Original articleDepression and increased risk of death in adults with stroke
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
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