Psychology
2011. Vol.2, No.5, 522-525
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.25081
Investigation of Prevalence and Associated Risk Factors of
Depressive Symptoms Following Acute Ischemic Stroke
(PSD) in the Aged
Yue Chen
Department of Geriatrics, the First Affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China
Received April 4th, 2011; revised May 13th, 2011; accepted June 19th, 2011
Objective: The study aimed to investigate the prevalence and associated risk factors for post stroke depression
(PSD), and their clinical correlations. Method: A consecutive cohort of 102 ischemic stroke patients with a
mean age of 72.6 ± 7.2 years, were studied. Hamilton depression rating scale (HDRS), modified motor assess-
ment scale (MMAS) and Barthel index (BI) were administered. Risk factors of PSD studied were gender, later-
ality of stroke, family history of depression and post stroke functional impairment. Results: From assessment
with the HDRS, 71 (69.6%) of the subjects were non-depressive and the rest 31 (30.4%) had depression. De-
pressive symptoms (HDRS > 10) were relatively common, but the prevalence of severe depression (HDRS >17)
was only 7.0%. Patients with depressive symptoms were more likely to be female(X2 = 4.01, P = 0.039), have a
family history of depression(X2 = 3.87, P = 0.045), and a poor functional status(MMAS, t = 2.18 and P = 0.016;
BI, t = 3.74 and P = 0.009). Conclusion: Our findings indicate that depressive symptoms occurred in about one
third of post stroke patients. Important risk factors found for PSD included gender, family history of depression
and functional impairment.
Keywords: Depression, Post-Stroke, Prevalence, Risk Factors, Investigation
Introduction
Stroke is a common neurological problem and the third lead-
ing cause of death in developed countries of the world (Katra ,
Dale & Crome, 1993; Warlow, 1998). Among survivors, over
50% have significant disabilities, and in clinical practice,
neuro-psychiatric disturbances are also frequent (Jongbloed
1990; Hankey, 2007). Depression is an important common
problem for patients who have experienced strokes, and
post-stroke depression (PSD) is present in at least 30% of the
survivors of strokes (Gainotti, Antonucci, Marra et al., 2001;
Carson, MacHale, Allen et al., 2000). However, a consensus on
the prevalence and associated factors of PSD has not been
reached. Recently systematic review suggested that stroke se-
verity or physical disability and functional impairment are im-
portant factors associated with depression (Herrmann, Black,
Lawrence et al., 1998; Singh, Black, Herrmann et al., 2000).
Other possible risk factors include age, gender, lack of social
support, and of psychiatric family history (Andersen, Vester-
gaard, Ingemann-Nielsen et al., 1995). In China, the paucity of
data on PSD and its associated risk factors prompted this study.
This prospective study was to assess the prevalence of depres-
sive symptoms following acute ischemic stroke in a teaching
hospital in China and the associated risk factors for PSD.
Subjects and Methods
Patient Population
One hundred-two patients were selected from consecutive
inpatients in the geriatric department of No.1 affiliated hospital
of medical school, Zhejiang university over two year period
from October, 2008, until September, 2010 for problems related
to acute ischemic stroke. The diagnosis of acute stroke met the
classification of cerebrovascular diseases III of the National
Institute of Neurological Disorders and Stroke (Special Report,
1990). The stroke patients were studied made up of 63(61.8%)
males and 39(38.2%) females. The mean age of this group was
72.6 ± 7.2 years (ranges: 68 - 82). All patients with a known
history of alcohol abuse, dementia, current antidepressant
treatment, or severe Parkinson’s syndrome were excluded. Pa-
tients with aphasia and difficulties for interview were also ex-
cluded. The necessary socio-demographic data was obtained
from each subject. Lesion location was defined by CT or MRI
during the stroke onset. As part of the approved ethical clear-
ance for the study, informed consent was also obtained from
each patient.
