6
52
The prevalence of poststroke depression has been assessed in a large number of patients who have been examined in various settings throughout the world. Since the first edition of this text, large numbers of patient populations have been added to the literature and pooling of the data has provided prevalence rates based on more than 6000 patients. There are at least three factors which have complicated the determination of prevalence rates. The first is the setting in which patients were examined. Community studies have generally reported somewhat lower preva-lence rates than studies done in hospital outpatient settings. Community studies have generally included many patients who had very mild or frequently no motor sensory or other neurological symptoms associated with their stroke. Thus, some of these patients have such minimal brain injury that they would not be expected to have stroke-induced depression. On the other hand, patients with more severe motor sensory or other physical symptoms of stroke who have been hospitalized would be expected to have more severe brain damage and higher rates of depres-sion reflecting the association between severity of depresdepres-sion and severity of phys-ical impairments associated with stroke.
The second factor which has complicated prevalence studies of poststroke depression is the number of patients who are excluded from studies of poststroke depression. Patients with hemorrhagic rather than ischemic stroke, decreased level of consciousness, fatigue, prior stroke, other brain injury, comorbid physical ill-ness, atypical strokes due to collagen disease, or other systemic illill-ness, comprehen-sion deficits due to fluent aphasias or global aphasias have been excluded from some studies or all studies of poststroke depression. Although some investigators have tried to estimate the frequency of depression in some of these patients based on behavioral observations (Egelko et al. 1989; Damecour and Caplan 1991), no reliable method has been devised to examine patients who are unable to reliably respond to a verbal interview. Examiner judgments about whether a patient is depressed depending upon observation of behavior such as difficulty falling asleep, waking up early in the morning, not eating, losing weight, frequent tearfulness,
social withdrawal, or acts of self harm are often unreliable. In addition, making a diagnosis of depression based on only observed behavior would require that these new diagnostic criteria be validated. Based on observations in patients without com-prehension deficits we know that symptoms, such as insomnia, decreased appetite, decreased energy, can occur in patients who deny depressed mood (Fedoroff et al.
1991). Furthermore, although some of these patients with comprehension deficits who may have improved in some of these symptoms (e.g., insomnia) after receiving antidepressants, the diagnosis of depressive disorder still remains uncertain. Until we have a laboratory test for depression or some other non-verbal means of diagnosing depression, it will be impossible to know for sure if the patient who cannot provide reliable responses to questions about their subjective mental state has a depressive disorder. Therefore, as a result of patient exclusions in all studies of poststroke depres-sion, prevalence estimates must be understood as rates based on the limited stroke population that was examined.
Based on our findings in patients with mild comprehension deficits, however, patients with comprehension deficits do not appear to have a significantly greater frequency of depression than those without comprehension deficits (Robinson and Benson 1981; Starkstein and Robinson 1988; Herrmann et al. 1993) (see Chapter 15). Therefore, it is likely that the prevalence rate for poststroke depres-sion are not dramatically distorted by the absence of patients with comprehendepres-sion impairments or patients with decreased level of consciousness but this issue remains uncertain.
The third factor which has led to variability in reported prevalence rates for poststroke depression is the use of cutoff scores on depression rating scales for the diagnosis of depression. As can be seen in Table 6.1. There are many studies which have used cutoff scores on a depression rating scale rather than a structured inter-view and established diagnostic criteria such as the Diagnostic and Statistical Manual (DSM-IV) or International Classification of Diseases (ICD-10). As dis-cussed in Chapter 5, a cutoff score only approximates a diagnosis and prevalence rates should be determined using standardized diagnostic criteria.
The “prevalence” rates from studies reported in the literature are shown in Table 6.1 divided by the setting in which patients were examined. The lowest prevalence rates for depressive disorder were found in patients studied in community settings.
