What question did this study set out to answer?

To evaluate the role of health insurance in influencing the relationship between depression and cardiovascular disease and to highlight geographic disparities.

March 28, 2026Open Access

Health Insurance as a Moderator of Cardiovascular Risk Among Adults with Depression: A Cross-Sectional and Geographic Analysis Using BRFSS 2019–2023 Data

Key Result

Depression increases the odds of cardiovascular disease (OR 1.69), a relationship that is significantly amplified among adults lacking health insurance (interaction OR 1.33).

Key Points

To evaluate the role of health insurance in influencing the relationship between depression and cardiovascular disease and to highlight geographic disparities.
Analyzed BRFSS data from 2019 to 2023 involving adults aged ≥18 years
Conducted logistic regression to examine the relationship between depression and cardiovascular disease
Included interaction terms to assess moderation by health insurance
Developed a composite burden index based on four-tier classifications
Created choropleth maps to visualize geographic patterns
21.1% of adults had depression, 12.3% had cardiovascular disease, and 5.8% were uninsured
Depression was significantly associated with cardiovascular disease (adjusted OR = 1.69)
Health insurance moderated this relationship (interaction OR = 1.33)
Geographic patterns revealed high-burden areas in the South and Appalachia
States like Kentucky and West Virginia demonstrated significant combined challenges in mental and cardiovascular health

Structured PICO

Does lack of health insurance moderate the association between depression and cardiovascular disease in US adults?

Population

457,670 adults aged ≥18 years from the US Behavioral Risk Factor Surveillance System (BRFSS) 2019–2023 with complete data on depression, CVD, and health insurance status.

Outcome

Prevalence of cardiovascular disease (CVD)

Lack of health insurance significantly amplifies the association between depression and cardiovascular disease among US adults, with marked geographic disparities highlighting the need for targeted public health strategies.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Background: Depression is a key psychosocial risk factor for cardiovascular disease (CVD); however, the degree to which lack of health insurance amplifies this risk remains unclear. Geographical disparities in mental health, cardiovascular outcomes, and insurance coverage further complicate prevention efforts. Understanding the interplay between these factors is crucial for planning targeted interventions to mitigate population-level cardiovascular risk. Objective: To assess whether health insurance modifies the relationship between depression and CVD among adults and to illustrate geographic disparities in combined mental health, cardiovascular risk, and insurance burden across US states and territories. Methods: We analyzed Behavioral Risk Factor Surveillance System (BRFSS) data from 2019 to 2023, including adults aged ≥18 years with complete data on depression, CVD, and health insurance status (n = 457,670). Logistic regression models were employed to estimate the relationship between depression and CVD, adjusting for demographic and behavioral risk factors. An interaction term between depression and lack of health insurance was included to examine moderation. State-level prevalence estimates were used to construct a four-tier composite burden index incorporating depression, CVD, and rates of lack of health insurance. Choropleth maps were developed to depict geographic patterns. Results: Overall, 21.1% of adults were found to have depression, 12.3% had CVD, and 5.8% had no health insurance. Depression was significantly associated with CVD (adjusted OR = 1.69; 95% CI: 1.65–1.72). Lack of health insurance significantly moderated the relationship between depression and CVD (interaction OR = 1.33; 95% CI: 1.18–1.51, p < 0.001). Geographic mapping analyses demonstrated marked heterogeneity. Tier 4 (highest burden) states included Kentucky, West Virginia, Louisiana, Oklahoma, Texas, New Jersey, Guam, and the U.S. Virgin Islands. Many Tier 3 and Tier 4 regions were clustered in the South and Appalachia. Conclusions: Depression is strongly associated with an increased prevalence of CVD, and this association is further amplified among individuals without health insurance coverage. Geographic disparities demonstrate critical hotspots where simultaneous mental health challenges, elevated risk of CVD, and limited insurance converge, highlighting the need for combined, area-specific public health strategies and approaches addressing both mental and cardiovascular health.