By: Sarah Chew, MPH, SWHR Science Programs Manager
Rates of depression and risk factors for cardiovascular disease (CVD) are increasing in young women (aged 18-49), which may also increase the rates of premature CVD and poor cardiovascular health (CVH) in women now and later in life. CVD and depression have a known reciprocal relationship, which research now suggests begins in younger adulthood. Raising awareness about young women’s lifetime risk of CVD and depression and introducing relevant individual and structural interventions can help reduce the burden of CVD and depression in women across the lifespan.
Increasing Risk of Cardiovascular Disease in Young Adults
CVD, commonly referred to as heart disease, is a type of illness which impacts the heart and blood vessels. There are many types of CVD, but the most common type is coronary artery disease, also known as coronary heart disease, or ischemic heart disease. Cardiovascular disease is the leading cause of death for women in the United States, with one in five women dying from CVD. It can impact women throughout the life course and can be tied to hormonal fluctuations seen during pregnancy and menopause. Despite the alarming number of women dying from CVD each year, women are underdiagnosed and undertreated for heart disease due to unequal awareness, screening, and treatment for women compared to men.
Historically, young adults have had fewer risk factors and lower rates of poor CVH and CVD than older populations, but that is changing. Despite rates declining in the general population, rates of poor CVH and CVD in young adults is increasing. Now, young adulthood is seen as the time in which people develop and engage in risk factors for CVD, such as obesity, diabetes, high blood pressure, insufficient sleep, and physical inactivity. While traditionally not a high-risk group, women ages 18-49 have increasing rates of risk factors for poor CVH and heart disease. These changes likely reflect the social, economic, and environmental climate in which many young people live, which is very different than it was 10-20 years ago. Increasingly, young adults are living lifestyles that do not promote heart health, and many known CVD risk factors impact women exclusively or differently than men. One of those relevant and consequential risk factors is depression.
Understanding Depression in Young Adults
Depression is a common mental health condition characterized by changes in mood, behavior, and cognition. Depression is a major contributor to disability, morbidity, mortality, and health care costs in the United States with one in ten U.S. adults reporting experiencing depression within the last year. Depression can affect all people regardless of age, race, gender, or ethnicity; and its prevalence is on the rise with significant increases reported in young adults, ages 18-25. Relatedly, depression is a leading cause of disability in young adults with a wide range of classification types, symptoms, and severity, some of which exclusively impact women, such as perinatal depression and premenstrual dysphoric disorder (PMDD).
Women are almost twice as likely as men to have depression with a one-year prevalence of 21.8% in women and 15% in men despite depression being underdiagnosed and undertreated. Depression often coincides with other mental illnesses and is a common comorbidity for chronic health conditions like CVD. As with other mental illnesses, women with depression are more likely to have worse physical and overall health outcomes. Depression not only worsens outcomes after a cardiovascular event like a heart attack, but it is also a known risk factor for stroke. Women with depression also have an almost 50% increased risk of cardiac death. Predictably, young adults with depression report poor CVH and premature CVD.
The Connection Between Cardiovascular Disease and Depression
Until recently, research on CVD and depression focused on women over age 50, the more traditional age group at risk for CVD. Estrogen and progesterone hormone (higher in young adult women) were thought to protect young women from high rates of CVD, yet, relevant risk factors may offset those protections. Depression can increase the development of risk factors for CVD, rates of premature disease, and suboptimal CVH in young women.
Recent data suggests that women under 50 with depression are nearly twice as likely to develop cardiovascular risk factors than any other group.
Simultaneously, CVD is a predictor of worse mental health outcomes in women with depression. Studies suggest that there are multiple physiological and biological mechanisms through which depression and CVD may have a bidirectional relationship. Depression and CVD may influence each other through mechanisms, such as chronic inflammation and dysregulation of biological systems. Additionally, it is important to acknowledge that lifestyle factors, such as adherence to treatments, self-care, and high-risk behaviors, and symptoms associated with depression may directly impact heart health. It is critical to recognize the complex factors through which the bidirectional relationship between depression and CVD impacts young women. A multilevel approach is essential to reducing the burden of both conditions in this population.
Opportunities for Action
There are many opportunities to mitigate the concerning trends and long-term health impacts concerning depression and CVD in young women. To reduce the burden of CVD and depression, it is important to increase awareness, improve care quality and access, and advance research.
Greater public awareness about women’s cardiovascular risks and education about the early signs of cardiovascular disease is essential. Women ages 18 to 49, and particularly those with depression, need to be informed about their increased risks of cardiovascular disease. Increased attention should also be placed on risk factors and symptoms of depression in young women. In the medical field, screening criteria for both depression and cardiovascular disease should be revised to incorporate emerging evidence of CVD risk in young women.
In addition to improving awareness and screening, increasing coverage for mental health care and access to targeted interventions for depression in women ages 18-49 are vital steps. Further, training providers to recognize risks for depression particularly in women living with CVD is critical. The separation of mental and physical health care can lead to delayed diagnoses, and limited time during patient visits can result in missed opportunities to diagnosis mental health conditions. Addressing health disparities and social determinants of health is also necessary to reducing the disproportionate burden of these conditions in certain subpopulations. Further research is needed to better understand women’s unique heart health issues, including the overlap between depression and CVD, but current findings show the gaps in outcomes are large and cannot be ignored. Investigating the effects of depression treatments on cardiovascular outcomes is also an important area for future research. There is significantly more work to be done in the fight against cardiovascular disease and depression in women’s health and as we enter October, National Depression and Mental Health Screening Month, now is the best time to begin.