Depresi Post Stroke1

Frequency of Depression After Stroke : A Systematic Review of Observational
Studies
Maree L. Hackett, Chaturangi Yapa, Varsha Parag and Craig S. Anderson
Stroke 2005, 36:1330-1340: originally published online May 5, 2005
doi: 10.1161/01.STR.0000165928.19135.35
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Progress Review
Frequency of Depression After Stroke
A Systematic Review of Observational Studies
Maree L. Hackett, MA (Hons); Chaturangi Yapa, BSc; Varsha Parag, MSc (Hons);
Craig S. Anderson, PhD, FRACP, FAFPHM
Background and PurposeAlthough depression is an important sequelae of stroke, there is uncertainty regarding its
frequency and outcome.
MethodsWe undertook a systematic review of all published nonexperimental studies (to June 2004) with prospective
consecutive patient recruitment and quantification of depressive symptoms/illness after stroke.
ResultsData were available from 51 studies (reported in 96 publications) conducted between 1977 and 2002. Although
frequencies varied considerably across studies, the pooled estimate was 33% (95% confidence interval, 29% to 36%)
of all stroke survivors experiencing depression. Differences in case mix and method of mood assessment could explain
some of the variation in estimates across studies. The data also suggest that depression resolves spontaneously within
several months of onset in the majority of stroke survivors, with few receiving any specific antidepressant therapy or
active management.
ConclusionsDepression is common among stroke patients, with the risks of occurrence being similar for the early,
medium, and late stages of stroke recovery. There is a pressing need for further research to improve clinical practice in
this area of stroke care. (Stroke. 2005;36:1330-1340.)
Key Words: depression epidemiology meta-analysis stroke
ome form of depression is considered to occur in at least

one-quarter of patients in the first year after acute
stroke,1 4 with the period of greatest risk being the first few
months after onset.2,5,6 However, such estimates vary considerably across studies because of differences in definitions,
study populations and the timing of assessments, as well as
complexities in the recognition, assessment, and diagnosis of
abnormal mood in the setting of stroke-related disability.3,4,7
The results of studies may also depend on whether subjects
are categorized on the basis of psychiatric interview using
standard diagnostic criteria such as the Diagnostic and Statistical Manual of Mental Disorders (eg, DSM-IIIR,8 DSMIV9), or a psychiatric rating scale such as the Montgomery
sberg Depression Rating Scale,10 or on the basis of a
self-rating mood scale. The goal of this review was to
determine the frequency, outcome, and management of depression after stroke from all high-quality published studies.
Materials and Methods

This review was restricted to published research articles, abstracts,
and letters of patients with a clinical diagnosis of stroke in whom an
assessment of mood was performed at a prespecified time point. The
review included incidence studies and case series that had prospective consecutive patient recruitment within clearly defined geograph-
ical and time-limited boundaries. There were no restrictions on the

basis of language, sample size, or duration of follow-up, but we
excluded studies of mixed populations (such as stroke and head
injury) unless separate results for stroke patients were identified.
Studies were also excluded if they had any of the following: (1)
limited to specific patient characteristics such as sex or location of
stroke lesion; (2) convenience sampling; (3) retrospective recruitment; or (4) there was only unstructured assessment of mood.
The primary endpoint was the proportion of patients who met the
diagnostic category of depression as applied in a study, which
included: (1) depressive disorder, depressive symptoms, or psychological distress, as defined by scores above a cut-point for abnormality on a standard mood scale; and (2) major depression or minor
depression (or dysthymia) according to DSM-IIIR,8 DSM-IV,9 or
other standard diagnostic criteria.
Studies that reported mood outcomes only as a continuous
variable, without a categorical diagnosis, were excluded.
Search Strategy and Data Extraction

Data for this review were identified from the following computerized databases: MEDLINE, EMBASE, CINAHL, PsychINFO,
Applied Science and Technology Plus, Biological Abstracts,
General Science Plus, Arts and Humanities Index, Science Citation Index, Social Sciences Citation Index, Sociofile, and Digital
Dissertations using terms and strategy based on the Cochrane
Stroke Group methodology (full details available on request; last
searched June 2004). In some cases, similarities between study
reports indicated the possibility of multiple publications from the
Received November 15, 2004; final revision received January 13, 2005; accepted February 15, 2005.
From the George Institute for International Health (M.L.H., C.S.A.), Neurological Diseases and Ageing Division, Royal Prince Alfred Hospital and
the University of Sydney, Australia; and the Clinical Trials Research Unit (C.Y., V.P.), Faculty of Medical and Health Sciences, the University of
Auckland, New Zealand.
Correspondence to Maree Hackett, the George Institute for International Health, PO Box M201, Missenden Road, Sydney, NSW 2050, Australia.
E-mail mhackett@thegeorgeinstitute.org
2005 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
DOI: 10.1161/01.STR.0000165928.19135.35
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by guest on October 29, 2011
Hackett et al
same cohort. In the absence of explicit cross-referencing, we
judged articles to be from the same cohort if they met the
following criteria: there was evidence of overlapping recruitment
sites, study dates, and grant funding numbers; and there were
similar or identical reported patient characteristics in the studies.11 If several articles reported outcomes from the same study
TABLE 1.
Study
population, data were taken from the first publication that referred
to each follow-up period. When a variety of methods of mood
assessment were undertaken, we reported results for each scale/
method. Because we were unable to obtain enough information on
publications from one group of papers (the Iowa Group), we
chose to present these studies separately.
Country
No. Assessed
Time Since Stroke
Depression Diagnosis/Criteria
UK
379
3 wk
WDI (score 1936, depressed)
22 (18 to 26)
WDI (score 1518, probably depressed)
11 (8 to 14)
All strokes
All strokes
377
All strokes
348
FINNSTROKE58
Finland
321
311
rebro Stroke Study
24
Sweden
UK
6 mo
12 mo
3 mo
12 mo
18 (14 to 22)
13 (10 to 17)
BDI (score 10)
47 (42 to 53)
BDI (score 3063 severe)
3 (1 to 5)
BDI (score 1929 moderate)
11 (8 to 14)
BDI (score 1018 mild)
28 (23 to 33)
BDI (score 10)
47 (42 to 53)
BDI (score 3063 severe)
2 (0 to 4)
BDI (score 1929 moderate)
15 (11 to 19)
BDI (score 1018 mild)
25 (20 to 30)
37 (31 to 43)
GDS (score 5)
DSM-IV depression
27 (22 to 33)
89
1 mo
DSM-III: major depression
11 (5 to 18)
DSM-III: dysthymic disorder
1 (0 to 3)
88
1 mo
6 mo
6 mo
12 mo
12 mo
Prevalence over 12 mo
UK

12 mo
112
SELSS63
20 (16 to 24)
12 (9 to 15)
12 mo
107
All strokes

231
119
Australia
Frequency (95% CI)
251
76
PCSS2
1331
Frequency of Depressed Mood After Stroke: A Summary of the Population-Based Evidence
Bristol Stroke Study25
OCSP6
PSE/index of definition
19 (11 to 27)
BDI (score 10)
32 (22 to 43)
BDI (score 13)
20 (11 to 29)
BDI (score 17)
8 (2 to 14)
9 (4 to 14)
3 (0 to 6)
19 (12 to 26)
BDI (score 10)
32 (23 to 41)
BDI (score 13)
15 (8 to 22)
BDI (score 17)
6 (2 to 11)
5 (1 to 9)
4 (0 to 8)
11 (5 to 17)
BDI (score 10)
16 (8 to 24)
BDI (score 13)
8 (2 to 14)
BDI (score 17)
1 (0 to 3)
BDI (score 10)
39 (30 to 48)
ICD-9 Psychiatric disorder
22 (15 to 29)
60
35 y
DSM-III-R major depression
18 (8 to 28)
191
4 mo
DSM-III major depression
17 (12 to 22)
DSM-III minor depression
11 (7 to 15)
294
4 mo
DSM-III major depression
15 (11 to 19)
96
5y
DSM-III minor depression
8 (5 to 11)
HADS (score10)
36 (26 to 46)
BDI indicates Beck Depression Inventory; CI, confidence interval; DSM, Diagnostic and Statistical Manual of Mental Disorders; HADS, Hospital Anxiety and
Depression Scale; OCSP, Oxford Community Stroke Study; PCSS, Perth Community Stroke Study; PSE, Present State Examination; SELSS, South East London Stroke
Study; UK, United Kingdom; WDI, Wakefield Depression Inventory.
1332
Stroke
June 2005
TABLE 2.
Frequency of Depressed Mood After Stroke: A Summary of the Hospital-Based Evidence
Author, Year
Country
Aben, 200233
Netherlands
No. Assessed
Time Since Stroke
Depression Diagnosis/Criteria
1 mo
DSM-IV depression
22 (15 to 28)
Prevalence over 1 y
DSM-IV major depression
23 (16 to 30)
DSM-IV minor depression
15 (9 to 21)
154
Frequency (95% CI)
Denmark
209
46 wk
HDRS (score 13)
21 (15 to 26)
Bayer, 200144
Jordan
168
3 mo
25 (19 to 32)
Berg, 200146
Finland
89
2 wk
6 (1 to 11)
BDI (score 10)
27 (18 to 36)
USA
421
3 mo
HDRS (score 12)
11 (8 to 14)
Andersen, 199432
Desmond, 200327
Ebrahim, 198764
UK
Eriksson, 2004*17
Sweden
Hayee, 200134
Bangladesh
Herrmann, 199526
Herrmann, 1998
Germany
Canada
149
6 mo
GHQ (score 12)
23 (16 to 30)
13 999
3 mo
Single simple question
14 (14 to 15)
BDI (score 10)
161
3 mo
156
1y
47
Within 2 mo
150
133
3 mo
1y
41 (33 to 49)
42 (34 to 50)
19 (8 to 30)
DSM-III-R minor depression
17 (6 to 28)
MADRS (score 7)
27 (20 to 34)
ZDS (score 50)
22 (15 to 29)
MADRS (score 7)
22 (15 to 29)
ZDS (score 50)
21 (14 to 28)
39 (28 to 50)
Hosking, 2000
New Zealand
79
3 mo
GDS (score 9)
Hwel, 199849
Germany
102
59 d
MADRS (cut-point not stated)
55 (45 to 65)
Jaracz, 200350
Poland
72
6 mo
ZDS (score 50)
46 (34 to 57)
Kotila, 198465
Finland
154
3 mo
BDI (cut-point not stated)
44 (36 to 52)
Pohjasvaara, 199866
Finland
277
3 mo
48
1y
Williams, 199955
USA
29 (22 to 36)
26 (21 to 31)
14 (10 to 18)
BDI (score 10)
44 (38 to 50)
276
15 mo
BDI (score 10)
45 (39 to 51)
71
1 mo
BDI (cut point not stated)
39 (28 to 50)
*Mood assessed using a single standard question.

GDS indicates Geriatric Depression Scale; HDRS: Hamilton Depression Rating Scale; MADRS: Montgomery sberg Depression Rating Scale; USA: United States of
America; ZDS: Zung Depression Scale.
One reviewer (M.H.) extracted the data, and a second reviewer

(C.Y.) cross-checked a selection of data extractions. Studies were
grouped into 3 categories that represented degrees of case selection.
The first group, population-based studies, considered to be of the
highest (least biased) quality, consisted of studies that attempted to
recruit all stroke patients, including those who were not admitted to
hospital for acute care. Although not all of these studies fulfilled
certain ideal criteria for population-based stroke incidence studies,12 we considered that these studies included stroke patients with
the most representative characteristics.
The other 2 categories were hospital-based studies, which
included all inpatients from acute care medical wards in general
hospitals, and rehabilitation-based studies, which included patients
from rehabilitation wards, or hospitals (including stroke units), with
one study of patients recruited from an outpatient clinic13 and one
study of patients from primary care general practices.14
Statistical Analysis
Studies were stratified by case selection, and according to the timing
of mood assessment from stroke onset, defined as: acute phase
(within 1 month and including date of admission to rehabilitation
beds); medium-term phase (between 1 and 6 months and including
date of discharge from rehabilitation); and long-term phase (6
months or more) after stroke. Studies with follow-up assessments
that spanned 2 time points (eg, 2 to 6 weeks after stroke) were

included in the latter time category.
We used the depression category that included the most patients to
determine the point estimate, together with 95% confidence intervals
(CIs) for each study. Pooled estimates were calculated using both
fixed and random effects. When one study contributed more than one
endpoint to the pooled estimate, sensitivity analyses were undertaken
using either the earliest or the latest assessment in that study,
although data were presented herein only for the earliest assessment.
Statistical heterogeneity was assessed using the standard Q statistic,
with P0.05. When there was evidence of statistical heterogeneity,
the random effects approach of DerSimonian and Laird15 was used to
pool the frequencies.
Results
More than 12 000 references were identified, of which 418
were retrieved to assess for inclusion/exclusion criteria, and a
total of 96 reports (51 studies) were considered eligible for
inclusion.
Patient Characteristics
The 6 population-based studies included 2869 patients from a
base population of 1 338 981 between 1981 and 2000 (Table
Hackett et al
TABLE 3.
1333
Frequency of Depressed Mood After Stroke: A Summary of the Rehabilitation-Based Evidence
First Author, Year,

Source of Patients
strom, 1993
Stroke unit
37
Bacher, 199038
Rehabilitation hospital
Country
No. Assessed
Time of Assessment
Depression Criteria
Frequency (95% CI)
Sweden
76
73
Discharge from hospital

3 mo after stroke
25 (15 to 35)
31 (20 to 42)
68
1 y after stroke
16 (7 to 25)
57
2 y after stroke
19 (9 to 29)
50
3 y after stroke
48
Admission to hospital
43
6 wk after admission
Canada
29 (16 to 42)
ZDS (score 60)
ZDS (score 5059)
4 (0 to 10)
25 (13 to 38)
ZDS (score 60)
9 (1 to 18)
ZDS (score 5059)
26 (13 to 39)
ZDS (score 60)
17 (5 to 28)
42
6 mo after admission
ZDS (score 5059)
24 (11 to 37)
39
1 y after admission
ZDS (score 60)
21 (8 to 33)
ZDS (score 5059)
31 (16 to 45)
Denmark
128
1.5 mo after stroke
16 (10 to 22)
Carod-Artal, 200067
Stroke unit
Spain
90
1 y after stroke
HDRS (cut-point not stated)
38 (28 to 48)
Daily, 198368
Stroke unit
USA
32
Admission to unit
7 d after admission
HDRS & BDI (cut-point not stated)
16 (3 to 29)
25 (10 to 40)
Diamond, 199529
Geriatric rehabilitation unit
USA
14
Admission to unit
Discharge from unit
GDS (score 10)
36 (11 to 61)
29 (5 to 53)
Folstein, 197716
USA
20
30 d after stroke
PSE ( 8 items on the 8th edition)
45 (23 to 67)
Gainotti, 199947
Neurology department &
rehabilitation center
Italy
153
2 mo after stroke
24 mo after stroke
4 mo after stroke
DSM-III-R major depression/

HDRS (score 17
DSM-III-R major depression/
HDRS (score 17)
27 (20 to 34)/
32 (25 to 39)
40 (32 to 48)/
60 (52 to 68)
Gillen, 200169
Inpatient rehabilitation
USA
243
15 d after stroke
GDS (score 15)
13 (9 to 17)
Gottlieb, 200270
Inpatient rehabilitation
Israel
65
3 mo after stroke
9 mo after stroke
GDS (50% items endorsed)
63 (51 to 75)
58 (46 to 70)
Germany
77
6 mo after discharge
20 (11 to 29)
Finland
101
92
3 mo after stroke
1 y after stroke

9 (3 to 15)
44 (34 to 54)
15 (8 to 22)
Bendsen, 199745
Jrgensen, 199971
Geriatric rehabilitation center
Kauhanen, 199951
Stroke unit
Kellermann, 199972
Stroke unit
Kim, 200213
Outpatient clinic
King, 200239
Rehabilitation units and
general hospital
26 (17 to 35)
Hungary
82
BDI (score 10)
20 (11 to 28)
Korea
145
312 mo after stroke
DSM-IV depression (5 items), BDI (score 13)
15 (9 to 21)
USA
53
Discharge from unit

610 wk after discharge
1 y after discharge
2 y after discharge
Prevalence over 2 y
CES-D (score 16)
30 (8 to 42)
26 (14 to 38)
17 (7 to 27)
23 (12 to 34)
51 (38 to 65)
1).18 23 All these studies included patients with standard

clinical criteria for stroke, although one excluded patients
with subarachnoid hemorrhage in the assessment of mood
outcomes,24 and between 38%20 and 92%19 of all stroke
patients were managed in hospital. All studies excluded
patients with communication difficulties (eg, aphasia, confusion, dementia), so that the proportion who completed mood
assessments ranged from 61% (3-week assessment)25 to 99%

(12-month assessment).24
The hospital-based studies included 16 302 patients (see
Table 2), and the rehabilitation-based studies included 6036
patients (Table 3) at the initial assessment. One study17
accounted for the majority (86%) of patients in the hospitalbased studies, with the remaining studies ranging in size from
1334
Stroke
TABLE 3.
Continued
June 2005
First Author, Year,

Source of Patients
Country
No. Assessed
Time of Assessment
Depression Criteria
Frequency (95% CI)
Scotland
311
Duration of hospitalization
Single simple question
16 (12 to 20)
UK
84
1 mo after stroke
HADS (score 10)
13 (6 to 20)
Sweden
47
3 y after stroke
DSM-IV ongoing depression
38 (24 to 52)
Malec, 199052
Rehabilitation unit
USA
20
830 d after stroke
HDRS (score 8)
35 (14 to 56)
Mast, 200473
USA
195
GDS (score 10)
36 (30 to 43)
Morris 199040
Hospital, geriatric unit &
rehabilitation hospital
Australia
99
2 mo after stroke
56
15 mo after stroke
Ng, 199557
Rehabilitation center
Singapore
52
49
22 da after stroke
Discharge from unit
DSM-III-R depressive illness
55 (42 to 69)
29 (16 to 42)
Italy
470
50 d after stroke
HDRS (score 18)
28 (24 to 32)
Canada
64
59 d after stroke
ZDS (score 60)

ZDS (score 5059)
22 (12 to 32)
25 (14 to 36)
Spalletta, 200256
Neuropsychiatric rehabilitation
Italy
153
714 d after admission

DSM-IV minor depression
41 (33 to 49)
17 (11 to 23)
Tang, 200274
Stroke rehabilitation unit
China
157
1 mo after stroke
DSM-III-R depression
17 (11 to 24)
Van de Weg, 199954

Rehabilitation centres
Holland
85
36 wk after stroke
DSM-III-R depression
35 (25 to 45)
Verdelho, 200460
Acute stroke unit
France
110
96
71
73
6 mo after stroke
1 y after stroke
2 y after stroke
3 y after stroke
MADRS (score 7)
43 (34 to 52)
36 (26 to 46)
24 (14 to 34)
18 (9 to 27)
Weimar, 200228
Mixed
Germany
2853
1 y after stroke
CES- D (score 17)
33 (31 to 35)
Langhorne, 2000*
Stroke unit & hospital
31
Lincoln, 199814
54 GP practices
Lfgren, 199959
Geriatric stroke and
rehabilitation ward
Paolucci, 199930
Rehabilitation unit
Sinyor, 198653
DSM-III
DSM-III
DSM-III
DSM-III
major
minor
major
minor
depression
depression
depression
depression
14 (7 to 21)
18 (10 to 26)
7 (2 to 12)
5 (1 to 10)
*Mood assessed using a single standard question.

CES-D indicates Centre for Epidemiologic Studies-Depression scale; DSM, Diagnostic and Statistical Manual of Mental Disorders; GP, General Practitioner.
4726 to 42127 patients. The largest rehabilitation-based study28

contributed 50% of patients, with the remaining studies
ranging in size from 1429 to 47030 patients. Only 2 separate
cohorts were clearly identified from the Iowa Group, which
included up to 463 patients (Table 4).
Diagnosis of Depression
A variety of methods were used to diagnose depressive illness
or assess the degree of depressive symptoms, covering 10
different mood scales and 4 different psychiatric interview
schedules. Mood scales were either self-completed by patients (in 4 studies) or interviewer administered and scored
(20 studies), and the psychiatric interviews were conducted
either alone (in 4 studies) or in combination with a selfadministered or interviewer-administered mood scale (10
studies). The remaining studies used either varying combinations of these methods, or the method was not explicitly
stated in the report. Two studies used a single simple question
to diagnose depression,17,31 but these data were not included
in the pooled estimates because of the nonstandard method of
assessment.
The criteria used to define depression (or depression symptom burden) also varied across studies. In the main, DSM
criteria were used to define depression (in 19 studies) using
information from completed mood scales, and occasionally
from structured interviews, although the criteria for dysthymia were modified by excluding the requirement for symptoms to be present for at least 2 years. There was also
variation in the cut-points used on the standardized mood
scales, whereas there was consistency for the Montgomery
sberg Depression Rating Scale (7) and the Zung Depression Scale (50), these scales were used in only a minority
(6) of studies, whereas multiple cut-points were used for the
Beck Depression Inventory (10, 10, 13, and 17), the
Geriatric Depression Scale (5, 10, 15, 50% items
positively endorsed), and the Hamilton Depression Rating
Scale (8, 12, 13, 17, 18).
Frequency of Depression
Although there was considerable variation in the reported
frequency of depression after stroke across individual studies,
Hackett et al
TABLE 4.
1335
Selection of Publications by the Iowa Group on the Frequency of Depression After Stroke
First Author, Year
Assessed/Alive
Time Since Stroke
Topic
103/154
Acute assessment
Prevalence and severity of depression
Depression Criteria
Frequency
Cohort 1*
Robinson, 198275
Robinson, 198376
Robinson, 198477
Robinson, 198778
Parikh, 199079
103
2 wk
40/154
3 mo
50/154
6 mo
37/154
12 mo
48/154
2y
63
2y
Predictors of depression
Prevalence and duration of depression
Prevalence of depression
Recovery over 2 y
GHQ-28 5
29
GHQ-28 6
23
GHQ-28 8
17
DSM-III Major D
27
DSM-III Minor D
20
DSM-III Major D
22
DSM-III Minor D
27
DSM-III Major D
34
DSM-III Minor D
26
DSM-III Major D
14
DSM-III Minor D
19
DSM-III Major D
21
DSM-III Minor D
21
DSM-III Major D
24
DSM-III Minor D
Cohort 2
Castillo, 199380
288/309
2 wk
Generalized anxiety disorder and depression
HDRS (no cutpoint), PSE (no cutpoint)
38
Downhill, 199481
140/309
Baseline
Depression and cognitive impairment
DSM-IV Major D
40
DSM-IV Minor D
35
Castillo, 199582
142/215
Baseline
Correlates of early and late onset GAD
78
3 mo
80
6 mo
Depression
51
DSM-III-R GAD
27
27
70
12 mo
36
66
2y
17
Kishi, 199683
301
Baseline
Validity of observed depression
DSM-IV Major D
17
DSM-IV Minor D
18
Paradiso, 199784
142
Baseline
Psychological symptoms associated with depression
HDRS (no cut-point), PSE (no cut-point)
76
3 mo
38
79
6 mo
39
69
12 mo
29
66
2y
142
Baseline
77
3 mo
22
79
6 mo
25
70
12 mo
11
66
2y
Shimoda, 199886
142
Baseline
GAD and depression on recovery
DSM-IV Major D
19
DSM-IV GAD
23
Shimoda, 199887
142
Baseline
Social functioning and depression on recovery
DSM-IV Major D
19
DSM-IV Minor D
25
DSM-IV Major D
17
DSM-IV Minor D
18
27
Schultz, 199785
Paradiso, 199888
301
2 wk
42
38
GAD and depression and recovery
DSM-IV GAD
19
18
Gender differences in depression
GAD indicates generalized anxiety disorder; GHQ, General Health Questionnaire.

*Funding numbers: MH00163, NS15178, NS16332, NS18622, NS9 2032; recruitment period 1.5 years, or between January 1980 and July/August 1981;
populations had similar demographic characteristics.
Did not report funding number NS9-2032.
Funding numbers: MH00163, MH40355; populations had similar demographic characteristics.
1336
Stroke
June 2005
Observational studies of the proportional

frequency of depression after stroke.
the pooled estimate indicates that depressive symptoms are

present in 33% (95% CI, 29% to 36%) of all stroke survivors
at any time during follow-up (Figure). The pooled estimate
from the population-based studies was 33% in the acute and
medium-term phases, with a slight increase to 34% in the
long-term phase of recovery after stroke. There was modest
variation in the pooled frequencies in the hospital-based
(acute 36%, medium-term 32%, and long-term 34%) and
rehabilitation-based studies (acute 30%, medium 36%, and
long-term 34%) over time, but the 95% CIs around all pooled
frequencies overlapped.
There was, however, more variation in the pooled frequencies when studies were grouped by method of mood assessment (data not presented). The 2 studies that used a single
simple question to determine depression status17,31 had a
pooled frequency of 14% (95% CI, 14% to 15%). The
smallest pooled frequency with standardized questionnaires
was from studies that used the Hamilton Depression Rating
Scale (26%; 95% CI, 11% to 42%), whereas the highest
frequency was in studies that used the Montgomery sberg
Depression Rating Scale (41%; 95% CI, 23% to 60%) or the
Zung Depression Scale (41%; 95% CI, 34% to 48%). The
estimates again varied when studies were grouped by type of

mood scale and timing of assessment.
The Oxfordshire Community Stroke Project,6 conducted
nearly 20 years ago, is the only population-based study to
date that recruited controls to allow estimates of the relative
risks of depression after stroke. Using Beck Depression
Inventory (scores 10) and the Present State Examination
psychiatric interview schedule (scores 5) to determine
caseness, the study showed that the frequency of depression
in stroke survivors (20% Beck Depression Inventory; 11%
Present State Examination) was twice that in controls, although this difference only reached statistical significance at
the 6-month follow-up assessment. In addition, 4 hospitalbased studies have compared mood data in cases with
controls, although only 1 study had controls selected from the
community.32 However, this latter study only assessed patients with new episodes of depression within the 6 months
after stroke, yet still included patients with depression that
had been present for 1 year. Despite this anomaly, the 5%
proportional frequency of new depression was similar in
stroke patients and controls. Another study showed no difference in the cumulative 1-year incidence of depression after
Hackett et al
stroke compared with a randomly selected control group of
patients with first-ever myocardial infarction (in contrast to
consecutive recruitment of stroke patients).33 Different results
were found in 2 other studies: one study in which controls
were randomly selected from the neighboring hospital community and including spouses of stroke patients27 showed
more depression in stroke survivors (11%) than controls (5%)
at 3 months after stroke (odds ratio [OR], 2.52; 95% CI, 1.35
to 4.80); and the other study that did not provide any details
on the selection of controls, reported that depression was also
more common in stroke patients than controls (OR, 3.16;
95% CI, 1.48 to 4.12).34
Another robust examination of the relative frequency of
depression in stroke survivors was undertaken in The Framingham Study, a prospective, observational, communitybased study that enrolled middle-aged subjects who have
been followed-up biennially since the middle of the past
century.35 When data from 74 of the 251 subjects who
experienced a stroke between 1982 and 1994 were isolated
and compared with data from 74 control subjects matched for
age and sex, significantly more stroke survivors (38%) were
depressed at 6 months after stroke than controls (10%). In a
separate analysis of 20-year outcomes from 148 subjects
with a stroke between 1972 and 1974,36 only 1 (11%) of 9
stroke survivors met the criteria for depression compared
with 3 (15%) of 20 nonstroke controls.
History of Depression, Antidepressants,

and Psychotherapy
Only 2 population-based studies have assessed the natural
history of depression within individual stroke patients.6,25
Both found that only a small proportion of patients had
depressive symptoms that persisted for most of the first year
after stroke, despite the relatively constant overall frequency
of depression among the total study population during this
time. Although some patients recovered spontaneously from
depression within a few months, others had depressive
symptoms for the first time later after stroke. Similar results
were found in 1 hospital-based,5 and 4 rehabilitation-based
studies,37 40 and are further confirmed by this review.
It is well-recognized that personal or family history of
depression may place an individual at increased risk of
depression.41 43 Although no population-based studies excluded patients with a history of depression from analyses, 17
hospital-based and rehabilitation-based studies excluded patients with recent or severe depression,13,26,30,32,38,44 55 including 6 studies in which patients using antidepressants at entry
were also excluded.30,46,48,5254
Use of antidepressants at entry or during follow-up was
assessed in less than half of the included studies, and ranged
from 0% in the first few weeks56 to 31% at 2 years after
stroke.39 The highest proportion of adequately treated
patients (ie, those using antidepressants who did not fulfil
criteria for depression) at the time of assessment in any one
study was 84%.27 The highest proportion of participants
receiving antidepressants who were inadequately treated
(ie, those on antidepressants who still fulfilled criteria for
depression) was 71%,57 but this frequency ranged between
17% and 36% in most studies.5,24,34,51,54,58 60 No data were
1337
available on the proportion of stroke patients who had

received psychotherapy.
Discussion
We report that one third of all people experience significant
depressive symptoms at some time after the onset of stroke.
We recognize, however, that this is likely to be a conservative
estimate because of potential under-reporting (or underrecognition) of abnormal mood, and the difficulties inherent
to the assessment of mood in patients with neurological
disability, particularly when there are communication problems caused by dysphasia and/or dementia. Given the importance of mood, which along with cognition, motivation, and
social support is a key factor influencing recovery from
stroke, it is surprising that there is much misconception over
the epidemiology of stroke-associated depression, although
the generally poor quality of studies has obviously contributed to this situation.
Whereas previous reports have acknowledged wide variation in the frequency of depression after stroke across studies
largely because of differences in patient characteristics and
study designs, they have also suggested that the lowest and
highest frequency of depression is found among patients in
population-based and rehabilitation-based studies, respectively, potentially reflecting selection bias toward the inclusion of more disabled stroke survivors in the latter studies.2,5,6
Moreover, the time period of greatest risk of depression has
traditionally been considered to be the first few months of
stroke onset. Our review, conversely, showed consistency in
the overall frequency of depression across the 3 different
types of studies and in relation to the time periods from stroke
onset, thus raising doubts about specific biological theories
related to an acute stroke lesion as the major cause of
depression in this condition. In addition, we found that few
stroke patients receive effective management (antidepressants
or psychotherapy) for their depression, although the limited
data would suggest that these symptoms are self-limited in
most after several months.
Because the design of observational studies, by their very
nature, may differ in a number of important ways,61 it is
useful to explore and quantify the reasons for such heterogeneity. We identified variation in the cut-points used to
determine caseness in the standardized mood scales as one
key source of variability in the data. It would appear that
many studies failed to consider that older people, and those
with physical illnesses, might require higher cut-points on
these scales. Two other problems were that multiple methods
were often used to diagnose depression, with few investigators clearly identifying an a priori primary endpoint in their
study, so that the endpoints reported varied between any
depression, first-ever depression, and severity of depression. Without greater uniformity or standardization of
such methodological issues, it will remain difficult to determine whether heterogeneity in study findings represent true
differences in characteristics of populations or simply artifact
caused by measurement bias and other error.
Of course, heterogeneity across studies can also be attributed to differences in case mix, including variation in stroke
features, clinical characteristics, source of patient recruit-
1338
Stroke
June 2005
ment, and the timing of assessment. In this review, we have

attempted to minimize heterogeneity by grouping studies by
source of case selection. It is particularly noteworthy that a
number of studies excluded patients at the greatest risk for
depression, that is those with a history of depression. Although a systematic review with meta-analysis can overcome
some of the shortcomings of unstructured examination of
individual studies, the gold standard review would include an
individual patient data analysis with adjustment for potential
confounding factors to calculate frequency estimates, but this
is complex and challenging to undertake.
There are other problems of study design that limit the
reliability of the comparisons of frequency estimates between
stroke patients and controls. It is important to note that stroke
patients are generally older, female, and more likely to have
concomitant illnesses and to have experienced some bereavement or other major life event than that of the general
population.62 In this respect, controls need to be matched by
age and sex, because these factors are associated with
depression at any age. Yet the selection of controls in 3 of the
5 case-control studies did not account for such factors.
Although it may appear likely that stroke-associated depression is no more common than other types of depression in the
general population, there have been no direct comparisons
between stroke patients and people with other disabling and
potentially life-threatening illnesses.
Although we attempted to adhere to the guidelines for
reporting meta-analyses of observational studies,61 this review does have several limitations. First, we did not handsearch journals and made no attempt to identify unpublished
studies, raising the possibility that some studies have been
missed. Second, only one person extracted most of the data.
Ideally, 2 people should complete data extraction to reduce
the possibility of errors when transcribing study results. Even
so, all the data were checked for accuracy on multiple
occasions and all analyses were conducted twice. Finally, it is
possible that some multiple publications have been miscoded or missed altogether. We have paid particular attention
to addressing this source of publication bias, because the lack
of cross-referencing of data from some cohorts has only
served to mislead the research community, specifically in
reference to the amount of information available on the
development of depression after stroke.
Acknowledgments
Maree Hackett holds a Senior Health Research Scholarship, and
Chaturangi Yapa was in receipt of a Faculty of Medical and Health
Sciences Summer Studentship, of The University of Auckland. The
funding body had no role in the conduct or reporting of the review.
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Frequency of Depression After Stroke : A Systematic Review of Observational

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ome form of depression is considered to occur in at least

Materials and Methods

ical and time-limited boundaries. There were no restrictions on the

Search Strategy and Data Extraction

Time Since Stroke

WDI (score 1936, depressed)

WDI (score 1518, probably depressed)

rebro Stroke Study

BDI (score 10)

BDI (score 3063 severe)

BDI (score 1929 moderate)

BDI (score 1018 mild)

BDI (score 10)

BDI (score 3063 severe)

BDI (score 1929 moderate)

BDI (score 1018 mild)

DSM-III: major depression

DSM-III: dysthymic disorder

WDI (score 1936, depressed)

WDI (score 1936, depressed)

Frequency (95% CI)

Frequency of Depressed Mood After Stroke: A Summary of the Population-Based Evidence

Bristol Stroke Study25

Frequency of Depression After Stroke

BDI (score 10)

BDI (score 13)

BDI (score 17)

DSM-III: major depression

DSM-III: dysthymic disorder

BDI (score 10)

BDI (score 13)

BDI (score 17)

DSM-III: major depression

DSM-III: dysthymic disorder

BDI (score 10)

BDI (score 13)

BDI (score 17)

BDI (score 10)

ICD-9 Psychiatric disorder

DSM-III-R major depression

DSM-III major depression

DSM-III minor depression

DSM-III major depression

DSM-III minor depression

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Frequency of Depressed Mood After Stroke: A Summary of the Hospital-Based Evidence

Time Since Stroke

DSM-IV major depression

DSM-IV minor depression

Frequency (95% CI)

HDRS (score 13)

DSM-IV major depression

DSM-III-R major depression

BDI (score 10)

HDRS (score 12)

GHQ (score 12)

Single simple question

BDI (score 10)

DSM-III-R major depression

DSM-III-R minor depression

ZDS (score 50)