Mental health disorders and cardiovascular diseases (CVDs) are major contributors to global morbidity and mortality, posing substantial burdens on public health systems. CVDs continue to be the leading cause of mortality and disability worldwide.[1] In 2022, CVDs were estimated to have caused approximately 19.8 million deaths globally, accounting for nearly 32% of all deaths. Notably, about 85% of these fatalities were due to heart attacks and strokes.[2] Whereas Mental disorders are estimated to cause around 8 million deaths each year. Individuals with these conditions exhibit a significantly elevated mortality risk relative to the general population.[3] The relationship between mental health disorders and CVDs is complex and bidirectional. On one hand, cardiovascular patients are more likely to develop mental health issues due to the physical and emotional strain of chronic illness. Conversely, individuals with mental health conditions, such as depression and anxiety, are at a higher risk of developing cardiovascular disease, particularly CAD. This interplay between mental and cardiovascular health underscores the importance of understanding their reciprocal relationship, as each domain can worsen the other, resulting in poor health outcomes and increased healthcare burdens.[4,5,6]

Myocardial infarction (MI), a major and potentially life-threatening consequence of CAD, is frequently associated with sudden cardiac death (SCD).[7] With approximately 32.4 million cases occurring annually, the impact is substantial. MI is typically classified into two clinical categories: ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI). Unstable angina, often preceding MI, is also part of the ACS spectrum.[8] The Framingham Heart Study highlights significant variations in the 10-year incidence of AMI by age and gender. For men aged 30-34, the estimated incidence is approximately 12.9 per 1,000, while women aged 35-44 have a lower incidence of around 5.2 per 1,000.[9]

According to the INTERHEART study, South Asians experience their first myocardial infarction at a relatively younger age, with a mean age of 53 years, compared to 58.8 years in other populations, highlighting a significant difference in cardiovascular health outcomes.[10] The INTERHEART study identified nine key risk factors, including physical inactivity, inadequate consumption of fruits and vegetables, and psychosocial stress, which collectively accounted for over 90% of AMIs in South Asians. This highlights the significant role of lifestyle and behavioural factors in cardiovascular disease. [11] Furthermore, individuals with a history of myocardial infarction or stroke are at heightened risk for subsequent cardiac and cerebrovascular events, underscoring the need for targeted prevention and management strategies. [12]

The Framingham Heart Study and the QRESEARCH Cardiovascular Risk Algorithm, version 3 (QRISK3) model have both contributed to our understanding of cardiovascular risk factors. The Framingham study identified traditional risk factors, including age, gender, diabetes, antihypertensive medication use, systolic blood pressure, smoking status, and lipid levels.[13] In contrast, the QRISK3 model has expanded this list to include additional predictors, such as chronic kidney disease and severe mental illness, providing a more comprehensive understanding of cardiovascular risk.[14]

Research has also shown that about 25% of individuals who experience a myocardial infarction face notable psychosocial challenges during recovery, underscoring the importance of holistic care.[15] The prevalence of depression among AMI survivors is substantial, with approximately two-thirds of hospitalized patients experiencing mild depression and about one-third developing depression post-discharge. Patients with AMI who exhibit depressive symptoms, regardless of severity, are at a higher risk of complications compared to those with minimal symptoms.[16]  This mental health burden has profound clinical implications, including increased risk of recurrent MI, sudden cardiac death, reduced adherence to therapy, and lower quality of life.[17] A recent study reported that individuals diagnosed with depression at any time after being diagnosed with CAD had a two-fold increased risk of all-cause mortality compared to CAD patients without depression. Notably, depression emerged as a stronger predictor of mortality than any other risk factor or comorbidity.[18]  Therefore, prioritizing depression screening and assessing its severity in diagnosed cases should be a key clinical focus. Despite the significant impact of depression on cardiac outcomes, it remains underdiagnosed and undertreated, particularly in developing countries like India. Social stigma, limited training among physicians, and inadequate integration of psychological services into cardiovascular care contribute to this gap. The American Heart Association (AHA) and European Society of Cardiology (ESC) strongly advocate for depression screening in all cardiac patients; however, this recommendation is not consistently implemented in Indian settings. [19]

This study aimed to address this critical gap by evaluating prevalence of depression in AMI survivors using validated screening tools, examining its associations with demographic and clinical variables, and providing evidence for the integration of mental health services into post-cardiac rehabilitation protocols. By doing so, this research will contributed to improving long-term outcomes for AMI survivors in India and informed strategies for better cardiovascular care.

