Explanatory factors for the increased mortality of stroke patients with depression

Abstract

Objective: To identify explanatory factors for the association between depression and increased mortality up to 5 years after stroke. Methods:In this cohort study, data from the South London Stroke Register (1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013) were used. Patients (n 5 3,722) were assessed at stroke onset. Baseline data included sociodemographics and stroke severity. Follow-up at 3 months included assessment for depression with the Hospital Anxiety and Depression Scale (scores $7 5 depression). Associations between depression at 3 months and mortality within 5 years of stroke were estimated with Cox regression models adjusted for age, sex, ethnicity, and stroke severity, and subsequently adjusted for possible explanatory factors for the association. These factors, introduced into the model individually, included comorbidities at baseline, smoking and alcohol use, compliance with medication, treatment with selective serotonin reuptake inhibitors (SSRIs), social support, and activities of daily living at 3 months.Results: A total of 1,354 survivors were assessed at 3 months: 435 (32.1%) had depression and 331 (24.4%) died within 5 years. Survivors with depression had a greater risk of mortality (hazard ratio [HR] 1.41 [95% confidence interval (CI) 1.13-1.77]; p 5 0.002). The association between depression and mortality was strongest in patients younger than 65 years. Adjustment for comorbidities, smoking and alcohol use, SSRI use, social support, and compliance with medication did not change these associations. SSRIs started after stroke were associated with higher mortality, independently of depression at 3 months (HR 1.72 [95% CI 1.34-2.20]; p , 0.001).Conclusion: Depression after stroke is associated with higher mortality, particularly among younger patients. Stroke survivors taking SSRIs have an increased mortality. The association between depression and mortality is not explained by other individual medical factors. Neurology ® 2014;83:2007-2012 GLOSSARY CI 5 confidence interval; GCS 5 Glasgow Coma Scale score; HADS 5 Hospital Anxiety and Depression Scale; HR 5 hazard ratio; SLSR 5 South London Stroke Register; SSRI 5 selective serotonin reuptake inhibitor.Depression has a prevalence of around 30% in the long term after stroke, with most patients developing their first symptoms shortly after the acute event.1,2 Depression after stroke is more prevalent among those with severe strokes, disability, and cognitive impairment, and has been found to be independently associated with higher mortality.3,4 A number of medical and social factors have been proposed to underlie the relationship between depression and mortality. They include younger age, lifestyle factors such as smoking and heavy alcohol use, lack of compliance with medication, comorbidities such as diabetes and heart failure, use of antidepressants, and social isolation.5-12 These explanatory factors have been reported in studies not specifically investigating stroke survivors 5,6,[8][9][...

Anxiety related to discharge from inpatient neurorehabilitation: Exploring the role of self-efficacy and internal health control beliefs

“…However, findings tended to contradict studies which have shown anxiety to be more prevalent among younger stroke survivors (Ayerbe et al, 2014;Castillo et al, 1993;Schultz, Castillo, Kosier & Robinson, 1997). One explanation may be that, since stroke is infrequent in younger cohorts, such an event may cause greater emotional distress in such cohorts (Petrea et al, 2009); however, it is recognised that the mixed sample included in the current study (i.e.…”

“…In preference to psychiatric diagnoses, these studies have increasingly explored anxiety via the use of self-report tools such as the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). In one such study -which involved a synthesis of predictors and associated outcomes of anxiety (up to 10 years after stroke) - Ayerbe et al (2014) reported prevalence rates ranging from 32-38%. Notably, in this study, 58% of patients were assessed as suffering from clinically significant levels of anxiety at 3 months post-stroke.…”

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

“…34-2.20). 57 This study should be interpreted with caution because numerous models were used to describe the association between depression and mortality, and the only common factors between these models were age, sex, ethnicity, and stroke severity. The relationship between SSRIs and mortality requires a rigorous analysis of the interactions with other key variables such as depression, disability, and comorbid medical conditions.…”

Early Antidepressant Treatment and All-Cause 30-Day Mortality in Patients with Ischemic Stroke

“…The most common neuropsychiatric complication after stroke, post-stroke depression (PSD), has been linked with increased mortality and morbidity whereas involuntary emotional expression disorder, including pathological crying (PC), another relatively common complication seen in many neurological disorders, is often socially disabling [1][2][3] . Treatment with antidepressants, in particular treatment with selective serotonin reuptake inhibitors (SSRIs), is often used in the treatment of both depression and PC after stroke [4][5][6][7] and has been linked with increased mortality in some, but not in all studies [8][9][10][11] . However, SSRIs have also been associated with a reduced risk of recurrent ischemic events and better functional outcome after stroke [12][13][14] .…”

“…However, SSRIs have also been associated with a reduced risk of recurrent ischemic events and better functional outcome after stroke [12][13][14] . Other previous studies have focused on long-term mortality associated with SSRI treatment initiated up to 1 year after stroke [11,15] . To our knowledge, there are no large-scale populationbased studies on the effect of early antidepressant treatment after ischemic stroke.…”