Investigation of Prevalence and Associated Risk Factors of Depressive Symptoms Following Acute Ischemic Stroke (PSD) in the Aged

doi:10.4236/psych.2011.25081

Paper Menu >>

Journal Menu >>

Psychology

2011. Vol.2, No.5, 522-525

Investigation of Prevalence and Associated Risk Factors of

Depressive Symptoms Following Acute Ischemic Stroke

(PSD) in the Aged

Yue Chen

Department of Geriatrics, the First Affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China

Email: [email protected]

Received April 4th, 2011; revised May 13th, 2011; accepted June 19th, 2011

Objective: The study aimed to investigate the prevalence and associated risk factors for post stroke depression

(PSD), and their clinical correlations. Method: A consecutive cohort of 102 ischemic stroke patients with a

mean age of 72.6 ± 7.2 years, were studied. Hamilton depression rating scale (HDRS), modified motor assess-

ment scale (MMAS) and Barthel index (BI) were administered. Risk factors of PSD studied were gender, later-

ality of stroke, family history of depression and post stroke functional impairment. Results: From assessment

with the HDRS, 71 (69.6%) of the subjects were non-depressive and the rest 31 (30.4%) had depression. De-

pressive symptoms (HDRS > 10) were relatively common, but the prevalence of severe depression (HDRS >17)

was only 7.0%. Patients with depressive symptoms were more likely to be female(X2 = 4.01, P = 0.039), have a

family history of depression(X2 = 3.87, P = 0.045), and a poor functional status(MMAS, t = 2.18 and P = 0.016;

BI, t = 3.74 and P = 0.009). Conclusion: Our findings indicate that depressive symptoms occurred in about one

third of post stroke patients. Important risk factors found for PSD included gender, family history of depression

and functional impairment.

Keywords: Depression, Post-Stroke, Prevalence, Risk Factors, Investigation

Introduction

Stroke is a common neurological problem and the third lead-

ing cause of death in developed countries of the world (Katra ,

Dale & Crome, 1993; Warlow, 1998). Among survivors, over

50% have significant disabilities, and in clinical practice,

neuro-psychiatric disturbances are also frequent (Jongbloed

1990; Hankey, 2007). Depression is an important common

problem for patients who have experienced strokes, and

post-stroke depression (PSD) is present in at least 30% of the

survivors of strokes (Gainotti, Antonucci, Marra et al., 2001;

Carson, MacHale, Allen et al., 2000). However, a consensus on

the prevalence and associated factors of PSD has not been

reached. Recently systematic review suggested that stroke se-

verity or physical disability and functional impairment are im-

portant factors associated with depression (Herrmann, Black,

Lawrence et al., 1998; Singh, Black, Herrmann et al., 2000).

Other possible risk factors include age, gender, lack of social

support, and of psychiatric family history (Andersen, Vester-

gaard, Ingemann-Nielsen et al., 1995). In China, the paucity of

data on PSD and its associated risk factors prompted this study.

This prospective study was to assess the prevalence of depres-

sive symptoms following acute ischemic stroke in a teaching

hospital in China and the associated risk factors for PSD.

Subjects and Methods

Patient Population

One hundred-two patients were selected from consecutive

inpatients in the geriatric department of No.1 affiliated hospital

of medical school, Zhejiang university over two year period

from October, 2008, until September, 2010 for problems related

to acute ischemic stroke. The diagnosis of acute stroke met the

classification of cerebrovascular diseases III of the National

Institute of Neurological Disorders and Stroke (Special Report,

1990). The stroke patients were studied made up of 63(61.8%)

males and 39(38.2%) females. The mean age of this group was

72.6 ± 7.2 years (ranges: 68 - 82). All patients with a known

history of alcohol abuse, dementia, current antidepressant

treatment, or severe Parkinson’s syndrome were excluded. Pa-

tients with aphasia and difficulties for interview were also ex-

cluded. The necessary socio-demographic data was obtained

from each subject. Lesion location was defined by CT or MRI

during the stroke onset. As part of the approved ethical clear-

ance for the study, informed consent was also obtained from

each patient.

Instruments

The subjects were studied using the following instruments:

Hamilton Depression Rating Scale (HDRS) (Carr, Shepherd,

Nordholm & Lynne, 1985)

The post-stroke depressive symptoms were assessed by a

neuropsychologist with the Hamilton Depression Rating Scale

(HDRS). We defined patients as having depression if the

HDRS score was above 10. Patients with an HDRS score be-

tween 10 - 13 were defined as having mild depression, 14 - 17

as moderate, and above 17 as severe.