Study Setting and Design

A cross-sectional study was conducted in the Department of Cardiology, Jawaharlal Nehru Medical College, KAHER, Belagavi, a multispecialty teaching hospital, from January 2024 to June 2025. The study included 551 adult survivors of a first episode of acute myocardial infarction (AMI) who returned for follow-up one month after discharge.

Inclusion Criteria:

Participants were eligible if they:

• Were admitted with a first episode of AMI within one week of onset,
• Had a confirmed diagnosis of AMI based on at least two of the following: typical chest pain, ECG changes, elevated cardiac biomarkers, or echocardiographic findings,
• Attended cardiac OPD follow-up one month post-discharge,
• Were aged >18 years and able to understand the study instructions.

Exclusion criteria:

• History of previous AMI, unstable angina, or chronic stable angina,
• Past or current psychiatric illness or use of psychotropic medication,
• Comorbid organic illnesses such as chronic kidney disease, thyroid disorders, or malignancy (except hypertension and diabetes),
• Cognitive impairment or physical inability to complete the survey.

Data Collection

During the one-month follow-up visit, eligible patients were approached by the investigator, and written informed consent was obtained. Sociodemographic and clinical data were collected using a structured proforma. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). The American Heart Association (AHA) specifically recommends the use of the PHQ-9, along with its shorter version, the PHQ-2, for routine depression screening in cardiac patients [20,21].  It is a nine-item self-report tool evaluating depressive symptoms over the past two weeks (score range: 0–27). Severity was categorized as: mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27). A PHQ-9 score >9 was considered indicative of depression, while ≤9 indicated no depression. , consistent with commonly used cutoffs in the literature.[22,23]

Participants completed the questionnaire privately to ensure confidentiality. Those with depression were counselled and referred to the Psychiatry Department for further management.

Statistical Analysis

Data were entered and cleaned using Microsoft Excel, and analysis was performed with SPSS version 26. Descriptive statistics (mean, median, interquartile range, frequencies, and percentages) were computed. Associations between variables were analyzed using the Chi-square test for categorical data and the z-test for continuous variables. Spearman’s correlation assessed relationships between continuous variables. Binary logistic regression was used to identify predictors of depression, reported as Odds Ratios (OR) with 95% Confidence Intervals (CI). A p-value < 0.05was considered statistically significant.

Sociodemographic data of the study participants

The sociodemographic characteristics of the study participants are summarized in Table 1. The majority of myocardial infarction cases occurred in the 51–60 years age group (32.7%), followed by those aged 61–70 years (29.8%). Males constituted 64.6% of the study population, while females accounted for 35.4%, resulting in a male-to-female ratio of 1.8:1. Most participants were married (87.7%). With regard to education, the largest proportion had completed primary (19.2%) or high school (19.1%) education, while 15.8% were illiterate. Only 2.0% of participants held professional or honours-level qualifications. In terms of occupation, the unemployed formed the largest group (28.5%), followed by skilled agricultural and fishery workers (19.4%). Socioeconomic assessment showed that more than half of the participants (55.2%) belonged to the lower middle class, and a significant majority (74.6%) resided in rural areas.

