Original article
Depression and increased risk of death in adults with stroke

https://doi.org/10.1016/j.jpsychores.2009.11.006Get rights and content

Abstract

Objective

Depression is a common condition among individuals with stroke and believed to influence post-stroke mortality. The objective of this study was to evaluate the effect of depression on all-cause mortality among adults with and without a history of stroke.

Methods

We studied 10,025 participants in the population-based National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study who were alive and interviewed in 1982 and had complete data for the Center for Epidemiologic Studies Depression Scale. Four groups were created based on history of stroke and depression status in 1982: (1) no stroke, no depression (reference group); (2) no stroke, depression present; (3) history of stroke, no depression; and (4) history of stroke present, depression present. Cox proportional hazards regression models were used to calculate multivariate-adjusted hazard ratios (HRs) of death for each group compared with the reference group.

Results

Over 8 years (83,624 person-years of follow-up), 1,925 deaths were documented. Mortality rate per 1,000 person-years of follow-up was highest in the group with both a history of stroke and depression. Compared with the reference group, HRs for all-cause mortality were: no stroke, depression present, 1.23 (95% CI 1.08–1.40); stroke present, no depression 1.74 (1.06–2.85); and stroke present, depression present, 1.88 (1.27–2.79).

Conclusions

The coexistence of stroke and depression increases the risk of death; however, the combined effect is less than additive.

Introduction

Studies suggest that at least 30% of all stroke patients develop depression [1], [2], [3], [4]. Because there are approximately 500,000 new strokes each year in the United States [5], estimates indicate that approximately 150,000 stroke survivors develop depression in the first year post stroke [1]. Unfortunately, depression is associated with poor stroke-related outcomes for both patients and their caregivers [1], [6]. Patients with depression experience worse stroke-related outcomes in the form of greater functional disability [6], [7], [8], [9] and higher mortality [6], [10], [11], [12], [13].

A number of studies suggest that depressive symptoms are key indicators for increased risk of post-stroke mortality [10], [11], [12], [13], [14]. Morris et al. [14] found that patients with depression were 3.4 times more likely to die during a 10-year follow-up period than non-depressed patients. They also observed that the relationship between mortality and depression was independent of other common stroke risk factors (e.g., age, sex, social class, and level of social functioning). Similarly, Everson et al. [11] examined 169 deaths during a 29-year follow-up period and found that after adjustment for established stroke risk factors, patients reporting the greatest number of depressive symptoms experienced a 50% increased risk of mortality due to stroke. Williams et al. [13] also found a higher 3-year mortality risk in patients with depression even though depressed patients were younger and had fewer chronic conditions than the comparison group.

Unfortunately, even though depression after stroke has been associated with greater mortality, it is not entirely clear whether depression is a contributor to post-stroke mortality as an individual stroke risk factor or as an independent factor that negatively influences other stroke risk factors [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]. For example, there is substantial evidence linking depression and post-stroke mortality; however, the contribution of depression to post-stroke mortality over and above the normal risk of death for individuals without stroke is much less clear. House et al. [10] proposed that depressive symptoms may be associated with mortality by behavioral (poor risk factor control and adherence to treatment) or physiological (alternations in autonomic control of cardiac rhythms and increased platelet reactivity). However, the nature of the relationship between depression and post-stroke mortality is not entirely clear and questions remain regarding prevention and treatment [1].

Few studies have examined whether the risk of death among people with both stroke and depression is greater than the risk of death associated with having stroke or depression alone. To address this issue, we examined mortality in a large nationally representative sample of adults aged 25–75 years in 1971–1975 [15] who were reinterviewed in 1982 and followed up until 1992 [16], [17]. We compared all-cause mortality among four subsets of participants based on their disease status at the 1982 survey to determine whether the risk of death among adults with both stroke and depression was greater than the risk of death from having each condition alone. We examine all-cause mortality using two multivariate models. Our first model includes sociodemographic variables (age, race/ethnicity, poverty, education and marital status) believed to contribute to stroke risk and stroke-related death and our second model includes the same socio-demographic variable in addition to common cardiovascular risk factors (smoking, limited physical activity, limited aspirin use, high body mass index (BMI) and history of cancer, hypertension, heart disease and diabetes) known to increase stroke risk and stroke-related death even in the absence of depression.

