(Stroke. 1997;28:1126-1129.)
© 1997 American Heart Association, Inc.
Articles |
Poststroke Depression Among the Chinese Elderly in a Rural Community
From the Neurological Institute, Veterans General Hospital–Taipei, and the Department of Neurology, National Yang-Ming University School of Medicine (J.-L.F., H.-C.L., S.-J.W., P.-N.W.), and the Department of Psychiatry, Chang-Gung Medical College, and Chang-Gung Memorial Hospital (C.-Y.L.), Taipei, Taiwan.
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Background and Purpose A door-to-door survey was conducted in two townships in the Kinmen islets to investigate the prevalence and other characteristics related to depressive disorders of stroke survivors in an elderly Chinese population.
Methods Our target population comprised the registered
residents 
65 years old (n=2056) of a total population of 26 105 on
August 1, 1993. All participants answered a questionnaire, filled in a
Geriatric Depression Scale–short form (GDS-S), and received a
neurological examination. Depression was defined as a GDS-S score
5.
Results Twenty-eight of 45 stroke survivors (62.2%) and 491 of 1471 nonstroke subjects (33.4%) were classified as depressed. The frequency of stroke survivors' depressive disorders was significantly higher that of nonstroke subjects (P<.001). Multiple regression analysis indicated that GDS-S scores were most related with the activities of daily living (R2=.19, P=.004) in the stroke survivors.
Conclusions Depressed mood was common after stroke, and activities of daily living were an important factor for depression in stroke survivors in the community.
Key Words: activities of daily living • Chinese • depression • elderly
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
The emotional aspects of stroke have received increasing attention over the past few years. Depression after a stroke is common.1 Because depression can significantly reduce the speed and success of rehabilitation, it is very important for the clinician to recognize it early.2
A number of factors contribute to PSD. The physical disability and location of the brain lesion are two important factors related to depression. Robinson and his colleagues3 4 concluded that PSD is not a simple reaction to the emotional trauma of physical impairment on the basis of the low correlation between severity of depression and the degree of impairment in stroke patients. In addition, some studies indicated greater severity of depression in stroke patients compared with control subjects who are matched for degree of impairment.5 6 7 The lesion-PSD relationship has remained controversial until now. Most studies demonstrated that lesions in the left hemisphere tend to play a role in the development of depression after the acute stage of stroke.8 9 10 However, different conclusions have been reached.
Most PSD studies have been performed in Western countries, and there is only one study that has been conducted to evaluate the mood disorder of the stroke survivors in the Chinese population.11 The aims of the present study were to estimate the prevalence of PSD in the elderly in a rural Chinese community and to examine the relationship of PSD and ADL.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
The present study was part of the KINDS. Detailed descriptions of the general methodology including locality, population, and methods of recruitment have been reported elsewhere.12 13
Locality of Investigation
Kinmen is an islet of 134 km2 that is located west
of Taiwan, just off the coast of mainland China. Its original settlers
came from southern China several hundred years ago. From 1949 through
1992, Kinmen was the home of a major military installation; contact
with the outside world was restricted. Otherwise, it had a small
farming community and virtually no modern industry. Kinmen had no
resident physician with psychiatric or neurological training before and
during the present study.
Target Population
There are four townships on Kinmen, the residents of which have
similar demographic characteristics. The townships of Kin-Hu and
Kin-Chen were selected for the KINDS study for logistic convenience.
The total population in Kin-Hu and Kin-Cheng on prevalence day, August
1, 1993, was 26 105, including 13 690 men and 12 415 women. The
target population was registered residents aged 65 years and older, and
their number on prevalence day was 2055, including 880 men and 1175
women.
Procedure
The study was conducted between August 1993 and March 1994 and
was based on a door-to-door survey. All participants were interviewed
and examined by a neurologist.
Approximately 2 weeks before the planned evaluation date, a letter was mailed to each prospective subject, indicating the date and place of the evaluation. Most of the participants attended their evaluations as scheduled. Those who were unable to attend were examined in their homes by neurologists and field-worker teams (medical or nursing students or research assistants).
