**2. Epidemiology**

Advancements in acute medical therapies have led to the reduction of mortality due to acute ischemic or hemorrhagic stroke [5]. Studies have shown that 10% of patients recover without any residual deficits, a quarter have mild residual deficits, while 50% are severely disabled or require skilled nursing care within a medical facility able to manage their needs [6]. Along with severe physical disability, patients that suffer from a stroke also experience neuropsychiatric changes. The most common neuropsychiatric sequelae, post-stroke, are depression and anxiety [7]. Patients that survive stroke often experience anxiety and depression related to making adjustments to their new reality [7]. With more patients surviving stroke, quality of life becomes an area of focus. Poststroke depression has been regarded as one of the most important measures for quality of life after an acute stroke. The presence of depression after stroke results in impaired recovery, decreased participation in rehab efforts, impaired cognition, and even increased mortality. The majority of the expressed concern from patients is related to their ability to work and provide financial stability for themselves/their families, the ability to manage their activities of daily living, and the loss of their functional independence [7].

The term poststroke depression puts a focus on ischemic rather than hemorrhagic strokes, which is mostly due to the fact that ischemic strokes have been studied more in the literature, and thus will be the focus of this chapter [8]. Poststroke depression can occur anywhere from days to years after an acute ischemic event with the peak incidence of poststroke depression occurring between 3 months and 2 years, even if the patient's symptoms are improving [9]. Patients that experience the onset of poststroke depression at or after 7 weeks from the acute event are less likely to have a spontaneous remission of this depression [9]. In the acute phase, patients that had a longer inpatient hospital stay were seen to score higher on the Beck Depression Inventory than those that were in the community or in a rehabilitation facility. However, many of these studies have excluded patients that are aphasic, have cognitive impairment, or experienced pre-stroke depression. This may be one of the main reasons that poststroke depression may be underdiagnosed and undertreated [10].

#### **2.1 Demographics associated with poststroke depression**

Patients younger than 60 are seen to have higher depression scores poststroke. In the general population, major depression is more prevalent in patients younger than 65 years old [11]. In multiple studies that adjusted for pre-stroke depression it was found that more than 30% of the patients younger than 65 could be diagnosed as having clinical depression using the Center for Epidemiologic Studies Depression Scale (CES-D). It was found that within this younger age group there was a higher rate of depression associated with lower socioeconomic status, familial stress, and the ability to provide financial stability [7, 11]. However, having good social support has been found to be protective against poststroke depression [7, 11]. Adults over the age of 65 represent the majority of stroke patients, which can skew the data.

**259**

*Post Stroke Depression*

*DOI: http://dx.doi.org/10.5772/intechopen.86935*

and more obvious depressive phenotype [6, 11].

gender is a definitive predictor of poststroke depression.

their risk of stroke, and thus their risk for poststroke depression.

**3. Comorbidities associated with poststroke depression**

Comorbid conditions prior to a stroke can affect the development of depression after an acute ischemic event. Conditions such as diabetes, and preexisting psychiatric disorders like depression, anxiety, and bipolar disorder can all have an effect on poststroke depression [17, 18]. One meta-analysis has demonstrated that patients that have vascular risk factors such as diabetes are at a higher risk for developing poststroke depression [17]. This is not thought to be related to the vascular depression theory, which will be discussed later in this chapter. In a Chinese study, it was

However, multiple meta-analyses have shown that when controlling for other variables such as sex, patients younger than 65 experienced more poststroke depression,

Biologic sex and poststroke depression is a controversial issue. Numerous meta-analyses have looked at the relationship between 'gender' and how it affects or predicts poststroke depression. The results were mixed when looking at data from across the globe. In some studies, women have been found to experience double the risk of poststroke depression compared to men [12, 38]. The gender disparity may be related to how each sex reacts to stressful life events. Women have been demonstrated to have more stress in reaction to negative life events, such as a stroke, which results in feelings of depression [12]. On self-reported survey, women were seen to indicate they have more depressive symptoms, compared to men, when age was controlled for [12]. The risk factors for women developing depression after an acute stroke were: pre-stroke psychiatric comorbidity, age younger than 65, and impairment in cognition [13]. Similarly, men with higher level of physical disability after a stroke had more depressive symptoms than women, or men with less physical disability. In multicenter analysis from China, and India, these studies found that male sex had a higher correlation with poststroke depression [10, 15]. However, there may be confounding factors when evaluating sex differences and poststroke depression. For example, in China there may be a higher number of men in the general population [14]. In the Indian study there were more men in the study [10]. In the USA, it is possible that there is a higher rate of self-reporting by women, as well as under reporting of depressive symptoms in men, based on their level of physical disability [14]. Therefore, more studies need to be done in this area to determine if

Socioeconomic status and education related to poststroke depression is also difficult to measure, due to multiple confounders and conflicting data. However, reviewing the meta-analysis of patient demographics and poststroke depression has shown that patients with lower overall education levels have an increased risk for poststroke depression with mild depressive symptoms [13]. A large meta-analysis of the literature found that there is an association between more years of education and lower risk for depression after a stroke. This study demonstrated that on average the participants in the study without poststroke depression had 0.32 years of education more than those that did have depressive symptoms after their stroke [16]. The symptoms that were seen in this data set were defined as mild depressive symptoms, but could not be classified as clinically depressed. However, this may also have confounding factors in this category. Patients that have lower socioeconomic status have been shown to have lower levels of education [16]. They may also be exposed to environmental factors that put them at increased risk for stroke, such as unhealthy diet, unhealthy lifestyle, more perceived stress, exposure to second hand smoke, and pollution in urban areas [10, 13, 16]. These factors may increase

