RESEARCH ARTICLE

Depression and hypertension among Chinese

nonagenarians and centenarians
Zhao Wen, Dong Bi-Rong, Huang Chang-Quan, Lu Zhen-Chan, Zhuang Yuan, Wu Hong-Mei,
Zhang Yan-Ling, Wang Hui and He Ping
Department of Geriatrics, West China Hospital, Sichuan University, China
Correspondence to: Professor D. Bi-Rong, E-mail: birong_d@yahoo.com.cn

Purpose: In this study, we explored association between hypertension and depression in the very elderly
using a sample ranged in age from 90 to 108 years.
Methods: A cross-sectional study.
Results: The sample included 687 unrelated Chinese nonagenarians/centenarians (67.4% women, mean
age 93.51 years). The mean depression score (measured with brief 23-item geriatrics depression scale
Chinese-edition (GDS-CD)) was 8.46 (standard deviation (SD) 3.33 range 0–20). There was no
significant difference in depression scores between subjects with and without hypertension and there
was also no significant difference in depression prevalence between subjects with and without
hypertension. There was no significant difference in prevalence of hypertension between subjects with
and without depression and there were also no significant differences in levels of arterial blood pressure
(including SBP and DBP). Neither odd ratio (OR) of depression as a function of increased hypertension
nor OR of hypertension as a function of increased depression was significant.
Conclusions: In summary, we found that depression was not directly correlated with hypertension among
Chinese nonagenarians and centenarians. Copyright # 2010 John Wiley & Sons, Ltd.
Key words: hypertension; depression; nonagenarians and centenarians
History: Received 25 October 2008; Accepted 16 June 2009; Published online in Wiley InterScience
(www.interscience.wiley.com).
DOI: 10.1002/gps.2364

Introduction Levenstein et al., 2001; Markovitz et al., 2001), but

There are reasons to suggest the association between
depression and hypertension. First, hypertension and
depression share a prominent risk factor, which is
stress. For example, stressful life events and poverty are
associated with both hypertension and depression
(Dohrenwend and Dohrenwend, 1974; Brown and
Harris, 1978; Dohrenwend et al., 1992; Winkelby et al.,
1992; Dimsdale, 1998). Second, increasing literature
has supported that depression contributes to hyper-
tension. Prior studies have found that depressive
symptoms and clinical depression are an independent
risk factor for hypertension (Friedman and Bennet,
1977; Rabkin et al., 1981; Jonas et al., 1997;
Okwumabua et al., 1997; Davidson et al., 2000;
these findings have not been consistent (Reiff et al.,
2001; Shinn et al., 2001). Biological explanations for
this relationship have included depression resulting
directly in acute autonomic arousal (Carney et al.,
1988; Warrenburg et al., 1989; Delehanty et al., 1991)
and blood pressure reactivity (Waked and Jutai, 1990).
Several earlier studies suggest that hypertension may be
a risk factor for depression or, of central concern here,
that depression may be a risk factor for hypertension
and depression was significantly associated with
hypertension. (Wood et al., 1979; Rabkin et al.,
1983; Simonseck et al., 1995; Davies et al., 1997; Jonas
et al., 1997; Davidson et al., 2000; Hayden et al., 2003).
A close association between hypertension and depres-
sion has already been highly reported in the general old