Instruments
The subjects were studied using the following instruments:
Hamilton Depression Rating Scale (HDRS) (Carr, Shepherd,
Nordholm & Lynne, 1985)
The post-stroke depressive symptoms were assessed by a
neuropsychologist with the Hamilton Depression Rating Scale
(HDRS). We defined patients as having depression if the
HDRS score was above 10. Patients with an HDRS score be-
tween 10 - 13 were defined as having mild depression, 14 - 17
as moderate, and above 17 as severe.
Barthel’s Index (BI) (Buchanan, 1986) and Modified Motor
Assessment Scale (MMAS) (Sim, Reid, Pallett &Gordon,
1975)
Functional status was measured by a neurologist in the ward

Y. CHEN 523
with the Barthel’s Index (BI) and Modified Motor Assessment
Scale (MMAS). The BI has scores between 0 and 100, with the
top scores implying a complete functional independence in
daily life activities. The MMAS is an instrument used to assess
functional, that is motor impairment in stroke patients. It is an
eight-task item instrument. The possible scores for each item task
is 0 - 6, with a maximum of 48 points in overall assessment.
Testing Routine
Each subject was administered the HDRS to complete.
Thirty-one patients (30.4%) had depressive symptoms from
HDRS assessment. The questionnaire was completed by the
first researcher in line with such subject’s choice for each item.
Each of the subjects was also assessed with the Modified Motor
Assessment Scale (MMAS) and Barthel index (BI) to determine
his/ her levels of motor functioning/ impairment for a compari-
son of percentage of PSD between two groups (Figure 1).
Data Analysis
Descriptive statistics were used to summarize data. Be-
tween-group comparisons were made with the t-test for con-
tinuous variables, and Chi-square test of independence for di-
chotomous variables. Pearson correlation was used to test the
strength for the relationship between depressive symptoms
(HDRS scores) and functional status (MMAS scores). Tests
were two-tailed, and the results were considered significant at P
< 0.05. Analyses were conducted using SPSS version 10.0 for
Windows (SPSS Inc. U.S.A.).
Results
Clinical Characteristics of Study Subjects
One hundred-two patients admitted to the geriatric depart-
ment of No.1 affiliated hospital of medical school, Zhejiang
Patients admitted to hospital
with acute ischemic stroke
n = 102
Assessment on
admission by HDRS
HDRS score < 10
n=71
HDRS score > 10
n = 31
Assessment by
MMAS, BI
MMAS score ≥ 25
n = 62
MMAS score < 25
n = 40
Comparison of % of PSD
between two groups
Figure 1.
Testing routine.
university over two year period from October, 2008, until Sep-
tember, 2010 for problems related to acute ischemic stroke. The
stroke patients were studied made up of 69(67.8%) males and
33(32.2%) females. The mean age of the subjects was 72.6 ±
7.2 years, and age range of 68 - 82 years. All the patients re-
ceived inpatient rehabilitation treatment every day after the
initial medication (e.g. Cerebrolysin, neuroprotective agent,
manufactured by EBEWE Pharma, Vienna, Austria and Seroxat,
antidepressant, manufactured by GlaxoSmithKline Pharma,
London, United Kingdom). The mean duration of hospital stay
was 45 days (range 21 - 85 days). Thirty-one patients (30.4%)
had depressive symptoms from Hamilton Depression Rating
Scale (HDRS) assessment. There were no significant differ-
ences in the age of stroke onset and the laterality of stroke focus.
In contrast, the depressed patients were more likely to be fe-
male(P < 0.05), and to have the family histories of depression(P
< 0.05) (Table 1).
HDRS scores/ post stroke depression (PSD)
From the scores obtained on HDRS by the subjects,
71(69.5%) were normal while the remainder, 31(30.4%) were
depressed. According to HDRS classification, eleven (10.8%)
were mildly depressed, 13 (12.7%) moderately depressed, and
7(7.0%) severely depressed (Table 2). Overall, the mean HDRS
score for the depressed subjects was 14.9 ± 6.3.