Prevalence rates in acute hospitals, rehabilitation hospitals, and outpatient settings have been quite similar. The mean prevalence for major depression in community studies was 14% while the prevalence rate for minor depression was 9%. In acute hospital or rehabilitation hospital studies, the mean prevalence rate of major depression was 19% and minor depression was 30%. In outpatient settings which have varied between 3 months and 3 or more years followings stroke, the mean prevalence rate for major depression was 24% and for minor depression was 24%.
53 Prevalence of depressive disorders
Table 6.1.Prevalence studies of poststroke depression InvestigatorsPatient populationNCriteriaMajor (%)Minor (%)Total(%) Wade et al.(1987)Community379Cutoffscore22 House et al.(1991)Community89PSE-DSM-III111223 Burvill et al.(1995)Community294PSE-DSM-III15823 Kotila et al.(1998)Community321Cutoffscore44 Hayee et al.(2001)Community161CutoffBDE,3 months41 156CutoffBDE 12 months42 Stewart et al.(2001)Community287Cutoffscore,GDS19 Desmond et al.(2003)Community421Cutoff,struct Ham-D11 Pooled data means for community studies210814.19.125.9 Robinson et al.merged data (1983–1990)Acute hospital278PSE-DSM-IV272047 Ebrahim et al.(1987)Acute hospital149Cutoffscore23 Shima et al.(1994)Hospital (1–2 months)99 Gonzalez-Torrecillas et al.(1995)Hospital130SADS,RDC261137 Astrom et al.(1993)Acute hospital80DSM-III25NR25* Herrmann et al.(1993)Acute hospital21RDC241438 Andersen et al.(1994)Acute hospital or outpatient285HDRS cutoff101121 Kauhanen et al.(1999)Stroke unit (3 months)106DSM-III-R94453 Palomaki et al.(1999)Hospital 100DSM-III-R66 Gainotti et al.(1999)Acute or Rehabilitation Hospital153PSDRS31NR31 Aben et al.(2002)Acute hospital190SCID & DSM-IV231639 Singh et al.(2000)Acute hospital (3 months)81Cutoffscore,Zung,MADRS262753 Berg et al.(2003)Acute hospital (2 weeks)89CutoffBDI27 House et al.(2001)Acute hospital448ICD 1022NR22 Pooled data means for acute hospital studies217822.117.331.6
Folstein et al.(1977)Rehabilitation hospital20PSE & items45 Finklestein et al.(1982)Rehabilitation hospital25Cutoffscore48 Sinyor et al.(1986)Rehabilitation hospital64Cutoffscore47 Finset et al.(1989)Rehabilitation hospital42Cutoffscore36 Eastwood et al.(1989)Rehabilitation hospital 87SADS-RDC104050 Morris et al.(1990)Rehabilitation hospital 99CIDI-DSM-III142135 Schubert et al.(1992)Rehabilitation hospital 18DSM-III-R284472 Schwartz et al.(1993)Rehabilitation hospital91DSM-III40NR40* Robinson (2000)95DSM-IV142842 Cassidy et al.(2004)Rehabilitation hospital50DSM-IV20NR20 Pooled data for rehabilitation hospital studies59119.330.440.8 Pooled data for acute and rehabilitation hospital studies276921.620.033.6 Kauhanen et al.(1999)Outpatient (1 year)92DSM-III-R162642 Palomaki et al.(1999)Outpatient (12 months)44DSM-III-R11NR11 (18 months)44DSM-III-R16NR16 Gainotti et al.(1999)Outpatient2 months58DSM-III-R27NR27 2–4 months52DSM-III-R27NR27 4 months43DSM-III-R40NR40 Pohjasvaara (1998)Outpatient277SCAN DSM-IV261440 Feibel et al.(1982)Outpatient (6 months)91Nursing evaluation26 Robinson and Price(1982)Outpatient (6 months–10 years)103Cutoffscore29 Robinson et al.(1983–1990)Merged data (3 months)77DSM-IV172744 (6 months)79DSM-IV202747 (12 months)70DSM-IV102434 (24 months)66DSM-IV241539 Herrmann et al.(1998)Outpatient150MDRS,Zung27 Singh et al.(2000)Outpatient (1 year)136Cutoffscore MDRS,Zung22 Kim et al.(2000)Outpatient (2–4 months)148DSM-IV,BDI,PSE-I18NR18
