title: Consequences of Comorbidity of Elevated Stress and/or Depressive Symptoms and Incident Cardiovascular Outcomes in Diabetes: Results From the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study.
abstract: OBJECTIVE
  To evaluate the impact of comorbid depressive symptoms and/or stress on adverse cardiovascular (CV) outcomes in individuals with diabetes compared with those without diabetes.
  
  
  METHODS
  Investigators examined the relationship between baseline depressive symptoms and/or stress in adults with and without diabetes and physician-adjudicated incident CV outcomes including stroke, myocardial infarction/acute coronary heart disease, and CV death over a median follow-up of 5.95 years in the national REGARDS cohort study.
  
  
  RESULTS
  Subjects included 22,003 adults (4,090 with diabetes) (mean age 64 years, 58% female, 42% black, and 56% living in the southeastern "Stroke Belt"). Elevated stress and/or depressive symptoms were more common in subjects with diabetes (36.8% vs. 29.5%; P < 0.001). In fully adjusted models, reporting either elevated stress or depressive symptoms was associated with a significantly increased incidence of stroke (HR 1.57 [95% CI 1.05, 2.33] vs. 1.01 [0.79, 1.30]) and CV death (1.53 [1.08, 2.17] vs. 1.12 [0.90, 1.38]) in subjects with diabetes but not in those without diabetes. The combination of both elevated stress and depressive symptoms in subjects with diabetes was associated with a higher incidence of CV death (2.15 [1.33, 3.47]) than either behavioral comorbidity alone (1.53 [1.08, 2.17]) and higher than in those with both elevated stress and depressive symptoms but without diabetes (1.27 [0.86, 1.88]).
  
  
  CONCLUSIONS
  Comorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes.
authors.affiliation: Department of Family Medicine and the Diabetes and Obesity Institute, Brody School of Medicine, East Carolina University, Greenville, NC cummingsd@ecu.edu.
authors.forename: Doyle M
authors.initials: DM
authors.lastname: Cummings
authors.affiliation: Department of Family Medicine and the Diabetes and Obesity Institute, Brody School of Medicine, East Carolina University, Greenville, NC.
authors.forename: Kari
authors.initials: K
authors.lastname: Kirian
authors.affiliation: Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: George
authors.initials: G
authors.lastname: Howard
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Virginia
authors.initials: V
authors.lastname: Howard
authors.affiliation: Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Ya
authors.initials: Y
authors.lastname: Yuan
authors.affiliation: Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Paul
authors.initials: P
authors.lastname: Muntner
authors.affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Brett
authors.initials: B
authors.lastname: Kissela
authors.affiliation: Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Nicole
authors.initials: N
authors.lastname: Redmond
authors.affiliation: Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Suzanne E
authors.initials: SE
authors.lastname: Judd
authors.affiliation: Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Monika M
authors.initials: MM
authors.lastname: Safford
mesh_terms: D001741:Black or African American; D000368:Aged; D002318:Cardiovascular Diseases / Q000453:epidemiology*; D015331:Cohort Studies; D015897:Comorbidity; D003327:Coronary Disease / Q000453:epidemiology; D003863:Depression / Q000453:epidemiology*; D003920:Diabetes Mellitus / Q000453:epidemiology*; D005260:Female; D006801:Humans; D015994:Incidence; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D011446:Prospective Studies; D012307:Risk Factors; D013315:Stress, Psychological; D020521:Stroke / Q000453:epidemiology; D044465:White People