Association of Catastrophic Health Expenditure With the Risk of Depression in Chinese Adults: Population-Based Cohort Study

Background: Depression is one of the most common mental illnesses, and it may have a lasting effect on one’s whole life. As a form of financial hardship, catastrophic health expenditure (CHE) may be associated with depression. However, current evidence about the relationship between CHE and the risk of depression is insufficient. Objective: This study aimed to explore the relationship between CHE and the risk of depression among Chinese adults. Methods: In this study, we used 3 waves of the China Family Panel Studies (CFPS) from 2012, 2016, and 2018. The CFPS are a nationally representative study covering 25 of 31 provinces in Chinese mainland and representing nearly 94.5% of the total population. We selected eligible household heads as participants, divided them into 2 groups by CHE events at baseline (exposed group: with CHE; unexposed group: without CHE), and followed them up. Households with CHE were defined as having out-of-pocket medical expenditures exceeding 40% of the total household nonfood expenditure, and people with depression were identified by the 8-item Centre for Epidemiological Studies Depression Scale (CES-D). We first described the baseline


Introduction
There is a strong bidirectional linkage between health and poverty. To cut off this linkage, the United Nation's Sustainable Development Goals include target 3.8, which aims to achieve universal health coverage (UHC) by 2030 [1]. UHC means that all people can receive the health services they need without experiencing financial hardship [1]. According to the World Health Organization, globally in 2017, almost 1.4 billion people experienced financial hardship due to out-of-pocket (OOP) health payments, among whom nearly 1 billion people were pushed into extreme poverty [2]. Therefore, there is still a long way to go to achieve UHC goals by 2030 considering the additional impact of COVID-19.
One of the 2 essential parts of UHC is providing financial protection for people to pay for health services [3], and the government of China has made great progress on this front. For example, as early as 2009, China reformed a series of health care reforms including three national basic medical insurance programs: (1) Urban Employee Basic Medical Insurance (UEBMI) designed for employed urban residents; (2) the Urban Resident Basic Medical Insurance (URBMI) covering the unemployed, retired, older adults, students, and children in urban areas; and (3) the New Rural Cooperative Medical Scheme (NRCMS) for rural residents [4]. Currently, China's national basic insurance programs cover over 1. 35 billion people, about 97% of the total population [5]. Additionally, to eliminate poverty, the Decision on Winning the Battle Against Poverty policy proposed by China in 2015 achieved substantial results in education, primary medical care, and the basic living needs of people living in poverty. In fact, in 2020, the government of China announced that all low-income counties in China had been lifted out of poverty [6]. Benefitting from policies and measures on financial protection of health, the incidence of catastrophic health expenditure (CHE) in China declined from 14.7% in 2010 to 8.7% in 2018 [7]. However, there are still a few people encountering financial hardship, and the impact on mental and physical health caused by CHE is still worth studying.
Depression is a prevalent mental illness globally that contributes to the global burden of diseases as the leading mental cause of mortality for all ages [8]. Once depression appears, it can have a lasting and profound influence on one's whole life. The direct outcome of depression is a poor quality of life [9]. A study conducted on patients with schizophrenia indicated that depression has a strong negative effect on all 8 domains of subjective quality of life [10]. Furthermore, a meta-analysis showed that compared to controls, patients with depression had significant moderate cognitive deficits in executive function, memory, and attention (Cohen d effect sizes ranging from −0.34 to −0.65) [11]. Moreover, depression is a negative factor in cardiovascular disease (CVD) incidence, severity, and outcomes [12]. Rajan et al [13] found that depression was associated with CVD incidence (hazard ratio [HR] 1.14, 95% CI 1.05-1.24) and myocardial infarction (HR 1.14, 95% CI 1.05-1.24). Meng et al [14] also found that depression was associated with a higher risk of CVD mortality (HR 1.22, 95% CI 1.04-1.44). Therefore, the prevention and management of depression is a crucial and urgent public health issue.
A series of social, psychological, and biological factors and their complex interactions can play a role in depression occurrence [15,16]. Some study results posit that lower social support, a lower socioeconomic position, and economic difficulties are associated with a higher risk of depression [17,18], and the association is stronger between financial hardship and depression than other socioeconomic variables [19]. CHE, in theory, may have an impact on the mental health of family members because of reduced necessary expenditures. Nevertheless, current studies mostly focus on the likelihood of CHE events among people with depression, not the impact of CHE on depression occurrence [20,21]. In this study, we used 3 waves (2012, 2016, and 2018) of nationally representative data from the China Family Panel Studies (CFPS) to analyze the association of CHE with the risk of depression.

