Depression and Risk of Stroke Morbidity and Mortality

Abstract

Context Several studies have suggested that depression is associated with an increased risk of stroke; however, the results are inconsistent. Objective To conduct a systematic review and meta-analysis of prospective studies assessing the association between depression and risk of developing stroke in adults. Data Sources A search of MEDLINE, EMBASE, and PsychINFO databases (to May 2011) was supplemented by manual searches of bibliographies of key retrieved articles and relevant reviews. Study Selection We included prospective cohort studies that reported risk estimates of stroke morbidity or mortality by baseline or updated depression status assessed by self-reported scales or clinician diagnosis. Data Extraction Two independent reviewers extracted data on depression status at baseline, risk estimates of stroke, study quality, and methods used to assess depression and stroke. Hazard ratios (HRs) were pooled using fixed-effect or random-effects models when appropriate. Associations were tested in subgroups representing different participant and study characteristics. Publication bias was evaluated with funnel plots and Begg test. Results The search yielded 28 prospective cohort studies (n = 317540 participants) that reported 8478 stroke cases (morbidity and mortality) during a follow-up period ranging from 2 to 29 years. The pooled adjusted HRs were 1.45 (95% confidence interval [CI], 1.29–1.63; P-for-heterogeneity <0.001; random-effects model) for total stroke, 1.55 (1.25–1.93; P-for-heterogeneity = 0.31; fixed-effects model) for fatal stroke (8 studies), and 1.25 (1.11–1.40; P-for-heterogeneity = 0.34; fixed-effects model) for ischemic stroke (6 studies). The estimated absolute risk differences associated with depression were 106 cases for total stroke, 53 cases for ischemic stroke, and 22 cases for fatal stroke per 100 000 individuals per year. The increased risk of total stroke associated with depression was consistent across most subgroups. Conclusion Depression is associated with a significantly increased risk of stroke morbidity and mortality.

Elucidating the Association Between Depressive Symptoms, Coronary Heart Disease, and Stroke in Black and White Adults: The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

“…Our study is consistent with prior studies demonstrating that depressive symptoms confer an increased risk of stroke,2, 10, 24 including prior meta‐analyses (aHR 1.34, 95% CI 1.17–1.54)10, 25 and a prospective study of stroke risk in middle‐aged women with time‐varying covariates (adjusted odds ratio 1.94, 95% CI 1.37–2.74) 26. We expanded on prior literature by accounting for factors such as atrial fibrillation and left ventricular hypertrophy as well as behavioral factors such as medication adherence and physical activity, which were rarely included in prior studies 2, 10.…”

“…We expanded on prior literature by accounting for factors such as atrial fibrillation and left ventricular hypertrophy as well as behavioral factors such as medication adherence and physical activity, which were rarely included in prior studies 2, 10. In addition, few studies simultaneously examined the association between depressive symptoms and both stroke and CHD among participants free from underlying CVD.…”

“…Although successive meta‐analyses have shown that depressive symptoms increase the risk of incident CHD and CHD death, with pooled hazard ratios (HRs) estimated at 1.6 and 1.8,2, 3, 6 there has been concern about incomplete risk factor adjustment in the majority of studies included in prior meta‐analyses and limited use of time‐dependent variables 2. Similarly, although depressive symptoms have been considered an inconsistent risk factor for incident cerebrovascular disease,7, 8, 9 a recent meta‐analysis found pooled HRs of 1.5 and 1.6 for total and fatal stroke; again, only 6 of 28 studies simultaneously controlled for alcohol, body mass index, and smoking status, and 1 controlled for medication adherence 10. In addition to unmeasured confounders, research also remains inconsistent as to whether race truly moderates the association between depressive symptoms and incident CVD 11, 12, 13, 14.…”

Depression in context of low neuroticism is a risk factor for stroke

“…First, our finding that depression increases the risk for stroke in patients with cardiac disease is in line with the theory that depressive symptoms in this population partly reflect the severity of underlying subclinical vascular Table 2 Characteristics of included patients by cardiac disease status disease. 5,8 In people without preexisting cardiac disease, neuroticism may be assumed to be the most important pathway to depression (neurotic depression). 32 Nonetheless, in this group, several persons have low neuroticism scores that by definition cannot have contributed to their depression.…”

Beta Adrenoceptor Polymorphism and Clinical Response to Sertraline in Major Depressive Patients

“…A significant association between excess mortality and depression has been reported in various samples (4,5). It has long been theorized that monoamines as neurotransmitters are involved in the pathogenesis of mental disorders such as depression (6,7).…”