Comorbid anxiety disorders alter the association between cardiovascular diseases and depression: the German National Health Interview and Examination Survey

Original Paper



This study aims to examine whether specific anxiety disorder comorbidity alters the purported association between depression and specific cardiovascular diseases (CVDs).


In 4,181 representative German participants of the general population, 12-month prevalence of psychiatric disorders was assessed through the Composite International Diagnostic Interview and CVDs by physician verified diagnosis. Adjusting for conventional risk factors logistic regression analyzed the association between CVDs (peripheral vascular disease (PVD), hypertension, cerebrovascular disease and heart disease) and combinations of comorbidity between depression and anxiety disorder types (panic disorder, specific phobia, social phobia and generalized anxiety).


There were 770 cases of hypertension (18.4 %), 763 cases of cerebrovascular disease (18.2 %), 748 cases of PVD (17.9 %), and 1,087 cases of CVD (26.0 %). In adjusted analyses phobia comorbid with depression was associated with cerebrovascular disease (odds ratio (OR) 1.61; 95 % confidence interval (CI) 1.04–2.50) as was panic disorder (OR 2.89; 95 % CI 1.47–5.69). PVD was significantly associated with panic disorder (adjusted OR 2.97; 95 % CI 1.55–5.69). Panic disorder was associated with CVDs (adjusted OR 2.28; 95 % CI 1.09–4.77) as was phobia (adjusted OR 1.35; 95 % CI 1.04–1.78).


Classification of anxiety and depression according to comorbidity groups showed discrete effects for panic disorder and specific phobia with CVDs, independent from covariates and depression.


Cardiovascular diseases Vascular diseases Anxiety disorders Depression Comorbidity 