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2010; 25: 554–561.
Depression and hypertension
population by many prospective and cross-sectional
observational studies. The results have shown that
incidence and prevalence of depression with hyperten-
sion had higher than those without hypertension.
(Goldberg et al., 1980; MacDonald et al., 1984; Jonas
et al., 1997; Dimsdale, 1998). Common to each of these
studies, however, was the relatively young age of the
participants. The average age of each sample was under
80 years, only a few of studies included subjects over
90 years of age and there was no study in which all
subjects were over 90 years of age.
However, hypertension and depression are both
major components of age-related deterioration and are
both differ from them in younger subjects in aspects of
etiology, presentation, treatment, and outcome
(Schneider and Olin, 1995; Simonseck et al., 1995;
Wright et al., 1998). Moreover, mortality may tend
remove those older people with both depression and
hypertension. This would leave those with one or the
other but not both and remove a correlation between
depression and hypertension. As a result, the relation-
ship between depression and hypertension in the
oldest-old population may be different from that in
general population.
As depression and hypertension are among the most
important mental health problems in elderly people.
Both conditions have severe consequences, including
diminished quality of life, functional decline, increased
use of services, and high mortality. The population of
older person increases, the number of hypertension or
depression older individuals can be expected to rise
(Knight et al., 1996; Lin et al., 2005). Therefore, it is
important to investigate the association between
hypertension and depression in the very elderly.
However, to our knowledge, no studies have explored
the association between hypertension and depression
among very old people aged 90 and over. In this study,
we aimed to observe the association between depres-
sion and hypertension among very old people using a
cohort of Chinese aged 90–108 years.
Subjects and methods
Study subjects
It is the part of Project of Longevity and Aging
in Dujiangyan (PLAD). PLAD was performed in
DuJiangYang. (Located outside the urban area of
ChengDu; 2 311 709 inhabitants, 870 aged 90 years or
more, women: 67.4%.)
In April 2005, 870 persons aged 90 years and over
were collected from the population. The study protocol
Copyright # 2010 John Wiley & Sons, Ltd.
555
was approved by the Research Ethics Committee of the
Sichuan University. Informed consent was obtained
from all participants (as well as their legal proxies).
Trained personnel visited all study participants at their
homes for data collection. We excluded the subjects
with cancer, low plasma cholesterol and glucose level,
end-stage disease, missing information on depression
function scores or blood pressure. Overall, 21 men and
26 women were not eligible for the study because they
had already died or moved away from the area. Of 262
men and 561 women who were interviewed, 8 men and
13 women were suffered from cancer or end-stage
disease, 12 men and 61 women did not complete brief
23-item geriatrics depression scale Chinese-edition
(GDS-CD) test, 30 men and 33 women did not
complete blood pressure test, and 11 men and 8
women did not complete tests of both GDS-CD and
blood pressure. Finally, we included 687 participants
(224 men, 463 women) in the analysis.
Measurement of blood pressure
Sitting or recumbent position, right arm blood
pressure (BP) was measured twice to the nearest
2 mmHg using a standard mercury sphygmoman-
ometer (phases I and V of Korotkoff) by trained nurses
or physicians. The mean value of two measurements
was used to calculate systolic BP (SBP) and diastolic BP
(DBP), and the SBP and DBP were calculated as the
mean of right and left arm values in exceptional
subjects. The mean of two readings was used for
classification of BP according to Joint National
Committee (JNC) VII criteria into normal
(SBP < 120 mmHg and DBP < 80 mmHg), pre-hyper-
tension (SBP 120–139 mmHg and/or DBP 80–
89 mmHg), stage 1 hypertension (SBP 140–159 mmHg
and/or DBP 90–99 mmHg), stage 2 hypertension
(SBP > 160 mmHg and/or DBP > 100 mmHg), the
isolated systolic hypertension (ISH) was defined as a
SBP > 140 mmHg and a DBP < 90 mmHg and the
isolated diastolic hypertension (IDH) was defined as a
SBP < 140 mmHg and a DBP > 90 mmHg. Hyperten-
sion was defined as a SBP > 140 mmHg and/or a
DBP > 90 mmHg and/or receiving anti-hypertensive
treatment. Subjects with confirmed hypertension and
no identified cause of secondary hypertension were
diagnosed with essential hypertension. Study subjects
BP were classified into four BP classifications accord-
ing to the criteria of the JNC on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure and
the International Society of Hypertension (Chobanian
