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Association of depression with mortality in an elderly treated hypertensive population

  • Enayet K. Chowdhury (a1), Michael Berk (a2) (a3), Mark R. Nelson (a4), Lindon M. H. Wing (a5) and Christopher M. Reid (a1) (a6)...



Both elevated blood pressure and/or depression increase the risk of cardiovascular disease and mortality. This study in treated elderly hypertensive patients explored the incidence of depression, its association (pre-existing and incident) with mortality and predictors of incident depression.


Data from 6,083 hypertensive patients aged ≥65 years enrolled in the Second Australian National Blood Pressure study were used. Participants were followed for a median of 10.8 years (including 4.1 years in-trial) and classified into: “no depression,” “pre-existing” and “incident” depression groups based on either being “diagnosed with depressive disorders” and/or “treated with an anti-depressant drug” at baseline or during in-trial period. Further, we redefined “depression” restricted to presence of both conditions for sensitivity analyses. For the current study, end-points were all-cause and any cardiovascular mortality.


313 (5%) participants had pre-existing depression and a further 916 (15%) participants developed depression during the trial period (incidence 4% per annum). Increased (hazard-ratio, 95% confidence-interval) all-cause mortality was observed among those with either pre-existing (1.23, 1.01–1.50; p = 0.03) or incident (1.26, 1.12–1.41; p < 0.001) depression compared to those without. For cardiovascular mortality, a 24% increased risk (1.24, 1.05–1.47; p = 0.01) was observed among those with incident depression. The sensitivity analyses, using the restricted depression definition showed similar associations. Incident depression was associated with being female, aged ≥75 years, being an active smoker at study entry, and developing new diabetes during the study period.


This elderly cohort had a high incidence of depression irrespective of their randomised antihypertensive regimen. Both pre-existing and incident depression were associated with increased mortality.


Corresponding author

Correspondence should be addressed to: Enayet Karim Chowdhury, Department of Epidemiology and Preventive Medicine, Monash University, 6th Floor, Alfred Centre, 99 Commercial Rd, Melbourne VIC 3004, Australia. Phone: +61 3 99030524; Fax: +61-3 9903 0556. Email:


