Relationship of depression to social
180 Poststroke depression
Table 16.1. SFE _____ Exam No.
_____ Interviewer Number _____ Informant
1 Patient 2 Closest other
3 Closest other person – not spouse 4 Other relative
5 Other friend or acquaintance (Specify)_____________________
_____ I. Relationship with significant other
Whom are you closest to: ____________________________
How close are you?
Is _______________________ affectionate?
Is _______________________ considerate of your feelings?
_____ 1. Rate closeness of relationship
Do you and _______________________ have separate interests or activities?
What kind of interests and activities?
Do you or _______________________ depend on others to help with everyday activities?
_____ 2. Rate independence
What do you and _______________________ usually disagree about?
How often?
Resolution _____ 3. Rate compatibility
(If applicable)
Are there difficulties in your sexual relationship?
Satisfaction
Extra-marital relationship _____ 4. Rate sexual adjustment
How happy have you been with _______________________?
Has _______________________ been the end of ____________________
that you wanted?
_____ 5. Rate satisfaction with relationship
_____ II. Relationship with spouse or other partner in the household (Ask question below only if spouse, common-law, or boyfriend/girlfriend of opposite sex and living in the household is not named in I.)
Do you have a close relationship with _______________________?
Is person affectionate?
Is person considerate of your feelings?
_____ 6. Rate closeness
Do you and _____________________ have separate interests and activities?
What kind of activities?
Are you or ______________________ dependent on others for routine daily activities?
181 Relationship of depression to social functioning
Table 16.1. (Continued)
_____ 7. Rate independence
What do you and ______________________ usually disagree about?
How often?
Resolution _____ 8. Rate compatibility
Are there difficulties in your sexual relationship?
_____ 9. Rate sexual adjustment
How satisfied are you with this relationship?
_____ 10. Rate satisfaction
_____ III. Relationship with children – for patients who have living children (and/or stepchildren)
Do you have a close relationship with any of your children (and/or stepchildren)?
Are you and they affectionate?
How often do you see them or talk with them?
_____ 11. Rate closeness of parent-child relationship _____ IV. Family relationships
Do your family pull together in good times and bad?
Give an example
Do you have family reunions?
Has someone been a major source of strength and support for the family over the years? Is that person available now? Has someone taken over that role?
_____ 12. Rate family solidarity
_____ V. Other persons in household (if person lives with others in a household arrangement)
Are you and others in the household close?
Do you spend much time together?
Do they help with household chores?
_____ 13. Rate relationship with household others
_____ VI. Rate performance of home and family responsibilities
_____ 14. Is there anybody in your family who is now sick or disabled or needs a lot of care?
Who? _____________ Who takes care of this person? ________________
_____ 15. Rate family energy devoted to other ill or dependent members _____ VII. Work experience
Do you (did you) enjoy your job?
_____ 16. Rate satisfaction with work experience
_____ 17. Rate presumed loss of job satisfaction due to present illness _____ VIII. Social activities
What are your social and leisure activities?
Do you belong to any groups, organizations, church?
How often do you attend?
182 Poststroke depression
Table 16.1. (Continued)
How important are these groups to you?
What kinds of things do you do there?
What do you and your friends do together?
How often?
_____ 18. Rate formal groups in patient’s life _____ 19. Rate informal groups in patient’s life _____ IX. Spiritual beliefs
Have your religious beliefs helped you through difficult times?
In what way?
_____ 20. Rate religious beliefs in coping with difficulties _____ X. Economic practices
How financially comfortable are you?
_____ 21. Rate usual financial security
_____ 22. Rate stability of family income in light of present illness _____ XI. Living environment
What is it like where you live?
What would you most like to change about where you live?
_____ 23. Rate (physical) adequacy of the residence What is your neighborhood like?
What would you most like to change about your neighborhood?
_____ 24. Rate adequacy of neighborhood _____ XII. Use of community resources
What social agencies do you have dealings with?
What is the nature of your contact with those agencies?
_____ 25. Rate use of social agency services _____ XIII. Health and illness experiences
How is the health of your family members?
Where do you go for checkups?
_____ 26. Rate general health of the family
When family members become ill, to whom do they go for medical care?
What problems arise in following a medical care plan?
_____ 27. Rate health practices
Has anybody in your family been sick for a long time or needed a lot of care?
Who? _____________ Who took care of that person? How was the family affected by all this?
