Depression Doubles Cardiovascular Risk Burden in Haiti’s Largest Urban Cohort

In the crowded neighborhoods of Port-au-Prince, where cardiovascular disease has quietly become the leading cause of death across low- and middle-income countries, researchers have uncovered a link that could reshape how one of the world’s poorest nations approaches heart health. A cross-sectional analysis of nearly 3,000 adults enrolled in the Haiti Cardiovascular Disease Cohort has found that people with moderate to severe depressive symptoms carry a substantially higher burden of cardiovascular disease than their peers with few or no symptoms, even after accounting for a wide range of social and behavioral factors that typically confound such associations in resource-limited settings.

The study, published in PLOS Mental Health, drew on enrollment data collected between March 2019 and August 2021 from adults aged 18 and older living in urban Haiti. Participants completed the Patient Health Questionnaire-9, a widely validated nine-item screening instrument that scores depressive symptoms on a scale from zero to 27. The researchers dichotomized the scores, treating values below 10 as none to mild and values of 10 or above as moderate to severe, a cutoff commonly used in clinical and epidemiological research to flag depression that warrants treatment. Cardiovascular outcomes were not self-reported in a casual sense; instead, cases of angina, myocardial infarction, transient ischemic attack, stroke, and heart failure were adjudicated using epidemiologic definitions aligned with international cohort studies, lending the prevalence estimates a rigor that is often difficult to achieve in settings without routine diagnostic infrastructure.

The scale of psychological distress documented in the cohort was striking. Among the 2,995 participants, who had a mean age of 41.9 years and were 58 percent female, 16.2 percent reported moderate to severe depressive symptoms. That overall figure, however, concealed a sharp gender divide: 22 percent of women screened in the moderate-to-severe range compared with just 8.5 percent of men. This nearly threefold difference in symptom burden echoes patterns seen globally, where women consistently report higher rates of depression, but it takes on particular significance in Haiti, where economic instability, food insecurity, and the aftermath of repeated disasters weigh heavily on household life.

When the researchers cross-tabulated depressive symptoms with adjudicated cardiovascular disease, the association emerged clearly in both sexes. Among men with moderate to severe symptoms, 21.5 percent had prevalent cardiovascular disease, compared with 10.6 percent of men with none to mild symptoms. Among women, the corresponding figures were 23.3 percent versus 15.3 percent. In other words, cardiovascular disease was roughly twice as common among the most symptomatic men and about half again as common among the most symptomatic women, a pattern that persisted across the cohort’s urban neighborhoods.

To move beyond raw prevalence differences, the team employed generalized estimating equation Poisson models with a log link, a statistical approach well suited to estimating prevalence ratios in cross-sectional data where odds ratios can overstate effect sizes for common outcomes. The models adjusted for an unusually comprehensive set of covariates: age, sex, education, income, food insecurity, smoking, alcohol use, physical activity, stress, and body mass index. This adjustment strategy matters enormously in a Haitian context, where food insecurity and material hardship are widespread and could otherwise masquerade as a depression–cardiovascular link. Even after these adjustments, moderate to severe depressive symptoms remained independently associated with a 36 percent higher prevalence of cardiovascular disease, with an adjusted prevalence ratio of 1.36 and a 95 percent confidence interval of 1.08 to 1.71.

Sex-stratified analyses revealed a consistent but nuanced picture. Among women, the adjusted prevalence ratio was 1.38 with a confidence interval of 1.06 to 1.78, indicating a statistically robust association. Among men, the point estimate was somewhat lower at 1.25, but the confidence interval of 0.75 to 1.99 crossed the null, reflecting the smaller number of men in the cohort and the lower prevalence of depressive symptoms among them. The researchers also examined effect modification on the additive scale using the relative excess risk due to interaction, a measure that captures whether the combined burden of being female and depressed exceeds what would be expected from adding the two risks together. The RERI estimate of 0.07, with a confidence interval spanning −0.74 to 0.88, provided limited evidence for additive interaction, and formal tests of multiplicative modification were likewise not statistically significant.

These null interaction findings should not be mistaken for evidence that sex is irrelevant. The point estimates for women were consistently stronger, and the authors describe a stronger pattern among women even while acknowledging that formal significance thresholds were not met. In epidemiological terms, the study was likely underpowered to detect interaction, particularly given the modest number of men with moderate to severe symptoms. The practical takeaway is that depression and cardiovascular disease travel together in both sexes in urban Haiti, with a suggestive but unproven intensification among women that future, larger studies will need to confirm.

The findings carry weight because they emerge from a setting where cardiovascular disease has overtaken infectious disease as the dominant killer, yet mental health remains chronically under-resourced. Haiti has only a handful of psychiatrists for a population of more than eleven million, and depression screening is rarely integrated into routine care, let alone into cardiovascular prevention programs. The study’s authors argue that integrating depression screening into cardiovascular disease prevention could help address the growing dual burden of both conditions in resource-limited settings. Such integration need not be technologically sophisticated; the Patient Health Questionnaire-9 is short, free to administer, and already validated in numerous languages and cultural contexts, making it a realistic addition to community health worker visits and hypertension clinics alike.

Mechanistically, the depression–cardiovascular connection is thought to run along several converging pathways. Depression is associated with dysregulation of the hypothalamic-pituitary-adrenal axis and elevated cortisol, heightened systemic inflammation, impaired endothelial function, and increased platelet aggregability, all of which promote atherosclerosis and thrombosis. Behavioral channels compound these biological ones: people with depression are more likely to smoke, drink heavily, remain physically inactive, and adhere poorly to medications, while also eating less healthful diets. In Haiti, where the cohort’s own adjustment variables reveal how tightly food insecurity, stress, and poverty are woven into daily life, disentangling these pathways is an empirical challenge that cross-sectional data cannot fully resolve. The authors are explicit on this point, calling for prospective studies to clarify the underlying mechanisms and causal pathways.

What the study establishes is a robust cross-sectional association in a population that has been almost entirely absent from the global cardiovascular literature. Most of what medicine knows about the depression–heart disease link comes from high-income countries, where patients have access to lipid panels, electrocardiograms, and cardiologists. The Haiti Cardiovascular Disease Cohort demonstrates that the same epidemiological tools—validated symptom scales, adjudicated outcome definitions, and carefully adjusted prevalence models—can be deployed in one of the world’s most constrained health systems and yield findings of genuine global relevance. If depression screening becomes a routine part of cardiovascular prevention in Port-au-Prince and cities like it, the payoff could extend beyond Haiti: roughly three-quarters of cardiovascular deaths worldwide occur in low- and middle-income countries, and this study suggests that a treatable mental health condition may be quietly amplifying that toll.

Subject of Research: The association between depressive symptoms and prevalent cardiovascular disease in urban Haiti

Article Title: Depressive symptoms and association with prevalent cardiovascular disease: A cross-sectional analysis in Port-au-Prince, Haiti

Article References: Pierre, D. M., Rasul, R., St. Sauveur, R., Celestin, K., Rouzier, V., Hilaire, E., Deschamps, M. M., Pape, J. W., Yan, L. D., Ogyu, A., Bennett, C., McNairy, M. L., Sufra, R., & Nash, D. (2026). Depressive symptoms and association with prevalent cardiovascular disease: A cross-sectional analysis in Port-au-Prince, Haiti. PLOS Mental Health, 3(8), e0000693. https://doi.org/10.1371/journal.pmen.0000693

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000693

Keywords: depression, cardiovascular disease, Haiti, Port-au-Prince, PHQ-9, cross-sectional study, sex differences, global health, mental health, low- and middle-income countries, epidemiology, comorbidity