Post Stroke Functional Impairment and Its
Relationship to PSD
For post stroke motor functional level as assessed with
MMAS, 40(39.2%, N = 102) of the subjects had poor motor
functioning (that is MMAS score less than 25). Of this category,
19(15.7%) had PSD on HDRS assessment. Hence, 47.5% (19
out of 40) of those with “poor” motor functiod thus subjects
with “poor” motor functioning constituted 61.3% (19 out of 31)
subjects with PSD. For the rest 62(60.8%, N = 102) with
“good” motor functioning ( MMAS score ≥ 25 ), only 12, that
is 19.4% of the 62 subjects with “good” MMAS scores had PSD;
Table 1.
Clinical characteristics among different groups with depressive symp-
toms.
Depressive Symptoms
Variable
Absent Present
Statistics
(HDRS < 10)
(n = 71)
(HDRS ≥ 10)
(n = 31) t or X2 P
Age onset year 71.9 ± 8.272.4 ± 7.3 T = 0.46NS
Gender (female)23 (32%) 16 (53%) X2 = 4.010.039*
Family history
(depression) 3(4%) 4 (14%) X2 = 3.870.045*
Right hemisphere
stroke 31(44%) 14(45%) X2 = 1.35NS
Left hemisphere
stroke 29(41%) 13(44%) X2 = 1.87NS
Modified Motor
Assessment Scale17.3 ± 6.111.2 ± 6.7 T = 2.180.016*
Barthel Index 91.8 ± 11.170.2 ± 9.3 T = 3.740.009**
* P < 0.05, ** P < 0.01, NS indicates not significant.

Y. CHEN
524
Table 2.
Severity of Depressive Symptoms from HDRS Assessment* (N = 102).
Number Percentage(%)
No depression
(HDRS score <10) 71 69.5
Mild depression
(HDRS score 10 - 13) 11 10.8
Moderate depression
(HDRS score 14 - 17) 13 12.7
Severe depression
(HDRS score >17) 7 7.0
Total 102 100.0
*Mean HDRS score in the depressed subjects: 14.9 ± 6.3.
showing that subjects with “good” motor functioning consti-
tuted 38.7% (12 out of 31) subjects with PSD. Thus, the ratio of
subjects with the “good MMAS score” to the “poor MMAS
score” that had the complication of PSD is 1:2.4 (Table 3).
Correlations between depression rating scale scores and
functional outcome measured by the MMAS and the handicap
level measured by Barthel index (Table 1) were significant
(rMMAS = –0.33, rBI = –0.38, respectively, P < 0.01), showing a
significantly negative relationship between depressive symp-
toms and functional status.
Discussion
Stroke remains a major cause of death and disability in China
(Wei, Huang, Wang et al., 2011 ), but little attention has been
focused on the possible psychiatric morbidity that could com-
plicate the problem among survivors (Fuh, Liu, Wang et al.,
1997). In our study, an attempt was made to evaluate for de-
pression with particular focus on prevalence and associated risk
factors in the old patients of ischemic stroke.
The prevalence of PSD in different studies is difficult to
compare because of different evaluation methods, diagnostic
criteria, and patient sources. Past studies have found that de-
pression is a frequent sequela of stroke, and the prevalence
ranged from 12% to 64% (Lam, Lee & To, 2010). Most of
these studies were restricted to stroke patients seen at outpatient
clinics or admitted to general hospital. Those studies may have
included patients with more severe and persistent handicaps.
Conversely, department of geriatrics sampling methods, may
include patients with more mild-moderate deficits and/or no
disabilities (Burvill, Johnson, Jamrozik et al., 1995]. The rate of
depressive symptoms in our study (30.4%, 31 out of 102) is
almost identical to the prevalence of depressive disorder in the
two studies by House et al. (1990) (32%) and Wade et al.
Table 3. Analysis of Post Stroke Functi on al Impairment (N = 102).
Post Stroke
Impairment No. of PSD % of PSD % of MMAS Scores
MMAS ≥ 25 12 38.7 19.4 (n = 62)*
MMAS < 25 19 61.3 47.5 (n = 40)
Total 31** 100
*“Better” Motor Functioning:“poor” Motor Impairment for PSD = 1:2.4; **Mean
MMAS scores in depressed subjects: 11.2 ± 6.7; Mean BI scores: 70.2 ± 9.3.
