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Prevalence of pre-stroke depression and its association with post-stroke depression: a systematic review and meta-analysis

  • Martin Taylor-Rowan (a1), Oyiza Momoh (a1), Luis Ayerbe (a2), Jonathan J. Evans (a3), David J. Stott (a1) and Terence J. Quinn (a1)...



Depression is a common post-stroke complication. Pre-stroke depression may be an important contributor, however the epidemiology of pre-stroke depression is poorly understood. Using systematic review and meta-analysis, we described the prevalence of pre-stroke depression and its association with post-stroke depression.


We searched multiple cross-disciplinary databases from inception to July 2017 and extracted data on the prevalence of pre-stroke depression and its association with post-stroke depression. We assessed the risk of bias (RoB) using validated tools. We described summary estimates of prevalence and summary odds ratio (OR) for association with post-stroke depression, using random-effects models. We performed subgroup analysis describing the effect of depression assessment method. We used a funnel plot to describe potential publication bias. The strength of evidence presented in this review was summarised via ‘GRADE’.


Of 11 884 studies identified, 29 were included (total participants n = 164 993). Pre-stroke depression pooled prevalence was 11.6% [95% confidence interval (CI) 9.2–14.7]; range: 0.4–24% (I2 95.8). Prevalence of pre-stroke depression varied by assessment method (p = 0.02) with clinical interview suggesting greater pre-stroke depression prevalence (~17%) than case-note review (9%) or self-report (11%). Pre-stroke depression was associated with increased odds of post-stroke depression; summary OR 3.0 (95% CI 2.3–4.0). All studies were judged to be at RoB: 59% of included studies had an uncertain RoB in stroke assessment; 83% had high or uncertain RoB for pre-stroke depression assessment. Funnel plot indicated no risk of publication bias. The strength of evidence based on GRADE was ‘very low’.


One in six stroke patients have had pre-stroke depression. Reported rates may be routinely underestimated due to limitations around assessment. Pre-stroke depression significantly increases odds of post-stroke depression.

Protocol identifier

PROSPERO identifier: CRD42017065544


Corresponding author

Author for correspondence: Martin Taylor-Rowan, E-mail:


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Aben, I, Lodder, J, Honig, A, Lousberg, R, Boreas, A and Verhey, F (2006) Focal or generalized vascular brain damage and vulnerability to depression after stroke: a 1-year prospective follow-up study. International Psychogeriatrics 18, 1935.
Atkins, D, Eccles, M, Flottorp, S, Guyatt, GH, Henry, D, Hill, S, Liberati, A, O'Connell, D, Oxman, AD, Philips, B, Schunemann, H, Edejer, TT, Vist, GE and Williams, JW (2004) Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches. The GRADE Working Group. BMC Health Services Research 4, 38.
Ayerbe, L, Ayis, S, Wolfe, CD and Rudd, AG (2013) Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analysis. The British Journal of Psychiatry 202, 1421.
Ayerbe, L, Ayis, S, Crichton, SL, Rudd, AG and Wolfe, CD (2014) Explanatory factors for the increased mortality of stroke patients with depression. American Academy of Neurology 83, 20072012.
Barra, M, Evensen, GSH and Valeberg, BT (2016) Cues and clues predicting presence of symptoms of depression in stroke survivors. Journal of Clinical Nursing 26, 546556.
Barlinn, K, Kepplinger, J, Puetz, V, Illigens, BM, Bodechtel, U and Siepmann, T (2014) Exploring the risk-factor association between depression and incident stroke: a systematic review and meta-analysis. Neuropsychiatric Disease and Treatment 11, 114.
Burvill, PW, Johnson, GA, Jamrozik, KD, Anderson, CS, Stewart-Wynne, EG and Chakera, TM (1995) Prevalence of depression after stroke: the Perth Community Stroke Study. The British Journal of Psychiatry 166, 320327.
Caeiro, L, Ferro, JM, Santos, CO and Figueira, ML (2006) Depression in acute stroke. Journal of Psychiatry and Neuroscience 31, 377383.
Castellanos-Pinedo, F, Hernandez-Perez, JM, Zurdo, M, Rodriguez-Funez, B, Hernandez-Bayo, JM, Garcia-Fernandez, C, Cueli-Rincon, B and Castro-Posada, JA (2011) Influence of premorbid psychopathology and lesion location on affective and behavioral disorders after ischemic stroke. The Journal of Neuropsychiatry and Clinical Neurosciences 23, 340347.
Counsell, C and Dennis, M (2001) Systematic review of prognostic models in patients with acute stroke. Cerebrovascular Diseases 12, 159170.
De Ryck, A, Fransen, E, Brouns, R, Guerden, M, Peij, D, Marien, P and De Deyn, PP (2013) Psychosocial problems associated with depression at 18 months poststroke. International Journal of Geriatric Psychiatry 29, 144152.
De Ryck, A, Brouns, R, Geurden, M, Elseviers, M, De Deyn, PP and Engelborghs, S (2014) Risk factors for poststroke depression: identification of inconsistencies based on a systematic review. Journal of Geriatric Psychiatry and Neurology 27, 147158.
Dossa, A, Glickman, ME and Berlowitz, D (2011) Association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation. BMC Health Services Research 11. doi: 10.1186/1472-6963-11-311.
Dou, J, Tang, J, Lu, C, Jiang, ES and Wang, P (2015) A study of suicidal ideation in acute ischaemic stroke patients. Health and Quality of Life Outcomes 13. doi: 10.1186/s12955-014-0198-9.
Gainotti, G, Antonucci, G, Marra, C and Paolucci, S (2001) Relation between depression after stroke, antidepressant therapy, and functional recovery. Journal of Neurology, Neurosurgery, and Psychiatry 71, 258261.
Gillen, R, Tennen, H, McKee, TE, Gernert-Dott, P and Affleck, G (2001) Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Archives of Physical Medicine and Rehabilitation 82, 16451649.
Hackett, ML and Anderson, CS (2006) Frequency, management, and predictors of abnormal mood after stroke the Auckland Regional Community Stroke (ARCOS) study, 2002 to 2003. Stroke 37, 21232128.
Hackett, ML, Yapa, C, Parag, V and Anderson, CS (2005) Frequency of depression after stroke: a systematic review of observational studies. Stroke 36, 13301340.
Hatano, S (1976) Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organisation 54, 541553.
Jorgensen, TSH, Wium-Andersen, IK, Wium-Andersen, MK, Jorgensen, MB, Prescott, E, Maartensson, S, Kragh-Anderson, P and Osler, M (2016) Incidence of depression after stroke, and associated risk factors and mortality outcomes, in a large cohort of Danish patients. JAMA Psychiatry 73, 10321040.
Kessler, RC, Aguilar-Gaxiola, S, Alonso, J, Chatterji, S, Lee, S, Ormel, J, Ustun, TB and Wang, PS (2009) The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiologia e Psichiatria Sociale 18, 2333.
Kim, JM, Stewart, R, Kang, HJ, Bae, KY, Kim, SW, Shin, IS, Kim, JT, Park, MS, Cho, KH and Yoon, JS (2014) A prospective study of statin use and poststroke depression. Journal of Clinical Psychopharmacology 34, 7279.
Kocer, E, Kocer, A, Degirmenci, Y and Eryilmaz, M (2011) Long-term depression is a stroke risk factor. Acta Neuropsychiatrica 23, 292296.
Kootker, JA, van Mierlo, ML, Hendricks, JC, Sparidans, J, Rasquin, SM, de Kort, PL, Visser-Meily, JM and Guerts, AC (2016) Risk factors for symptoms of depression and anxiety one year poststroke: a longitudinal study. Archives of Physical Medicine and Rehabilitation 97, 919928.
Kutlubaev, MA and Hackett, ML (2014) Part II: predictors of depression after stroke and impact of depression on stroke outcome: an updated systematic review of observational studies. International Journal of Stroke 9, 10261036.
Lewin-Richter, A, Volz, M, Jobges, M and Werheid, K (2015) Predictivity of early depressive symptoms for post-stroke depression. Journal of Nutrition, Health and Aging 19, 754758.
