Poststroke Depression Among the Chinese Elderly in a Rural Community
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.
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
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.
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.
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).
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.
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, χ2 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.
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).
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
|ADL||=||activities of daily living|
|GDS-S||=||Geriatric Depression Scale–short form|
|KINDS||=||Kinmen Neurological Disorders Survey|
This study was supported in part by National Science Council grants (NSC 85-2331-B-075-002).
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.
- Copyright © 1997 by American Heart Association
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