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Long-term incidence of depression and predictors of depressive symptoms in older stroke survivors

  • Louise M. Allan (a1), Elise N. Rowan (a1), Alan J. Thomas (a1), Tuomo M. Polvikoski (a1), John T. O'Brien (a1) and Raj N. Kalaria (a1)...

Abstract

Background

Depression is common and an important consequence of stroke but there is limited information on the longer-term relationship between these conditions.

Aims

To identify the prevalence, incidence and predictors of depression in a secondary-care-based cohort of stroke survivors aged over 75 years, from 3 months to up to 10 years post-stroke.

Method

Depression was assessed annually by three methods: major depression by DSM-IV criteria, the self-rated Geriatric Depression Scale (GDS) and the observer-rated Cornell scale.

Results

We found the highest rates, 31.7% baseline prevalence, of depressive symptoms with the GDS compared with 9.7% using the Cornell scale and 1.2% using DSM-IV criteria. Incidence rates were 36.9, 5.90 and 4.18 episodes per 100 person years respectively. Baseline GDS score was the most consistent predictor of depressive symptoms at all time points in both univariate and multivariate analyses. Other predictors included cognitive impairment, impaired activities of daily living and in the early period, vascular risk factor burden and dementia.

Conclusions

Our results emphasise the importance of psychiatric follow-up for those with early-onset post-stroke depression and long-term monitoring of mood in people who have had a stroke and remain at high risk of depression.

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Copyright

Corresponding author

Raj N. Kalaria, Institute for Ageing and Health, Newcastle University Campus for Ageing and Vitality, Newcastle upon Tyne NE4 5PL, UK. Email: r.n.kalaria@ncl.ac.uk

Footnotes

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Declaration of interest

None.

Footnotes

References

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Long-term incidence of depression and predictors of depressive symptoms in older stroke survivors

  • Louise M. Allan (a1), Elise N. Rowan (a1), Alan J. Thomas (a1), Tuomo M. Polvikoski (a1), John T. O'Brien (a1) and Raj N. Kalaria (a1)...
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eLetters

Depression in older stroke survivors: comment on Allan et al.

Linda Kwakkenbos, Linda Kwakkenbos, Post-doctoral Fellow
06 January 2014

Dr. Allan and colleagues [1] assessed depression among a sample of elderly post-stroke survivors, with an initial assessment at least 3 months post-stroke, and annual follow-up assessments over a period of 10 years. They reported that at the initial assessment depression was presentin 31.7% of patients when assessed with the self-reported Geriatric Depression Scale (GDS), 9.7% based on the observer-rated Cornell Scale at baseline, and 1.2% according to a clinical interview conducted by a clinical research nurse or assistant psychologist using DSM-IV criteria. They concluded that the prevalence and incidence of post-stroke depressionis high, and recommend long-term monitoring of mood for stroke survivors at high risk of depression.

The conclusions of Allan et al. appear to be based on the percentage of patients who scored over a cutoff score on the GDS. The GDS, however, is not intended to be used as a diagnostic instrument, and scores above cutoff thresholds on self-reported measures are not equivalent to depression diagnoses. Rather, measures such as the GDS are intended to identify patients who may have a condition, so that they can be assessed to determine if they meet diagnostic criteria. The exact rates produced with self-report measures depend on the instrument and cutoff score used, but these measures typically tend to identify a far greater number of patients as possible cases than the number of patients who actually have depression based on diagnostic criteria, and, thus overestimate depressionrates. Indeed, when considering the DSM-IV criteria, the rate of patients with MDD was 1.2%, which is similar to depression rates in the general population of elderly people [2]. The authors dismissed this as likely biased downward due to inexperienced diagnosticians and, thus, prioritizedthe self-report questionnaire results. However, the lack of qualified diagnosticians does not justify inappropriately using a self-report questionnaire as if it were a diagnostic tool.

Allan et al. reported that depression rates based on the DSM-IV criteria increased over time, with a prevalence of 20% (95% confidence interval 0 to 40%) at 10-year follow-up. However, there was a high rate ofparticipant dropout, and the number of people in their sample who were assessed for depression according to DSM-IV criteria decreased substantially (n=15 at year 10). In addition to raising concerns about bias due to non-random dropout, this number is far too small to reasonablyestimate prevalence.

In conclusion, it is not clear from the present study to what degree depression is more prevalent among post-stroke patients than among other elderly individuals. Depression is a disorder with serious consequences that should be diagnosed and adequately treated when present, irrespectiveof age. Whether this should be done through monitoring in the form of regular screening, as suggested by the authors, is an empirical question, and to date, no randomized controlled trials in stroke or other settings have found that routine screening improves depression outcomes [3,4].

REFERENCES

[1] Allan LM, Rowan EN, Thomas AJ, Polvikoski TM, O'Brien JT, KalariaRN. Long-term incidence of depression and predictors of depressive symptoms in older stroke survivors. Br J Psychiatry 2013; 203: 453-60.

[2] Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand 2006; 1135: 372-87.

[3] Gilbody S, Sheldon T, House A. Screening and case-finding instruments for depression: a meta-analysis. CMAJ 2008; 178: 997-1003.

[4] Thombs BD, Coyne JC, Cuijpers P, de Jonge P, Gilbody S, IoannidisJP, et al. Rethinking recommendations for screening for depression in primary care. CMAJ 2012; 184: 413-8.

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Conflict of interest: None declared

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