The cross-sectional association of stressful life events with depression severity among patients with hypertension and diabetes in Malawi

PLOS ONE RESEARCH ARTICLE The cross-sectional association of stressful life events with depression severity among patients with hypertension and diabetes in Malawi Kelsey R. Landrum ID1*, Brian W. Pence1, Bradley N. Gaynes1,2, Josée M. Dussault ID1, Mina C. Hosseinipour ID3,4, Kazione Kulisewa5, Jullita Kenela Malava4, Jones Masiye6, Harriet Akello4, Michael Udedi6, Chifundo C. Zimba4 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 University of North Carolina at Chapel Hill, Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America, 2 University of North Carolina at Chapel Hill, Department of Psychiatry, Chapel Hill, North Carolina, United States of America, 3 University of North Carolina at Chapel Hill, Department of Medicine, Chapel Hill, North Carolina, United States of America, 4 UNC Project Malawi, UNC Project, Tidziwe Centre, Lilongwe, Malawi, 5 Kamuzu University of Health, Department of Psychiatry and Mental Health, Blantyre, Malawi, 6 Malawi Ministry of Health, Noncommunicable Diseases and Mental Health Unit, Lilongwe, Malawi * OPEN ACCESS Citation: Landrum KR, Pence BW, Gaynes BN, Dussault JM, Hosseinipour MC, Kulisewa K, et al. (2022) The cross-sectional association of stressful life events with depression severity among patients with hypertension and diabetes in Malawi. PLoS ONE 17(12): e0279619. https://doi.org/10.1371/ journal.pone.0279619 Editor: Yann Benetreau, Public Library of Science, UNITED STATES Received: February 28, 2022 Accepted: November 23, 2022 Published: December 30, 2022 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0279619 Copyright: © 2022 Landrum et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: De-identified, individual-level SHARP data is shared via the National Institute of Mental Health Data Archive Abstract Depressive disorders are a leading cause of global morbidity and remain disproportionately high in low- and middle-income settings. Stressful life events (SLEs) are known risk factors for depressive episodes and worsened depressive severity, yet are under-researched in comparison to other depression risk factors. As depression is often comorbid with hypertension, diabetes, and other noncommunicable diseases (NCDs), research into this relationship among patients with NCDs is particularly relevant to increasing opportunities for integrated depression and NCD care. This study aims to estimate the cross-sectional association between SLEs in the three months preceding baseline interviews and baseline depressive severity among patients with at least mild depressive symptoms who are seeking NCD care at 10 NCD clinics across Malawi. SLEs were measured by the Life Events Survey and depressive severity (mild vs. moderate to severe) was measured by the Patient Health Questionnaire-9. The study population (n = 708) was predominately currently employed, grand multiparous (5–8 children) women with a primary education level. Two thirds (63%) had mild depression while 26%, 8%, and 3% had moderate, moderately severe, and severe depression, respectively. Nearly all participants (94%) reported at least one recent SLE, with the most common reported SLEs being financial stress (48%), relationship changes (45%), death of a family member or friend (41%), or serious illness of a family member or friend (39%). Divorce/separation, estrangement from a family member, losing source of income, and major new health problems were significant predictors of greater (moderate or severe) depressive severity compared to mild severity. Having a major new health problem or experiencing divorce/separation resulted in particularly high risk of more severe depression. After adjustment, each additional SLE was associated with a 9% increased risk of moderate or worse depressive severity compared to mild depressive PLOS ONE | https://doi.org/10.1371/journal.pone.0279619 December 30, 2022 1 / 17 PLOS ONE (https://ndar.nih.gov/contribute_data_sharing_ regimen.html) and is updated every 6 months. Researchers can apply to the National Institute of Mental Health Data Archive to access these data. The data used and analyzed in this study are also available from the corresponding author and the parent study principal investigator upon a reasonable request. Funding: This study received funding from the National Institute of Mental Health (MPIs: Brian W. Pence, PhD, Mina C. Hosseinipour, MD MPH; Jones Masiye; U19MH113202-01). KRL received support from supplement U19MH113202-04S1. JD received support from supplement U19MH113202-01S2 and T32AI070114. Neither the funding agency nor funders had any part in study conceptualization, data collection, data analysis, or decision-making about publication. Competing interests: The authors have declared that no competing interests exist. Abbreviations: DAG, Directed Acyclic Graph; DALY, Disability adjusted life years; GAD, Generalized Anxiety Disorder; LMICs, Low- and middle-income countries; MNS, Mental, neurological, and substance abuse; NCD, Noncommunicable disease; PHQ-9, Patient Health Questionnaire-9; PR, Prevalence ratio; PTSD, Posttraumatic stress disorder; RCT, Randomized control trial; SHARP, Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building; SLE, Stressful life event; YLD, Years lived with disability. Stressful life events and depression severity among NCD patients in Malawi severity (RR: 1.09; (95% CI: 1.05, 1.13), p<0.0001). Among patients with NCDs with at least mild depressive symptoms, SLEs in the prior 3 months were associated with greater depressive severity. While many SLEs may not be preventable, this research suggests that assessment of SLEs and teaching of positive coping strategies when experiencing SLEs may play an important role in integrated NCD and depression treatment models. Introduction Depression is the leading cause of mental health-related illness globally, and a leading contributor of Disability Adjusted Life Years (DALYs) and Years Lived with Disability (YLD) among mental, neurological, and substance use (MNS) disorders [1, 2]. While not all individuals with non-communicable diseases (NCDs) develop depression, having an illness may increase one’s risk if depression [3–8]. Increasing global depression rates and association of depression with hypertension, diabetes, and other NCDs highlight the importance of researching and implementing cost-effective methods of integrating depression care into existing NC (...truncated)