(32%) (Wade, Legh-Smith & Hewer, 1987), but the incidence
of severe depressive symptoms (7.0%, 7 out of 102) was lower
than these two studies (13% and 20%, respectively). The preva-
lences from all three studies are considerably lower than those
reported from surveys from rehabilitation units (Robinson,
Kubos, Starr et al., 1984; Sinyor, Jacques, Kaloupek et al.,
1986). The reason why the prevalences were so different may
be because of the difference in the nature of the sample or the
assessment measures utilized.
From various studies in Europe and America, a number of
risk factors have been identified for PSD among stroke survi-
vors. In a systematic review by Oumet et al. (2001), gender,
family history of depression or psychiatric illness, social isola-
tion and functional impairment were consistently identified as
risk factors for PSD. In our study, gender was found to be an
important risk factor of PSD that is, the female subjects were
more likely to develop PSD than their male counterparts (P <
0.05). And the presence of family history of depression was in
agreement with some previous studies where a positive family
history showed a higher probability of developing PSD than
none (Angelelli, Paolucci, Bivona et al., 2004). The relationship
between stroke laterality and PSD is a controversial one. In a
systematic review by Carson et al., 39 studies found no signifi-
cant difference between stroke laterality (site of lesion) and
PSD, two reported increased risk with left sided lesions and
seven reported increased risk with right sided lesions (Carson,
MacHale, Allen, 2000). However, in our study, subjects with
PSD were not more likely to have their stroke lesions over the
left or right hemisphere and the difference in laterality was not
statistically significant.
Stroke survivors often suffer some degree of long term im-
pairment such as partial or complete loss of locomotion with
about 80% of patients with acute stroke presenting with weak-
ness or paralysis of either the upper or lower extremity or both.
Other possible areas of impairments include activities of daily
living (ADL), cognition and communication skills (Green,
Forster, Bogle & Young, 2002; Nannetti, Paci, Pasquini et al.,
2005). In our study, motor impairment was found to be an im-
portant risk factor of PSD. The study demonstrated 19.4% of
subjects (62) with “good” MMAS score (motor performance,
MMAS ≥ 25) had PSD as compared with 47.5% of subjects (40)
with “poor” MMAS score(MMAS < 25), showing that the ratio
of “better” motor functioning versus “poor” motor impairment
for PSD was 1:2.4.
Thus, we found a significantly negative relationship between
the prevalence of depressive symptoms following ischemic
stroke and their activities of daily living (functional status).
These results should not be surprising, especially in view of the
findings of the Medical Outcome Study which has showed that
patients with depressive symptoms had poor functioning (Wells,
Stewart, Hays et al., 1989).
Psychologically, early identification of depression symptoms
and early initiation of aggressive treatment may prove benefi-
cial in reducing stroke recurrence and decreasing mortality
(Dafer, Rao, Shareef & Sharma, 2008). The present study em-
phasizes the need to screen for depressive symptoms because it
is related to the prognosis. Double-blind controlled trials have
documented the efficacy of tricyclic antidepressants (Lipsey,
Robinson, Pearlson et al., 1984) and selective serotonin reup-
take inhibitors (Dam, Tonin, De Boni et al., 1996) in treating

Y. CHEN 525
post-stroke depression. It is unclear whether the amelioration in
depressive symptoms will be associated with improvement of
functional status. Further studies are needed.
Conclusion
Our study indicates that depressive symptoms occurred in
about one third of post stroke patients. Important risk factors
found for PSD included gender, family history of depression
and functional impairment. There is a negative correlation be-
tween depressive symptoms and functional status of the pa-
tients.
Acknowledgements
The authors would like to thank Dr Jiu-jiao Wang (No.1
affiliated hospital of Zhejiang University, Hangzhou, Zhejiang
Province, China) for her psychological assistance in HDRS
assessment in our study.
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