_____ 28. Rate family coping with prolonged illness/disability _____ Number of points scored – social functioning.
_____ Number of applicable questions – social functioning.
_____ Score functioning examination.
The STC is a 10-item questionnaire, which determines the number of social con-nections available to the patient, such as frequency of seeing friends, membership of clubs, churches or other organizations. Scores range from 0 to 10 with higher num-bers indicating fewer social connections. The correlation between SFE and STC scores was r 0.65 (p 0.01) for the 31 patients with acute stroke involved in our reliability study and the correlation between the SFE score and the Hollingshead social class was r 0.41 (p 0.05). We have also examined the agreement between ratings based on patient information as compared to information provided by sig-nificant others. The percentage agreement between patient ratings and other derived ratings on individual items of the SFE ranged from 50 to 100%. The correlation coef-ficient between SFE total scores based on information from the patient and infor-mation obtained from significant others for 30 cases was r 0.60 (p 0.001). This agreement was maintained even when we included data from patients who were depressed or had cognitive impairment. Thus, given relatively simple questions about their social situation, patients who were able to participate in these studies gave reliable and accurate information about their social functioning.
The correlation coefficients between SFE scores and Hamilton depression (Ham-D) scores over the course of the 2 years following acute stroke are shown in Fig. 16.1. These correlations were based on findings from our 2-year longitudinal 183 Relationship of depression to social functioning
0 0.1 0.2 0.3 0.4 0.5
2 weeks (n 103)
3 months (n 40)
6 months (n 50)
1 year (n 37)
2 years (n 48) Time since stroke
p 0.05 Correlation coefficient SFE versus Ham-D score
Figure 16.1 Correlation coefficient between HDS and Social Function Exam (SFE) scores over the first 2 years following stroke in 103 patients with acute stroke. Although the strength of the correlation varied over time (the number of patients at each follow-up was 40 at 3 months, 50 at 6 months, 37 at 1 year, and 48 at 2 years). The finding suggests that social functioning is related to depression over the first 2 years following stroke. The strength of the correlation suggests that about 10 to 20% of the variance in depression severity may be related to social functioning.
study of 143 patients with acute stroke. Impairment in social functioning was significantly correlated with severity of depression at the acute in-hospital evalua-tion and at 6 and 24 months following stroke. In addievalua-tion, the strength of the correlation between social functioning and depression increased from 0.26 to 0.47 between the in-hospital evaluation and the 6 months follow-up. We also exam-ined SFE scores at each follow-up time point that were compared between patients with major depression and those who were not depressed. Patients with poststroke major depression had significantly higher SFE scores than non-depressed patients in hospital, at 3 months, 6 months, and 12 months poststroke but not at 2 years.
As with physical and cognitive impairment, the relationship between depression and social functioning appears to be both time dependent and complex. For example, it is possible that inadequate social support might lead to depression. On the other hand, depression might lead to deterioration of social relationships and impaired social functioning. Alternatively, depression and social functioning might be related to a third factor, such as cognitive impairment.
In an effort to try to determine the way in which impairment in social func-tioning influences depression, and vice versa, we examined the relationship between in-hospital measures and outcome 6 months later (Robinson et al. 1985b).
In-hospital depression scores were not significantly correlated with SFE scores at 3 months, but at 6 months poststroke, the mean correlation between in-hospital depression and follow-up SFE was 0.37 (p 0.01). On the other hand, in-hospital SFE (reflecting prestroke social adjustment) did not predict depression scores at either 3 months or 6 months follow-up. Since in-hospital depression was signifi-cantly (although weakly) related to social functioning 6 months later, patients with depression following stroke may undergo social deterioration during the post-stroke period. Finding that social withdrawal and deterioration of social function could be a consequence of depression is certainly not surprising. The fact that in-hospital depression did not predict social function at the 3 months follow-up suggests that this process may take several months to occur and the impact of depression on social functioning may not be evident until after the patient is fin-ished with several months of rehabilitation and tries to resume their usual family and social relationships. Limitations in patient’s emotional or intellectual capacity to resume these relationships may lead to social withdrawal and deterioration of social functioning.
The other in-hospital factors which significantly correlated with social functioning scores at follow-up were the mini-mental state examination score (r 0.43, p 0.01) and the activities of daily living (Johns Hopkins functioning inventory or JHFI) score (r 0.35, p 0.01). Thus, depression during the acute poststroke period was not the only factor, which contributed to impaired social functioning 6 months later. Again, it is not surprising that limitations of physical and 184 Poststroke depression
intellectual capacity could lead to social withdrawal and dissatisfaction with social relationships.
