The association of baseline depressive symptoms and stress on withdrawal in a national longitudinal cohort: The REGARDS Study.

Poorer mental health symptoms have been linked to a variety of adverse health outcomes. [1], [2], [3] Individuals with worse depressive symptoms and/or perceived stress in their lives have poorer metabolic health including worse lipid profile, blood pressure control, and glucose control, which in turn leads to worse cardio- and cerebral-vascular health. [1], [4], [5] Depression and stress symptoms following a stroke or a heart attack are also associated with substandard recovery and poor quality of life. [6], [7], [8] Previous studies have suggested that individuals with depressive symptoms [9] and stress [10] are interested in participating in research; however, these same conditions are associated with higher attrition rates in research studies. [11] Higher rates of attrition can in turn lead to issues with internal validity and reduced statistical power. [11] Studies commonly attempt to offset the loss of statistical power by proportional increase in the sample size, where differential attrition may threaten validity and can be a challenge to limited resources. [12] Assessing depressive symptoms and perceived stress levels can potentially be used to identify a group of study participants that are at high risk for dropout in both clinical and research programs.

Population-based cohort studies are particularly valuable when it comes to understanding risk factors associated with attrition rates. [13] Longitudinal cohort studies have been trying to assess their follow-up and dropout rates and improve retention strategies. [14], [15] Interestingly, there have been contradictory findings on best strategies. The Coronary Artery Risk Development in Young Adults Study documented that using multiple retention strategies simultaneously may help result in higher retention rates. [16] This observation was discordant with a systemic review on retention strategies in longitudinal cohorts that found that employing large number of retention strategies was not associated with improved retention rates. [15] While there are no absolute clear strategies that improve retention in cohort studies, most agree that these epidemiological cohorts can continue to help clinicians and researchers better understand how to retain patients and study participants while reducing no-shows and withdrawals.

The association of depressive symptoms and stress with follow-up rates have not been well-studied in general population epidemiological cohort studies. While some studies focused on mental health have indicated more depressive symptoms leading to higher attrition, limitations in these studies have included follow-up time frames that have been relatively short for epidemiological studies at less than 1 to 2 years. [17], [18] One of the few non-psychiatric epidemiological cohorts with long-term follow-up to report depressive symptoms and its impact on attrition was the National Health and Nutrition Examination Survey 1 (NHANES 1), which had a 8-year follow-up period. [19] However, this was based on data collected from 1971-1974, and these findings are dated. The aim of our study was to examine if depressive symptoms and perceived stress were associated with withdrawal from a non-psychiatric population-based longitudinal cohort study. Additionally, we also examined if clinical characteristics and sociodemographic factors were also associated with attrition.

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