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Original Investigation
October 2016

Incidence of Depression After Stroke, and Associated Risk Factors and Mortality Outcomes, in a Large Cohort of Danish Patients

Author Affiliations
  • 1Research Center for Prevention and Health, Rigshospitalet-Glostrup, Copenhagen University, Glostrup, Denmark
  • 2Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  • 3Psychiatric Center Ballerup, Ballerup, Denmark
  • 4Department of Psychiatry, Frederiksberg Hospital, Frederiksberg, Denmark
  • 5Department of Psychiatry O, Rigshospitalet, Copenhagen, Denmark
  • 6Department of Cardiology Y, Bispebjerg Hospital, Copenhagen, Denmark
  • 7Competence Center for Dual Diagnosis, Psychiatric Center Section Hans, Roskilde, Denmark
  • 8Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
JAMA Psychiatry. 2016;73(10):1032-1040. doi:10.1001/jamapsychiatry.2016.1932

Importance  More than 30 million people live with a stroke diagnosis worldwide. Depression after stroke is frequent, and greater knowledge of associated risk factors and outcomes is needed to understand the etiology and implications of this disabling complication.

Objectives  To examine whether the incidence of and risk factors for depression differ between patients with stroke and a reference population without stroke and to assess how depression influences mortality.

Design, Setting, and Participants  Register-based cohort study in Denmark. Participants were all individuals 15 years or older with a first-time hospitalization for stroke between January 1, 2001, and December 31, 2011 (n = 157 243), and a reference population (n = 160 236) matched on age, sex, and municipality. The data were analyzed between January and March 2016.

Main Outcomes and Measures  The incidence of depression and mortality outcomes of depression (defined by hospital discharge diagnoses or antidepressant medication use) were examined using Cox proportional hazards regression analyses.

Results  In total, 34 346 patients (25.4%) with stroke and 11 330 (7.8%) in the reference population experienced depression within 2 years after study entry. Compared with the reference population, patients with stroke had a higher incidence of depression during the first 3 months after hospitalization (hazard ratio for stroke vs the reference population, 8.99; 95% CI, 8.61-9.39), which declined during the second year of follow-up (hazard ratio for stroke vs the reference population, 1.93; 95% CI, 1.85-2.08). Significant risk factors for depression for patients with stroke and the reference population included older age, female sex, single cohabitation status, basic educational attainment, diabetes, high level of somatic comorbidity, history of depression, and stroke severity (in patients with stroke). The associations were strongest for the reference population. In both populations, depressed individuals, especially those with new onset, had increased all-cause mortality (hazard ratio for new-onset depression, 1.89 [95% CI, 1.83-1.95] for patients with stroke and 3.75 [95% CI, 3.51-4.00] for the reference population) after adjustment for confounders. Similar patterns were found for natural and unnatural causes of death. In most models, the depression-related relative mortality was approximately twice as high in the reference population vs the stroke population.

Conclusions and Relevance  Depression is common in patients with stroke during the first year after diagnosis, and those with prior depression or severe stroke are especially at risk. Because a large number of deaths can be attributable to depression after stroke, clinicians should be aware of this risk.