Table 6.1.(Continued) InvestigatorsPatient populationNCriteriaMajor (%)Minor (%)Total(%) Collin et al.(1987)Outpatient111Cutoffscore42 Astrom et al.(1993)Outpatient (3 months)77DSM-III31NR31* (1 year)73DSM-III16NR16* (2 years)57DSM-III19NR19* (3 years)49DSM-III29NR29* Castillo et al.(1995)Outpatient (3 months)77PSE-DSM-III201333 (6 months)80PSE-DSM-III212142 (1 year)70PSE-DSM-III111627 (2 years)67PSE-DSM-III181735 Pooled data for outpatient studies219124.023.931.5 Pooled data for all studies706821.719.530.6 Note:BDI:Beck depression inventory;CIDI:composite international diagnostic interview;DSM:diagnostic and statistical manual;HDRS:Hamilton depression rating scale;ICD:international classification ofdiseases;MADRS:Montgomery aspery depression rating scale;NR:not reported.*Because minor depression was not included,these values may be low;PSDRS:poststroke depression rating scale;PSE:present state examination;RDC:research diagnostic criteria;SADS:schedule for affective disorders and schizophrenia;SCAN:schedules for clinical assessment in neuropsychiatry.SCID:structured clinical interview for DSM-IV.
When these estimates of the prevalence of poststroke depression are combined with the annual incidence of stroke in the USA, of approximately 500,000 new strokes and 100,000 recurrent strokes per year (see Chapter 1), the major impact of poststroke depression can be appreciated. Based on an acute poststroke survival rate of approximately 75%, 220,000 new cases of poststroke depression would occur in the acute or rehabilitation hospital setting each year in the USA.
These new cases of poststroke major and minor depression are then compounded by the fact that these depressions last an average of almost 1 year for major depres-sion (a minority of cases last 3 years or more) and minor depresdepres-sion may last from a few months to 2 or more years or develop into major depression. In addition, many patients develop late-onset depression several months after the brain injury. We have found that the risk period for developing poststroke depression lasts for at least 2 years and Astrom et al. (1993) reported that the prevalence of major depression increased between 2 and 3 years poststroke from 19% to 29%.
Based on 2 years of follow-up data on 357 patients that we examined with acute stroke, combining four acute and rehabilitation hospital studies, 19.9% had major and 17.6% developed minor depression during the acute stroke period, while another 16.3% developed major depression and 37.4% developed minor depres-sion during the first year, 8.3% developed major depresdepres-sion and 10.4% developed minor depression during the second year after stroke. Thus, if patients who died or were lost to follow-up are excluded, 44.5% of patients developed a major depres-sion and 65.4% developed a minor depresdepres-sion some time during the 2 years of fol-low-up. At any one time point the mean prevalence rates for major and minor depression were 14.6% and 18.3% and, based on the 158 patients seen at 1 or 2 years follow-up, 37.3% had never developed a known depression.
Based on a prevalence estimates by the American Heart Association, there are 4.4 million stroke survivors in the USA. Using our worldwide mean outpatient depression rates, there would be 2.1 million patients at any one time with poststroke depression, almost half of these cases being major depression. It is likely that 3 mil-lion of these patients would have been depressed at some time since their initial stroke. Thus, there are millions of people worldwide who are afflicted with these depressive disorders. The financial impact of these depressive disorders has never been studied but the enormity of the problem is obvious from these statistics.
In summary, depression appears to be the most common and the most severe emotional disorder associated with stroke. Furthermore, the consistent findings that poststroke depression is associated with impaired recovery in cognitive func-tion (see Chapter 14), impaired recovery in activities of daily living (see Chapter 13), and increased mortality (see Chapter 19) supports the conclusion that among all the emotional disorders following stroke, depression produces the most severe consequences for patients.
57 Prevalence of depressive disorders
58 Poststroke depression
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