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PostPosted: 17 May 2014 19:30 
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J Neurol Neurosurg Psychiatry 2014;85:514-521
The long-term outcomes of depression up to 10 years after stroke; the South London Stroke Register

Abstract
Background Post-stroke depression is a frequent chronic and recurrent problem that starts shortly after stroke and affects patients in the long term. The health outcomes of depression after stroke are unclear.

Aims (1) To investigate the associations between depression at 3 months and mortality, stroke recurrence, disability, cognitive impairment, anxiety and quality of life (QoL), up to 5 years post-stroke. (2) To investigate these associations in patients recovering from depression by year 1. (3) To investigate associations between depression at 5 years and these outcomes up to 10 years.

Methods
Data from the South London Stroke Register (1997–2010) were used. Patients (n at registration=3240) were assessed at stroke onset, 3 months after stroke and annually thereafter. Baseline data included sociodemographics and stroke severity measures. Follow-up assessments included anxiety and depression (Hospital Anxiety and Depression scale), disability, QoL and stroke recurrence. Multivariable regression models adjusted for age, gender, ethnicity, stroke severity and disability were used to investigate the association between depression and outcomes at follow-up.

Results
Depression at 3 months was associated with: increased mortality (HR: 1.27 (1.04 to 1.55)), disability (RRs up to 4.71 (2.96 to 7.48)), anxiety (ORs up to 3.49 (1.71 to 7.12)) and lower QoL (coefficients up to −8.16 (−10.23−6.15)) up to year 5. Recovery from depression by 1 year did not alter these risks to 5 years. Depression in year 5 was associated with anxiety (ORs up to 4.06 (1.92 to 8.58)) and QoL (coefficients up to −11.36 (−14.86 to −7.85)) up to year 10.

Conclusions: Depression is independently associated with poor health outcomes.


Discussion

Outcomes of depression up to 10 years after stroke

The association between depression and higher mortality after stroke is not consistent in previous studies
Apart from suicide, a number of biobehavioral mechanisms have been hypothesised to underlie the relationship between depression and mortality

. First, depression is associated with poor health behaviour (eg, smoking, physical inactivity, lack of medication compliance).
Second, depression is correlated with other major comorbidities, such as diabetes and hypertension, that are cardiovascular risk factors.
Third, depression is associated with biological changes, which include neuroendocrine (eg, sympathetic nervous system activation, dysregulation of the hypothalamic-pituitary-adrenocortical axis) and immunological/inflammation changes, that could influence mortality.

The short duration but high recurrence rate of depression5 may explain its persistent association with higher mortality rate up to 10 years after stroke. Patients surviving one episode of depression remain at risk of dying during a recurrent one.
Two previous systematic reviews reported an increased cardiovascular risk among patients with depression.

This study did not find evidence of an association between depression and stroke recurrence. Depression seems to be a less relevant cardiovascular risk factor after stroke than before. Another possibility is that the number of recurrences registered in our study is not enough to observe the association between depression and recurrence of stroke

. The association between depression and disability at follow-up may be explained by the poor involvement in rehabilitation or by the low level of activity that these patients have. Previous literature had reported an association between depression and lower QoL only in the first year after stroke.

. The high comorbidity rate of anxiety and depression may explain the association between depression in the short term and anxiety at follow-up.

Recovering from depression does not reduce the risk of negative health outcomes in the long term. The high recurrence rate of depression can explain the independent association between depression shortly after stroke and poor health outcomes in the long term.

Depression in year 5 was not associated with higher mortality up to 10 years suggesting that the link between depression and mortality may be different in the long term after str
oke

. It also shows that depression shortly after stroke may be a more relevant clinical predictor of stroke prognosis in the long term. However, depression at 5 years still predicts lower QoL and anxiety at follow-up, and therefore, requires clinical attention.

Dr G Mohan.

Views from experience of stroke patients, would be most welcome , in our forum.


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PostPosted: 04 Mar 2015 20:02 
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Joined: 30 Sep 2013 19:35
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Hi Mohan,

Your narration on stroke/depression is short and sweet.

In stroke it's not only the motor disability but much more.

If psychometric battery of tests are done,there will be number of cognitive and affective

problems will be revealed.may be due to affection of association fibres due to ischaemia.

more important, the alteration in neurotransmiters which govern the neuropsychological

functions.A neuropsychologist may throw more light on this area.

Hari.


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