Study Design and Participants
Data in this study were obtained from CFPS, which is almost a nationally representative longitudinal study covering 25 of 31 provinces/municipalities in Chinese mainland (not including Xinjiang, Tibet, Inner Mongolia, Ningxia autonomous region, and Qinghai and Hainan provinces), representing nearly 94.5% of the total population in the Chinese mainland [22]. The CFPS were implemented by the Institute of Social Science Survey of Peking University to collect individual-, household-, and community-level data every 2 years. A baseline survey was conducted in 2010, and follow-up data from 2012, 2014, 2016, and 2018 were available for download from the official CFPS website [23].
As the information on depression in some of the CFPS waves was deficient, we used data from 2012, 2016, and 2018. The survey in 2012 included 35,720 adults (aged ≥16 years) and 13,315 households with valid interview responses. Individuals who had missing data at baseline (n=505), had depression at baseline (n=448), were lost to follow-up (n=2462), and had missing data of depression at the end of follow-up (n=271) were excluded. Finally, a total of 9629 households (household heads) were included in this study (Figure 1).

Ethics Approval
The CFPS, which involved human participants, were approved by the Biomedical Ethics Review Committee of Peking University (IRB00001052-14010). All written informed consent was provided by participants aged over 15 years or their parents (for those aged 15 years and under). The participants' personal information and privacy were strictly protected by the CFPS according to the rules set by Peking University's Biomedical Ethics Review Committee.

Measurements of Catastrophic Health Expenditure
The measurement of catastrophic health expenditure (CHE) was based on households, where a household member was defined by marriage, blood, or adoptive relationship, as well as an ongoing economic tie [24]. The head of the household was identified as the key decision-maker when the household faced important matters and decisions. Household OOP health payments were measured as the medical expenditure of all family members excluding reimbursed expenses in the past 12 months. The yearly household food expenditure was estimated as the monthly meal expenses multiplied by 12, and the total household expenditure in the past 12 months was calculated as the sum of monthly daily expenditures (food, daily used commodities and necessities, transportation, etc) multiplied by 12 plus yearly special expenditures (electricity, medical care, clothing, etc).
Households who experienced CHE were defined as those with OOP medical expenditures exceeding 40% of the household's capacity to pay (calculated as total household expenditure minus household food expenditure) [25]. CHE prevalence at baseline was measured as the percentage of the number of household heads incurring CHE to total participants. The formula was: where N is the total number of participants, and CHE i is 1 when the i th household incurred CHE and 0 otherwise.

Measurements of Depression
Depression was measured by the 8-item Center for Epidemiological Studies Depression Scale (CES-D), which is a shortened version of the original 20-item CES-D including 8 depressive symptoms (Table S1 in Multimedia Appendix 1). CES-D was not designed as a diagnostic tool but is widely used to identify individuals at high risk of depression in general populations and various subpopulations [26]. The score of each item in the 20-item CES-D ranges from 0 to 3 according to the frequency response of depressive symptoms in the past week, with 0 indicating rarely or none of the time (<1 day), 1 indicating some or a little of the time (1-2 days), 2 indicating occasionally or a moderate amount of time (3-4 days), and 3 indicating most or all of the time (5-7 days) [26]. The commonly used 8-item CES-D asked respondents whether they experienced any of the 8 depressive symptoms "most of time during the last week" [27], which was scored according to the answer (yes=1; no=0). The 8-item CES-D used in CFPS included the same depressive symptoms but was scored by frequency response. As "most or all of the time" in frequency response is equal to the "yes" answer to "most of time last week," we transferred the 4-score level of frequency response to the yes/no response [28]. Hence, the score of 8-item CES-D ranged from 0-8, and a total score ≥3 was deemed to indicate depression [28]. As the 8-item CES-D cannot diagnose depressive disorders, people with an 8-item CES-D score ≥3 in our study were identified as having depressive symptoms [29].
The family economic level was classified by the quartiles of household annual income, which was converted into 2012 US dollars based on purchasing power parities published by the World Bank [30] (lowest: <$4775.56, lower: $4775.56 to <$9831.46, higher: $9831.46 to <$17173.60, highest: ≥$17173.60). Numerous studies have reported that nighttime light intensity is highly associated with socioeconomic development [31,32]. Therefore, the socioeconomic development level in this study was identified by the quartiles of provinces' mean nighttime light intensity in 2012 (lowest: <0.089, lower: 0.089-0.31, higher: 0.32-0.68, highest: ≥0.69), which was obtained from the Harvard Dataverse [33].