The trained field workers interviewed participants using standardized instruments. They gathered demographic data; they inquired about chronic medical conditions including hypertension, heart disease, renal disease, pulmonary disease, and diabetes mellitus; and they administered a Chinese version of the GDS-S.
The GDS is a commonly used instrument consisting of 30 yes/no
questions,14 and a translated and adapted Chinese version
has been developed.15 16 The GDS places less emphasis on
physical symptoms of depression and therefore is especially useful for
adults who have physical illness and symptoms. The GDS-S consists of 15
items of the original scale; it was developed to reduce the fatigue and
deteriorating concentration that can occur with older individuals.
Scores on the GDS-S showed a high correlation with that on the original
form, and scores of 5 on the GDS-S are associated with clinical
diagnosis of depression.17
A neurologist performed a physical and neurological examination and graded the ADL for each participant. Every subject also received a screening questionnaire to determine focal disturbance of cerebral function such as hemiparesis, aphasia, dysarthria, etc. Findings on all possible stroke cases were discussed at a consensus meeting for diagnosis. When the subject was diagnosed as a stroke case, information was obtained concerning the date of cerebrovascular accident, the patient's age at that time, initial symptoms and signs, and hospital admission and diagnosis.
We graded the ADL on a 5-point scale18 as follows: 1, no significant disability (can carry out all usual activities); 2, slight disability (cannot perform some of the activities that were previously performed but can look after everyday needs without assistance); 3, moderate disability (requires some help but can walk without assistance); 4 moderately severe disability (cannot walk without assistance or attend to bodily needs without assistance); and 5, severe disability (bedridden, incontinent, and requires constant nursing care and attention).
Diagnostic Criteria
Patients were classified as depressed if GDS-S score was
5.17 Stroke was diagnosed on the basis of the World
Health Organization definition of "rapidly developed clinical signs
of focal (or global) disturbance of cerebral function, lasting
more than 24 hours or leading to death, with no apparent cause other
than of vascular origin."19 Ischemic cerebral
infarction, intracerebral hemorrhage, and
subarachnoid hemorrhage were included, but transient
ischemic attacks were excluded.
Statistical Analysis
Descriptive and analytical statistics were computed with the use
of a packaged statistical program. For continuous measures, comparisons
between groups were made by means of Student's t test and
Spearman's correlation analysis. For categorical data,
2 was used. To assess the relative importance of
the variables in their separate association with the severity of
depression as assessed by the GDS-S, a forward stepwise regression
analysis was conducted. All tests were two-tailed. A value of
P<.05 was considered significant.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
From 2055 target subjects, a total of 1745 individuals (84.9%) aged
65 years, including 758 men and 987 women, participated in the
stroke survey. The nonparticipants included 219 individuals (70.7%)
who were not home during any of three visits; 10 (3.2%) died during
the survey period before evaluation was completed, and 81 (26.1%)
declined participation. Sixty-two cases of stroke were identified. Subjects with dementia, hearing impairment, aphasia, dysarthria, mutism, or previous psychiatric disorder that restricted a reliable communication were excluded from the study. This reduced the total population to 1516 subjects. It included 45 stroke survivors. The time since last stroke ranged from 1 month to 15 years, with a mean±SD of 5.7±4.3 years.
The demographic, medical, and functional variables of the total
subjects, nonstroke subjects, and stroke survivors are shown in Table 1
. The mean GDS-S scores differed significantly between
stroke survivors and nonstroke subjects (t test,
P<.001). The frequency of their depressive disorders was
significantly higher than that of the nonstroke subjects (62.2% versus
33.4%, P<.001).
|
Depression in the General Elderly Population
Of the participants, 519 (34.2%) had a GDS-S score of 5. The
GDS-S score was significantly correlated with the ADL scale by
Spearman's correlation analysis (r=.2,
P=.0001). In the forward stepwise regression
analysis, the first variable selected by the statistical
program was the ADL score, followed by age, education, and presence or
absence of chronic medical illness. The fifth variable entering the
model was presence of stroke, but this was not statistically
significant. Table 2 showed the results of the final
regression model. We checked the residuals and the interactions of
stroke and other variables and found that none of them were
significant.