We have more recently examined the relationship of depression to individual items of the SFE using a consecutive series of 50 patients selected from our overall group of 215 patients studied at the University of Maryland who had assessment of social functioning at the initial hospitalization and at both short term follow-up (i.e., 3 or 6-months) and at long-term follow-up (i.e., 1 or 2 years). At the time of initial evaluation, seven patients fulfilled DSM-IV criteria for major depression.
Fifteen met DSM-IV research criteria for minor depression and 28 were non-depressed. At short-term follow-up, 10 patients had major depression, 10 had minor depression and 30 were non-depressed and at long-term follow-up, 10 patients had major depression, 11 had minor depression and 29 were non-depressed. Using a multiple linear regression analysis, we looked for independent effects of specific items of the SFE on Ham-D score after controlling for age, gender, family psychiatric history, and stroke severity. The individual items at the initial evaluation which were significantly associated with severity of Ham-D scores, were social activities prior to the stroke (p 0.04) and an impaired relationship with the patient’s closest other prior to the stroke (p 0.05). At short-term follow-up (i.e., 3–6 months), fear of economic loss due to the stroke (p 0.03) was signifi-cantly correlated with Ham-D score and impairment in social activities was nearly a significant predictor of Ham-D score (p 0.06). At long-term follow-up (i.e., 1–2 years) limitations in work experience (e.g., absence of skilled work experience or training) (p 0.01) was a significant predictor of Ham-D (p 0.05) (Robinson et al. 1999).
Using logistic regression, controlling for age, gender, family psychiatric history and stroke severity, we also examined whether the patient’s diagnosis at the initial evaluation or at short- or long-term follow-up would be predicted by social func-tioning items prior to the stroke onset (i.e., social funcfunc-tioning evaluation during the initial hospitalization) (Robinson et al. 1999). Although none of the social dimen-sions predicted patients diagnosis at short-term follow-up, relationship with closest other (p 0.048), spiritual beliefs (p 0.049) and social activities (p 0.027) prior to the stroke were all significantly associated with depression diagnosis at 1–2 years following stroke. Thus, this study found that an impaired relationship with the patient’s closest other prior to the stroke and limited social activities were asso-ciated with depression immediately after the stroke as well as depression 1–2 years later. Within 3–6 months, fears of economic stability and limited social activity were associated with depression while loss of job or job satisfaction was associated with depression at 1–2 years following stroke (Robinson et al. 1999).
We have also examined the relationship between social impairment and recov-ery from stroke (Shimoda and Robinson 1998). In this study we utilized all of the 185 Relationship of depression to social functioning
142 patients admitted for acute poststroke evaluation to the University of Maryland Hospital who received either short-term (3 or 6 months) or long-term (12 or 24 months) follow-up. Of the 142 patients included in the study, 27 had major depression, 35 had minor depression and 79 were non-depressed at the ini-tial evaluation. SFE scores were significantly more impaired in patients with major or minor depression compared with the non-depressed patients (major versus non-depressed, p 0.01) (Fig. 16.2) minor versus non-depressed (p 0.04).
Patients were divided into those with social impairment and those without social impairment based on a score of 0.2 impaired or 0.2; non-impaired on the SFE. Patients were also grouped by depression diagnosis (major or minor) or non-depressed. Comparison of background characteristics among the four groups are shown in Table 16.2 (Shimoda and Robinson 1998b). Comparison of characteristics among the four groups revealed significant differences in age, sex, race, socioeco-nomic status, family, and personal psychiatric history. There were no between group differences in the frequency of motor sensory deficits or other neurological impair-ments. Because our outcome measures included activities of daily living and cognitive function, patients were matched for initial impairment severity (i.e., JHFI score 1 186 Poststroke depression
0 0.1 0.2 0.3 0.4
Hospital 3 6 12 24
Time since stroke
SFE score
p 0.05
Major depression Non-depression
Figure 16.2 SFE scores for patients with major depression and no mood disturbance follow acute stroke and at various follow-up evaluations. Patients with DSM-IV diagnosed major depression (n 27) were significantly more socially impaired (i.e., higher SFE scores) than non-depressed patients (n 79) for the first year following stroke. The initial evaluation reflected pre-stroke social functioning while the follow-up exams reflected post-stroke adjustment. Higher scores indicate greater impairment in social functioning. Note that while non-depressed patients improved in their perception of social functioning over time, patients with major depression showed greater impairment over the first year following stroke. Patients with minor depression (n 36) are not shown but their SFE scores fell between major depression and non-depressed patients.
and mini-mental status examination score2). Depressed patients with and without social impairment had a significantly higher frequency of left hemisphere lesions compared with the non-depressed patients (25 of 35 versus 13 of 32, p 0.011).
