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 Table of Contents  
Year : 2014  |  Volume : 1  |  Issue : 3  |  Page : 119-123

Depression in long-term stroke survivors

1 Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
2 Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Psychiatry, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Submission21-Nov-2013
Date of Acceptance25-Jun-2014
Date of Web Publication17-Aug-2014

Correspondence Address:
Sani A Abubakar
Department of Medicine, Neurology Unit, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
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DOI: 10.4103/2384-5147.138935

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The long-term consequences of stroke, especially disability have been recognized but little attention has been paid to psychological and psychiatric consequences of stroke (particularly depression) in Nigeria. Patients with depression following stroke have poorer functional outcome and increased mortality. The aim of this study was to determine the frequency of depression at 1 year poststroke and risk factors associated with poststroke depression in Zaria, Nigeria. Materials and Methods: Consecutively presenting long-term stroke survivors attending neurology outpatients' clinic were prospectively examined 1 year poststroke, sociodemographic data were obtained from the patient using structured questionnaire. Admission stroke severity was obtained retrospectively using National Institute of Health Stroke Score. Modified Rankin scale (MRS) was used to assess the level of handicap, while screening for depression was done using the Hamilton Depression Rating Scale. Results: Sixty-eight consecutive patients (36 males, 32 females) were evaluated. The mean age of the subjects was 54.99 ± 11.8 years. Thirty-eight (55.9%) patients had right hemispheric localization of stroke lesion. Eight (11.8%) of the patients evaluated remained disabled 1 year postictus, while depression was present in 11 (16.2%). Using multiple logistic regression, the major independent determinant of depression at 1 year postictus was the presence of residual disability quantified using MRS. Conclusion: Depression occurred in 16.2% of long-term stroke survivors and the most independent determinant of depression at 1 year poststroke is degree of functional disability (handicap).

Keywords: Depression, risk factors, stroke

How to cite this article:
Abubakar SA, Obiakor RO, Sabir AA, Iwuozuo EU, Magaji MI. Depression in long-term stroke survivors. Sub-Saharan Afr J Med 2014;1:119-23

How to cite this URL:
Abubakar SA, Obiakor RO, Sabir AA, Iwuozuo EU, Magaji MI. Depression in long-term stroke survivors. Sub-Saharan Afr J Med [serial online] 2014 [cited 2020 Nov 26];1:119-23. Available from: https://www.ssajm.org/text.asp?2014/1/3/119/138935

  Introduction Top

Stroke is a major clinical and public health problem. Stroke represents the third most common cause of death in developed countries following only coronary artery disease and cancer. [1] Stroke is also the world leading cause of severe permanent adult disability with significant economic losses due to functional impairment. [2] The combined impact of increased life expectancy and improved medical care has resulted in a larger number of persons surviving stroke [3] with attendant consequences. The physical and psychological sequel caused by stroke could be devastating, including compromised quality of life. [4] Poststroke depression is one of the unresolved issues in recovery and rehabilitation of stroke patients. It has been considered the most common neuropsychiatric consequence of stroke. [5] Depression may either directly or indirectly lead to more significant impairment in daily activities, which require more careful services and institutionalization of stroke patients. [6] Depression is associated with poor stroke related outcomes for patients and their caregivers. [7] Stroke patients with depression experience worse stroke-related outcomes in form of greater functional disability and higher mortality. [8]

The National Institute of Mental Health estimated that 10-27% of stroke survivors will experience major depression, while additional 15-40% will have symptoms of depression within 2 months following a stroke. [9] Oladiji et al. in South-Western Nigeria reported poststroke depression in 25.5% of stroke survivors accessing rehabilitation facility at Lagos University Teaching Hospital. [10] A number of risk factors for depression have been established in nonstroke population, including female gender, previous history and family history of depression. These factors and others including cerebral lesion localization and extent of poststroke functional disability have been suggested as predictive of depression following stroke, but opinions vary among studies as relative contribution of these factors to the risk of depression following stroke. [11] The prevalence rate of poststroke depression also show considerable variations between studies and among different populations.