Section snippets

Research design and methods

The National Health and Nutrition Examination Survey (NHANES) I was a multistage, stratified, national probability sample of the civilian noninstitutionalized population of the United States aged 1–74 years [15]. The survey was conducted between 1971 and 1975 and included a standardized examination and questionnaires that addressed various health topics. Persons living in poverty areas, women of childbearing age (25–44 years), and elderly persons (≥65 years) were oversampled. The NHANES I

Results

In this nationally representative sample of 10,025 adults followed up for an average duration of 8 years (83,624 person-years of follow-up), 1,925 (19%) of the study subjects died. Stroke accounted for 74 deaths (4%). Table 1 shows the baseline characteristics of the study participants. In general, the group of individuals with both stroke and depression were more likely to be female, white, married, have less than a high school education, live sedentary lifestyles, and be overweight/obese.

Conclusions

This is the first study to our knowledge to determine whether the risk of death among adults with stroke and depression is greater or less than the sum of the risk of death from having each condition alone. After adjusting for relevant sociodemographic factors and clinical comorbidities, individuals with both stroke and depression had a 1.88-fold risk of death from all causes compared to those without a history of stroke or depression (reference group). Additionally, depressed individuals

References (35)

  • RamasubbuR et al.

    Effect of depression on stroke morbidity and mortality

    Can J Psychiatry

    (2003)
  • ParikhRM et al.

    The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up

    Arch Neurol

    (1990)
  • SinyorD et al.

    Post-stroke depression: relationships to functional impairment, coping strategies, and rehabilitation outcome

    Stroke

    (1986)
  • KauhanenM et al.

    Poststroke depression correlates with cognitive impairment and neurological deficits

    Stroke

    (1999)
  • HouseA et al.

    Mortality at 12 and 24 months after stroke may be associated with depressive symptoms at 1 month

    Stroke

    (2001)
  • EversonSA et al.

    Depressive symptoms and increased risk of stroke mortality over a 29-year period

    Arch Intern Med

    (1998)
  • GumpBB et al.

    Depressive symptoms and mortality in men: results from the multiple risk factor intervention trial

    Stroke

    (2005)
  • Cited by (90)

    • Post stroke depression and risk of stroke recurrence and mortality: A systematic review and meta-analysis

      2019, Ageing Research Reviews
      Citation Excerpt :

      After reviewing the full text of these articles, 190 were excluded for not meeting the inclusion criteria, and a further 4 studies were excluded due to the reasons described in Fig. 1. A total of 15 articles were included (Ayerbe et al., 2014; Sibolt et al., 2013; Hong et al., 2018; Freak-Poli et al., 2018; Razmara et al., 2017; Jorgensen et al., 2016; de Mello et al., 2016; Hornsten et al., 2013; Ried et al., 2011; Willey et al., 2010; Naess et al., 2010; Melkas et al., 2010; Ellis et al., 2010; Almeida and Xiao, 2007; Williams et al., 2004); 14 studies reported results for all-cause mortality, of which one study also reported total stroke recurrence outcome, and a further one study focused on ischemic stroke recurrence. No studies reported on stroke-specific mortality.

    • Reduced Serum Adiponectin Level and Risk of Poststroke Depression in Patients with Ischemic Stroke

      2019, Journal of Stroke and Cerebrovascular Diseases
      Citation Excerpt :

      Psychological evaluation was performed at 3 months after stroke by the same trained psychologist who was blinded to the laboratory results and clinical data. All patients were screened for depressive symptoms using the 17-item Hamilton Depression Scale.2 Patients with a Hamilton Depression Scale score greater than or equal to 7 were further assessed using the Chinese version of structured clinical interview of DSM-IV, for diagnosing the PSD.3,20,21

    View all citing articles on Scopus
    View full text