#### *Post Stroke Depression DOI: http://dx.doi.org/10.5772/intechopen.86935*

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

scale (CES-D), Zung self-rating depression scale and the Hamilton Depression Rating Scale (HDRS) [5]. Post stroke depression has a great impact on the healthcare system as well as on the individual patient. In this chapter, we will examine all aspect of depression as it relates to stroke by using these scales and large metaanalyses to define post-stroke depression, and assess how it relates to stroke and

Advancements in acute medical therapies have led to the reduction of mortality due to acute ischemic or hemorrhagic stroke [5]. Studies have shown that 10% of patients recover without any residual deficits, a quarter have mild residual deficits, while 50% are severely disabled or require skilled nursing care within a medical facility able to manage their needs [6]. Along with severe physical disability, patients that suffer from a stroke also experience neuropsychiatric changes. The most common neuropsychiatric sequelae, post-stroke, are depression and anxiety [7]. Patients that survive stroke often experience anxiety and depression related to making adjustments to their new reality [7]. With more patients surviving stroke, quality of life becomes an area of focus. Poststroke depression has been regarded as one of the most important measures for quality of life after an acute stroke. The presence of depression after stroke results in impaired recovery, decreased participation in rehab efforts, impaired cognition, and even increased mortality. The majority of the expressed concern from patients is related to their ability to work and provide financial stability for themselves/their families, the ability to manage their activities of daily living, and the loss of their functional independence [7]. The term poststroke depression puts a focus on ischemic rather than hemorrhagic strokes, which is mostly due to the fact that ischemic strokes have been studied more in the literature, and thus will be the focus of this chapter [8]. Poststroke depression can occur anywhere from days to years after an acute ischemic event with the peak incidence of poststroke depression occurring between 3 months and 2 years, even if the patient's symptoms are improving [9]. Patients that experience the onset of poststroke depression at or after 7 weeks from the acute event are less likely to have a spontaneous remission of this depression [9]. In the acute phase, patients that had a longer inpatient hospital stay were seen to score higher on the Beck Depression Inventory than those that were in the community or in a rehabilitation facility. However, many of these studies have excluded patients that are aphasic, have cognitive impairment, or experienced pre-stroke depression. This may be one of the main reasons that poststroke depression may be underdiagnosed

**258**

and undertreated [10].

**2.1 Demographics associated with poststroke depression**

Patients younger than 60 are seen to have higher depression scores poststroke. In the general population, major depression is more prevalent in patients younger than 65 years old [11]. In multiple studies that adjusted for pre-stroke depression it was found that more than 30% of the patients younger than 65 could be diagnosed as having clinical depression using the Center for Epidemiologic Studies Depression Scale (CES-D). It was found that within this younger age group there was a higher rate of depression associated with lower socioeconomic status, familial stress, and the ability to provide financial stability [7, 11]. However, having good social support has been found to be protective against poststroke depression [7, 11]. Adults over the age of 65 represent the majority of stroke patients, which can skew the data.

recovery.

**2. Epidemiology**

However, multiple meta-analyses have shown that when controlling for other variables such as sex, patients younger than 65 experienced more poststroke depression, and more obvious depressive phenotype [6, 11].

Biologic sex and poststroke depression is a controversial issue. Numerous meta-analyses have looked at the relationship between 'gender' and how it affects or predicts poststroke depression. The results were mixed when looking at data from across the globe. In some studies, women have been found to experience double the risk of poststroke depression compared to men [12, 38]. The gender disparity may be related to how each sex reacts to stressful life events. Women have been demonstrated to have more stress in reaction to negative life events, such as a stroke, which results in feelings of depression [12]. On self-reported survey, women were seen to indicate they have more depressive symptoms, compared to men, when age was controlled for [12]. The risk factors for women developing depression after an acute stroke were: pre-stroke psychiatric comorbidity, age younger than 65, and impairment in cognition [13]. Similarly, men with higher level of physical disability after a stroke had more depressive symptoms than women, or men with less physical disability. In multicenter analysis from China, and India, these studies found that male sex had a higher correlation with poststroke depression [10, 15]. However, there may be confounding factors when evaluating sex differences and poststroke depression. For example, in China there may be a higher number of men in the general population [14]. In the Indian study there were more men in the study [10]. In the USA, it is possible that there is a higher rate of self-reporting by women, as well as under reporting of depressive symptoms in men, based on their level of physical disability [14]. Therefore, more studies need to be done in this area to determine if gender is a definitive predictor of poststroke depression.

Socioeconomic status and education related to poststroke depression is also difficult to measure, due to multiple confounders and conflicting data. However, reviewing the meta-analysis of patient demographics and poststroke depression has shown that patients with lower overall education levels have an increased risk for poststroke depression with mild depressive symptoms [13]. A large meta-analysis of the literature found that there is an association between more years of education and lower risk for depression after a stroke. This study demonstrated that on average the participants in the study without poststroke depression had 0.32 years of education more than those that did have depressive symptoms after their stroke [16]. The symptoms that were seen in this data set were defined as mild depressive symptoms, but could not be classified as clinically depressed. However, this may also have confounding factors in this category. Patients that have lower socioeconomic status have been shown to have lower levels of education [16]. They may also be exposed to environmental factors that put them at increased risk for stroke, such as unhealthy diet, unhealthy lifestyle, more perceived stress, exposure to second hand smoke, and pollution in urban areas [10, 13, 16]. These factors may increase their risk of stroke, and thus their risk for poststroke depression.
