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
Open accessAbstract
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. RESEARCH DESIGN AND 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.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the US adults REGARDS cohort (n=22,003; n=4,090 with diabetes mellitus; 5.95-year follow-up), depressive symptoms or perceived stress increased risk of stroke (HR 1.57; 95% CI 1.-2.33), myocardial infarction (HR 1.57; 95% CI 1.02-2.40), and CVD death (HR 1.53; 95% CI 1.08-2.17).
“US adults REGARDS cohort ( n = 22,003; n = 4,090 with diabetes mellitus; 5.95 year follow-up) | Depressive symptoms assessed by the CES-D (four item questionnaire) and perceived stress assessed by Cohen Perceived Stress Scale (four item questionnaire) | ‡ Depressive symptoms or perceived stress increased risk of stroke”
From Type 2 diabetes mellitus and psychological stress — a modifiable risk factor (2017) · cites this paper as Cummings (2016) 143
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredIn the REGARDS cohort, people with type 2 diabetes who reported elevated depressive symptoms or perceived stress had a higher incidence of stroke over 6 years (HR, 1.57 [95% CI, 1.05-2.33]).
“people with T2DM who reported elevated depressive symptoms or perceived stress had a significantly increased incidence of stroke (HR, 1.57 [95% CI, 1.05–2.33])”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [148]
In the REGARDS cohort, people with type 2 diabetes who reported elevated depressive symptoms or perceived stress had a higher incidence of acute cardiovascular disease over 6 years (HR, 1.57 [95% CI, 1.02-2.40]).
“acute cardiovascular disease (HR, 1.57 [95% CI, 1.02–2.40]) over 6 years of follow-up”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [148]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
A Global Measure of Perceived Stress
Cohen, S., Kamarck, T., & Mermelstein, R. (1983) · Journal of Health and Social Behavior · doi:10.2307/2136404 · Cited by 32,807 · see citing works
Standards of medical care in diabetes—2014
American Diabetes Association (2014) · Diabetes Care · doi:10.2337/dc14-s014 · Cited by 4,572 · see citing works
Universal Definition of Myocardial Infarction
Thygesen, K. A., Alpert, J. S., White, H. D., TASK FORCE MEMBERS: Chairpersons: Kristian Thygesen (Denmark), J. S. A. (., Biomarker Group: Allan S. Jaffe, C. (., ECG Group: Bernard Chaitman, C.-O. (., Imaging Group: Richard Underwood, C. (., Intervention Group: Jean-Pierre Bassand, C.-O. (., Mendis, S., Implementation Group: Lars C. Wallentin Coordinator (Sweden), F. F.-A. (., et al. (2007) · Circulation · doi:10.1161/circulationaha.107.187397 · Cited by 4,422 · see citing works
Sokolow, M., & Lyon, T. P. (1949) · American Heart Journal · doi:10.1016/0002-8703(49)90562-1 · Cited by 1,990 · see citing works
Collaborative care for patients with depression and chronic illnesses
Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., Peterson, D., Rutter, C. M., McGregor, M., & McCulloch, D. (2010) · New England Journal of Medicine · doi:10.1056/nejmoa1003955 · Cited by 1,697 · see citing works
Nicholson, A., Kuper, H., & Hemingway, H. (2006) · European Heart Journal · doi:10.1093/eurheartj/ehl338 · Cited by 1,353 · see citing works
The Reasons for Geographic and Racial Differences in Stroke Study: Objectives and Design
Howard, V. J., Cushman, M., Pulley, L., Gomez, C. R., Go, R. C. P., Prineas, R. J., Graham, A., Moy, C. S., & Howard, G. (2005) · Neuroepidemiology · doi:10.1159/000086678 · Cited by 1,175 · see citing works
Self-citationDepression and Diabetes Treatment Nonadherence: A Meta-Analysis
Gonzalez, J. S., Peyrot, M., McCarl, L. A., Collins, E. M., Serpa, L., Mimiaga, M. J., & Safren, S. A. (2008) · Diabetes Care · doi:10.2337/dc08-1341 · Cited by 1,060 · see citing works
Depression and the risk for cardiovascular diseases: Systematic review and meta analysis
