Depressive symptoms 6 years after stroke are associated with a marked effect of stroke, ADL limitations and restricted participation


Participants from the Longitudinal Study of Life After Stroke Stage 1 (LAS-1), who participated in a 6-year follow-up, were eligible for inclusion. LAS-1 was a prospective observational study on the rehabilitation process after stroke, described in detail elsewhere13. From an original sample of 349 patients diagnosed with stroke, who were consecutively recruited in the years 2006-2007 to the stroke units at Karolinska University Hospital in Stockholm, Sweden, 183 surviving subjects were contacted by mail to participate. Signed informed consent was obtained from all participants. Ethical permission for the original 6-year follow-up study was granted by the Stockholm Regional Ethics Committee (2011/1573-32, 2012/428-32), and procedures were performed in accordance with the Declaration of Helsinki.

In the current study, all participants from the LAS-1 study who agreed to participate in the 6-year follow-up and who completed the Hospital Anxiety and Depression Scale (HADS)14 have been included.


Data were collected through structured face-to-face interviews by experienced occupational therapists and physiotherapists. Interviews were in most cases conducted in the participant’s home. If necessary, a relative was present during the interviews.

Data collection

Sociodemographic data were collected at baseline, within 5 days after stroke, and at 6-year follow-up. The Barthel Index (BI) showed good agreement with other measures of stroke severity15th It was used to classify stroke severity at baseline. A score of less than 15 is classified as severe, 15-49 as moderate, and 50 as mild16. Cognitive function was assessed with the Mini Mental State Examination (MMSE)17. A single component Nordic Stroke Scale was used to initially assess the presence and severity of aphasia18. At 6 years the following data were collected.

Hospital Anxiety and Depression Scale

Depressive symptoms were collected by the Hospital Anxiety and Depression Scale (HADS), a 14-item self-rating scale for examining anxiety and depression among people with poor physical health.14. The items cover the non-physical symptoms of anxiety and depression, with seven items covering anxiety (HADS-A) and seven items covering depression (HADS-D). The respondent is asked to rate agreement with the data for one week, on a four-point scale ranging from 0 = no symptoms to 3 = maximum symptoms. The maximum score in HADS-D is 21 and the cut-off commonly used for depression is >819. However, it has been suggested that the lower score is more accurate for detecting depression among people with stroke20 Hence cutoff limit 4 was used in this study.

Stroke Effect Scale

The observed effect of stroke was assessed using the Stroke Impact Scale (SIS) version 3.0 .21, a 59-item scale assessing eight domains: strength, hand function, ADL, mobility, communication, emotion, memory, thinking, and engagement. Responses to each domain are converted to a score of 0–100, where 0 indicates maximum and 100 indicates no perceptible stroke effect. The scale also contains a single item reflecting marked recovery from a stroke, which is rated on a visual analogue scale with a range of 0-100, where 0 reflects no, and 100 is maximum recovery.

Barthel index

Barthel’s Index15th was used to assess the ADL. The tool consists of ten questions about activities related to personal care and mobility. The overall score is 0-100 with higher scores indicating more independence. Any score less than 100 indicates a certain level of dependency.

Frenchay . Activities Index

Participation in social and daily activities was assessed using the Frenchay Activities Index (FAI)22. The scale consists of 15 items covering household chores, outdoor activities, and leisure/work time. Each item is rated from 0 to 3, depending on the frequency of activity over the past three or six months. A higher score indicates more frequent participation in social and daily activities. An overall score <15 is considered as the inactive/restricted person23.

statistical analysis

For the metadata, the mean, standard deviation (SD), median, interquartile range (IQR), minimum and maximum values ​​were calculated. A HADS-D cutoff ≥ 4 for depressive symptoms was used in the bivariate analyses. Group differences between participants with depressive symptoms versus no depressive symptoms were calculated using CHI2The Mann-Whitney test for categorical variables WL for ordinal scale data. The level of significance was set to p < 0.05. Eleven hierarchical multiple regression models were performed to investigate the contribution of depression to dependent variables: perceived effect of stroke (each SIS domain), ADL (BI), participation in social and daily activities (FAI), and control for age, gender, and stroke severity. In the first step, age, sex, and stroke severity were simultaneously entered as independent variables. In a second step, independent variable depression, as measured by scores on the HADS-D, was added to the model. Models were evaluated by R2, F, and F change level and significance. The statistical package of the Social Sciences software (SPSS version 27, Armonk, NY: IBM Corp.) was used.

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