et al., 2003).
Int J Geriatr Psychiatry 2010; 25: 554–561.
556
Assessment of depression symptom
Depression symptom was measured with GDS-CD
test. GDS-CD includes 23 items (each has two options:
yes or no), which index depression in the old. GDS-CD
is commonly used for depression test in old people in
Chinese and a score above 10 on it usually defined as
depression, which has been shown to be both above
92% sensitive and 89% specific in previous study
(Chan, 1996; Mui, 1996; Liu et al., 1998). In GDS-CD
test, subjects were categorized according to the
following: major depression (scores on GDS-CD
between 16–23), minor depression (scores on GDS-
CD between 10–15) and non-depression (scores
between 0–9). To decrease methodological faults and
assure methodological reliability, the administrator:
(1) reviewed the GDS-CD procedure and grading
system outlined in a short booklet and video, (2)
observed a geriatrician conduct the GDS-CD on
residents not part of the study, and (3) was supervised
when conducting the GDS-CD on residents not part of
the study. The GDS-CD was administered on the
subjects that gave consent for study participation.
Assessment of covariates
The baseline examination included information on age
(years), gender (male and female), body weight index,
temperament (introversion, general, extroversion),
sleep time one day, satisfaction of sleep (very
unsatisfactory, general unsatisfactory, general satisfac-
tory, and very satisfactory), habits of religion (yes or
no), habits (current and former) of smoking (present
or not), tea drinking (present or not), alcohol
consumption (present or not), and exercise (present
or not). Body mass index (kg/m2, BMI) was calculated
as body weight in kilograms divided by height in
meters squared. The other covariates were collected by
using a general questionnaire.
Statistical analysis
All of the statistical analyses for this study were
performed with the SPSS for Windows software
package, version11.5 (SPSS Inc, Chicago, Illinois,
USA). Baseline characteristics were compared between
those with and without prevalent depression or
between those with and without prevalent hyperten-
sion using x2 or Fisher’s exact test (where an expected
cell count was <5) for categorical variables and
unpaired Student’s t test for continuous variables. The
Copyright # 2010 John Wiley & Sons, Ltd.
Z. Wen et al.
analysis of variance (ANOVA) was used to test for
differences owing to depression scores among the
different arterial BP groups. Wald x2 test was used to
estimate the odds ratio (OR) and 95% confidence
interval (CI) of hypertension as a function of increased
depression and those of depression as a function of
increased hypertension. Multiple logistic regression
models were used to adjust for factors associated with
depression, to adjust for those associated with
hypertension and to adjust for all the covariates
(age, gender, BMI, temperament, sleep time one day,
satisfaction of sleep, religion, smoking, tea drinking
alcohol consumption, educational levels, and exercise),
respectively. All these covariates are closely related to
the incidence and prevalence of depression and
variation of blood pressure. P-value < 0.05 was
considered to be statistically significant, and all of
the p-values have two sides.
Results
Baseline characteristics and prevalence of
depression and hypertension
Among the 687 volunteers, mean age was 93.51 years
(SD 3.35 years, range 90–108 years) and 463(67.4%)
were women, including 76 centenarians. Ninety per
cent of subjects lived in the countryside. The mean
depression score for the old population was 8.46 (SD
3.33 range 0–20). Only 39 subjects depression scores
had greater than 15, so we defined subject with a score
higher than 10 as depression. In the oldest-old
population, the prevalence rate of depression was
25.5% including minor depression 19.8% and major
depression 5.7%. The prevalence rate of hypertension
was 57.8% including stage 1 hypertension 33.3% and
stage 2 hypertension 24.5%, in which 44.5% was ISH
and 2.2% was IDH. There were 196 subjects (28.5%)
with pre-hypertension in the population.
Subjects with hypertension had higher BMI than
those without hypertension (mean difference, MD ¼ 1.05,
p < 0.001), there were no significant differences in the
other covariates, including age, gender, sleep habits,
smoking habits, alcoholic habits, tea habits, exercise
habits, educational levels, religion habits, and tempera-
ment between subjects with and without hypertension
(see Table 1). The prevalence rate of depression in
women was higher than that in men ( p ¼ 0.014).
Subjects with depression had higher BMI (mean
difference, MD ¼ 0.67, p ¼ 0.041) than that without
depression. There were also significant differences in
Int J Geriatr Psychiatry 2010; 25: 554–561.
 Table 1 Baseline characteristics according to arterial blood pressure and according to depressive symptom (n ¼ 687)