Statistical Analyses
Baseline characteristics of the participants were presented as mean (SD) for continuous variables or frequencies and percentages for categorical variables. The Pearson χ 2 test was used to compare distributions of CHE according to different baseline characteristics. A multivariate logistical regression model was used to analyze the determinants of CHE.
We calculated the incidence rates (number of events divided by accumulated person-month) and used the univariate and multivariate Cox proportional hazard models to estimate the HRs and 95% CIs of depression among participants with CHE compared with those without CHE. First, the model adjusted demographic characteristics in multivariate model 1, including gender, age group, marital status, education, and insurance. Next, the model adjusted health-related factors in model 2 based on model 1, including self-reported health, chronic diseases, BMI, outpatient services, inpatient services, current smoking, and current drinking. Finally, the model adjusted socioeconomic factors in model 3 based on model 2, including residence, family economic level, family size, and socioeconomic development level.
To examine the robustness of our findings, we conducted 3 sensitivity analyses. First, we defined households with CHE as those having OOP medical expenditure exceeding 25% of the total household expenditure according to the World Bank. [25] Second, we transferred the categorical variables of age group and family economic level into continuous variables and conducted the same analysis in the final model. Third, we changed the variable nighttime light intensity into the gross regional product (GRP, divided into 4 groups based on the quartiles of 2012 per capita GRP [34]) to indicate the socioeconomic development level in the final model.
Finally, the analysis was stratified by gender, age group, insurance, chronic diseases, self-reported health, outpatient services, inpatient services, residence, socioeconomic development level, and family economic level, and a multiplicative interaction term was included in the final model with the stratification variable removed for subgroup analysis.
All data were analyzed in R software (version 4.2.1; R Foundation for Statistical Computing). A 2-sided P value <.05 was considered to be significant.

CHE Prevalence
At baseline, the prevalence of CHE was 12.9% (1393/9629) among the participants. Except for gender, insurance, and socioeconomic development level, the distribution of baseline characteristics was significantly different between households with CHE and those without CHE (

Risk of Depression
During a median of 71 (interquartile range: 69-72) person-months of follow-up, 532 (5.53%) of 9629 participants developed depression, of which 403 (75.75%) cases had no CHE and 129 (24.25%) cases had CHE. The incidence rate of depression among participants without and with CHE was 0.73 and 1.41 per 1000 person-months, respectively (Table 2). In the unadjusted analysis, participants who had CHE at baseline were associated with a 99% higher risk of depression (crude HR 1.99, 95% CI 1.63-2.42; Table 2). All multivariable-adjusted analyses showed a significant association of CHE with the risk of depression (Table S3 in Multimedia Appendix 1). In the fully adjusted model, participants with CHE had a 33% increased risk of developing depression compared to those without CHE (adjusted HR [aHR] 1.33, 95% CI 1.08-1.64; Table 2).
In the sensitivity analyses, the association between CHE and risk of depression was stable when we (1) defined CHE as OOP medical expenditure exceeding 25% of the total household expenditure, (2) transferred the categorical variables age group and family economic level to continuous variables, and (3) changed the variable nightlight time intensity into GRP to indicate socioeconomic development level in the final model (Table S4 in Multimedia Appendix 1). b Adjusted for demographic characteristics (gender, age group, education, marital status, and insurance), health-related characteristics (self-reported health, smoking status, drinking, chronic disease, BMI, and outpatient and inpatient services), and socioeconomic characteristics (residence, family economic level, family size, and socioeconomic development level). c cHR: crude hazard ratio.

Subgroup Analyses
In the subgroup analyses, the association of CHE with the risk of depression did not appear to be modified by most selected baseline characteristics, such as gender, age group, insurance, or chronic diseases ( Figure 2). However, the association between CHE and the risk of depression was found to be somewhat greater among participants without outpatient services (for interaction, P=.048). The risk of depression was higher among participants with CHE who did not have outpatient services (aHR 1.57, 95% CI 1.10-2.25) than those who had outpatient services (aHR 1.06, 95% CI 0.76-1.48).