Liu, R, Yingying, Y, Haitang, J, Lu, J, Wu, A, Geng, D, Wang, J, Lu, J, Li, S, Tang, H, Lu, X, Zhang, K, Liu, T, Yuan, Y and Wang, Q (2017) A risk prediction model for post-stroke depression in Chinese stroke survivors based on clinical and socio-psychological features. Oncotarget 8, 6289162899.
McCarthy, MJ, Sucharew, HJ, Alwell, K, Moomaw, CJ, Woo, D, Flaherty, ML, Khatri, P, Ferioli, S, Adeoye, O, Kleindorfer, DO and Kissela, BM (2016) Age, subjective stress, and depression after ischemic stroke. Journal of Behavioral Medicine 39, 5564.
Ng, KC, Chan, KL and Straughan, PT (1995) A study of post-stroke depression in a rehabilitative center. Acta Psychiatrica Scandinavica 92, 7579.
Nuyen, J, Spreeuwenberg, PM, Groenwegen, PP, Van den Bos, GA and Schellevis, FG (2008) Impact of preexisting depression on length of stay and discharge destination among patients hospitalized for acute stroke linked register-based study. Stroke 9, 132138.
Paolucci, S, Gandolfo, C, Provinciali, L, Torta, R and Toso, V, DESTRO Study Group (2006) The Italian multicenter observational study on post-stroke depression (DESTRO). Journal of Neurology 253, 556562.
Pohjasvarra, T, Leppavuori, A, Siira, I, Vataja, R, Kaste, M and Erkinjuntti, T (1998) Frequency and clinical determinants of poststroke depression. Stroke 29, 23112317.
Prisnie, JC, Fiest, KM, Couts, SB, Patten, SB, Atta, CA, Blaikie, L, Bulloch, AG, Demchuk, A, Hill, MD, Smith, EE and Jette, N (2016) Validating screening tools for depression in stroke and transient ischaemic attack patients. The International Journal of Psychiatric Medicine 51, 262277.
Reid, DL, Jia, H, Cameon, R, Feng, H, Wang, X and Tueth, M (2010) Does prestroke depression impact poststroke depression and treatment? The American Journal of Geriatric Psychiatry 18, 624–623.
Robinson, RG and Jorge, RE (2016) Post-stroke depression: a review. American Journal of Psychiatry 173, 221231.
Rodin, GJC and Littlefield, C (1991) Depression in the Medically Ill. New York: Routledge.
Schottke, H and Giabbiconi, CM (2015) Post-stroke depression and post-stroke anxiety: prevalence and predictors. International Psychogeriatrics 27, 18051812.
Sienkiewicz-Jarosz, H, Milewska, D, Bochynska, A, Chelmniak, A, Dworek, N, Kasprzyk, K, Galecka, K, Szcepanska-Szarej, A, Chwojnicki, K, Zyluk, B, Slowik, A and Ryglewicz, D (2010) Predictors of depressive symptoms in patients with stroke – a three-month follow-up. Neurologia i Neurochirurgia Polska 44, 1320.
Singh, A, Black, SE, Hermann, N, Leibovitch, FS, Ebert, PL, Lawrence, J and Szalai, JP (2000) Functional and neuroanatomic correlations in poststroke depression the Sunnybrook stroke study. Stroke 31, 637644.
Slater, K, McClure, AJ, Mahon, H, Foley, N and Teasell, R (2012) Adherence to Canadian best practice recommendations for stroke care: assessment and management of poststroke depression in an Ontario rehabilitation facility. Topics in Stroke Rehabilitation 19, 132140.
Stroup, DF, Berlin, JA, Morton, SC, Olkin, I, Williamson, GD, Rennie, D, Moher, D, Becker, BJ, Sipe, TA and Thacker, SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOO.SE) group. JAMA 283, 20082012.
Tang, KW, Chang, SSM, Chiu, HFK, Ungavari, GS, Wong, KS, Mok, V, Wong, KT, Richards, PS and Ahuja, AT (2005) Poststroke depression in Chinese patients: frequency, psychosocial, clinical, and radiological determinants. Journal of Geriatric Psychiatry and Neurology 18, 4551.
Tang, WK, Lu, JY, Chen, YK, Chu, WCW, Mok, V, Ungavari, GS and Wong, KS (2011) Association of frontal subcortical circuits infarcts in poststroke depression: a magnetic resonance imaging study of 591 Chinese patients with ischemic stroke. Journal of Geriatric Psychiatry and Neurology 24, 4449.
Towfighi, A, Ovbiagele, B, Husseini, NE, Hackett, ML, Jorge, RE, Kissela, BM, Mitchell, PH, Skolarus, LE, Whooley, MA and Williams, LS (2016) Post stroke depression a scientific statement for healthcare professionals from the American Heart Association. Stroke 47, e30e43.
Tse, T, Douglas, J, Lentin, P, Linden, T, Churilov, L, Henry, M, Davis, S, Donnan, G and Carey, LM (2017) Reduction in retained activity participation is associated with depressive symptoms 3 months after mild stroke: an observational cohort study. Journal of Rehabilitation Medicine 49, 120127.
Verdelho, A, Henon, H, Lebert, F, Lebert, F, Pasquier, F and Leys, D (2004) Depressive symptoms after stroke and relationship with dementia A three-year follow-up study. Neurology 62, 905911.
Vermeer, J, Rice, D, McIntyre, A, Viana, R, Macaluso, S and Teasell, R (2017) Correlates of depressive symptoms in individuals attending outpatient stroke clinics. Disability and Rehabilitation 39, 4349.
White, JH, Attia, J, Sturm, J, Carter, G and Magin, P (2014) Predictors of depression and anxiety in community dwelling stroke survivors: a cohort study. Disability and Rehabilitation 36, 19751982.
Williams, LS, Ghose, SS and Swindle, RW (2004) Depression and other mental health diagnoses increase mortality risk after ischemic stroke. The American Journal of Psychiatry 161, 10901095.
Wulsin, L, Alwell, K, Moomaw, CJ, Lindsell, CJ, Kleindorfer, DO, Woo, D, Flaherty, ML, Khatri, P, Adeoye, O, Ferioli, S, Broderick, JP and Kissela, BM (2012) Comparison of two depression measures for predicting stroke outcomes. Journal of Psychosomatic Research 72, 175179.
Zhang, T, Wang, C, Liu, L, Zhao, X, Xue, J, Zhou, Y, Wang, Y and Wang, Y (2010) A prospective cohort study of the incidence and determinants of post-stroke depression among mainland Chinese patients. Neurological Research 32, 347352.


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