Characteristics Total Hypertension Norm tension df x2 or t p-value Depression Non-depression df x2 or t p-value

Number of case 687 397 290 0.274 175 512

Age (years) 93.51
3.35 93.52
3.44 94.8
3.25 642 0.02 0.998 93.55
3.55 94.49
3.41 319 0.23 0.822
Gender (female/male) 463/224 274/123 189/101 1 1.20 0.274 131/44 332/180 1 6.03 0.014
BMI (kg/m2) 19.02
3.63 19.47
3.83 18.42
3.24 637 3.81** < 0.001 19.53
3.58 18.86
3.67 699 2.11* 0.036
Depression and hypertension

Systolic BP (mmHg) 140.14
22.86 154.54
17.28 120.42
12.48 674 38.60** <0.001 139.99
23.53 140.19
22.65 285 0.61 0.544
Diastolic BP(mmHg) 72.79
12.10 77.02
12.15 67.02
9.35 560 11.81** <0.001 73.27
12.07 72.63
12.12 295 0.16 0.872
Hypertension (%) 57.8 — — — — — 59.43 57.23 1 0.26 0.611
Depression score 8.46
3.33 8.56
3.29 8.32
3.39 612 0.91 0.362 12.98
1.93 6.91
2.05 318 31.33** <0.001
Depression (%) 25.5 26.20 24.48 1 0.26 0.611 — — — — —
Sleep time one day 10.23
1.55 10.18
1.48 10.30
1.64 575 0.94 0.346 10.20
1.70 10.23
1.50 261 0.24 0.810
Satisfaction of sleep

Copyright # 2010 John Wiley & Sons, Ltd.

Very satisfaction 394 227 167 68 326
General satisfaction 129 73 56 41 88
Not satisfaction 153 90 63 3 0.88 0.831 64 89 3 38.53** <0.001
Sleep at noon
Everyday 198 127 71 40 158
Usually 111 63 48 40 71
Occasionally 95 42 43 27 58
Never 286 159 127 3 6.30 0.098 67 219 3 11.79** 0.008
Smoking habits
Former (%) 59.80 57.95 65.37 1 2.37 0.112 58.72 60.08 1 3.85 0.144
Current (%) 44.10 43.29 45.17 1 0.24 0.624 46.86 43.14 1 0.73 0.392
Alcoholic habits
Former (%) 40.80 42.30 38.81 1 0.84 0.361 44.12 39.72 1 1.02 0.313
Current (%) 26.80 28.17 24.83 1 0.95 0.324 23.56 27.84 1 1.21 0.271
Tea habits
Former (%) 43.5 44.04 45.58 1 0.16 0.692 41.52 45.78 1 0.94 0.333
Current(%) 42.10 40.91 43.79 1 0.57 0.450 38.86 43.44 1 1.42 0.233
Exercise habits
Former (%) 33.3 33.07 33.57 1 0.02 0.893 29.24 34.68 1 1.69 0.193
Current (%) 40.6 42.13 38.46 1 0.93 0.336 40.79 40.55 1 0.01 0.973
Educational levels
Illiteracy 499 294 205 138 361
Primary school 121 65 56 23 98
Secondary school 47 23 24 10 37
Colle and post-gradu 14 13 5 4 5.16 0.271 3 15 4 5.28 0.259
Religion (%) 24.40 24.43 24.39 1 0.27 0.696 31.43 23.97 1 6.65* 0.038
Temperament
Introversion 72 41 31 31 41
General 486 283 203 111 375
Extroversion 120 67 53 3 0.98 0.807 32 88 3 13.87** 0.003

GDS-CD, brief 23-item geriatrics depression scale Chinese-edition; BP: blood pressure; BMI: body mass index.
*p < 0.05; **p < 0.01 vs. Hypertension group or vs. depression group. Compared between subjects with and without hypertension or those with and without depression using x2 or Fisher’s exact test
(where an expected cell count was <5) for categorical variables and unpaired Student’s t test for continuous variables.

Int J Geriatr Psychiatry 2010; 25: 554–561.

557
558 Z. Wen et al.

30
Compared prevalence of hypertension between
subjects with and without depression
20

There was no significant difference in prevalence of

Depression scores

10
hypertension between subjects with and without
depression (59.43 vs. 57.23, p ¼ 0.611) and there were
also no significant differences in levels of arterial blood
0
pressure (including SBP and DBP) between subjects
with and without hypertension (139.99
23.53 vs.
-10
N= 94 196 229 168
140.19
22.65 p ¼ 0.921, 73.27
12.07 vs. 72.63

Normal Stage 1 hypertension 12.12 p ¼ 0.554, for SBP and DBP, respectively)
Prehypertension Stage 2 hypertension

Arterial blood pressure

(Figure 2).

