Measures Associated With Early, Late, and Persistent Clinically Significant Symptoms of Depression 1 Year After Stroke in the AFFINITY Trial

Background and Objectives

To determine the sociodemographic and clinical factors associated with early, late, and persistent clinically significant symptoms of depression during the first year after a stroke.

Methods

This cohort study included 1,221 men and women recruited within 2 weeks of stroke onset in Australia, New Zealand, and Vietnam. The NIH Stroke Scale (NIHSS) was used to assess stroke severity. Other study measures included age, sex, marital status, living arrangements, function before the stroke, depression before the stroke, modified Rankin Scale (mRS) score, and treatment with fluoxetine or placebo for 26 weeks. Clinically significant symptoms of depression during the 52 weeks after baseline was the outcome of interest, and the presence of depression was defined by a total Patient Health Questionnaire (PHQ-9) score of ≥9 at week 4, 12, 26, or 52; a clinician diagnosis of depression between assessments; or pharmacologic or psychological treatment of depression during follow-up. Participants were classified as not depressed or as having early (initial 12 weeks), late (12–52 weeks), or persistent (before and after 12 weeks) depression. We used multinomial logistic regression to assess depression risk, with all listed measures entered simultaneously into the model.

Results

The mean age of participants was 63.8 (SD 12.3) years, and 775 (63.5%) were male. At baseline, 48 (3.9%) participants had previous treated depression, and 228 (18.7%) had clinically significant symptoms of depression (PHQ-9 score ≥9). Seven hundred thirty-four (63.3%) participants showed no evidence of depression in the year after the stroke; 208 (17.9%) had early, 86 (7.4%) had late, and 131 (11.3%) had persistent depression. Increased stroke severity, as measured by doubling of the NIHSS scores, was associated with an increased risk of early (risk ratio [RR] 2.08, 95% CI 1.65–2.62), late (RR 1.53, 95% CI 1.14–2.06), and persistent (RR = 2.50, 95% CI 1.89–3.32) clinically significant symptoms of depression. Similar findings were apparent for the mRS, a measure of functional disability. Past depression was associated with increased risk of persistent clinically significant symptoms of depression (RR = 6.28, 95% CI 2.88–13.71), as was being married or partnered (RR = 3.94, 95% CI 2.42–6.41). The risk of clinically significant symptoms of depression was higher in Australia and New Zealand than in Vietnam.

Discussion

The severity of neurologic and functional deficits increases the risk of poststroke clinically significant symptoms of depression early and persistently. Depression before stroke, personal relationships, and cultural context contribute to mediate depression risk. Interventions that minimize the severity of neurologic and functional deficits should decrease the risk of poststroke clinically significant symptoms of depression.

Trial Registration Information

Clinical trial registration number ACTRN12611000774921.

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