|
Depression in Stroke Survivors
The GDS-S score of stroke survivors was significantly correlated
with the ADL scale by Spearman's correlation analysis
(r=.4, P=.007). A forward multiple regression
analysis was used to model the relative importance of the
variables in their separate association with the severity of
depression as assessed by the GDS-S in the stroke survivors. It showed
that GDS-S scores were most related with ADL scores
(R2=.19, F=9.43, P=.004) in the
stroke survivors. The regression equation was GDS-S score=3.11(SE
1.25)+1.48(SE 0.49) (ADL score).
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
The present data suggest that depression is a frequent companion of stroke and that ADL is related to PSD. The prevalence of PSD in different studies is difficult to compare because of different evaluation methods, diagnostic criteria, patient sources, and poststroke intervals. Past studies have found that depression is a frequent sequela of stroke, and its frequency ranged from 12% to 64.1%.4 10 20 21 22 23 24 25 26 27 28 Most of these studies were restricted to stroke patients admitted to hospitals or outpatient clinics. In the few community studies, results also varied widely. A community survey of prevalence of depression in the American elderly showed a high prevalence rate in stroke survivors: 42.9% for men and 64.1% for women.26 Wade et al,23 in a community study of 976 patients, found that 25% to 30% of them were diagnosed on at least one of three occasions in the year after a stroke. However, House et al27 found depression in only 12% of a series of 128 patients identified in the community. This was significantly higher than the rate of 7.5% found in matched community control subjects. In the same community, PSD rates at 5 years were 8% for major depression and 18% for any depressive disorder.28 This was an affluent region, and most stroke patients were quite mildly disabled. This may underlie the low rate of PSD in this community.
One hospital survey of PSD among the Chinese population has been conducted recently.11 The obtained prevalence rate for PSD in the acute stroke patients was 43%. The study also showed that the depression scores were related with ADL scores in the stroke patients with right-sided lesions.
Comparisons between depressed and nondepressed patients indicated that depression among stroke survivors was associated with poor ADL in our study. These data appear to be inconsistent with previous studies reporting weak or no association between PSD and physical disability.20 25 29 30 However, some studies4 22 23 supported this association, and there is some suggestion from a follow-up study29 that the association increases over time. Given these discrepancies, methodological differences between the studies need to be reviewed. First, the studies differ in terms of the time interval between stroke episode and depression evaluation. PSD is probably a dynamic mechanism. In the acute stage, it may be biologically determined, and in the chronic stage it may be a reactive depressive change.1 Most of our stroke subjects are chronic survivors, with a mean interval of 5.7 years after the first stroke. In other studies, the longest follow-up period was 3 years. The other possibility is that the onset of depression results in a poor long-term functional recovery. We cannot infer a causal relationship between PSD and ADL from this study.
In conclusion, PSD is very common within the Chinese elderly community. The level of ADL has a strong association with the level of PSD.
|
Selected Abbreviations and Acronyms |
|---|
|
|
Acknowledgments |
|---|
This study was supported in part by National Science Council grants (NSC 85-2331-B-075-002).
|
Footnotes |
|---|
Reprint requests to Dr Jong-Ling Fuh, Neurological Institute, Veterans General Hospital–Taipei, 11217, Taiwan.
Received September 23, 1996; revision received February 18, 1997; accepted March 11, 1997.
|
References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
1. Herrmann M, Wallesch CW. Depressive changes in stroke patients. Disabil Rehabil. 1993;15:55-66.[Medline] [Order article via Infotrieve]
2.
Parikh RM, Robinson RG, Lipsey JR, Starkstein SE,
Fedoroff JP, Price TR. The impact of poststroke depression on
recovery in activities of daily living over a 2-year follow-up.
Arch Neurol. 1990;47:785-789.