Figure 1 The analysis of variance (ANOVA) was used to test for

differences owing to depression scores among the different arterial BP
groups. (F ¼ 1.228, p ¼ 0.229) Depression and hypertension were not risk factors
for each other

We further assessed whether depression and hyperten-

sion were associated with risk factors for each other or
sleep habits, religion habits, and temperament subjects not, unadjusted and adjusted for factors associated
with and without depression (see Table 1). with depression, for those associated with hypertension
and for all clinical covariates, None of odds ratio (ORs)
of depression as a function of increased hypertension
and ORs hypertension as a function of increased
Compared prevalence of depression and depression
depression was significant (Table 2).
scores between subjects with and without
hypertension
Discussion
There was no significant difference in depression scores
between subjects with and without hypertension In the cross-sectional observations, in community-
(8.56
3.29 vs. 8.32
3.39, p ¼ 0.934) and there was dwelling nonagenarians/centenarians among Chinese,
also no significant difference in depression prevalence there were high prevalence rates of depression (25.5%)
between subjects with and without hypertension (26.20 and hypertension (57.8%). In the cross-sectional
vs. 24.48, p ¼ 0.611). Depression scores for popu- observations, in community-dwelling nonagenarians/
lations were shown by BP classifications in the cohort centenarians among Chinese, there were no significant
and ANOVA was used to test for differences owing to differences in both depression scores and prevalence of
depression scores among the different arterial BP depression between subjects with and without hyper-
groups. (F ¼ 1.228, p ¼ 0.229) (Figure 1). tension; there were also no significant differences in

Table 2 Odds ratio (OR) and 95% confidence interval (CI) of depression as a function of increased hypertension or hypertension as a function of increased
depression

Depression Hypertension

Hypertension Normal blood pressure Depression Non-depression

Unadjusted OR(CI) 1.120(0.540, 2.124) 1.00(reference) 1.120(0.540, 2.124) 1.00(reference)

Adjusted OR(CI)
Model 1 1.079(0.513, 2.269) 1.00(reference) 1.094(0.519, 2.307) 1.00(reference)
Model 2 1.036(0.486, 2.205) 1.00(reference) 1.031(0.674, 1.578) 1.00(reference)
Model 3 1.434(0.661, 3.565) 1.00(reference) 1.528(0.575,3.778) 1.00(reference)

Unadjusted: Wald x2 test with df ¼ 1 was used; Multiple-adjusted: Adjusted multiple logistic regression; Model 1: adjustment made with factors associated with
depression (shown in Table 1); Model 2: adjustment made with factors associated with hypertension (shown in Table 1); Model 3: adjustment made with all the
covariates (shown in Table 1).