Barthel’s Index (BI) (Buchanan, 1986) and Modified Motor

Assessment Scale (MMAS) (Sim, Reid, Pallett &Gordon,

1975)

Functional status was measured by a neurologist in the ward

Y. CHEN 523

with the Barthel’s Index (BI) and Modified Motor Assessment

Scale (MMAS). The BI has scores between 0 and 100, with the

top scores implying a complete functional independence in

daily life activities. The MMAS is an instrument used to assess

functional, that is motor impairment in stroke patients. It is an

eight-task item instrument. The possible scores for each item task

is 0 - 6, with a maximum of 48 points in overall assessment.

Testing Routine

Each subject was administered the HDRS to complete.

Thirty-one patients (30.4%) had depressive symptoms from

HDRS assessment. The questionnaire was completed by the

first researcher in line with such subject’s choice for each item.

Each of the subjects was also assessed with the Modified Motor

Assessment Scale (MMAS) and Barthel index (BI) to determine

his/ her levels of motor functioning/ impairment for a compari-

son of percentage of PSD between two groups (Figure 1).

Data Analysis

Descriptive statistics were used to summarize data. Be-

tween-group comparisons were made with the t-test for con-

tinuous variables, and Chi-square test of independence for di-

chotomous variables. Pearson correlation was used to test the

strength for the relationship between depressive symptoms

(HDRS scores) and functional status (MMAS scores). Tests

were two-tailed, and the results were considered significant at P

< 0.05. Analyses were conducted using SPSS version 10.0 for

Windows (SPSS Inc. U.S.A.).

Results

Clinical Characteristics of Study Subjects

One hundred-two patients admitted to the geriatric depart-

ment of No.1 affiliated hospital of medical school, Zhejiang

Patients admitted to hospital

with acute ischemic stroke

n = 102

Assessment on

admission by HDRS

HDRS score < 10

n=71

HDRS score > 10

n = 31

Assessment by

MMAS, BI

MMAS score ≥ 25

n = 62

MMAS score < 25

n = 40

Comparison of % of PSD

between two groups

Figure 1.

Testing routine.

university over two year period from October, 2008, until Sep-

tember, 2010 for problems related to acute ischemic stroke. The

stroke patients were studied made up of 69(67.8%) males and

33(32.2%) females. The mean age of the subjects was 72.6 ±

7.2 years, and age range of 68 - 82 years. All the patients re-

ceived inpatient rehabilitation treatment every day after the

initial medication (e.g. Cerebrolysin, neuroprotective agent,

manufactured by EBEWE Pharma, Vienna, Austria and Seroxat,

antidepressant, manufactured by GlaxoSmithKline Pharma,

London, United Kingdom). The mean duration of hospital stay

was 45 days (range 21 - 85 days). Thirty-one patients (30.4%)

had depressive symptoms from Hamilton Depression Rating

Scale (HDRS) assessment. There were no significant differ-

ences in the age of stroke onset and the laterality of stroke focus.

In contrast, the depressed patients were more likely to be fe-

male(P < 0.05), and to have the family histories of depression(P

< 0.05) (Table 1).

HDRS scores/ post stroke depression (PSD)

From the scores obtained on HDRS by the subjects,

71(69.5%) were normal while the remainder, 31(30.4%) were

depressed. According to HDRS classification, eleven (10.8%)

were mildly depressed, 13 (12.7%) moderately depressed, and

7(7.0%) severely depressed (Table 2). Overall, the mean HDRS

score for the depressed subjects was 14.9 ± 6.3.

Post Stroke Functional Impairment and Its

Relationship to PSD

For post stroke motor functional level as assessed with

MMAS, 40(39.2%, N = 102) of the subjects had poor motor

functioning (that is MMAS score less than 25). Of this category,

19(15.7%) had PSD on HDRS assessment. Hence, 47.5% (19

out of 40) of those with “poor” motor functiod thus subjects

with “poor” motor functioning constituted 61.3% (19 out of 31)

subjects with PSD. For the rest 62(60.8%, N = 102) with

“good” motor functioning ( MMAS score ≥ 25 ), only 12, that

is 19.4% of the 62 subjects with “good” MMAS scores had PSD;

Table 1.

Clinical characteristics among different groups with depressive symp-

toms.