The prompt recognition of depression and those at risk of depression following stroke is important as depressive disorder adversely affect survival, cost of medical care and compliance with therapy. [12],[13] Suicidal ideation is also known to be common following stroke. Few studies have looked at poststroke depression in Nigeria, but none in North Western Nigeria. This study aimed to determine the frequency of depression in patients who have survived stroke for 12 months and to determine independent predictors of depression in these subset of long-term stroke survivors, as early recognition of depression will enable physician to promptly commence treatment to optimize survival, quality of life and in overall reduction in the cost of medical care in the region.

  Materials and METHODS Top


The subjects were consecutively presenting long-term stroke survivors attending neurology outpatients' clinic of Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. ABUTH is a tertiary health care hospital located in Shika-Zaria, North Western Nigeria. The hospital accepts referral from all over the country although majority come from neighboring primary and secondary health care centers. Patients also come on self-referral. Subjects that fulfilled the predetermined inclusion criteria were prospectively recruited after well-informed consent. Consent was also obtained from Ethical Research Committee of ABUTH before embarking on the study. Included were; stroke patients who were admitted and managed in ABUTH patients during the acute phase of stroke and have survived stroke for 1 year, subjects who fulfilled WHO clinical criteria for diagnosis of stroke or those with computed tomography (CT)-scan/magnetic resonance imaging confirmation of stroke. Excluded are those patients who cannot communicate intelligently or with any form of aphasia and those that were demented. Patients with premorbid history of depression before stroke onset were also excluded.


Sociodemographic data including age, gender, blood pressure and duration of formal education were obtained from the patient using structured questionnaire. Admission stroke severity was obtained retrospectively using National Institute of Health Stroke Score (NIHSS). [14] Detailed clinical and neurological examinations were carried out by the team of neurologists. Modified Rankin scale was used to assess the level of functionality. This is an observer-rated global measure of handicap assessing any limitation in the patient social role. It is rated zero (no symptoms) to five (severely disabled or bedridden). Patients with score of 0-3 were categorized as haven good outcome (not handicapped) and those with score of 4-5 as handicapped. [15] Screening for depression was done using Hamilton depression rating scale (HDRS), [16] patients with score of 7 or more were further evaluated by liaison psychiatry research fellow. HDRS is the most widely used observer-rated rating scale for depression. Structured interview guide for HDRS was used to enhance reliability of HDRS administration. The scale consists of 17-items assessing different depression symptoms. In stroke patients, HDRS total score has been found to increase with increasing severity of depression and decrease with effective treatment of depression. [17] Patients who scored above seven on HDRS were considered to have poststroke depression [18] and were further graded as mild (8-13), moderate (14-18), severe (19-22) and very severe (≥23). [18]

Statistical Analysis

Data were analyzed using Statistical Package for Social Sciences 17th edition for windows xp/vista/7 (SPSS 17.0). Means, standard deviations and percentages were calculated. Independent t-test was used to compare means, while categorical variables were compared using Fischer exact test. Multiple binary logistic regression was used to determine independent predictor of depression in presence of covariates. P ≤ 0.05 was considered as statistically significant.

  Results Top

Sixty-eight consecutive patients (36 males, 32 females) were evaluated. The mean age of the subjects was 54.99 ± 11.8 years with 11 (16.18%) of the patients above the age of 65 years [Table 1]. Twenty-nine (42.6%) of the patients could not do brain CT-scan possibly because of cost and diagnosis of stroke was made using WHO criteria. Thirty-eight (55.9%) patients had right hemispheric stroke and mean duration of hospitalization during the acute phase was 31 days. Twenty-one (30.9%) subjects had tertiary education and 22 (32.4%) did not have any formal education. The most common comorbid condition was systemic hypertension 59 (86.8%), followed by diabetes mellitus 6 (8.8%) [Table 2]. Eleven (16.2%) of the patients scored above seven on HDRS and were considered depressed, while 8 (11.8%) had residual poststroke disability. Presence of depressive symptom was proportionately higher in the elderly than in the younger age group [Table 2], depression was also significantly higher in patients with left hemispheric stroke. Physical disability from stroke was the major independent determinant of depression in the presence of other covariate such as age at stroke, admission stroke severity (NIHSS), hemispheric localization, diastolic blood pressure, duration of formal education, and degree of disability, as shown in [Table 3].
Table 1: Baseline characteristic of the stroke patients