Van der Kooy, K., van Hout, H., Marwijk, H., Marten, H., Stehouwer, C., & Beekman, A. (2007) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.1723 · Cited by 951 · see citing works
Nicolucci, A., Kovacs Burns, K., Holt, R. I. G., Comaschi, M., Hermanns, N., Ishii, H., Kokoszka, A., Pouwer, F., Skovlund, S. E., Stuckey, H., et al. (2013) · Diabetic Medicine · doi:10.1111/dme.12245 · Cited by 739 · see citing works
Fisher, L., Mullan, J. T., Arean, P., Glasgow, R. E., Hessler, D., & Masharani, U. (2010) · Diabetes Care · doi:10.2337/dc09-1238 · Cited by 681 · see citing works
Geiss, L. S., Wang, J., Cheng, Y. J., Thompson, T. J., Barker, L. E., Li, Y., Albright, A. L., & Gregg, E. W. (2014) · JAMA · doi:10.1001/jama.2014.11494 · Cited by 668 · see citing works
Fisher, L., Skaff, M. M., Mullan, J. T., Arean, P., Glasgow, R., & Masharani, U. (2008) · Diabetic Medicine · doi:10.1111/j.1464-5491.2008.02533.x · Cited by 524 · see citing works
Fisher, L., Gonzalez, J. S., & Polonsky, W. H. (2014) · Diabetic Medicine · doi:10.1111/dme.12428 · Cited by 470 · see citing works
Clinical Depression Versus Distress Among Patients With Type 2 Diabetes
Fisher, L., Skaff, M. M., Mullan, J. T., Arean, P., Mohr, D., Masharani, U., Glasgow, R., & Laurencin, G. (2007) · Diabetes Care · doi:10.2337/dc06-1614 · Cited by 465 · see citing works
Bidirectional Association Between Depression and Type 2 Diabetes Mellitus in Women
Pan, A., Lucas, M., Sun, Q., van Dam, R. M., Franco, O. H., Manson, J. E., Willett, W. C., Ascherio, A., & Hu, F. B. (2010) · Archives of Internal Medicine · doi:10.1001/archinternmed.2010.356 · Cited by 447 · see citing works
Bonnet, F., Irving, K., Terra, J., Nony, P., Berthézène, F., & Moulin, P. (2004) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2004.08.035 · Cited by 438 · see citing works
Depression and risk of mortality in individuals with diabetes: a meta-analysis and systematic review
Park, M., Katon, W. J., & Wolf, F. M. (2013) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2013.01.006 · Cited by 355 · see citing works
REDEEM: A pragmatic trial to reduce diabetes distress
Fisher, L., Hessler, D., Glasgow, R. E., Arean, P. A., Masharani, U., Naranjo, D., & Strycker, L. A. (2013) · Diabetes Care · doi:10.2337/dc12-2493 · Cited by 266 · see citing works
Bogner, H. R., Morales, K. H., de Vries, H. F., & Cappola, A. R. (2012) · The Annals of Family Medicine · doi:10.1370/afm.1344 · Cited by 227 · see citing works
Lin, E. H. B., Von Korff, M., Ciechanowski, P., Peterson, D., Ludman, E. J., Rutter, C. M., Oliver, M., Young, B. A., Gensichen, J., McGregor, M., et al. (2012) · The Annals of Family Medicine · doi:10.1370/afm.1343 · Cited by 150 · see citing works
Redmond, N., Richman, J., Gamboa, C. M., Albert, M. A., Sims, M., Durant, R. W., Glasser, S. P., & Safford, M. M. (2013) · Journal of the American Heart Association · doi:10.1161/jaha.113.000447 · Cited by 129 · see citing works
Self-citationHessler, D., Fisher, L., Glasgow, R. E., Strycker, L. A., Dickinson, L. M., Arean, P. A., & Masharani, U. (2014) · Diabetes Care · doi:10.2337/dc13-0762 · Cited by 102 · see citing works
Katon, W. J., Young, B. A., Russo, J. E., Lin, E., Ciechanowski, P. S., Ludman, E. J., & Korff, M. R. V. (2013) · The Annals of Family Medicine · doi:10.1370/afm.1501 · Cited by 84 · see citing works
Depression and cardiovascular disease: a reciprocal relationship
Plante, G. E. (2005) · Metabolism · doi:10.1016/j.metabol.2005.01.013 · Cited by 84 · see citing works
Coleman, S. M., Katon, W. J., Lin, E. H. B., & Korff, M. V. (2013) · Psychosomatics · doi:10.1016/j.psym.2013.02.015 · Cited by 63 · see citing works
Depression symptoms and the progression of carotid intima–media thickness: A 5-year follow-up study
Pizzi, C., Costa, G. M., Santarella, L., Flacco, M. E., Capasso, L., Bert, F., & Manzoli, L. (2014) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2014.01.012 · Cited by 51 · see citing works