  1. 1.
    Meng L et al (2012) Depression increases the risk of hypertension incidence: a meta-analysis of prospective cohort studies. J Hypertens 30(5):842–851PubMedCrossRefGoogle Scholar
  2. 2.
    Player MS, Peterson LE (2011) Anxiety disorders, hypertension, and cardiovascular risk: a review. Int J Psychiatry Med 41(4):365–377PubMedCrossRefGoogle Scholar
  3. 3.
    Gunn J et al (2012) The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Psychiatr Epidemiol 47(2):175–184PubMedCrossRefGoogle Scholar
  4. 4.
    Pratt AG, Norris ER, Kaufmann M (2005) Peripheral vascular disease and depression. J Vasc Nurs 23(4):123–127 (quiz 128–129)PubMedCrossRefGoogle Scholar
  5. 5.
    Gothe F et al (2012) Cerebrovascular diseases and depression: epidemiology, mechanisms and treatment. Panminerva Med 54(3):161–170PubMedGoogle Scholar
  6. 6.
    Wouts L et al (2008) Cardiac disease, depressive symptoms, and incident stroke in an elderly population. Arch Gen Psychiatry 65(5):596–602PubMedCrossRefGoogle Scholar
  7. 7.
    Krishnan KR (2000) Depression as a contributing factor in cerebrovascular disease. Am Heart J 140(Suppl 4):70–76PubMedCrossRefGoogle Scholar
  8. 8.
    Barth J, Schumacher M, Herrmann-Lingen C (2004) Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis. Psychosom Med 66(6):802–813PubMedCrossRefGoogle Scholar
  9. 9.
    Nicholson A, Kuper H, Hemingway H (2006) Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J 27(23):2763–2774PubMedCrossRefGoogle Scholar
  10. 10.
    Gasse C, Laursen TM, Baune BT (2012) Major depression and first-time hospitalization with ischemic heart disease, cardiac procedures and mortality in the general population: a retrospective Danish population-based cohort study. Eur J Prev Cardiol Google Scholar
  11. 11.
    Baumeister H et al (2011) Quality of life in somatically ill persons with comorbid mental disorders: a systematic review and meta-analysis. Psychother Psychosom 80:275–286PubMedCrossRefGoogle Scholar
  12. 12.
    Wagner J, Pietrzak R, Petry N (2008) Psychiatric disorders are associated with hospital care utilization in persons with hypertension. Soc Psychiatry Psychiatr Epidemiol 43(11):878–888PubMedCrossRefGoogle Scholar
  13. 13.
    Pizzi C et al (2011) Meta-analysis of selective serotonin reuptake inhibitors in patients with depression and coronary heart disease. Am J Cardiol 107(7):972–979PubMedCrossRefGoogle Scholar
  14. 14.
    Baumeister H, Hutter N, Bengel J (2011) Psychological and pharmacological interventions for depression in patients with coronary artery disease. Cochrane Database Syst Rev 9:CD008012PubMedGoogle Scholar
  15. 15.
    Lopez AD et al (2006) Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 367(9524):1747–1757PubMedCrossRefGoogle Scholar
  16. 16.
    McIntyre RS et al (2012) The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid metabolic disorders. Ann Clin Psychiatry 24(1):69–81PubMedGoogle Scholar
  17. 17.
    Frasure-Smith N, Lespérance F (2008) Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiatry 65(1):62–71PubMedCrossRefGoogle Scholar
  18. 18.
    Martens EJ et al (2010) Scared to death? Generalized anxiety disorder and cardiovascular events in patients with stable coronary heart disease:the heart and soul study. Arch Gen Psychiatry 67(7):750–758PubMedCrossRefGoogle Scholar
  19. 19.
    Phillips AC et al (2009) Generalized anxiety disorder, major depressive disorder, and their comorbidity as predictors of all-cause and cardiovascular mortality: the Vietnam experience study. Psychosom Med 71(4):395–403PubMedCrossRefGoogle Scholar
  20. 20.
    Scherrer JF et al (2010) Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans administration patients. Am Heart J 159(5):772–779PubMedCrossRefGoogle Scholar
  21. 21.
    Tully PJ et al (2011) Cardiac morbidity risk and depression and anxiety: a disorder, symptom and trait analysis among cardiac surgery patients. Psychol Health Med 16(3):333–345PubMedCrossRefGoogle Scholar
  22. 22.
    Härter M et al (2007) Increased 12-month prevalence rates of mental disorders in patients with chronic somatic diseases. Psychother Psychosom 76:354–360PubMedCrossRefGoogle Scholar
  23. 23.
    Barger SD, Sydeman SJ (2005) Does generalized anxiety disorder predict coronary heart disease risk factors independently of major depressive disorder? J Affect Disord 88(1):87–91PubMedCrossRefGoogle Scholar
  24. 24.
    Chen YH, Lin HC (2011) Patterns of psychiatric and physical comorbidities associated with panic disorder in a nationwide population-based study in Taiwan. Acta Psychiatr Scand 123(1):55–61PubMedCrossRefGoogle Scholar
  25. 25.
    Gomez-Caminero A et al (2005) Does panic disorder increase the risk of coronary heart disease? A cohort study of a national managed care database. Psychosom Med 67(5):688–691PubMedCrossRefGoogle Scholar
  26. 26.
    Kibler JL, Joshi K, Ma M (2009) Hypertension in relation to posttraumatic stress disorder and depression in the US National Comorbidity Survey. Behav Med 34(4):125–132PubMedCrossRefGoogle Scholar
  27. 27.
    Carroll D et al (2010) Generalized anxiety and major depressive disorders, their comorbidity and hypertension in middle-aged men. Psychosom Med 72(1):16–19PubMedCrossRefGoogle Scholar
  28. 28.
    Tully PJ, Cosh SM, Baune BT (2013) A review of the affects of worry and generalized anxiety disorder upon cardiovascular health and coronary heart disease. Psychol Health Med 18(6):627–644Google Scholar
  29. 29.
    Tully PJ, Cosh SM (2013) Generalized anxiety disorder prevalence and comorbidity with depression in coronary heart disease: a meta analysis. J Health PsycholGoogle Scholar
  30. 30.
    Krueger RF (1999) The structure of common mental disorders. Arch Gen Psychiatry 56(10):921–926PubMedCrossRefGoogle Scholar
  31. 31.
