Bidirectional transitions of depressive symptoms among middle-aged and older Chinese adults: A multi-state Markov model analysis

OBJECTIVE: Evidence on bidirectional transitions of mid- to late-life depressive symptoms and their determinants remains limited. This study aimed to characterize the progression and remission of depressive symptoms in Chinese middle-aged and older adults and to identify modifiable risk factors. METHODS: Data from the China Health and Retirement Longitudinal Study (2011-2020) were utilized, including 13,921 participants aged ≥45 years with at least 2 assessments using the Center for Epidemiologic Studies Depression Scale (CESD-10). Depressive symptoms were defined as a CESD-10 score ≥ 10. Continuous-time multi-state Markov models estimated transition intensities, probabilities, and mean sojourn times. Multivariable models provided transition-specific hazard ratios (HRs). RESULTS: Among 45,102 observed transitions, remission intensity exceeded progression intensity (0.255 vs 0.154 per year). The mean sojourn time was longer for non-depressive symptoms than for depressive symptoms (5.241 vs 3.238 years). At 5 years, remission probability was 43.40 % while progression was 26.20 %. Female sex, lower economic status, multimorbidity, limitations in activities of daily living, and short sleep predicted higher progression, with HRs of 1.320, 1.251, 1.238, 1.264, 1.283, respectively, and lower remission, with HRs of 0.816, 0.859, 0.854, 0.830, 0.855, respectively. Falls (HR = 1.147) and smoking (HR = 1.109) increased progression. Urban residence, higher levels of education, participation in activities, and greater life satisfaction reduced progression, with HRs of 0.724, 0.717, 0.842, 0.770, respectively, while urban residence, greater life satisfaction, and drinking at least once per month increased remission, with HRs of 1.109, 1.235, 1.151, respectively. CONCLUSION: Depressive symptoms in mid- to late life were bidirectional and potentially reversible. Socioeconomic disadvantage, multimorbidity, and functional impairment shaped unfavorable transitions, while modifiable behaviors and subjective well-being related to improved remission.