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Adamis, D. and Ball, C. (2000). Physical morbidity in elderly psychiatric inpatients: prevalence and possible relations between the major mental disorders and physical illness. International Journal of Geriatric Psychiatry, 15, 248253.
Ancelin, M. L., Carriere, I., Scali, J., Ritchie, K., Chaudieu, I. and Ryan, J. (2013). Angiotensin-converting enzyme gene variants are associated with both cortisol secretion and late-life depression. Translational Psychiatry, 3, e322.
Anderson, R. J., Freedland, K. E., Clouse, R. E. and Lustman, P. J. (2001). The prevalence of comorbid depression in adults with diabetes. Diabetes Care, 24, 1069.
Australian Bureau of Statistics (1998). Mental Health and Wellbeing: Profile of Adults, Australia 1997. ABS Catalogue No. 4326.0. Canberra: ABS.: Australian Bureau of Statistics.
Australian Bureau of Statistics (2008). National Survey of Mental Health and Wellbeing: Summary of Results, 2007. Cat. no. (4326.0). Canberra: ABS.: Australian Bureau of Statistics.
Axon, R. N., Zhao, Y. M. and Egede, L. E. (2010). Association of depressive symptoms with all-cause and ischemic heart disease mortality in adults with self-reported hypertension. American Journal of Hypertension, 23, 3037.
Baldwin, R. C. (2008). Depressive disorders. In Jacoby, R., Oppenheimer, C., Dening, T. and Thomas, A. (eds.), Oxford Textbook of Old Age Psychiatry (pp. 529556). Oxford, UK: Oxford University Press.
Boal, A. H. et al. (2016). Monotherapy with major antihypertensive drug classes and risk of hospital admissions for mood disorders. Hypertension, 68, 11321138.
Bonnet, F., Irving, K., Terra, J.-L., Nony, P., Berthezène, F. and Moulin, P. (2005). Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis, 178, 339344.
Brownstein, D. J. et al. (2018). Blockade of the angiotensin system improves mental health domain of quality of life: a meta-analysis of randomized clinical trials. Australian & New Zealand Journal of Psychiatry, 52, 2438.
Chowdhury, E. K., Ademi, Z., Moss, J. R., Wing, L. M. H., Reid, C. M. and on behalf of the Second Australian National Blood Pressure Study Management Committee (2015). Cost–utility of angiotensin-converting enzyme inhibitor-based treatment compared with thiazide diuretic-based treatment for hypertension in elderly australians considering diabetes as comorbidity. Medicine, 94, e590.
Cole, M. G. and Dendukuri, N. (2003). Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. American Journal of Psychiatry, 160, 11471156.
Davidson, K., Jonas, B. S., Dixon, K. E. and Markovitz, J. H. (2000). Do depression symptoms predict early hypertension incidence in young adults in the cardia study?. Archives of Internal Medicine, 160, 14951500.
Egan, B. M., Zhao, Y. and Axon, R. (2010). Us trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA, 303, 20432050.
Golden, S. H. et al. (2017). The prevalence and specificity of depression diagnosis in a clinic-based population of adults with type 2 diabetes mellitus. Psychosomatics, 58, 2837.
Grant, B. F., Hasin, D. S., Chou, S., Stinson, F. S. and Dawson, D. A. (2004). Nicotine dependence and psychiatric disorders in the united states: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 61, 11071115.
Hamer, M., Batty, G. D., Stamatakis, E. and Kivimaki, M. (2010). The combined influence of hypertension and common mental disorder on all-cause and cardiovascular disease mortality. Journal of Hypertension, 28, 24012406.
Johansen, A., Holmen, J., Stewart, R. and Bjerkeset, O. (2012). Anxiety and depression symptoms in arterial hypertension: the influence of antihypertensive treatment. The hunt study, Norway. European Journal of Epidemiology, 27, 6372.
Kendrick, T., King, F., Albertella, L. and Smith, P. W. F. (2005). GP treatment decisions for patients with depression: an observational study. The British Journal of General Practice, 55, 280286.
King, M. et al. (2008). Development and validation of an international risk prediction algorithm for episodes of major depression in general practice attendees: The predicted study. Archives of General Psychiatry, 65, 13681376.
Kuo, P.-L. and Pu, C. (2011). The contribution of depression to mortality among elderly with self-reported hypertension: analysis using a national representative longitudinal survey. Journal of Hypertension, 29, 20842090.
Lim, S. S. et al. (2012). A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 22242260.
Maatouk, I. et al. (2016). Association of hypertension with depression and generalized anxiety symptoms in a large population-based sample of older adults. Journal of Hypertension, 34, 17111720.
Maes, M., Fišar, Z., Medina, M., Scapagnini, G., Nowak, G. and Berk, M. (2012). New drug targets in depression: inflammatory, cell-mediated immune, oxidative and nitrosative stress, mitochondrial, antioxidant, and neuroprogressive pathways. And new drug candidates—Nrf2 activators and GSK-3 inhibitors. Inflammopharmacology, 20, 127150.
Meng, L., Chen, D., Yang, Y., Zheng, Y. and Hui, R. (2012). Depression increases the risk of hypertension incidence: a meta-analysis of prospective cohort studies. Journal of Hypertension, 30, 842851.
Moylan, S. et al. (2014). Oxidative & nitrosative stress in depression: why so much stress?. Neuroscience and Biobehavioral Reviews, 45, 4662.
Moylan, S., Eyre, H. A., Maes, M., Baune, B. T., Jacka, F. N. and Berk, M. (2013). Exercising the worry away: how inflammation, oxidative and nitrogen stress mediates the beneficial effect of physical activity on anxiety disorder symptoms and behaviours. Neuroscience & Biobehavioral Reviews, 37, 573584.
Mühlig, Y., Antel, J., Föcker, M. and Hebebrand, J. (2016). Are bidirectional associations of obesity and depression already apparent in childhood and adolescence as based on high-quality studies? A systematic review. Obesity Reviews, 17, 235249.
Musselman, D. L., Evans, D. L. and Nemeroff, C. B. (1998). The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Archives of General Psychiatry, 55, 580592.
O'Connor, D. W. (2006). Do older Australians truly have low rates of anxiety and depression? A critique of the 1997 national survey of mental health and wellbeing. Australian & New Zealand Journal of Psychiatry, 40, 623631.
Rait, G., Walters, K., Griffin, M., Buszewicz, M., Petersen, I. and Nazareth, I. (2009). Recent trends in the incidence of recorded depression in primary care. The British Journal of Psychiatry, 195, 520.
Sandström, Y. K., Ljunggren, G., Wändell, P., Wahlström, L. and Carlsson, A. C. (2016). Psychiatric comorbidities in patients with hypertension – a study of registered diagnoses 2009–2013 in the total population in Stockholm County, Sweden. Journal of Hypertension, 34, 414420.
Seymour, J. and Benning, T. B. (2009). Depression, cardiac mortality and all-cause mortality. Advances in Psychiatric Treatment, 15, 107113.
Sherwood, A., Hinderliter, A. L., Watkins, L. L., Waugh, R. A. and Blumenthal, J. A. (2005). Impaired endothelial function in coronary heart disease patients with depressive symptomatology. Journal of the American College of Cardiology, 46, 656659.
Strawbridge, W. J., Deleger, S., Roberts, R. E. and Kaplan, G. A. (2002). Physical activity reduces the risk of subsequent depression for older adults. American Journal of Epidemiology, 156, 328334.
Strine, Tara W. et al. (2008). Depression and anxiety in the United States: findings from the 2006 behavioral risk factor surveillance system. Psychiatric Services, 59, 13831390.
Taylor, W. D. et al. (2012). AGTR1 gene variation: association with depression and frontotemporal morphology. Psychiatry Research, 202, 104109.
Taylor, W. D. et al. (2013). Fiber tract-specific white matter lesion severity findings in late-life depression and by AGTR1 A1166C genotype. Human Brain Mapping, 34, 295303.
Vian, J. et al. (2017). The renin–angiotensin system: a possible new target for depression. BMC Medicine, 15, 144.
Williams, L. J., Pasco, J. A., Kessing, L. V., Quirk, S. E., Fernandes, B. S. and Berk, M. (2016). Angiotensin converting enzyme inhibitors and risk of mood disorders. Psychotherapy and Psychosomatics, 85, 250252.
Wing, L. M. H. et al. (2003). A comparison of outcomes with angiotensin-converting–enzyme inhibitors and diuretics for hypertension in the elderly. New England Journal of Medicine, 348, 583592.


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