# Prevalence and Correlates of Depression and Suicidal Ideation Across Stages 0–4 of Cardiovascular‐Kidney‐Metabolic Syndrome

## TL;DR

Depression becomes more common as cardiovascular-kidney-metabolic syndrome progresses, with significant increases in stage 4, especially among women and Hispanic individuals.

## Contribution

This study identifies stage-specific correlates of depression and suicidal ideation across CKM syndrome stages using a large US population sample.

## Key findings

- Depression prevalence rises from 10.9% in Stage 0 to 30.0% in Stage 4 of CKM syndrome.
- Suicidal ideation is notably higher in Stage 4 among females (8.0%) and Hispanic individuals (10.3%).
- Stage-specific correlates shift from socioeconomic factors in early stages to biomedical factors in advanced stages.

## Abstract

The American Heart Association (AHA) recently introduced the cardiovascular‐kidney‐metabolic (CKM) syndrome framework to improve cardiovascular health management. However, evidence on the prevalence of depression and suicidal ideation (SI) across distinct CKM stages is limited.

This cross‐sectional study analyzed data from 10,519 US adults participating in the National Health and Nutrition Examination Survey (NHANES) 2007 to 2018. Depression and SI were assessed using the nine‐item Patient Health Questionnaire (PHQ‐9). CKM syndrome stages were classified as: Stage 0 (absence of risk factors); Stage 1 (excess/dysfunctional adiposity); Stage 2 (metabolic risk factors or moderate‐to‐high‐risk CKD); Stage 3 (subclinical cardiovascular disease [CVD] or its risk equivalents); and Stage 4 (clinical CVD). Weighted statistical analyses were conducted to account for the complex sampling design of NHANES and obtain nationally representative estimates.

The prevalence of depression increased progressively with advancing CKM syndrome stages: 10.9% (Stage 0), 13.9% (Stage 1), 19.0% (Stages 2 and 3 combined), and 30.0% (Stage 4) (p for trend < 0.001). In contrast, the overall prevalence of SI remained relatively stable across stages (2.9%–4.9%; p for trend = 0.25). However, SI was significantly elevated specifically among females (8.0%) and Hispanic individuals (10.3%) in Stage 4. Stage‐specific correlates of depression varied, encompassing socioeconomic and lifestyle factors in early stages and incorporating additional complex biomedical factors in advanced stages. Depression was consistently and strongly associated with SI across all stages. Models combining stage‐specific correlates demonstrated moderate to good discrimination (area under the curve [AUC]: 0.650–0.748 for depression; 0.734–0.869 for SI).

Advancing stages of CKM syndrome are associated with a significantly increased prevalence of depression, highlighting the critical need for integrating mental healthcare into CKM management. The identification of stage‐specific correlates provides valuable insights for developing targeted screening and intervention strategies.

Depression prevalence rises with CKM stage (10.9%–30.0%), with suicidal ideation spiking in Stage 4 (females 8.0%, Hispanics 10.3%); correlates shift from socioeconomic/lifestyle to biomedical, necessitating mental health screening in CKM care.