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2010; 25: 554–561.
Depression and hypertension
Figure 2 Unpaired Student’s t test was used to test for differences owing to arterial BP between subjects with and without depression. (139.99
23.53 vs.
140.19
22.65 p ¼ 0.921, 73.27
12.07 vs. 72.63
12.12 p ¼ 0.554, for SBP and DBP, respectively)
both levels of arterial blood pressure and prevalence of
hypertension between subjects with and without
depression. Neither odd ratio (OR) of depression as
a function of increased hypertension nor OR of
hypertension as a function of increased depression was
significant.
To the best of our knowledge, this was the first
research that focused on the association between
depression and hypertension in nonagenarians and
centenarians. This study showed that there was no
relationship between depression and hypertension
among Chinese nonagenarians and centenarians. It
is inconsistent that compared with previous studies,
which has a close association between hypertension
and depression in the general old population and
incidence and prevalence of depression with hyperten-
sion had higher than those without hypertension
(Goldberg et al., 1980; MacDonald et al., 1984; Jonas
et al., 1997; Dimsdale, 1998; Andréia et al., 2005;
Scalco et al., 2005). Inferring causality in the relation
between hypertension and depression in old age has
been performed by many previous studies. Several
causative factors have been proposed to explain this
association, such as autonomic nervous system
dysfunction, and more recently, genetic influences
(Southam et al., 1982; Chesney et al., 1987; Jones et al.,
1996; Townsend et al., 1998; Lafer and Vallada, 1999;
Grewen et al., 2004; Andréia et al., 2005). Behavioral
mechanisms for the relationship between depression
Copyright # 2010 John Wiley & Sons, Ltd.
559
and hypertension is that some life-style variables that
are risk factors for hypertension, such as obesity,
alcohol use, smoking, and lack of physical activity, may
increase as a result of depression and mediate the
relationship between depression and hypertension.
The clinical relevance of this theme is clear, since
depressive symptomatology is associated with poor BP
control in hypertensive patients and with the devel-
opment of complications of hypertension (Musselman
et al., 1990; Simonseck et al., 1995; Wassertheil et al.,
1996; Delisi et al., 1999; Abramson et al., 2001;
Greenwald et al., 2001; Oshira et al., 2001; Penninx
et al., 2001; Andréia et al., 2005). However, our
findings, based on the very elderly population, were not
in line with the view that depression was associated
with hypertension.
Hypertension and depression are both components
of age-related deterioration. It has been confirmed that
both depression and hypertension in late life is
different from those in younger subjects in aspects
of etiology, presentation, treatment, and outcome
(Schneider and Olin, 1995; Simonseck et al., 1995;
Wright et al., 1998). In China, the oldest-old had
received more attention than elderly. We considered it
could be that hypertension in nonagenarians and
centenarians receiving more family support as it is
important moderators for depression, it may result in
non-significant differences in depression between
hypertensive and normotensive. Moreover, mortality
Int J Geriatr Psychiatry 2010; 25: 554–561.
560
may tend to remove those older people with both
depression and hypertension. This would leave those
with one or the other but not both and remove a
correlation between depression and hypertension.
Therefore, although our results showed that among
nonagenarians/centenarians there was no association
between hypertension and depression, this was not
contradictory with the previous studies; moreover, this
study extends the findings of previous studies.
There were other interesting findings in the present
study. Firstly, as many previous studies showed that,
among nonagenarians and centenarians, both depres-
sion and hypertension had high prevalence. This study
not only provided evidence that women had more
liability to depression, but also extended this finding of
previous studies, the more liability to depression also
existed among the very elderly. Secondly, previous
studies showed that BMI may not be a good indicator
for obesity in elderly (Ho et al., 2008). But, in this
study, BMI was associated with both depression and
hypertension, this showed that BMI can be an
intermediate variable linking symptoms of depression
and hypertension among nonagenarians and cente-
narians, to improve BMI is benefit for both depression
and hypertension; the other risk factors for both
depression and hypertension in general population,
e.g., sleep habits, smoking habits, alcoholic habits, tea
habits, exercise habits, educational levels, religion
habits, and temperament, were not in the very elderly.
Our study had some limitations that deserved
mention. First, there was the gender imbalance in our
population, which was the common characteristic of
long-lived subjects in the world. There were total 870
long-lived subjects (above 90 years) in Dujiangyan
district (2005), 463 females and 224 males were
included in this study in finally. Second, we still lacked
of adjustment for other potential confounders, such as
socio-economic status, and family history of depres-
sion. Most of all (90%) participants lived in the
countryside in the present study. So far, some subjects
had been working in farm every day, and so physical
activity might be a potential confounder. Thus this
population might not be representative of the urban
population. Third, because of special populations that
we had studied, we still lack collection for past
psychiatric history including their subjects’ level of
medical care and family support as they are important
moderators for depression. We cannot compare these
factors between hypertensive and normotensive and
include them as covariates in regression. But it is a
traditional virtue for Chinese nation to respect the old
and care for the young, nonagenarians/centenarians
(>90s) received more attention than elderly (60s–80s).
Copyright # 2010 John Wiley & Sons, Ltd.
Z. Wen et al.
Key points
 Depression is not directly correlated with hy-
pertension among Chinese nonagenarians and
centenarians.
Thus, family support cannot be ruled out, it plays an
important role in moderating depression which
resulted in low GDS score and non-significant
differences in depression between hypertensive and
normotensive.
In conclusion, we found among nonagenarians and
centenarians, there was no significant correlation
between depression and hypertension
Conflicts of interest
None.
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