Clinical Profile of the study participants

The clinical characteristics of the study population are summarized in Table 2. A substantial burden of comorbidities was observed among patients with acute myocardial infarction (AMI). Among the 551 participants, 67.3% had at least one comorbidity in the form of hypertension (HTN), diabetes mellitus (DM), or both. The most common combination was the coexistence of HTN and DM (31.2%), followed by isolated HTN (20.5%) and isolated DM (15.6%). Only 32.7% of patients had no comorbidities, highlighting the high prevalence of cardiometabolic risk factors in this cohort. Regarding personal habits, tobacco chewing was the most common, reported by 207 patients (37.6%), followed by smoking in 85 (15.4%) and alcohol consumption in 74 (13.4%). The mean pulse rate was 80.4 ± 10.71 bpm, with an average systolic blood pressure of 121.60 ± 13.34 mmHg and diastolic blood pressure of 78.62 ± 9.06 mmHg. The mean left ventricular ejection fraction (LVEF) was 47.91 ± 10.82%, indicating a moderate reduction in systolic function across the study population. Anthropometric assessment showed a mean body mass index (BMI) of 27.52 ± 11.45. Based on BMI categories, 41.9% of participants were overweight, 32.3% had a normal BMI, 24.7% were obese, and only 1.1% were underweight. With respect to the type of AMI, 76.8% of patients presented with ST-elevation myocardial infarction (STEMI), whereas 23.2% had non-ST-elevation myocardial infarction (NSTEMI). The anterior wall was the most common infarct site (72.8%), followed by the inferior wall (14.7%). Right ventricular, posterior wall, and combined infarctions were less frequent. Coronary angiography revealed that single-vessel disease (SVD) was most prevalent (48.3%), followed by double-vessel disease (DVD) in 34.5% and triple-vessel disease (TVD) in 17.2%. In terms of management, angioplasty was performed in 90.2% of cases, while thrombolysis was carried out in 37.4%. Complications were relatively uncommon, with only 5.1% of participants developing a complicated myocardial infarction.

Prevalence of Depression

The burden of depressive symptoms among survivors of acute myocardial infarction (AMI) was considerable. The mean Patient Health Questionnaire-9 (PHQ-9) score for the study population was 5.31 ± 5.59, indicating a mild overall symptom burden (Table 3). Among the 551 participants, 76.9% (n = 424) reported at least one depressive symptom (PHQ-9 ≥ 1), whereas 23.0% (n = 127) were completely free of depressive symptoms (PHQ-9 = 0). Clinical depression, defined as a PHQ-9 score > 9, was observed in 27.2% (n = 150) of patients (Table 4). The distribution of depression severity showed that 23.0% had no depression, 39.6% had minimal depression, 10.2% had mild depression, 20.1% had moderate depression, 4.9% had moderately severe depression, and 2.2% had severe depression (Figure 1). These findings indicate a high prevalence of depressive symptoms with varying severity among post-AMI patients, underscoring the need for routine psychological screening and timely intervention as part of comprehensive cardiac care.

Association Between Depression and Sociodemographic Variables

The association between depression and various sociodemographic characteristics is summarized in Table 5. Statistical analysis revealed that gender (p = 0.001), education level (p = 0.001), occupation (p = 0.001), and socio-economic status (p = 0.002) were significantly associated with depression. Specifically, females were more likely to experience depression compared to males.

Association Between Clinical Variables and Depression

The relationship between depression and clinical variables is presented in Table 6. A significant association was observed between depression and the occurrence of STEMI (χ² = 4.304, p = 0.038), with a higher proportion of patients without depression presenting with STEMI (79.1%) compared to those with depression (70.7%). There was a significant association between BMI categories and depression (p = 0.001), as shown in Table 6. A higher proportion of individuals with depression were overweight (60.7%), while a larger percentage of those without depression were obese (29.9%).

 Logistic regression analysis of factors associated with depression in AMI patients

Lower education, lower socio-economic status, and female gender were strong risk factors for depression. Higher BMI, better cardiac function (EF), and STEMI presentation were protective against depression. Other clinical risk factors like age, hypertension, diabetes, smoking, and alcohol were not significant as shown in table 7.

Table 1. Sociodemographic profile of study participants (N = 551)

Table 2. Clinical Profile of the Study Population

Table 3: Mean PHQ-9 Score

Table 4. Prevalence of Depression among Study Participants

Table 5. Association Between Depression and Various Sociodemographic variables.

Table 6: Association Between Clinical Variables And Depression Status among study participants.

Table 7: Logistic Regression Analysis of Factors Associated with Depression in AMI Patients

In the present study, the prevalence of depression among survivors of AMI at one-month follow-up, defined as a PHQ-9 score greater than 9, was found to be 27.2%. Among the 551 survivors assessed, 127 patients (23.0%) had no depression (PHQ-9 = 0), while 424 patients (76.9%) reported at least one depressive symptom (PHQ-9 ≥1), indicating that a large majority of patients experienced some degree of mood disturbance. Clinical depression (PHQ-9 >9) was identified in 150 patients, with the distribution of severity showing 39.6% minimal depression, 10.2% mild depression, 20.1% moderate depression, 4.9% moderately severe depression, and 2.2% severe depression. These findings suggest that although not all patients develop major depression, a substantial proportion experience sub-threshold or clinically significant symptoms, which may still impact recovery, adherence, and quality of life.

