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Do Depression and Anxiety Mediate the Link Between Educational Attainment and CHD?

From the Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA.

Address correspondence and reprint requests to Rebecca C. Thurston, PhD, Department of Psychiatry, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA 15213. E-mail: thurstonrc{at}upmc.edu

Objective: Depression and anxiety are frequently hypothesized yet rarely examined pathways linking low socioeconomic status (SES) to coronary heart disease (CHD). This study evaluates depression and anxiety as mediators of the association between educational attainment and incident CHD.

Methods: Subjects (n = 6265, age 25–74) were participants in NHANES I and follow-up studies, a longitudinal, nationally representative study of the US population. Measures of educational attainment and depressive and anxious symptoms (General Well-Being Schedule) were derived from the baseline interview and incident CHD from hospital records and death certificates. Analyses included logistic regression and Cox proportional hazards models.

Results: In fully adjusted models, less than high school (relative risk [RR] = 1.46; 95% confidence interval [CI], 1.15–1.86) and some college (RR = 1.40; 95% CI, 1.05–1.88) education were associated with increased CHD risk relative to a college education. High depressive (RR = 1.31; 95% CI, 1.06–1.61) or anxious (RR = 1.35; 95% CI, 1.13–1.62) symptoms were associated with significantly increased CHD risk relative to low symptoms. Low educational levels were associated with increased risk for high depressive (OR = 3.43; 95% CI, 2.34–5.03) and anxious (OR = 1.71; 95% CI, 1.32–2.22) symptoms. However, depressive and anxious symptoms accounted for little of the association between education and CHD.

Conclusion: Education and depressive and anxious symptoms are associated with each other and risk of incident CHD. Although depressive and anxious symptoms are highest among those with lowest levels of education, they do not appear to mediate the relation between educational attainment and incident CHD. Findings suggest the importance of interventions to reduce socioeconomic disadvantage and negative affect in preventing CHD.

Key Words: socioeconomic status • education • depression • anxiety • coronary heart disease • mediation

Abbreviations: SES = socioeconomic status; CHD = coronary heart disease; NHANES I = First National Health and Nutrition Survey; NHEF = First National Health and Nutrition Epidemiologic Follow-up Surveys; GWB = General Well-Being Schedule; GWB-A = General Well-Being Schedule Anxiety subscale; GWB-D = General Well-Being Schedule Depression subscale; BMI = body mass index; SBP = systolic blood pressure; DBP = diastolic blood pressure; RR = relative risk; CI = confidence interval; MI = myocardial infarction.

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