Depression and Heart Failure in US Veterans

Abstract

Importance: Depression and heart failure (HF) affect millions of US adults. Incident HF risk following depression diagnosis is understudied.

Objective: To examine the association between incident HF and prevalent depression among veterans.

Design, setting, and participants: This cohort study analyzed sociodemographic and clinical data of US veterans participating in the Veterans Affairs (VA) Birth Cohort. Data were obtained from the VA Corporate Data Warehouse between January 1, 2000, and October 1, 2015. Participants were born between 1945 and 1965, were free of HF at baseline, and met a medical home definition (had 3 outpatient visits within 5 years). Statistical analysis was performed from May 2022 to February 2025.

Exposures: Prevalent depression, defined as 1 inpatient or 2 outpatient visits with International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes for depression.

Main outcomes and measures: The primary outcome was time to incident HF, defined as time from baseline to documented date of the first inpatient or second outpatient visit with ICD-9 or ICD-10 codes for HF. A Cox proportional hazards regression model adjusted for relevant covariates was used to assess the association of depression and incident HF.

Results: A total of 2 843 159 veterans (median [SD] age, 54 [49-59] years; 2 677 919 males [94.2%]; 556 914 [19.6%] self-identified as Black, 144 485 [5.1%] as Hispanic, 1 975 068 [69.5%] as White, and 99 011 [3.5%] as other race and ethnicity) were included. Participants were followed up for incident HF over a median (IQR) duration of 6.9 (3.4-11.0) years. Generally, 8.0% of participants (226 247 of 2 843 159) had prevalent depression at baseline. Females made up a larger percentage of those with vs without depression (11.4% vs 5.3%). Participants with depression demonstrated higher unadjusted incident HF rates compared with those without depression (136.9 [95% CI, 132.2-141.7] cases per 10 000 person-years vs 114.6 [95% CI, 113.4-115.9] cases per 10 000 person-years, respectively). After adjusting for sociodemographic and cardiovascular risk factors, depression was associated with an increase in incident HF hazard of 14.0% (hazard ratio [HR], 1.14; 95% CI, 1.13-1.16), with an estimated adjusted median (IQR) incidence rate difference of 16.0 (14.9-18.3) cases per 10 000 person-years. Among patients without comorbidities, depression was associated with a higher increase in incident HF hazard (HR, 1.58; 95% CI, 1.39-1.80), with an estimated adjusted median (IQR) rate difference of 14.2 (9.5-19.5) cases per 10 000 person-years.

Conclusions and relevance: In this cohort study, depression among veterans was associated with an increased hazard of incident HF after controlling for demographic and cardiovascular risk factors. Higher incident HF rates in patients with depression remained consistent in an otherwise low-risk cohort.

Figure 1.. Heart Failure (HF)–Free Survival Stratified by Depression Status, Sex, and Self-Identified Race and Ethnicity

Patients were evaluated over a 14-year period for development of incident HF. Other race includes American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, and other (which is undefined in the Veterans Affairs dataset). Shaded areas represent 95% CIs.

Figure 2.. Adjusted Hazard Ratios (HRs) of Incident Heart Failure (HF) for Categorical Variables

The HRs and 95% CIs of incident HF are reported for atrial fibrillation, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and valvular heart disease (VHD). AUD indicates alcohol use disorder. Other race includes American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, and other (which is undefined in the Veterans Affairs dataset). See eFigure 2 in Supplement 1 for HRs of continuous variables.

Figure 3.. Adjusted Hazard Ratios (HRs) of Incident Heart Failure (HF) for Categorical Variables in the Subcohort of Veterans With Prevalent Depression

The HRs and 95% CIs of incident HF are reported for atrial fibrillation, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and valvular heart disease (VHD). AUD indicates alcohol use disorder. Other race includes American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, and other (which is undefined in the Veterans Affairs dataset).