    Ormel J et al (2007) Mental disorders among persons with heart disease—results from World Mental Health surveys. Gen Hosp Psychiatry 29(4):325–334PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Goodwin RD, Davidson KW, Keyes K (2009) Mental disorders and cardiovascular disease among adults in the United States. J Psychiatr Res 43(3):239–246PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Jacobi F et al (2002) Estimating the prevalence of mental and somatic disorders in the community: aims and methods of the German National Health Interview and Examination Survey. Int J Methods Psychiatr Res 11(1):1–18PubMedCrossRefGoogle Scholar
  34. 34.
    Wittchen HU et al (1999) Screening for mental disorders: performance of the Composite International Diagnostic Screener (CID-S). Int J Methods Psychiatr Res 8(2):59–70CrossRefGoogle Scholar
  35. 35.
    Baune BT et al (2006) Associations between major depression, bipolar disorders, dysthymia and cardiovascular diseases in the general adult population. Psychother Psychosom 75(5):319–326PubMedCrossRefGoogle Scholar
  36. 36.
    Knäuper B, Wittchen HU (1994) Diagnosing major depression in the elderly: evidence for response bias in standardized diagnostic interviews? J Psychiatr Res 28(2):147–164PubMedCrossRefGoogle Scholar
  37. 37.
    Kessler RC (1999) The World Health Organization International Consortium in Psychiatric Epidemiology (ICPE): initial work and future directions—The NAPE lecture 1998. Acta Psychiatr Scand 99(1):2–9PubMedCrossRefGoogle Scholar
  38. 38.
    Wittchen HU (1994) Reliability and validity studies of the WHO—Composite international diagnostic interview (CIDI): a critical review. J Psychiatr Res 28(1):57–84PubMedCrossRefGoogle Scholar
  39. 39.
    Stanley S et al (2013) Assessing overweight and obesity across mental disorders: personality disorders at high risk. Soc Psychiatry Psychiatr Epidemiol 48(3):487–492PubMedCrossRefGoogle Scholar
  40. 40.
    Winkler J, Stolzenberg H (1999) Social status scaling in the German National Health Interview and Examination Survey. Der Sozialschichtindex im Bundes-Gesundheitssurvey 61(Suppl. 2):S178–S183Google Scholar
  41. 41.
    Fiedorowicz JG, He J, Merikangas KR (2011) The association between mood and anxiety disorders with vascular diseases and risk factors in a nationally representative sample. J Psychosom Res 70(2):145–154PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Fleet R, Lavoie K, Beitman BD (2000) Is panic disorder associated with coronary artery disease? A critical review of the literature. J Psychosom Res 48(4–5):347–356PubMedCrossRefGoogle Scholar
  43. 43.
    Katerndahl DA (2008) The association between panic disorder and coronary artery disease among primary care patients presenting with chest pain: an updated literature review. Prim Care Companion J Clin Psychiatry 10(4):276–285PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Watson D (2009) Differentiating the mood and anxiety disorders: a quadripartite model. Ann uRev Clin Psychol 5:221–247CrossRefGoogle Scholar
  45. 45.
    Frasure-Smith N, Lesperance F (2008) Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiatry 65(1):62–71PubMedCrossRefGoogle Scholar
  46. 46.
    Katon WJ et al (2010) Collaborative care for patients with depression and chronic illnesses. N Engl J Med 363(27):2611–2620PubMedCentralPubMedCrossRefGoogle Scholar
  47. 47.
    Shemesh E et al (2011) A randomized controlled trial of the safety and promise of cognitive-behavioral therapy using imaginal exposure in patients with posttraumatic stress disorder resulting from cardiovascular illness. J Clin Psychiatry 72(2):168–174PubMedCrossRefGoogle Scholar
  48. 48.
    Salmoirago-Blotcher E, Ockene IS (2009) Methodological limitations of psychosocial interventions in patients with an implantable cardioverter-defibrillator (ICD) A systematic review. BMC Cardiovasc Disord 9:56PubMedCentralPubMedCrossRefGoogle Scholar
  49. 49.
    Harter M et al (2004) Recognition of psychiatric disorders in musculoskeletal and cardiovascular rehabilitation patients. Arch Phys Med Rehabil 85(7):1192–1197PubMedCrossRefGoogle Scholar
  50. 50.
    Lavoie KL et al (2004) Heart rate variability in coronary artery disease patients with and without panic disorder. Psychiatry Res 128(3):289–299PubMedCrossRefGoogle Scholar
  51. 51.
    Hoehn-Saric R et al (2004) Somatic symptoms and physiologic responses in generalized anxiety disorder and panic disorder: an ambulatory monitor study. Arch Gen Psychiatry 61(9):913–921PubMedCrossRefGoogle Scholar
  52. 52.
    Pajak A et al (2013) Depression, anxiety, and risk factor control in patients after hospitalization for coronary heart disease: the EUROASPIRE III Study. Eur J Prev Cardiol 20(2):331–340Google Scholar
  53. 53.
    Busch MA et al (2013) Prevalence of stroke in adults aged 40 to 79 years in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 56(5–6):656–660PubMedCrossRefGoogle Scholar
  54. 54.
    Gosswald A et al (2013) Prevalence of myocardial infarction and coronary heart disease in adults aged 40-79 years in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 56(5–6):650–655PubMedCrossRefGoogle Scholar
  55. 55.
    Scheidt-Nave C et al (2013) Prevalence of dyslipidemia among adults in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS 1). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 56(5–6):661–667PubMedCrossRefGoogle Scholar
  56. 56.
    Pelissolo A et al (2002) Personality dimensions in social phobics with or without depression. Acta Psychiatr Scand 105(2):94–103PubMedCrossRefGoogle Scholar
  57. 57.
    Baune BT et al (2012) The relationship between subtypes of depression and cardiovascular disease: a systematic review of biological models. Transl Psychiatry 2:e92PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Discipline of PsychiatryThe University of AdelaideAdelaideAustralia
  2. 2.Royal Adelaide HospitalThe University of AdelaideAdelaideAustralia

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