3.
Robinson RG, Price TR. Post-stroke depressive
disorders: a follow-up study of 103 patients.
Stroke. 1982;13:635-641.
4.
Robinson RG, Starr LB, Kubos KL, Price TR. A
two-year longitudinal study of post-stroke mood disorder: findings
during the initial evaluation. Stroke. 1983;14:736-741.
5.
Folstein MF, Maiberger R, McHugh PR. Mood
disorder as specific complication of stroke. J
Neurol Neurosurg Psychiatry. 1977;40:1018-1020.
6. Robinson RG, Szetela B. Mood change following left hemispheric brain injury. Ann Neurol. 1981;9:447-453.[Medline] [Order article via Infotrieve]
7. Finkelstein S, Benowitz LI, Baldessarini RJ, Arana GW, Levine D, Woo E, Bear D, Moya K, Stoll AL. Mood, vegetative disturbance, and dexamethasone suppression test after stroke. Ann Neurol. 1982;12:463-468.[Medline] [Order article via Infotrieve]
8.
Robinson RG, Kubos KL, Starr LB, Rao K, Price
TR. Mood disorders in stroke patients: importance of location of
lesion. Brain. 1984;107:81-93.
9.
Sinyor D, Jacques P, Kaloupek DG, Becker R, Goldenberg
M, Coopersmith H. Post-stroke depression and lesion location: an
attempted replication. Brain. 1986;109:537-546.
10.
Herrmann M, Bartels C, Schumacher M, Wallesch
CW. Poststroke depression. Is there a pathoanatomic correlate
for depression in the postacute stage of stroke?
Stroke. 1995;26:850-856.
11. Zhang Q. A correlative study on post-stroke depression and CT, physical, psychological and social parameters. Chin J Neurol Psychiatry. 1992;25:203-207.
12.
Wang SJ, Fuh JL, Liu CY, Lin KP, Chen HM, Lin CH, Wang
PN, Ting YC, Wang HC, Lin KN, Chou P, Larson EB, Teng EL, Liu
HC. A door-to-door survey of Parkinson's disease in a Chinese
population in Kinmen. Arch Neurol. 1996;53:66-71.
13. Liu HC, Wang SJ, Fuh JL, Liu CY, Lin KP, Lin CH, Wang PN, Lin KN, Wang HC, Chen HM, Chang R, Larson EB, Wu GS, Chou P, Teng EL. The Kinmen Neurological Disorders Survey (KINDS): a study by neurologists of a Chinese population. Neuroepidemiology. 1997;16:60-68.[Medline] [Order article via Infotrieve]
14. Brink TL, Yesavage JA, Lum O, Heersema PH, Adey M, Rose TL. Screening tests for geriatric depression. Clin Gerontologist. 1982;1:37-43.
15. Lee HCB, Chiu HFK, Kwok WY, Leung CM, Kwong PK, Chung DWS. Chinese elderly and the GDS short form: a preliminary study. Clin Gerontologist. 1993;14:37-42.
16. Sheikh JA, Vesavage JA. Recent findings and development of shorter version. In: Brink TL, ed. Clinical Gerontology: a Guide to Assessment and Intervention. New York, NY: Haworth Press; 1986:165-173.
17. Burke WJ, Roccaforte WH, Wengel SP. The short form of the geriatric depression scale: a comparison with the 30-item form. J Geriatr Psychiatry Neurol. 1991;4:173-178.
18. Rankin J. Cerebral vascular accidents in patients over the age of 60, II: prognosis. Scott Med J. 1957;2:200-215.[Medline] [Order article via Infotrieve]
19. Hatano S. Experience from a multicentre stroke register: a preliminary report. Bull WHO. 1976;54:541-553.[Medline] [Order article via Infotrieve]
20. Feibel JH, Springer CJ. Depression and failure to resume social activities after stroke. Arch Phys Med Rehabil. 1982;63:276-278.[Medline] [Order article via Infotrieve]
21.