Cummings, D. M., Lutes, L. D., Littlewood, K., DiNatale, E., Hambidge, B., Schulman, K., & Morisky, D. E. (2014) · Annals of Pharmacotherapy · doi:10.1177/1060028014536532 · Cited by 38 · see citing works
Self-citation
Flagged first, then by citations
Research works printed but not linked: 7
- [5]Lustman PJ, Clouse RE Depression in diabetic patients: the relationship between mood and glycemic control. J Diabetes Complications 2005; 19: 113– 122 15745842
- [19]Melchior LA, Huba GJ, Brown VB, Reback CJ A short depression index for women. Educ Psychol Meas 1993; 53: 1117– 1125
- [20]Radloff LS The CES-D Scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977; 3: 385– 401
- [25]Luepker RV, Apple FS, Christenson RH,.; AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; National Heart, Lung, and Blood Institute Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute. Circulation 2003; 108: 2543– 2549 14610011
- [27]Prineas R, Crow R, Zhang ZM Minnesota Code Manual of Electrocardiographic Findings. 2nd ed. London, U.K., Springer-Verlag, 2010
- [30]Whang W, Kubzansky LD, Kawachi I, Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses’ Health Study. J Am Coll Cardiol 2009; 53: 950– 958 19281925 PMC2664253
- [34]Hamer M, Molloy GJ, Stamatakis E Psychological distress as a risk factor for cardiovascular events: pathophysiological and behavioral mechanisms. J Am Coll Cardiol 2008; 52: 2156– 2162 19095133
Cited by
Sorted by citations
van Sloten, T. T., Sedaghat, S., Carnethon, M. R., Launer, L. J., & Stehouwer, C. D. A. (2020) · The Lancet Diabetes & Endocrinology · doi:10.1016/s2213-8587(19)30405-x · Cited by 702 · see citing works
Type 2 diabetes mellitus and psychological stress — a modifiable risk factor
Hackett, R. A., & Steptoe, A. (2017) · Nature Reviews Endocrinology · doi:10.1038/nrendo.2017.64 · Cited by 480 · see citing works
Arnold, S. V., Bhatt, D. L., Barsness, G. W., Beatty, A. L., Deedwania, P. C., Inzucchi, S. E., Kosiborod, M., Leiter, L. A., Lipska, K. J., Newman, J. D., et al. (2020) · Circulation · doi:10.1161/cir.0000000000000766 · Cited by 304 · see citing works
Psychosocial Factors in Diabetes and Cardiovascular Risk
Hackett, R. A., & Steptoe, A. (2016) · Current Cardiology Reports · doi:10.1007/s11886-016-0771-4 · Cited by 152 · see citing works
Xue, E., Zhao, J., Ye, J., Wu, J., Chen, D., Shao, J., Li, X., & Ye, Z. (2025) · BMC Medicine · doi:10.1186/s12916-025-03864-y · Cited by 3 · see citing works
- Authors
- Cummings, D. M., Kirian, K., Howard, G., Howard, V., Yuan, Y., Muntner, P., Kissela, B., Redmond, N., Judd, S. E., & Safford, M. M.
- Affiliations
- East Carolina University (US)
- University of Alabama at Birmingham (US)
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- Corresponding author
- Cummings, Doyle M.
- ORCID
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2015-11-17
- Volume
- 39
- Issue
- 1
- Pages
- 101-109
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- PMC
- PMC4876731
- OpenAlex
- W2177552479
- Cited by
- 73
- References
- 29
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 3 · 2023: 8 · 2022: 7 · 2021: 5 · 2020: 8 · 2019: 6 · 2018: 9 · 2017: 11 · 2016: 7
- FWCI
- 6.54
- Type
- journal article
- Language
- en
- Update notices
- correction (2016-03-01)
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Diabetes Care (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (U01-NS-041588)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Keywords
- diabetes mellitus, depressive symptoms, psychological stress, cardiovascular outcomes, stroke, myocardial infarction, cardiovascular mortality, comorbidities, REGARDS study, stroke belt
- MeSH terms
- Aged, Black or African American, Cardiovascular Diseases, Coronary Disease, Depression, Diabetes Mellitus, Female, Humans, Longitudinal Studies, Male, Middle Aged, Myocardial Infarction, Prospective Studies, Risk Factors, Stress, Psychological, Cohort Studies, Comorbidity, Incidence, Stroke, White People
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
