INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL.

12: 219 226 (1997)

RISK FACTORS FOR POST-STROKE DEPRESSION

1 2 3 4 5
PETER BURVILL , GLORIA JOHNSON , KONRAD JAMROZIK , CRAIG ANDERSON AND EDWARD STEWART-WYNNE
1
Professor of Psychiatry, University of Western Australia, Western Australia
2
Lecturer in Psychiatry, University of Western Australia, Western Australia
3
Associate Professor of Public Health, University of Western Australia, Western Australia
4
Research Assistant, now Senior Lecturer in Neurology, Flinders University, South Australia
5
Neurologist, Royal Perth Hospital, Western Australia

ABSTRACT
Objective. To examine possible risk factors in post-stroke depression (PSD) other than site of lesion in the brain
Data sources. 191 rst-ever stroke patients were examined physically shortly after their stroke and examined
psychiatrically and physically 4 months post-stroke.
Setting. A geographically dened segment of the metropolitan area of Perth, Western Australia, from which all
strokes over a course of 18 months were examined (the Perth Community Stroke Study).
Measures. Psychiatric Assessment Schedule, Mini Mental State Examination, Barthel Index, Frenchay Activities
Index, physical illness and sociodemographic data were collected. Post-stroke depression (PSD) included both major
depression and minor depression (dysthymia without the 2-year time stipulation) according to DSM-III (American
Psychiatric Association) criteria. Patients depressed at the time of the stroke were excluded.
Patients. 191 rst-ever stroke patients, 111M, 80F, 28% had PSD, 17% major and 11% minor depression.
Results. Signicant associations with PSD at 4 months were major functional impairment, living in a nursing
home, being divorced and having a high pre-stroke alcohol intake (M only). There was no signicant association
with age,
sex, social class, cognitive impairment or pre-stroke physical illness.
Conclusion. Results favoured the hypothesis that depression in an unselected group of stroke patients is no more
common, and of no more specic aetiology, than it is among elderly patients with other physical illness.

Int. J. Geriatr. Psychiat. 12: 219 226, 1997.

No. of Figures: 0. No. of Tables: 2. No. of Refs: 48.

KEY WORDS aetiology; stroke; depression

In the past two decades much has been written
about the aetiology of post-stroke depression
(PSD), the most common psychiatric condition
following stroke. Three themes about PSD are
discernible in the literature: the relationship
between PSD and location of the lesion in the
brain (Robinson and Starkstein, 1990), that PSD is
predominantly secondary to social factors (House,
1987a) and the view that the incidence of depres-
sion after stroke is much the same as with other
physical illnesses of acute onset (House, 1987a).
Robinson and his co-workers from the Johns
Hopkins University in Baltimore have been the
strongest advocates for the view that the location
*Correspondence to: Professor P. W. Burvill, Department
of Psychiatry and Behavioural Science, The University of
Western Australia, Nedlands WA 6009, Western Australia.
Tel: (09) 346 2174. Fax: (09) 346 3828.
CCC 0885 6230/97/020219
08
# 1997 by John Wiley & Sons,
Ltd.
of the lesion in the brain is the single most
important risk factor in the development of PSD
(Robinson et al., 1984; Robinson and Starkstein,
1990). They have claimed that the frequency of
PSD is higher in patients with lesions in the left
hemisphere rather than the right hemisphere, and
that the highest incidence is in those with damage
to the left anterior region of the brain. However,
recent reviews of the literature conclude that the
data reported so far do not allow rm conclusions
to be drawn about characteristics of cerebral
lesions in PSD (House, 1987b; Lishman, 1988;
Primeau, 1988; Johnson, 1991).
The recent literature on PSD has identied other
risk factors for depression, including age, male
gender, personality development, neuroticism,
degree of disability, lack of social support, disrup-
tion of social roles, dependence on others for
activities of daily living, negative life events and
 RISK FACTORS FOR POST-STROKE DEPRESSION
both personal and family history of aective
disorders and anxiety (Castillo and Robinson,
1991; Morris et al., 1992; Burvill, 1994). Socio-
demographic factors such as age, sex, level of
education and marital status have not generally
been documented as important (Johnson, 1991).
In their review of the literature, both House
(1987a) and Primeau (1988) concluded that it is
unproven whether depression is more common in
an unselected group of patients after strokes than
it
is among the elderly with other physical illnesses.
Factors such as admission to hospital, family
pressures, bereavement and socialization make
comparison of these two groups especially dicult
(Morris and Raphael, 1987).
Depression is common among the physically ill
(Cohen-Cole and Stoudemire, 1987). Most studies
of medical inpatients have reported a prevalence of
depression of between 10 and 20%, and some even
higher (Evans, 1993; Finch et al., 1992; O'Riordan
et al., 1989). Some medical conditions that are
associated with a high risk of stroke, such as
hypertension (Wells et al., 1989), diabetes mellitus
(Gavard et al., 1993) and cancer (Brown and
Paraskevas, 1982), may be associated with a high
incidence of PSD, independent of any eect of a
stroke. Fractured neck of femur is a physical
condition of sudden onset like stroke, aecting
predominantly elderly people and associated with
admission to hospital similar to stroke. Billig et al.
(1986) reported a frequency of depression in such
patients 10 days after admission of 28%. What is
striking about the literature is that the prevalence
of depression found in a wide variety of physical
conditions is very similar and within the range
reported for PSD.
Less work has been done on depression in
vascular dementia, but Cummings et al. (1987)
and Erkinjuntti (1987) have reported prevalences
of depressive illness around 28% and Ballard et al.
(1993) 20%. These ndings are similar to those
reported in the early stages of Alzheimer's disease
(Ballard et al., 1993). All these studies raise the
possibility of a link between the cognitive impair-
ment after a stroke and PSD.
The Perth Community Stroke Study (PCSS)
was a community-based study of the incidence,
aetiology and outcome of all strokes in the
population from a dened geographical area over
a period of 18 months in Perth, Western Australia
(Anderson et al., 1993). The prevalence of depres-
sion (23%) and anxiety (11%) among survivors at
4 months after stroke has been reported by Burvill
1
et al. (1995a,b). This study overcame the major
objections to former studies of PSD in being a
broadly based community investigation rather
than including only highly selected stroke patients.
A suciently large number of subjects was studied,
and the localization of the lesion in the brain
was determined by conventional neuroanatomical
means. A study of 117 survivors of rst-ever stroke
in the PCSS found no support for the assertion that
location of the lesion is a prime factor in the
occurrence of PSD at 4 months post-stroke (Burvill
et al., 1996). The authors advocated that a much
broader range of variables should be studied, as the
aetiology of PSD is likely to be multifactorial. The
aim of this article is to examine a range of possible
risk factors in PSD other than site of lesion, using
data from the PCSS.
METHOD
Details of case ascertainment and baseline assess-
ment of patients seen in the PCSS have been
described in full by Anderson et al. (1993). Briey,
all residents of a geographically dened segment of
the Perth metropolitan area (estimated population
69 008 males and 69 700 females at June 30, 1989)
who had a stroke in the 18 months between
February 20, 1989 and August 19, 1990 were
included. Multiple community-wide overlapping
sources were used to ascertain the cases. These
included notications from general practitioners,
scrutiny of all attendances at and admissions to all
hospitals and nursing homes, coroners' reports and
death registrations, and monitoring of computer-
ized hospital discharge statistics.
All patients were seen as soon as possible after
an event by the study registrar (CSA), who
conducted a standardized interview and physical
examination to conrm that they had had a stroke.
Stroke was dened according to WHO criteria
(Hatono, 1978) and the new special report from the
Institute of Neurological Disorders and Stroke
(Whisnant et al., 1990). A total of 492 patients were
detected of whom 408 were seen by CSA. Sixty-
nine per cent had had their rst-ever stroke.
Eighty-three patients had died before being seen
by the registrar and only one patient refused to
take part in the study. The evaluation of each
patient at baseline and at follow-up at 4 and
12 months included the use of the Mini-Mental
State Examination (MMSE) (Folstein et al., 1975),
the Frenchay Activities Index (FAI) (Holbrook
and Shilbeck, 1983) and the Barthel Index (BI)
(Mahoney and Barthel, 1965). The BI and FAI are
well-validated, established, commonly used mea-
sures in the assessment of function in stroke
patients. The BI (score of 0 20) is a measure
of activities of daily living, whereas the FAI (score
of
0 60) is an objective measure of social
activities such as domestic duties, shopping, social
outings,
gardening, travel, hobbies and gainful work. The
patients' usual occupation was used to classify
them into a social class, according to categories
1 6 dened by the Classication of Occupations
of
the Australian Bureau of Statistics (1980). House-
wives and those retired were classied on the basis
of their longest held occupation. Twenty per cent
of all patients were managed entirely outside
hospital, either at home or in a nursing home.
The case fatality was 24% at 28 days and 38% at
12 months post-stroke.
When seen again at 4 months after the index
event, 318 patients from the original cohort were
still alive. Seven patients had emigrated from
Australia. The remaining 311 patients were
assessed physically by CSA, of whom 248 were
assessed by a consultant psychiatrist, either PWB
or GAJ. Four patients died before being seen by
the psychiatrists and 13 refused to see a psychia-
trist. Forty-three patients were severely demented
and three were so severely aphasic that full
psychiatric assessment was not made. Of the 248
patients assessed by a psychiatrist, 191 had rst-
ever strokes. These 191 rst-ever stroke patients
are reported in this article.
Patients were seen in their own homes, in nursing
homes, or occasionally in the psychiatrist's oce.
Each patient was assessed psychiatrically using the
Psychiatric Assessment Schedule (PAS) (Dean
et al., 1983), which is a modication of the Present
State Examination (PSE) (Wing et al., 1974) and
enables both PSE and DSM-III diagnoses to be
derived. Both psychiatrists had been trained in the
use of the PSE. Careful enquiry was made of each
patient, and of relatives where available, as to the
presence or absence of any psychiatric disorder,
especially of depression or anxiety disorder, at the
time of the index stroke.
Analysis
All data were collected on precoded inter-
view forms and entered onto a database held
in a mini-computer for analysis using SAS
(1991) and EGRET (1991) statistical packages. A
non-hierarchical approach to diagnosis was used
with the PAS data so that patients were assigned all
the DSM-III diagnoses for which they satised the
criteria. PSD was dened as those who had either
major depression (DSM-III) or minor depression.
Patients with minor depression were those who
satised the DSM-III diagnostic criteria for
dysthymia, but not the requirement for a duration
of 2 years, in accordance with the criteria adopted
by Robinson and his colleagues in their studies of
post-stroke depression in Baltimore (Starkstein
and Robinson, 1989). Those depressed at the time
of the stroke (6M, 11F) were excluded from the
analysis.
The protocol for the study was approved by the
Committee for Human Rights of the University of
Western Australia.
RESULTS
Age and sex
Of the 191 (111M, 80F) rst-ever stroke patients,
54 (28%) were depressed, 33 (17%) with major
depression and 21 (11%) with minor depression.
Thirty (27%) of the men and 24 (30%) of the
women were depressed. A higher proportion of the
males aged less than 60 years (48%) than those
aged 60 years or older (20%) were depressed. The
corresponding frequencies for females were 23%
and 31%. None of these dierences was statisti-
cally signicant. There was very little dierence in
the proportion depressed in the 10-year age groups
in those 60 years and older.
Marital status
A higher proportion of those divorced (40%) or
separated (33%) were depressed than those single
(21%), married/de facto (20%) or widowed (28%).
Living arrangements
Only 17% of those living alone 4 months post-
stroke were depressed compared with 25% of those
in rehabilitation hospitals, 31% living with their
spouse or relatives and 45% in nursing homes.
Physical condition prior to stroke
Table 1 outlines a number of selected physical
conditions at the time of the stroke, giving the
percentage of patients depressed at 4 months
post-stroke in those with the physical condition
Table 1. Pre-stroke physical illness, alcohol intake and PSD at 4 months (percentages)

Feature 2
Prevalenc % depressed in % depressed in those
e of those with Signicance without feature
feature feature
Cardiovascular disorders
History of hypertension 62 28 29 0.014 NS
Hypertension under treatment 70 24 37 1.97 NS
Exertional angina 27 23 30 0.95 NS
Prior myocardial infarction 18 20 30 1.45 NS
Intermittent claudication 14 30 28 0.39 NS
Other
History of malignancy 20 18 30 2.18 NS
History of diabetes mellitus 12 36 27 0.89 NS
Alcohol intake per week
male
>140 g 33 50 17 12.29 < 0.001
>280 g 23 50 21 7.59 < 0.01
female
>140 g 8 50 29 1.28 NS

Table 2. Functional impairment and PSD (percentages)

2
Depressed Not depressed Signicance

Frenchay score 430 at 4 months 72 47 10.14 < 0.01

Barthel score 415 at 4 months 24 7 10.29 < 0.01

and in those who did not have that condition.
These fall into four major groups, hypertension,
other cardiovascular conditions, malignancy
and diabetes mellitus. There were no statistical
dier- ences in the prevalence of depression in
those patients with and in those without these
conditions.
Alcohol intake
There was a signicantly higher percentage of
depression at 4 months post-stroke in males who
drank either more than 140 g of alcohol per week
(50%) ( p < 0:001) or more than 280 per week
(50%) ( p < 0:01) than in those who drank
less than these amounts (Table 1). The
frequency of depression in those women who
drank more than
140 g per week was higher than in those who drank
less but this dierence was not statistically
signicant.
were functionally impaired with a BI less than 16
( p < 0:01) and an FAI less than 31 ( p <
0:01) (Table 2).
Cognitive impairment
There was no dierence in the level of cognitive
impairment at 4 months post-stroke, as measured
by the MMSE, in the depressed and non-depressed
patients. In each 11% scored 1 18, 20%
scored
19 23 and 69% 24 30. The mean MMSE
was almost identical in the depressed (24.3) and
non- depressed patients (24.6).
Social class
At 4 months post-stroke 36% of patients in
social classes 5 and 6 were depressed compared
with 25% of those in social classes 1 4.
These dierences were not statistically signicant.

Functional impairment DISCUSSION

Functional impairment at 4 months post-stroke
was assessed using two measurements, the BI and Most studies of PSD to date have focused on
the FAI. A signicantly higher proportion of patients in hospital or in rehabilitation units and
depressed patients than non-depressed patients hence are biased towards including patients with
more severe initial strokes and more persistent
disabilities as well as other factors that may be
more likely to promote depression (Johnson, 1991).
Some of the most inuential studies of PSD have
come from Robinson and his colleagues in
Baltimore. These studies were based on inpatients
with severe strokes, who were predominantly male,
black and from low socioeconomic status and who
were managed in hospital. Being a community-
based study, the PCSS has been able to avoid such
selection bias. The PCSS has shown that the
prevalence of PSD is lower than that reported in
most other studies (Burvill et al., 1995a,b) and is
not related to site of the lesion (Burvill et al. 1996).
Similar ndings were reported in the Oxford
Community Stroke Study (House et al. 1990).
This study adopted the methodology of most
studies in this eld of measuring PSD at a xed
point post-stroke. Four months was chosen as the
most appropriate time after reviewing other
studies, as it was suciently close to the stroke to
be temporarily connected with the event, but
allowed sucient time for early transient mood
changes to have settled. Other investigations
indicated that once established, PSD lasted many
months (Starkstein and Robinson, 1989; Morris
et al., 1990). However, it had the disadvantage
of probably missing some short-lived minor
depressive episodes, which are the equivalent of
the adjustment reactions to having a stroke
reported by House (1988), and possibly PSD,
which may develop for the rst time in the fth
and sixth months post-stroke. Very few patients
were on antidepressant medication or any other
psychotropic medication when interviewed.
The only major dierences we have found
between those with and without depression at
4 months post-stroke were that the depressed
patients had a higher intake of alcohol pre-stroke
and, at 4 months, greater degree of disability and a
higher likelihood of living in nursing homes. There
were no major dierences at 4 months post-stroke
in sex, age, social class, cognitive impairment or in
the pre-stroke prevalence of those physical condi-
tions measured. The data available from the PCSS
did not allow us to consider all the possible risk
factors suggested by Castillo and Robinson (1991).
While a denite association was found between
PSD and impaired function at 4 months post-
stroke, as measured by the Barthel Index and the
Frenchay Index of Activity, there are at least three
possible explanations for such an association. The
depression may be a reactive process to the eects
of the stroke, it may impair the patient's general
functional capacity beyond the eect of the
physical impairment alone, or thirdly, both the
depression and the functional impairment may be
secondary to a common underlying, probably bio-
logical process. It is highly likely that various
combinations of these three processes were operat-
ing in dierent individuals and that, in some, they
led to a vicious cycle involving depression and
function. Underlying personality, life-long ability
to cope with adversity and past experiences might
have been additive contributing factors.
There is a well-established association between
heavy intake of alcohol and both mood disorders
and very high rates of suicide (Ritson, 1977). In this
study PSD was associated with a heavy pre-stroke
intake of alcohol. Given that more men than
women
have a heavy intake, it is not surprising that the
most signicant associations were found in men.
The high proportion of PSD among those
living in nursing homes is in keeping with the
reported high prevalence of depression generally
in residents of nursing homes (Ames, 1994).
Henderson et al. (1994) found that when allow-
ance was made for the level of physical illness,
the prevalence of depression in such individuals
was no dierent from that in people residing in the
community. Following stroke it would be expected
that the more physically disabled the patient, the
more likely he/she is to be accommodated in a
nursing home. By contrast, the presence of more
than minor PSD or post-stroke physical disability
or both would make it very dicult for an elderly
person to live alone. In other words, the associ-
ation we observed between living arrangements
and depression is more likely to be secondary to the
eects of combined physical impairment, func-
tional impairment and depression than to be the
primary cause of depression.
The lack of association between PSD and socio-
demographic variables is in keeping with Johnson's
(1991) ndings. That review of the literature found
that demographic variables such as age, sex, social
class and marital status have generally not
appeared important, although there have been
reports of increased depression with younger
patients and with women. The higher levels of
PSD in the younger men in this study may well
reect the greater signicance of, and reaction to,
the eects and implications of a stroke. The
distribution of PSD by marital status, with the
highest frequency in the separated/divorced and
the lowest in those single, is in keeping with
reported ndings in depressive illness generally demographic factors, cognitive impairment or pre-
(Checkley, 1988). stroke physical illness. Three factors were found to
Diabetes mellitus (Gavard et al., 1993) and be signicantly associated with PSD: pre-stroke
cancer (Brown and Paraskevas, 1982) are particu- intake of alcohol especially in males, post-stroke
functional impairment and post-stroke living
larly associated with a high frequency of depressive arrangements. Of these, intake of alcohol pre-
illness, the former more with a high lifetime stroke is the only one that could be seen as a risk
incidence and the latter with more acute depressive factor for PSD. We were not able to explore
illness. Our ndings, however, do not support the whether PSD could be linked with other known
concept that depression in patients with stroke is risk factors such as family history of depression, a
explained by a higher prevalence of physical condi- personal history of depression and the presence of
tions which themselves are associated with a high depression at the time of the stroke. An earlier
prevalence of depression. report from the PCSS study failed to show an
A family history and a past personal history association between PSD and anatomical site of
of depression, which are well-established risk lesion of the stroke. The results are more in keeping
with the hypothesis that depression is no more
factors for depression generally, would be expected common, and of no more specic aetiology, in an
to be important in the development of PSD unselected group of patients with stroke than it is
(Morris and Raphael, 1987). Unfortunately, we among elderly patients with other physical illnesses
were not able to explore these possibilities from the of acute onset. However, in order to sustain such
available PCSS data. In the prevalence study of an hypothesis, it would be necessary to compare
depression 50% (3/6) of the men and 83% (10/12) the prevalence of PSD found in the PCSS with a
of the women who were depressed at the time of the control group of patients from the same popula-
stroke were found to be depressed 4 months post- tion base, who had an acute onset illness such as
stroke (Burvill et al., 1995a). myocardial infarction or fractured neck of femur.
The results of this study are in accord with the
opinions of others (House, 1987b; Johnson, 1991)
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