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| Subscribe to Clinical Compass™ | VOLUME 3, ISSUE 9 - APRIL 22, 2008 | ||||||||||||||||||||||||
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Depression, Psychological Distress, and Risk of Stroke by Lisa Brauer, PhD May is National Stroke Awareness month. This issue of Clinical Compass will focus on a relatively underrecognized risk factor for stroke - pre-existing depression/psychological distress. Although awareness of traditional risk factors for stroke, including smoking, diet, exercise, hormonal, and cardiovascular factors is high, relatively less appears to be known about psychiatric factors that may place individuals at risk for stroke morbidity and mortality.(1) The relationship between psychological/psychiatric symptoms and stroke is far from definitive, but data are accumulating that depressive symptoms in particular merit attention as independent risk factors.(1,2) Since depression is a treatable condition, and prevention of other risk factors has been shown to reduce or prevent stroke(3,4) it is important to understand the extent to which depression also plays a role. According to the American Heart Association, approximately 780,000 individuals experience a stroke each year. For about 600,000 of those individuals, the stroke will be their first. On an annual basis, stroke is more common in women than men, with 60,000 more cases occurring in women. In 2004, stroke was responsible for one out of every 16 deaths; it is the third leading cause of death in the United States and a leading cause of serious long-term disability. The relationship between depression and stroke appears to be bidirectional. Several large studies have shown that depression is common after a stroke and that it is associated with increased healthcare demands and increased risk of suicide.(5-8) What is less clear is the relationship between the presence of pre-existing depression and risk of later stroke. Although a number of studies have suggested that depression is an independent risk factor for stroke, data are inconsistent due in large part to methodological differences regarding the classification of an individual as depressed. Many studies use the presence or absence of depressive symptoms to classify patients, rather than an actual diagnosis of a depressive disorder, which takes into account level of impairment and a prolonged period of symptomatology.(2,9,10) To more carefully address the relationship between depression, depressive symptoms, and stroke, Surtees and associates(2) examined data from a large population-based prospective cohort study conducted in the UK. The cohort consisted of 20,627 stroke-free individuals between the ages of 41 and 80 years of age. Individuals provided data at baseline and were followed up for a median of 8.5 years. Participants completed the Health and Life Experiences Questionnaire (HLEQ), which assessed "psychosocial circumstances," DSM-IV criteria for major depressive disorder (MDD), and a short form of the Mental Health Inventory (MHI-5), which measures psychological well-being. Among the participants, 5.3% reported having episodes of MDD during the year prior to baseline, and 15.4% reported experiencing MDD at some point in their lives. In both cases, significantly more women than men reported having MDD (p < .001). In terms of stroke, 595 stroke endpoints occurred during the 8 years of follow-up; 169 of these events were fatal. When the relationship between stroke and MDD was examined, there was no association between reported 12-month or lifetime MDD and stroke after adjusting for other independent risk factors. In contrast, there was a significant and substantial relationship between psychological distress, as measured by scores on the MHI-5 scale, and stroke. A decrease of one standard deviation in MHI-5 score (decreases represent more psychological distress) was correlated with an 11% increased risk of stroke, particularly in the case of fatal strokes; this relationship was "dose-related." The results of this study suggest that general psychological well-being - but not episodes of major depressive disorder - is significantly related to risk of stroke and that this relationship is independent of other known risk factors. High levels of psychological distress may be identifiable and amenable to treatment, but clinicians need to become more aware of its possible impact on development of future stroke. Additional research is needed to more precisely elucidate how pre-existing psychological distress impacts stroke risk, and to investigate whether such distress may represent a prodrome.(2) As more data become available, physicians will be better able to identify at-risk individuals and to develop strategies for management. For more information on identifying and managing depressive symptoms visit the Major Depressive Disorder Clinical Knowledge Center at www.neuroscienceCME.com. For more information on stroke, visit the National Stroke Association website at www.stroke.com. Do you have feedback for the author? Click here to send us an email. References
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