Hypertension and depression are two of the most prevalent diseases in the United States, and the occurrence of these diseases is significantly higher for American Indian adults as compared with White adults. The percentage of American Indians/Alaska Natives (AI/AN) adults aged 18 years and above with mental illness as per the 2019 statistics was 18%. It also revealed that they have a 50% higher chance of developing coronary heart disease compared to white adults and a 10% higher chance of high blood pressure.
Researchers conducting the strong heart family study (SHFS) found that close to half of patients had depressive signs and 30% were suffering from moderate to severe depression. Depression is associated with hypertension as a risk factor for hypertension and a contributing factor to poor blood pressure management. This analysis aims to quantify the association between depressive symptoms and the development of hypertension in a cluster of American Indians considering the moderation effect of social support.
The SHFS is a family-based, prospective study of cardiovascular disease (CVD) risk factors in 12 American Indian (AI) communities across the four states: Arizona, North Dakota, South Dakota, and Oklahoma. This study enlisted 2,756 AI clients from 92 extended families who were aged between 14 and 93 years. SHFS participants provided information in a baseline survey of 2001–2003 and a follow-up survey of 2006–2009 and were followed for morbidity and mortality.
Depressive symptoms were assessed using the Center for epidemiologic studies depression (CES-D) scale. Patients with a total score of 16 or more were considered as having clinical depression. Hypertension is confirmed if the systolic blood pressure (SBP) is ≥140 mm Hg, and diastolic blood pressure (DBP) is ≥90 mm Hg.
The participants in the study had a median age of 33.5 years in which 36.5% of the participants were male. At baseline, around 27.3% of the participants had depressive symptoms with a CES-D total score of ≥16. Depressive symptoms are also associated with female gender, young age, low education level, high body mass index (BMI), and low physical activity.
The cross-sectional survey results indicated that participants with depressive symptoms had a 54% increased risk of hypertension as realized through multivariable analyses. In this study, there was evidence of no statistically significant two-way interaction between social support and depressive symptoms on hypertension odds, even after controlling for the potential covariates that included age, BMI, and diabetes status.
The study involving a cohort of a large population of American Indian adults reported that individuals who developed depressive symptoms were at a higher risk of developing hypertension. This supports the hypothesis that depression may contribute to the development of hypertension. The results corroborate several studies, including a meta-analysis of cross-sectional studies, that have linked depression to increased hypertension risk in non-American Indians.
They also revealed no or inverse associations, which may be attributed to variations in the demographic settings and geographic locations. Hence, future studies should attempt to establish the association between social support factors and culture on the moderating effect of depressive symptoms on hypertension.
Although the study has some limitations, the social desirability bias inherent to the CES-D scale could be a possibility, residual confounding from unmeasured factors could also interfere with the results and the study could not generalize findings to other large rural families from other regions of the United States specifically to other American Indians.
In conclusion, those American Indian adults who presented the symptoms of depression are likely to increase their hypertension risk hence, the need for mental health in cardiovascular risk and community-based preventive mental health outreach programs. Therefore, it hypothesizes that higher levels of depressive symptoms increase one’s risk of hypertension, particularly in the absence of sufficient social support.
References: Santoni S, Kernic MA, Malloy K, et al. Depression and incident hypertension: the Strong Heart Family Study. Prev Chronic Dis. 2025;22:240230. doi:10.5888/pcd22.240230