Depressive Symptoms

Variable

Absent Present

Statistics

(HDRS < 10)

(n = 71)

(HDRS ≥ 10)

(n = 31) t or X2 P

Age onset year 71.9 ± 8.272.4 ± 7.3 T = 0.46NS

Gender (female)23 (32%) 16 (53%) X2 = 4.010.039*

Family history

(depression) 3(4%) 4 (14%) X2 = 3.870.045*

Right hemisphere

stroke 31(44%) 14(45%) X2 = 1.35NS

Left hemisphere

stroke 29(41%) 13(44%) X2 = 1.87NS

Modified Motor

Assessment Scale17.3 ± 6.111.2 ± 6.7 T = 2.180.016*

Barthel Index 91.8 ± 11.170.2 ± 9.3 T = 3.740.009**

* P < 0.05, ** P < 0.01, NS indicates not significant.

Y. CHEN

524

Table 2.

Severity of Depressive Symptoms from HDRS Assessment* (N = 102).

Number Percentage(%)

No depression

(HDRS score <10) 71 69.5

Mild depression

(HDRS score 10 - 13) 11 10.8

Moderate depression

(HDRS score 14 - 17) 13 12.7

Severe depression

(HDRS score >17) 7 7.0

Total 102 100.0

*Mean HDRS score in the depressed subjects: 14.9 ± 6.3.

showing that subjects with “good” motor functioning consti-

tuted 38.7% (12 out of 31) subjects with PSD. Thus, the ratio of

subjects with the “good MMAS score” to the “poor MMAS

score” that had the complication of PSD is 1:2.4 (Table 3).

Correlations between depression rating scale scores and

functional outcome measured by the MMAS and the handicap

level measured by Barthel index (Table 1) were significant

(rMMAS = –0.33, rBI = –0.38, respectively, P < 0.01), showing a

significantly negative relationship between depressive symp-

toms and functional status.

Discussion

Stroke remains a major cause of death and disability in China

(Wei, Huang, Wang et al., 2011 ), but little attention has been

focused on the possible psychiatric morbidity that could com-

plicate the problem among survivors (Fuh, Liu, Wang et al.,

1997). In our study, an attempt was made to evaluate for de-

pression with particular focus on prevalence and associated risk

factors in the old patients of ischemic stroke.

The prevalence of PSD in different studies is difficult to

compare because of different evaluation methods, diagnostic

criteria, and patient sources. Past studies have found that de-

pression is a frequent sequela of stroke, and the prevalence

ranged from 12% to 64% (Lam, Lee & To, 2010). Most of

these studies were restricted to stroke patients seen at outpatient

clinics or admitted to general hospital. Those studies may have

included patients with more severe and persistent handicaps.

Conversely, department of geriatrics sampling methods, may

include patients with more mild-moderate deficits and/or no

disabilities (Burvill, Johnson, Jamrozik et al., 1995]. The rate of

depressive symptoms in our study (30.4%, 31 out of 102) is

almost identical to the prevalence of depressive disorder in the

two studies by House et al. (1990) (32%) and Wade et al.

Table 3. Analysis of Post Stroke Functi on al Impairment (N = 102).

Post Stroke

Impairment No. of PSD % of PSD % of MMAS

Scores

MMAS ≥ 25 12 38.7 19.4 (n = 62)*

MMAS < 25 19 61.3 47.5 (n = 40)

Total 31** 100

*“Better” Motor Functioning:“poor” Motor Impairment for PSD = 1:2.4; **Mean

MMAS scores in depressed subjects: 11.2 ± 6.7; Mean BI scores: 70.2 ± 9.3.

(32%) (Wade, Legh-Smith & Hewer, 1987), but the incidence

of severe depressive symptoms (7.0%, 7 out of 102) was lower

than these two studies (13% and 20%, respectively). The preva-

lences from all three studies are considerably lower than those

reported from surveys from rehabilitation units (Robinson,

Kubos, Starr et al., 1984; Sinyor, Jacques, Kaloupek et al.,

1986). The reason why the prevalences were so different may

be because of the difference in the nature of the sample or the

assessment measures utilized.

From various studies in Europe and America, a number of

risk factors have been identified for PSD among stroke survi-

vors. In a systematic review by Oumet et al. (2001), gender,

family history of depression or psychiatric illness, social isola-

tion and functional impairment were consistently identified as

risk factors for PSD. In our study, gender was found to be an

important risk factor of PSD that is, the female subjects were

more likely to develop PSD than their male counterparts (P <

0.05). And the presence of family history of depression was in

agreement with some previous studies where a positive family

history showed a higher probability of developing PSD than

none (Angelelli, Paolucci, Bivona et al., 2004). The relationship

between stroke laterality and PSD is a controversial one. In a

systematic review by Carson et al., 39 studies found no signifi-

cant difference between stroke laterality (site of lesion) and

PSD, two reported increased risk with left sided lesions and

seven reported increased risk with right sided lesions (Carson,

MacHale, Allen, 2000). However, in our study, subjects with

PSD were not more likely to have their stroke lesions over the

left or right hemisphere and the difference in laterality was not

statistically significant.

