Temporal trends in mortality related to heart failure and depression in the United States: 1999-2020

Abstract

Introduction: Heart failure (HF) remains a leading cause of death in the United States. While depression is known to affect 17–37% of HF patients, its contribution to recorded mortality is poorly characterized in national datasets. Death certificate documentation of comorbid depression in HF deaths provides insight into clinical recognition and reporting patterns rather than the comprehensive burden of disease.

Aims: To analyze temporal trends and demographic disparities in death certificate documentation of depression among decedents with HF as the underlying cause, using the CDC Multiple Causes of Death (MCD) database from 1999–2020.

Methodology: A retrospective observational study was conducted using the CDC MCD database for adults aged ≥25 years in the U.S. from 1999–2020. Deaths with HF (ICD-10: I50) as the underlying cause and depression (ICD-10: F32) as a contributing cause were identified. Age-adjusted mortality rates (AAMRs) per 1,000,000 population were calculated using the 2000 U.S. standard population, and trends were assessed with Joinpoint regression, expressed as annual percentage change (APC) with 95% confidence intervals (CIs).

Results: A total of 3,593 deaths were recorded where HF was listed as the underlying cause and depression as a contributing cause. The overall AAMR for HF with depression showed a declining trend from 1999–2009 (APC = –6.24; 95% CI = –8.31 to –4.12), followed by a plateau from 2009–2020 (APC = 0.05; 95% CI = –0.31 to 0.42). Females accounted for 69.6% of deaths, with higher AAMRs than males. The highest mortality documentation occurred in metropolitan areas and among White individuals (95.1%).

Conclusions: This study reveals declining documentation of depression on HF-related death certificates through 2009, followed by stabilization thereafter. The low absolute count of 3,593 deaths across two decades indicates substantial under-ascertainment compared to the known clinical prevalence of depression in HF patients. These findings primarily reflect documentation and reporting patterns rather than the total mortality burden, emphasizing the need for improved recognition and recording of mental health comorbidities in cardiovascular disease surveillance.