Goldberg, M and Zins, M (2017) When blue-collars feel blue: depression and low occupational grade as synergistic predictors of incident cardiac events in middle-aged working individuals. Circulation: Cardiovascular Quality and Outcomes 10, 110.
Lozano, R, Naghavi, M, Foreman, K, Lim, S, Shibuya, K, Aboyans, V, Abraham, J, Adair, T, Aggarwal, R and Ahn, SY (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. Lancet 380, 20952128.
McDade, TW, Hawkley, LC and Cacioppo, JT (2006) Psychosocial and behavioral predictors of inflammation in middle-aged and older adults: the Chicago health, aging, and social relations study. Psychosomatic Medicine 68, 376381.
McGee, DL (2005) Body mass index and mortality: a meta-analysis based on person-level data from twenty-six observational studies. Annals of Epidemiology 15, 8797.
Meier-Ewert, HK, Ridker, PM, Rifai, N, Regan, MM, Price, NJ, Dinges, DF and Mullington, JM (2004) Effect of sleep loss on c-reactive protein, an inflammatory marker of cardiovascular risk. Journal of the American College of Cardiology 43, 678683.
Mezick, EJ, Hall, M and Matthews, KA (2011) Are sleep and depression independent or overlapping risk factors for cardiometabolic disease? Sleep Medicine Reviews 15, 5163.
Nicholson, A, Kuper, H and Hemingway, H (2006) Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. European Heart Journal 27, 27632774.
Nutt, D, Wilson, S and Paterson, L (2008) Sleep disorders as core symptoms of depression. Dialogues in Clinical Neuroscience 10, 329.
Poole, L and Jackowska, M (2019) The association between depressive and sleep symptoms for predicting incident disease onset after 6-year follow-up: findings from the English longitudinal study of ageing. Psychological Medicine 49, 607616.
Redline, S and Foody, J (2011) Sleep disturbances: time to join the top 10 potentially modifiable cardiovascular risk factors? Circulation 124, 20492051.
Sarwar, N, Gao, P, Seshasai, SR, Gobin, R, Kaptoge, S, Di Angelantonio, E, Ingelsson, E, Lawlor, DA, Selvin, E, Stampfer, M, Stehouwer, CD, Lewington, S, Pennells, L, Thompson, A, Sattar, N, White, IR, Ray, KK and Danesh, J (2010) Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 375, 22152222.
Sattelmair, J, Pertman, J, Ding, EL, Kohl, HW, Haskell, W and Lee, IM (2011) Dose response between physical activity and risk of coronary heart disease a meta-analysis. Circulation 124, 789–U84.
Schmitz, N, Deschenes, SS, Burns, RJ, Smith, KJ, Lesage, A, Strychar, I, Rabasa-Lhoret, R, Freitas, C, Graham, E, Awadalla, P and Wang, JL (2016) Depression and risk of type 2 diabetes: the potential role of metabolic factors. Molecular Psychiatry 21, 17261732.
Scott, KM (2014) Depression, anxiety and incident cardiometabolic diseases. Current Opinion in Psychiatry 27, 289293.
Signal, TL, Gale, J and Gander, PH (2005) Sleep measurement in flight crew: comparing actigraphic and subjective estimates to polysomnography. Aviation Space and Environmental Medicine 76, 10581063.
Sniderman, AD, Williams, K, Contois, JH, Monroe, HM, McQueen, MJ, de Graaf, J and Furberg, CD (2011) A meta-analysis of low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B as markers of cardiovascular risk. Circulation: Cardiovascular Quality and Outcomes 4, 337345.
Sofi, F, Cesari, F, Casini, A, Macchi, C, Abbate, R and Gensini, GF (2014) Insomnia and risk of cardiovascular disease: a meta-analysis. European Journal of Preventive Cardiology 21, 5764.
Van Den Berg, JF, Van Rooij, FJ, Vos, H, Tulen, JH, Hofman, A, Miedema, HM, Neven, AK and Tiemeier, H (2008) Disagreement between subjective and actigraphic measures of sleep duration in a population-based study of elderly persons. Journal of Sleep Research 17, 295302.
Van der Kooy, K, van Hout, H, Marwijk, H, Marten, H, Stehouwer, C and Beekman, A (2007) Depression and the risk for cardiovascular diseases: systematic review and meta analysis. International Journal of Geriatric Psychiatry 22, 613626.
VanderWeele, TJ and Knol, MJ (2014) A tutorial on interaction. Epidemiologic Methods 3, 3372.
Varghese, T, Schultz, WM, McCue, AA, Lambert, CT, Sandesara, PB, Eapen, DJ, Gordon, NF, Franklin, BA and Sperling, LS (2016) Physical activity in the prevention of coronary heart disease: implications for the clinician. Heart 102, 904909.
Wang, H, Naghavi, M, Allen, C, Barber, RM, Bhutta, ZA, Carter, A, Casey, DC, Charlson, FJ, Chen, AZ, Coates, MM and GBD 2015 Mortality and Causes of Death Collaborators (2016) Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the global burden of disease study 2015. The Lancet 388, 14591544.
Watson, NF, Badr, MS, Belenky, G, Bliwise, DL, Buxton, OM, Buysse, D, Dinges, DF, Gangwisch, J, Grandner, MA, Kushida, C, Malhotra, RK, Martin, JL, Patel, SR, Quan, SF and Tasali, E (2015) Recommended amount of sleep for a healthy adult: a joint consensus statement of the American academy of sleep medicine and sleep research society. Sleep 38, 843844.
Windle, M and Windle, RC (2013) Recurrent depression, cardiovascular disease, and diabetes among middle-aged and older adult women. Journal of Affective Disorders 150, 895902.
Wium-Andersen, MK, Wium-Andersen, IK, Prescott, EIB, Overvad, K, Jorgensen, MB and Osler, M (2019) An attempt to explain the bidirectional association between ischaemic heart disease, stroke and depression: a cohort and meta-analytic approach. British Journal of Psychiatry 18. Online Ahead of Print.
Wu, Q and Kling, JM (2016) Depression and the risk of myocardial infarction and coronary death: a meta-analysis of prospective cohort studies. Medicine (Baltimore) 95, e2815.
Yusuf, S, Hawken, S, Ounpuu, S, Dans, T, Avezum, A, Lanas, F, McQueen, M, Budaj, A, Pais, P, Varigos, J and Lisheng, L (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the interheart study): case-control study. Lancet 364, 937952.
Zuithoff, NPA, Vergouwe, Y, King, M, Nazareth, I, van Wezep, MJ, Moons, KGM and Geerlings, MI (2010) The patient health questionnaire-9 for detection of major depressive disorder in primary care: consequences of current thresholds in a crosssectional study. BMC Family Practice 11, 17.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed