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Prevalence and natural history of depression after stroke: A systematic review and meta-analysis of observational studies [1]

['Lu Liu', 'School Of Life Course', 'Population Sciences', 'King S College London', 'London', 'United Kingdom', 'Min Xu', 'Iain J. Marshall', 'Nihr Applied Research Collaboration', 'Arc']

Date: 2023-04

Summary of the finding

To the best of our knowledge, this is the first study comparing the prevalence of PSD in terms of robust clinical interview versus rating questionnaires. We found that across all studies to date, the pooled estimate of the prevalence of PSD was 27%. This was slightly higher when assessed by rating scales at 29%, compared to 24% diagnosed by clinical interview. Moreover, to our knowledge, this is also the first meta-analysis evaluating the pooled proportion of recovered, persistent, and new-onset cases of depression. The natural history of depression after stroke within 1 year is dynamic. Two-thirds of episodes of depression during 1 year after stroke started within 3 months. At further follow-up, over half of these patients experienced persistent depression and just under half had recovered. Onset of depression was less common after 3 months.

Our results suggested the pooled prevalence of PSD is 27% (95% CI 25 to 30) at any time point after stroke. This is consistent with previous meta-analyses, suggesting the prevalence of PSD has not changed appreciably in more recent studies. This consistency in estimates is notable as earlier studies also varied in whether they included studies excluding participants with prestroke depression. The one meta-analysis to directly address this issue also showed little variation when comparing pooled estimates of depression in studies including people with a history of depression and that in studies excluding people with a history of depression [4]. Studies have shown conflicting results on whether prestroke depression increases the odds of PSD [62,64,100]. The present pooled prevalence in studies including people with aphasia is comparable to that in studies excluding people with aphasia [4]. This may be because most of the studies only included people with mild to moderate aphasia as meaningful communication skills are essential to complete the questionnaire. It remains challenging to estimate the prevalence of PSD in the full stroke population.

Rating scales are widely used to screen for depression as they have the advantage of requiring fewer resources and being easily applicable [101]. These assessment tools have been shown to have a high sensitivity but low specificity [102–104]. The relatively small difference between the two methods in our study suggests only modest overreporting of depression by screening questionnaires [3]. This may be due to patients who are capable to complete the scales are fully self-aware to provide an accurate self-assessment, which might not reflect the real condition. For example, sleep alterations, appetite, and attention deficits might lead patients to overestimate the prevalence of depression [105].

In the sensitivity analyses, the pooled estimates of depression when restricted to studies that included both ischemic stroke and haemorrhagic stroke patients were similar to the overall pooled estimate. Comparison of PSD between ischemic and haemorrhagic stroke patients was less frequently demonstrated, and results were conflicting. Zeng and colleagues reported nearly twice the prevalence of PSD in intracerebral haemorrhage group than that in ischemic stroke group [106], while the prevalence of depression after ischemic stroke and haemorrhagic stroke was similar in Sienkiewicz-Jarosz’s study [71]. The experience of depression may vary across socioeconomic and clinical circumstances. However, no significant difference was seen between developed countries and low- or middle-income countries. It may result from unrecognised depression in developing countries. As seen in our results, only 8 studies were in low- or middle-income countries.

Pooled estimates of studies assessing patients at more than one time point showed that about half of patients with depression soon after stroke experienced persistent depression and that the remaining 50% patients recovered from this problem within 1 year. The frequency of new-onset depression between 3 and 12 months after stroke was 9% (95% CI 7 to 12). The systematic review by Ayerbe and colleagues [3] found that PSD presented a dynamic natural history, with new cases and recovery of depression occurring over time. Here, we confirmed and extended their findings by providing formal meta-analysis and pooled estimates of measures of natural history of depression after stroke from the larger number of studies now available. Our study also found two-thirds of PSD onset within 1 year occur during the first 3 months. It indicates that early-onset depression makes up the majority of episodes during 1 year after stroke, while onset of depression was less common after 3 months.

A possible explanation for the dynamic nature of PSD is the level of concurrent functional deficits experienced. Studies comparing patients with persistent depression and nonpersistent depression found that absolute degree of functional disability and poorer health status over time are associated with persistent and progressive symptoms. Correspondingly, as functional and intellectual performance improve, depressive symptoms decreased [25,27,31,43]. Another study found that stroke survivors with persistent depression were those with a prestroke history of psychiatric problems [42]. Based on these results, it is recommended that clinical attention should be paid to patients with depressive symptoms within 3 months poststroke, especially those with worse functional impairments at baseline and those with prestroke depression. Finally, about 10% of new cases of depression had onset between 3 months and 1 year after stroke, which comprised 30% of the cumulative cases within 1 year. Whether patients with late-onset depression have a high risk of experiencing persistent depression is unknown since there are insufficient data to estimate the natural history of PSD over 1 year. Population-based studies investigating the prevalence, incidence of PSD at different time points, and the persistent patterns with long-term follow-up are needed.

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[1] Url: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004200

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