A recent meta-analysis by Feng, Li et al. [24] reported a pooled prevalence of 28.7% across 19 studies conducted in 10 countries, which is strikingly similar to our findings. Furthermore, Feng and colleagues identified female sex, Asian region, anterior MI, diabetes, and hypertension as significant risk factors for post-MI depression. These observations resonate with our results, where female gender, lower educational attainment, and lower socioeconomic status were found to be strong independent predictors of depression, highlighting the combined influence of biological, demographic, and social determinants.

Our prevalence estimates are in close agreement with several earlier studies. Mallik et al. [25] reported a prevalence of 22.3% using a PHQ-9 cutoff of ≥10, while Shajrawi et al. [26] found 22.0% moderate-to-severe depression (PHQ-9 >10) in STEMI and NSTEMI patients four weeks post-hospitalization. Similarly, Murphy et al.[27] demonstrated depression rates of 22%, 17%, and 15% at the event, early (2–4 months), and late convalescence (6–12 months) respectively, indicating that although depressive symptoms may decline over time, they remain clinically relevant.

Other studies have reported both lower and higher rates compared to ours. Smolderen, Buchanan et al. [28] observed a prevalence of 18.7%, and importantly noted that mortality rates were higher among untreated depressed patients, underscoring the prognostic importance of screening and intervention. Parashar et al. found 13.1% depression one month after discharge, which is lower than in our cohort, whereas Kjellström and Gustafsson [29] reported a much higher prevalence of 39%, likely reflecting differences in study populations, cultural context, or methodological approaches.

Gender-related differences in post-MI depression are a consistent finding across the literature. In our study, depression was found to be significantly associated with gender, with females showing a higher prevalence compared to males. Among patients diagnosed with depression, 56.0% were female, while only 44.0% were male. This has been similarly documented by Doyle and McGee [30] and Serpytis and Navickas [31], who both reported that women are at significantly higher risk of developing post-MI depression compared to men.

Further supporting this, Vural et al. [32] showed that higher scores of depression, anxiety, and panic–agoraphobia were particularly common among female patients with acute coronary syndrome, suggesting a broader vulnerability to psychiatric comorbidity in women. Likewise, Dikić et al. [33] demonstrated that the probability of developing depression post-AMI was 3.5 times greater in women than in men. Together, these findings emphasize that gender is not merely a demographic variable but a critical risk factor influencing the burden of depression in post-MI patients. Biological vulnerability, hormonal differences, higher psychosocial stress exposure, and social role expectations may collectively explain this disparity.

Taken together, the prevalence of 27.2% observed in our study aligns well with global estimates, which place post-ACS depression between 15% and 30%, approximately three times higher than in the general population. The consistency of our findings with meta-analyses and multicenter studies reinforces their reliability. Moreover, our identification of female gender, low education, and low socioeconomic status as risk factors provides valuable insight into high-risk groups who may benefit from targeted screening and intervention.

Depression is a highly prevalent yet often underrecognized comorbidity among survivors of acute myocardial infarction, with more than three-quarters experiencing at least one depressive symptom and over one-quarter meeting criteria for clinical depression. The burden is particularly high among women, overweight individuals, and those from socio-economically disadvantaged backgrounds. Mood disturbances, fatigue, and sleep problems dominate the symptom profile, underscoring the interplay between physical recovery and psychological well-being. These findings emphasize the urgent need for routine depression screening and integrated psychosocial interventions within post-MI care, to improve not only mental health outcomes but also long-term cardiovascular prognosis. In this context, we strongly suggest that a trained clinical psychologist should be incorporated into the cardiac department team, dedicated to the systematic screening, early detection, and management of depression in post-MI patients. Their specialized expertise can ensure timely intervention, optimize recovery, and contribute to a truly holistic model of cardiac rehabilitation.

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