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Table 2: Comparison of characteristics of depressed and nondepressed patients

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Table 3: Determinant of depression at 1-year PS using multivariate logistic regression

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  Discussion Top

Stroke also has significant impact on individual's life, including health-related quality of life. [4] It constitutes a major cause of admission into neurology unit [19] and account for 1.2% of all hospital admission in Sokoto. [20] Psychological and psychiatric morbidity associated with stroke is yet to receive sufficient attention in Nigeria and Sub-Saharan Africa. Poststroke depression is a common accomplishment of stroke, [21] from our study we found frequency of poststroke depression of 16.2% at 1 year poststroke. Our study revealed that depression affected 16.2% of long-term stroke survivors; which is similar to 16.0% reported by Astrφm et al. in a 3-year longitudinal study, [22] but much lower than 25.5% previously reported in South Western Nigeria. [10] Our cohort been only long-term stroke survivors whether disabled or not could probably account for lower frequency of depression.

The subjects recruited in their study were those having some form of motor disability requiring physiotherapy. This is also likely to have influenced their study. Some factors notably age at stroke, side and site of stroke, female gender and living alone have been implicated as important predictor of depression in some studies. [10],[23] Poststroke depression occurred at almost equal frequency in males and females as opposed to findings in other studies that reported poststroke depression occurring more in females. [10],[24] Controversy exists between stroke laterality and development of poststroke depression; while some studies found depression to be more common among patients with left hemispheric lesion others found no clear association. In our study, poststroke depression was significantly higher in patients with left hemispheric lesion (χ2 = 7.71, P < 0.0001). The association between the location of brain lesion as a result of stroke and poststroke depression is complex and is not well-understood. [25] In a systemic review by Carson et al.[26] pooled data from 34 primary studies found no association between lesion location and depression, but Robinson identified specific relationship between location of brain lesion and character and severity of poststroke mood disturbance. Left anterior cerebral lesions were also noted to be associated with higher depression scores by Robinson. [27]

Second, this study also showed that younger stroke survivors are less likely to be depressed compared to elderly stroke survivors (P < 0.0001), which is similar to finding in some other studies, [28],[29] possible explanation could be that older people in the population are more likely to have chronic medical conditions, including systemic hypertension and diabetes mellitus which are modifiable risk factors both stroke and depression. [30] Over 11% of patients examined remained handicapped (disabled) at 1 year poststroke. Presence of disability was a very important determinant of depression, as almost all patients that were disabled exhibited one form of depressive symptom or the other (P < 0.0001). Existing literature is somewhat conflicting about whether significant functional disability following stroke commonly predict depression, but conceivably, severity of poststroke disability may predict depression as is the case reported in this study, but Cassidy et al.[21] found no relationship between extent of functional disability and poststroke depression. A large study involving mostly elderly poststroke subjects found that marked depressive symptoms were associated with greater neurological impairments and worse 3-month and 1-year functional outcome, [31] but Paolucci et al. in a sub population of patients undergoing in-patients rehabilitation reported no relationship between depressive symptoms and poststroke disability. [32] Various mechanisms have been proposed to explain the increased occurrence of depression in stroke patients in western literature, Ischemic insults directly affect neural circuit involved in mood regulation. [33],[34] An injury to brain catecholamine pathway reduces the release of neurotransmitter with likely depression as a result. The increased prevalence of depression specifically among stroke patients may also be attributable to other causes, including the following:

  1. Depression is a risk factor for stroke, therefore the proportion of patients at risk of depression may be increased among stroke patients;
  2. Depression and stroke have risk factors in common, such as sedentary lifestyle;
  3. Depression is a secondary psychological reaction to stroke;
  4. Depression is secondary to other outcomes of stroke, such as cognitive impairment; and
  5. Stroke has a direct pathophysiological effect on the brain (e.g., increase of cytokine levels). [35]

Although patients with poststroke depression had more severe stroke at presentation, stroke severity measured by NIHSS was not an independent determinant of poststroke depression concurring with previous report by Strober and Arnett. [36]

There are potential limitations to our study; the cost of brain CT-scan was prohibitively high and since not all patients had brain CT-scan it was not possible to relate depression with the stroke sub-type.

  Conclusion Top

Poststroke depression occurred in 16.2% of long-term stroke survivors in Zaria and presence of disability was its major independent predictor.

  References Top

1.Mackay J, Mensah GA. Deaths from Stroke. The Atlas of Heart Disease and Stroke. Geneva, Switzerland: World Health Organization; 2004. Available from: http://www.who.int/cardiovascular diseases/en/cvd atlas 16 death from stroke.pdf [Last accessed on 2014 Nov 10].  Back to cited text no. 1
2.Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:517-84.  Back to cited text no. 2
3.Sanossian N, Ovbiagele B. Prevention and management of stroke in very elderly patients. Lancet Neurol 2009;8:1031-41.  Back to cited text no. 3
4.Abubakar SA, Isezuo SA. Health related quality of life of stroke survivors: Experience of a stroke unit. Int J Biomed Sci 2012;8:183-7.  Back to cited text no. 4
5.Robinson RG. Neuropsychiatric consequences of stroke. Annu Rev Med 1997;48:217-29.  Back to cited text no. 5
6.van de Weg FB, Kuik DJ, Lankhorst GJ. Poststroke depression and functional outcome: A cohort study investigating the influence of depression on functional recovery from stroke. Clin Rehabil 1999;13:268-72.  Back to cited text no. 6
7.Ramasubbu R, Patten SB. Effect of depression on stroke morbidity and mortality. Can J Psychiatry 2003;48:250-7.  Back to cited text no. 7
8.House A, Knapp P, Bamford J, Vail A. Mortality at 12 and 24 months after stroke may be associated with depressive symptoms at 1 month. Stroke 2001;32:696-701.  Back to cited text no. 8
9.About.com. Depression after a stroke (Reviewer: Kate Grossman). Available from: http://www.stroke.about.com/od/lifeafterastroke/p/depression.htm. [Last accessed on 2013 Apr 22].  Back to cited text no. 9
10.Oladiji JO, Akinbo SR, Aina OF, Aiyejusunle CB. Risk factors of poststroke depression among stroke survivors in Lagos, Nigeria. Afr J Psychiatry (Johannesbg) 2009;12:47-51.  Back to cited text no. 10
11.Whyte EM, Mulsant BH. Poststroke depression: Epidemiology, pathophysiology, and biological treatment. Biol Psychiatry 2002;52:253-64.  Back to cited text no. 11
12.Creed F, Morgan R, Fiddler M, Marshall S, Guthrie E, House A. Depression and anxiety impair health-related quality of life and are associated with increased costs in general medical inpatients. Psychosomatics 2002;43:302-9.  Back to cited text no. 12
13.Lespérance F, Frasure-Smith N, Talajic M, Bourassa MG. Five-year risk of cardiac mortality in relation to initial severity and 1-year changes in depression symptoms after myocardial infarction. Circulation 2002;105:1049-53.  Back to cited text no. 13
14.De Haan R, Horn J, Limburg M, Van Der Meulen J, Bossuyt P. A comparison of five stroke scales with measures of disability, handicap, and quality of life. Stroke 1993;24:1178-81.  Back to cited text no. 14