Stroke survivors often suffer some degree of long term im-

pairment such as partial or complete loss of locomotion with

about 80% of patients with acute stroke presenting with weak-

ness or paralysis of either the upper or lower extremity or both.

Other possible areas of impairments include activities of daily

living (ADL), cognition and communication skills (Green,

Forster, Bogle & Young, 2002; Nannetti, Paci, Pasquini et al.,

2005). In our study, motor impairment was found to be an im-

portant risk factor of PSD. The study demonstrated 19.4% of

subjects (62) with “good” MMAS score (motor performance,

MMAS ≥ 25) had PSD as compared with 47.5% of subjects (40)

with “poor” MMAS score(MMAS < 25), showing that the ratio

of “better” motor functioning versus “poor” motor impairment

for PSD was 1:2.4.

Thus, we found a significantly negative relationship between

the prevalence of depressive symptoms following ischemic

stroke and their activities of daily living (functional status).

These results should not be surprising, especially in view of the

findings of the Medical Outcome Study which has showed that

patients with depressive symptoms had poor functioning (Wells,

Stewart, Hays et al., 1989).

Psychologically, early identification of depression symptoms

and early initiation of aggressive treatment may prove benefi-

cial in reducing stroke recurrence and decreasing mortality

(Dafer, Rao, Shareef & Sharma, 2008). The present study em-

phasizes the need to screen for depressive symptoms because it

is related to the prognosis. Double-blind controlled trials have

documented the efficacy of tricyclic antidepressants (Lipsey,

Robinson, Pearlson et al., 1984) and selective serotonin reup-

take inhibitors (Dam, Tonin, De Boni et al., 1996) in treating

Y. CHEN 525

post-stroke depression. It is unclear whether the amelioration in

depressive symptoms will be associated with improvement of

functional status. Further studies are needed.

Conclusion

Our study indicates that depressive symptoms occurred in

about one third of post stroke patients. Important risk factors

found for PSD included gender, family history of depression

and functional impairment. There is a negative correlation be-

tween depressive symptoms and functional status of the pa-

tients.

Acknowledgements

The authors would like to thank Dr Jiu-jiao Wang (No.1

affiliated hospital of Zhejiang University, Hangzhou, Zhejiang

Province, China) for her psychological assistance in HDRS

assessment in our study.

References

Andersen G., Vestergaard K., Ingemann-Nielsen M., et al. (1995). Risk

factors for post-stroke depression. Acta Psychiatrica Scandinavica,

92:193-198. doi:10.1111/j.1600-0447.1995.tb09567.x

Angelelli P., Paolucci S., Bivona U., Piccardi L., Ciurli P., Cantagallo A.,

et al. (2004). Development of neuro-psychiatric symptoms in post

stroke patients: A cross sectional study. Acta Psychiatrica Scandi-

navica, 110, 55-63. doi:10.1111/j.1600-0447.2004.00297.x

Buchanan B. F. (1986). Functional assessment: measurement with the

Barthel Index and PULSES profile. Home Healthc Nurse., 4, 11-17.

doi:10.1097/00004045-198611000-00004

Burvill P. W., Johnson G. A., Jamrozik K. D., et al. (1995). Prevalence

of depression after stroke: the Perth Community Stroke Study. The

British Journal of P sychiatry, 166, 320-327.

doi:10.1192/bjp.166.3.320

Carson A. J., MacHale S., Allen K., et al. (2000). Depression after stroke

and lesion location: A systematic review. Lancet, 356, 122-126.

doi:10.1016/S0140-6736(00)02448-X

Carson AJ, MacHale S, Allen K. (2000) Depression after stroke and

lesion location: a systematic review. Lancet, 8, 122-126.

Carr J. H., Shepherd R. B., Nordholm I., & Lynne D. (1985). Investiga-

tion of a new motor assessment for stroke patients. Physical Therapy,

65, 175-190.

