Association of Depressive Symptoms With Health Service Use and Catastrophic Health Expenditure Among Middle-Aged and Older Chinese Adults: Analysis of Population-Based Panel Data

  • Rui Yan
    Big Data Center for Clinical Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China
    Search for articles by this author
  • Lifeng Li
    Internet Medical and System Applications of National Engineering Laboratory, Zhengzhou, Henan, P. R. China

    Department of Oncology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China
    Search for articles by this author
  • Xiaoran Duan
    Internet Medical and System Applications of National Engineering Laboratory, Zhengzhou, Henan, P. R. China
    Search for articles by this author
  • Jie Zhao
    Address correspondence to Jie Zhao, PhD, the First Affiliated Hospital of Zhengzhou University, 1 East Jianshe Road, Zhengzhou, Henan, 450052, China.
    Internet Medical and System Applications of National Engineering Laboratory, Zhengzhou, Henan, P. R. China

    Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P. R. China
    Search for articles by this author
Published:December 24, 2022DOI:



      To determine the impact of depressive symptoms on health service use and catastrophic health expenditure, and whether it varied by per-capita household consumption, health insurance schemes, and physical comorbidities.


      Population-based panel data analysis.

      Setting and Participants

      Participants were 8585 adults aged 45 years and older in 2011, and had completed a follow-up survey in 2013, 2015, and 2018 from the China Health and Retirement Longitudinal Study (CHARLS).


      Depressive symptoms were assessed using the short form of the Center for Epidemiologic Studies Depression Scale. The number of outpatient visits and inpatient hospital days were used as proxies for health service use. When households’ out-of-pocket spending on health was 40% or above its total expenditure, it was defined as a catastrophic health expenditure. With the panel data approach, random-effects negative binomial regression and logistic regression were used to analyze the effect of depressive symptoms on health service use and health care expenditure, respectively.


      Depressive symptoms were associated with increased number of outpatient visits (incidence rate ratio 1.52; 95% CI 1.44–1.60) and days spent in the hospital as an inpatient (1.52; 1.43–1.62). Depressive symptoms were also associated with a significantly increased likelihood of catastrophic health expenditure (odds ratio 1.54; 95% CI 1.43–1.66). Their effect on outpatient visits, inpatient hospital days, and catastrophic health expenditure persisted in different age, per-capita household consumption, and physical comorbidities groups, and across all health insurance programs.