15.Bamford JM, Sandercock PA, Warlow CP, Slattery J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1989;20:828.  Back to cited text no. 15
16.Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 16
17.Ng KC, Chan KL, Straughan PT. A study of poststroke depression in a rehabilitative center. Acta Psychiatr Scand 1995;92:75-9.  Back to cited text no. 17
18.Malec JF, Richardson JW, Sinaki M, O'Brien MW. Types of affective response to stroke. Arch Phys Med Rehabil 1990;71:279-84.  Back to cited text no. 18
19.Ojini FI, Danesi MA. Pattern of neurological admissions at Lagos University Teaching Hospital. Niger J Clin Pract 2003;5: 38-41.  Back to cited text no. 19
20.Abubakar SA, Yunusa GH, Isezuo SA. Predictors of 30 days outcome of patients with acute stroke in Sokoto. Sahel Med J 2010;13:68-73.  Back to cited text no. 20
21.Cassidy E, O'Connor R, O'Keane V. Prevalence of poststroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation. Disabil Rehabil 2004;26:71-7.  Back to cited text no. 21
22.Aström M, Adolfsson R, Asplund K. Major depression in stroke patients. A 3-year longitudinal study. Stroke 1993;24:976-82.  Back to cited text no. 22
23.Paradiso S, Robinson RG. Gender differences in poststroke depression. J Neuropsychiatry Clin Neurosci 1998;10:41-7.  Back to cited text no. 23
24.Ouimet MA, Primeau F, Cole MG. Psychosocial risk factors in poststroke depression: A systematic review. Can J Psychiatry 2001;46:819-28.  Back to cited text no. 24
25.Ghika-Schmid F, Bogousslavsky J. Affective disorders following stroke. Eur Neurol 1997;38:75-81.  Back to cited text no. 25
26.Carson AJ, MacHale S, Allen K, Lawrie SM, Dennis M, House A, et al. Depression after stroke and lesion location: A systematic review. Lancet 2000;356:122-6.  Back to cited text no. 26
27.Robinson RG. Poststroke mood disorders. Hosp Pract (Off Ed) 1986;21:83-9.  Back to cited text no. 27
28.Kim JS, Choi-Kwon S, Kwon SU, Lee HJ, Park KA, Seo YS. Factors affecting the quality of life after ischemic stroke: Young versus old patients. J Clin Neurol 2005;1:59-68.  Back to cited text no. 28
29.Carod-Artal J, Egido JA, González JL, Varela de Seijas E. Quality of life among stroke survivors evaluated 1 year after stroke: Experience of a stroke unit. Stroke 2000;31:2995-3000.  Back to cited text no. 29
30.Elderon L, Whooley MA. Depression and cardiovascular disease. Prog Cardiovasc Dis 2013;55:511-23.  Back to cited text no. 30
31.Herrmann N, Black SE, Lawrence J, Szekely C, Szalai JP. The Sunnybrook Stroke Study: A prospective study of depressive symptoms and functional outcome. Stroke 1998;29:618-24.  Back to cited text no. 31
32.Paolucci S, Antonucci G, Pratesi L, Traballesi M, Grasso MG, Lubich S. Poststroke depression and its role in rehabilitation of inpatients. Arch Phys Med Rehabil 1999;80:985-90.  Back to cited text no. 32
33.Robinson RG. Vascular depression and poststroke depression: Where do we go from here? Am J Geriatr Psychiatry 2005;13:85-7.  Back to cited text no. 33
34.Robinson RG, Starr LB, Lipsey JR, Rao K, Price TR. A 2-year longitudinal study of poststroke mood disorders: Dynamic changes in associated variables over the first 6 months of follow-up. Stroke 1984;15:510-7.  Back to cited text no. 34
35.Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003;54:216-26.  Back to cited text no. 35
36.Strober LB, Arnett PA. Assessment of depression in three medically ill, elderly populations: Alzheimer's disease, Parkinson's disease, and stroke. Clin Neuropsychol 2009;23: 205-30.  Back to cited text no. 36


  [Table 1], [Table 2], [Table 3]

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