Discussion
CHE can introduce great financial pressure to a household, as household members may have to borrow money, use savings, and even sell assets [35], which may lead to a longtime negative effect on their mental health [36]. To our knowledge, this is the first cohort study on the association between CHE and the risk of depression. We found that health-related characteristics (chronic diseases, self-reported health, and outpatient and inpatient services) and socioeconomic characteristics (residence, socioeconomic development level, family size, and family economic level) had an impact on CHE. We also found that prior CHE events were strongly associated with depression experienced by household heads and that there was an interaction between CHE and outpatient services for depression.
Our results revealed that people with chronic diseases, medium and poor self-reported health, outpatient services and inpatient services, rural, family size ≥5 people, and the highest socioeconomic development level had a higher prevalence of CHE, and these findings are consistent with those of other studies [7,37]. Poor health directly leads to a higher frequency of accessing health services, further leads to a heavy financial burden of medical expenditure, and finally, leads to CHE. Nighttime light intensity is an indicator of socioeconomic development, and areas with higher economic growth may have access to diagnostic technology for most illnesses. In addition, people in areas undergoing rapid socioeconomic development may pay more attention to the early detection of diseases and other preventive health care services [38]. Consequently, health-related characteristics and socioeconomic characteristics were the main factors behind CHE.
The results of our study revealed that people with CHE had a 33% higher risk of developing depression (aHR 1.33, 95% CI 1.08-1.64) than people without CHE. Socioeconomic variables, especially financial hardship, have a great influence on depression [39]. As a form of financial hardship, CHE plays a role in depression incidence. Once a household incurred CHE, family members had to take various measures to cope with financial loss, which could take a long time to recover [35]. Given this, household heads had a higher risk of developing depression with CHE than those without CHE under financial pressure.
As CHE could trigger depression, which may further lead to adverse outcomes [40,41], it is crucial to eliminate CHE to prevent depression. The first step to eliminating CHE is based on reducing OOP health expenditures. Because poor health is associated with an increased need and use of outpatient and inpatient care, and this negative correlation can be intensified by the number of chronic diseases [37], our results suggest that relevant departments should continue to expand health promotion, especially for chronic diseases. Additionally, governments should provide sufficient and targeted financial protection, including medical insurance and poverty subsidies, to reduce OOP payments and mitigate impoverishment caused by poor health. Most studies on CHE are interested in subpopulations that have specialized diseases like cancers, HIV, and tuberculosis [42][43][44]. The common features of these diseases are long duration, which may even coexist with people and cause a higher risk of CHE. To decrease individual OOP health expenditure, inclined policies and measures should be introduced for these diseases. For example, to relieve the financial burden faced by people living with chronic diseases, China launched catastrophic medical insurance (critical illness insurance) in 2012 and implemented it nationwide in 2016 after city-based testing, with the aim of reimbursing patients whose OOP health expenditure exceeded a predetermined basic medical insurance level [45]. In addition, for eligible people facing unaffordable medical expenses, China provided medical assistance and even offered treatment for free or at a reduced price for some priority diseases [46]. Of course, these policies are mostly aimed at financially vulnerable people. However, our study found that people with a higher family economic level and the highest socioeconomic development level were more likely to occur CHE, which may be explained by the concentrated distribution and utilization of health services. [47] In view of this, more financial protection policies should be implemented for the whole population regardless of their economic capacity. Additionally, as the current health care delivery in China is still fragmented and treatment-based [48], with increasing incidence of age-related diseases, integrated establishment and improvement of primary health services should be intensified in health-related policies.
To cut off the linkage between CHE and depression, the second point is to halt the progression to depression. As the evidence shows in studies on financial hardship and depression, not all people experiencing financial hardship will develop depression [39]. These differing responses to CHE may be explained by various socioeconomic and psychological variables in the stress process model, such as social support, self-esteem, personal agency, and personal ability to manage difficulties [39,49,50]. Therefore, measures to prevent and regulate depression should be extended widely. Additionally, timely financial assistance should be implemented for vulnerable populations, such as people with chronic diseases and households under the minimum living guarantee.
In this study, we found that the risk of depression was higher among participants with CHE who did not have outpatient services (aHR 1.57, 95% CI 1.10-2.25) than those who had outpatient services (aHR 1.06, 95% CI 0.76-1.48). In CFPS, the variable "outpatient services" was measured by whether participants had used outpatient services in the past 2 weeks when they felt uncomfortable. Those without outpatient services included people who did not feel uncomfortable and who felt uncomfortable but did not use health services. The latter group may have a lower socioeconomic status. Moreover, heads of households with lower social support, a lower socioeconomic position, and economic difficulties were more likely to experience depression due to life pressures [17,18]. Consequently, not accessing outpatient services intensified the association between CHE and the risk of depression.
There are several limitations to our study. First, because the 8-item CES-D is not equal to clinical diagnosis, our study could only estimate the association between CHE and the risk of depressive symptoms, which calls for future research on CHE and depressive disorders. Second, due to the limitation of the original data, households with CHE did not include those facing extreme poverty who could not seek health services and whose household medical expenditure was zero. Third, expenditure data for calculating CHE were mainly based on the participants' memory, which may be prone to recall bias.
In conclusion, people with poor health and a higher socioeconomic position had a higher prevalence of CHE and CHE was significantly associated with a higher risk of depression. To prevent depression induced by CHE, concentrated work should be made to monitor CHE, and more efforts to ensure financial protection need to be introduced and strengthened, especially for people with higher health care needs.