Dafer R. M., Rao M., Shareef A., & Sharma A. (2008). Poststroke

depression. Topics in Stroke Rehabilitation, 15, 13-21.

doi:10.1310/tsr1501-13

Dam M., Tonin P., De Boni A., et al. (1996). Fluoxetine and

maprotiline on functional recovery in poststroke hemiplegic patients

undergoing rehabilitation therapy. Stroke, 2 7, 1211-1214.

doi:10.1161/01.STR.27.7.1211

Fuh J. L., Liu H. C., Wang S. J., et al. (1997). Poststroke depression

among the Chinese elderly in a rural community. Stroke, 28,

1126-1129. doi:10.1161/01.STR.28.6.1126

Gainotti G., Antonucci G., Marra C., et al. (2001). Relation between

depression after stroke, antidepressant therapy, and functional recov-

ery. Journal of Neurology, Neurosurgery & Psychiatry, 71, 258-261.

doi:10.1136/jnnp.71.2.258

Green J, Forster A, Bogle S, & Young J. (2002). Physiotherapy for

patients with mobility problems more than 1 year after stroke: A

randomized controlled trial. Lancet, 359, 199-203.

doi:10.1016/S0140-6736(02)07443-3

Hankey G. J. (2007). Clinical update: management of stroke. Lancet,

369, 1330-1332. doi:10.1016/S0140-6736(07)60614-X

Herrmann N., Black S. E., Lawrence J., et al. (1998). The Sunnybrook

Stroke Study: A prospective study of depressive symptoms and func-

tional outcome. Stroke, 29, 618-624.

doi:10.1161/01.STR.29.3.618

House A., Dennis M., Warlow C., et al. (1990). Mood disorders after

stroke and their relation to lesion location. Brain, 113, 1113-1129.

doi:10.1093/brain/113.4.1113

Jongbloed L. (1990) Problems of methodological heterogeneity in

studies predicting disability after stroke. Stroke, 21, 32-34.

Katra L., Dale P., & Crome P. (1993). Improving stroke rehabilitation:

A controlled study. Stroke, 24, 1462-1467.

doi:10.1161/01.STR.24.10.1462

Lam S. C., Lee L. Y. & To K. W. (2010). Depressive symptoms among

community-dwelling, post-stroke elders in Hong Kong. International

Nursing Review, 57, 269-273.

doi:10.1111/j.1466-7657.2009.00789.x

Lipsey J. R., Robinson R. G., Pearlson G. D., et al. (1984). Nortrip-

tyline treatment of post-stroke depression: a double-blind study.

Lancet, 1, 297-300. doi:10.1016/S0140-6736(84)90356-8

Nannetti L., Paci M., Pasquini J., Lombardi B., & Taiti P. G. (2005).

Motor and functional recovery in patients with post stroke depression.

Disability and Rehabilitation, 27, 170-175.

doi:10.1080/09638280400009378

Ouimet M. A., Primeau F., &Cole M. G. (2001). Psychosocial risk

factors in post-stroke depression: A systematic review Can. The

American Journal of Psychia tr y, 46, 819-828.

Robinson R. G., Kubos K. L., Starr L. B., et al. (1984). Mood disorders

in stroke patients. Importance of location of lesion. Brain, 107, 81-93.

doi:10.1093/brain/107.1.81

Special Report from the National Institute of Neurological Disorders

and Stroke. (1990). Classification of cerebrovascular diseases III.

Stroke, 21, 637-676. doi:10.1161/01.STR.21.4.637

Singh A, Black SE, Herrmann N, et al. (2000). Functional and neuro-

anatomic correlations in post stroke depression. Stroke, 31, 637-644.

doi:10.1161/01.STR.31.3.637

Sim M., Reid D., Pallett J., & Gordon E. (1975). The Hamilton rating

scale. An assessment bases on a dothiepin versus imipramine clinical

trial. International Pha rm ac op s yc hi atry, 10, 142-148.

Sinyor D., Jacques P., Kaloupek D. G., et al. (1986). Post-stroke de-

pression and lesion location: an attempted replication. Brain, 109,

537-546. doi:10.1093/brain/109.3.537

Wade D. T., Legh-Smith J., & Hewer R. A. (1987). Depressed mood

after stroke: A community study of its frequency. The British Journal

of Psychiatry, 151, 200-205. doi:10.1192/bjp.151.2.200

Warlow C. P. (1998). Epidemiology of stroke. Lancet, 352, S111-S1114.

doi:10.1016/S0140-6736(98)90086-1

Wei J. W., Huang Y., Wang J. G., Liu M., Wong L. K., Huang Q., &

Wu L. (2011). Current management of intracerebral haemorrhage in

China: A national, multi-centre, hospital register study. BMC Neu-

rology, 11, 16-21.

Wells K. B, Stewart A., Hays R. D., et al. (1989). The functioning and

well-being of depressed patients: results from the Medical Outcomes

Study. The Journal of the American Medical Association, 262,

914-919. doi:10.1001/jama.262.7.914