Sinyor D, Amato P, Kaloupek DG, Becker R, Goldenberg M,
Coopersmith H. Post-stroke depression: relationships to
functional impairment, coping strategies, and rehabilitation
outcome. Stroke. 1986;17:1102-1107.
22.
Ebrahim S, Barer KD, Nouri F. Affective illness
after stroke. Br J Psychiatry. 1987;151:52-56.
23.
Wade DT, Legh-Smith J, Hewer RA. Depressed mood
after stroke: a community study of its frequency. Br
J Psychiatry. 1987;151:200-205.
24.
Starkstein SE, Robinson RG. Affective disorders
and cerebral vascular disease. Br J Psychiatry.. 1989;154:170-182.
25.
Astrom M, Adolfsson R, Asplund K. Major
depression in stroke patients: a 3-year longitudinal study.
Stroke. 1993;24:976-982.
26.
Murrell SA, Himmelfarb S, Wright K. Prevalence
of depression and its correlates in older adults. Am
J Epidemiol. 1983;117:173-185.
27.
House A, Dennis M, Mogridge L, Warlow C, Hawton K,
Jones L. Mood disorders in the year after first stoke.
Br J Psychiatry. 1991;158:83-92.
28. Sharpe M, Hawton K, House A, Molyneux A, Sandercock P, Bamford J, Warlow C. Mood disorders in long-term survivors of stroke: associations with brain lesion location and volume. Psychol Med. 1990;20:815-828.[Medline] [Order article via Infotrieve]
29.
Robinson RG, Starr LB, Lipsey JR, Rao K, Price
TR. A two-year longitudinal study of post-stroke mood disorders:
dynamic changes in associated variables over the first six months
of follow-up. Stroke. 1984;15:510-517.
30.
Stern RA, Bachman DL. Depressive symptoms
following stroke. Am J Psychiatry. 1991;148:351-356.
This article has been cited by other articles:
 |
|
 |
|
  C. M Sackley, T. J Hoppitt, and K. Cardoso An investigation into the utility of the Stroke Aphasic Depression Questionnaire (SADQ) in care home settings Clinical Rehabilitation, July 1, 2006; 20(7): 598 - 602. [Abstract] [PDF]
|
|
|
|
 |
|
 J.-M. Kim, R. Stewart, S.-W. Kim, S.-J. Yang, I.-S. Shin, and J.-S. Yoon Vascular risk factors and incident late-life depression in a Korean population The British Journal of Psychiatry, July 1, 2006; 189(1): 26 - 30. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. K. Tang, S. S. M. Chan, H. F. K. Chiu, G. S. Ungvari, K. S. Wong, T. C. Y. Kwok, V. Mok, K. T. Wong, P. S. Richards, and A. T. Ahuja Poststroke Depression in Chinese Patients: Frequency, Psychosocial, Clinical, and Radiological Determinants J Geriatr Psychiatry Neurol, March 1, 2005; 18(1): 45 - 51. [Abstract] [PDF]
|
|
|
|
|
|
J.-M. KIM, R. STEWART, I.-S. SHIN, and J.-S. YOON Vascular disease/risk and late-life depression in a Korean community population The British Journal of Psychiatry, August 1, 2004; 185(2): 102 - 107. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Verdelho, H. Henon, F. Lebert, F. Pasquier, and D. Leys Depressive symptoms after stroke and relationship with dementia: A three-year follow-up study Neurology, March 23, 2004; 62(6): 905 - 911. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S.-L. Wang, W.-H. Pan, M.-C. Lee, S.-P. Cheng, and M.-C. Chang Predictors of Survival Among Elders Suffering Strokes in Taiwan : Observation From a Nationally Representative Sample Stroke, October 1, 2000; 31(10): 2354 - 2360. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Gesztelyi, I. Fekete, M. Kellermann, L. Csiba, and D. Bereczki Screening for Depressive Symptoms among Post-Stroke Outpatients in Eastern Hungary J Geriatr Psychiatry Neurol, December 1, 1999; 12(4): 194 - 199. [Abstract] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||