      Conclusions and Implications

      Depressive symptoms were risk indicators that can drive health service use and household financial stress. Given the rapidly aging population in China, there is an urgent need to integrate mental health care into routine physical examinations to alleviate the economic impacts of depressive symptoms on individuals in China. specifically for individuals with physical comorbidities and in poorer socioeconomic conditions.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Smith K.
        Mental health: a world of depression.
        Nature. 2014; 515: 181
      1. Depression. Updated September 13, 2021.
        • Huang Y.
        • Wang Y.
        • Wang H.
        • et al.
        Prevalence of mental disorders in China: a cross-sectional epidemiological study.
        Lancet Psychiatry. 2019; 6: 211-224
        • Hsieh C.R.
        • Qin X.
        Depression hurts, depression costs: the medical spending attributable to depression and depressive symptoms in China.
        Health Econ. 2018; 27: 525-544
        • Xu J.
        • Wang J.
        • Wimo A.
        • Qiu C.
        The economic burden of mental disorders in China, 2005–2013: implications for health policy.
        BMC Psychiatry. 2016; 16: 137
        • Xu K.
        • Evans D.B.
        • Kawabata K.
        • Zeramdini R.
        • Klavus J.
        • Murray C.J.
        Household catastrophic health expenditure: a multicountry analysis.
        Lancet. 2003; 362: 111-117
        • Wagstaff A.
        • Flores G.
        • Hsu J.
        • et al.
        Progress on catastrophic health spending in 133 countries: a retrospective observational study.
        Lancet Glob Health. 2018; 6: e169-e179
        • Kang J.-H.
        • Kim C.-W.
        Relationship between catastrophic health expenditures and income quintile decline.
        Osong Public Health Res Perspect. 2018; 9: 73
        • Koch S.F.
        • Setshegetso N.
        Catastrophic health expenditures arising from out-of-pocket payments: evidence from South African income and expenditure surveys.
        PLoS One. 2020; 15: e0237217
        • Li Y.
        • Wu Q.
        • Xu L.
        • et al.
        Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance.
        Bull World Health Organ. 2012; 90: 664-671
        • Devadasan N.
        • Criel B.
        • Van Damme W.
        • Ranson K.
        • Van der Stuyft P.
        Indian community health insurance schemes provide partial protection against catastrophic health expenditure.
        BMC Health Serv Res. 2007; 7: 1-11
        • Hu T.W.
        • He Y.
        • Zhang M.
        • Chen N.
        Economic costs of depression in China.
        Soc Psychiatr Psychiatr Epidemiol. 2007; 42: 110-116
        • Wu Y.
        • Zhao D.
        • Guo J.
        • et al.
        Economic burden of depressive symptoms conditions among middle-aged and elderly people with hypertension in China.
        Int J Environ Res Public Health. 2021; 1810009
        • Egede L.E.
        • Walker R.J.
        • Bishu K.
        • Dismuke C.E.
        Trends in costs of depression in adults with diabetes in the United States: medical expenditure panel survey, 2004–2011.
        J Gen Intern Med. 2016; 31: 615-622
        • Zhao Y.
        • Atun R.
        • Oldenburg B.
        • et al.
        Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data.
        Lancet Global Health. 2020; 8: e840-e849
        • Zhao Y.
        • Hu Y.
        • Smith J.P.
        • Strauss J.
        • Yang G.
        Cohort profile: the China health and retirement longitudinal study (CHARLS).
        Int J Epidemiol. 2014; 43: 61-68
        • Irwin M.
        • Artin K.H.
        • Oxman M.N.
        Screening for depression in the older adult: criterion validity of the 10-item center for epidemiological studies depression scale (CES-D).
        Arch Intern Med. 1999; 159: 1701-1704
        • Chen H.
        • Mui A.C.
        Factorial validity of the center for epidemiologic studies depression scale short form in older population in China.
        Int Psychogeriatr. 2014; 26: 49-57
        • Andresen E.M.
        • Malmgren J.A.
        • Carter W.B.
        • Patrick D.L.
        Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale).
        Am J Prev Med. 1994; 10: 77-84
        • Cylus J.
        • Thomson S.
        • Evetovits T.
        Catastrophic health spending in Europe: equity and policy implications of different calculation methods.
        Bull World Health Organ. 2018; 96: 599-609
        • Liu C.
        • Liu Z.M.
        • Nicholas S.
        • Wang J.
        Trends and determinants of catastrophic health expenditure in China 2010–2018: a national panel data analysis.
        BMC Health Serv Res. 2021; 21: 526
        • Dong Y.
        • Peng C.Y.
        Principled missing data methods for researchers.
        SpringerPlus. 2013; 2: 222
        • Fried E.I.
        • Nesse R.M.
        Depression sum-scores don't add up: why analyzing specific depression symptoms is essential.
        BMC Med. 2015; 13: 72
        • Cameron A.C.
        • Trivedi P.K.
        Regression analysis of count data.
        2nd ed. Cambridge University Press, 2013
        • Richardson R.
        • Westley T.
        • Gariepy G.
        • Austin N.
        • Nandi A.
        Neighborhood socioeconomic conditions and depression: a systematic review and meta-analysis.
        Soc Psychiatr Psychiatr Epidemiol. 2015; 50: 1641-1656
        • Luber M.P.
        • Meyers B.S.
        • Williams-Russo P.G.
        • et al.
        Depression and service utilization in elderly primary care patients.
        Am J Geriatr Psychiatr. 2001; 9: 169-176
        • Bock J.O.
        • Luppa M.
        • Brettschneider C.
        • et al.
        Impact of depression on health care utilization and costs among multimorbid patients--from the MultiCare Cohort Study.
        PLoS One. 2014; 9: e91973
        • Katon W.J.
        Epidemiology and treatment of depression in patients with chronic medical illness.
        Dialogues Clin Neurosci. 2011; 13: 7-23
        • Grenard J.L.
        • Munjas B.A.
        • Adams J.L.
        • et al.
        Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis.
        J Gen Intern Med. 2011; 26: 1175-1182
        • Bloom D.E.
        • Cafiero E.
        • Jané-Llopis E.
        • et al.
        The global economic burden of noncommunicable diseases.
        • Meng Q.
        • Xu L.
        • Zhang Y.
        • et al.
        Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study.
        Lancet. 2012; 379: 805-814
        • Patel V.
        • Xiao S.
        • Chen H.
        • et al.
        The magnitude of and health system responses to the mental health treatment gap in adults in India and China.
        Lancet. 2016; 388: 3074-3084
        • Lu J.
        • Xu X.
        • Huang Y.
        • et al.
        Prevalence of depressive disorders and treatment in China: a cross-sectional epidemiological study.
        Lancet Psychiatry. 2021; 8: 981-990
        • Chen P.
        • Li F.
        • Harmer P.
        Healthy China 2030: moving from blueprint to action with a new focus on public health.
        Lancet Public Health. 2019; 4: e447
        • Li W.
        • Yang Y.
        • Liu Z.H.
        • et al.
        The first national action plan on depression in China: progress and challenges.
        Lancet Reg Health West Pac. 2021; 7: 100078
        • Yang W.
        • Hu B.
        Catastrophic health expenditure and mental health in the older Chinese population: the moderating role of social health insurance.
        J Gerontol B Psychol Sci Soc Sci. 2022; 77: 160-169
        • Regier D.A.
        • Kuhl E.A.
        • Kupfer D.J.
        The DSM-5: classification and criteria changes.
        World Psychiatr. 2013; 12: 92-98