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][...