At short-term follow-up repeated measures ANOVA of JHFI scores (factor 1 presence or absence of in-hospital depression; factor 2 presence or absence of pre-stroke social impairment; factor 3 time) showed significant interactions of depres-sion with time as well as social impairment with time but no significant interaction of social impairment by depression by time (Figs 16.3a and b) (Shimoda and Robinson 1998b). Thus, patients with social impairment or depression did not recover as well in activities of daily living as patients without social impairment or patients without depression at short-term follow-up. At long-term follow-up, repeated measures ANOVA showed a significant effect of depression by time (p 0.002) but no significant effect for social impairment.
187 Relationship of depression to social functioning
Table 16.2. Demographic information
Not depressed Depressed
Without With Without With
social social social social impairment impairment impairment impairment
(n 58) (n 21) (n 29) (n 34)
Age (years SD)a 60.4 12.1 61.8 11.1 57.6 12.3 52.8 13.9 Education (years SD) 9.8 4.6 7.3 2.5 10.0 3.9 8.7 3.6
Sex, male (%)b 63.8 62.0 31.0 61.8
Race, African–American (%)c 56.1 90.5 75.9 58.8
Marital status, married (%) 60.0 35.0 39.3 47.8
Socioeconomic status, 64.3 100 65.5 75.9
class IV–V (%)d
Alcohol abuse, positive (%) 6.9 14.3 3.5 11.8
Family history of psychiatric 10.5 0 0 8.8
disorder, positive (%)e
Personal history of psychiatric 12.3 0 10.7 26.5
disorder, positive (%)f
Major depression (%) 37.9 47.1
aSignificant intergroup differences (F 3.3, df 3, 138, p 0.02).
bSignificant intergroup differences (2 9.6, df 3, p 0.02).
cSignificant intergroup differences (2 12.6, df 3, p 0.02).
dSignificant intergroup differences (2 20.8, df 3, p 0.0001).
eSignificant intergroup differences (2 8.0, df 3, p 0.05).
fSignificant intergroup differences (2 10.1, df 3, p 0.02).
Reprinted with permission from Shimoda and Robinson (1998b).
Thus, our findings demonstrated for the first time that either depression during the acute stroke period or impairment in social functioning prior to the stroke independently influenced the course of recovery in activities of daily living during the first 3–6 months following stroke.
At short-term follow-up repeated measures ANOVA of mini-mental state examination scores showed a significant interaction of social impairment with time (p 0.04) but no significant effect of depression by time. Thus, patients with social impairment showed significantly less short-term recovery in cognitive examination scores than patients without social impairment. The fact that there was no significant interaction between depression, social functioning and time 188 Poststroke depression
Effect of social function
0 1 2 3 4 5 6 7
Initial 3–6 months Months after stroke Activities of daily living (JHFI) score
Effect of depression
0 1 2 3 4 5 6
Initial 3–6 months
Months after stroke Activities of daily living (JHFI) score
Non-depressed in-hospital (n 30) Depressed in-hospital (n 30) Significant effect for depression, time interaction, p 0.05 Without
prestroke social impairment (n 40)
Significant effect for social impairment, time interaction, p 0.01 With
prestroke social impairment (n 20)
(a)
(b)
Figure 16.3 (a) The effect of high or low social support on recovery in activities of daily living (JHFI) over short-term (i.e., 3–6 months) follow-up. There was a significant group by time interaction (F 11.0, f 1.56, p 0.002) with the high social support group improving more than the low social support group (reprinted with permission from Shimoda and Robinson (1998b); (b) The effect of presence or absence of depression on recovery in activities of daily living over short-term (i.e., 3–6 months) follow-up. There was a significant group by time interaction (F 4.6, df 1,56, p 0.04) with the non-depressed group improving more than the depressed group [reprinted with permission from Shimoda and Robinson (1998b)].