Poststroke depression has been shown to affect rehabilitation progress. This study evaluated patients after stroke who actively participated in a home-based rehabilitation program to determine variables that correlated with depressive symptoms in this population. A retrospective review of patients who were provided rehabilitation by Community Stroke Rehabilitation Team clinicians between January 1, 2009, and September 30, 2015, was completed. Logistic regression analysis was conducted to determine which demographic and outcome variables (Functional Independence Measure [FIM™] and Reintegration to Normal Living Index [RNLI]) were independently associated with depressive symptoms, as defined by Patient Health Questionnaire (PHQ-9) scores. 889 patients (53.2% male, mean age = 69.8 years) were included. Based on PHQ-9 scores, 89.7% of patients presented with no or mild depressive symptoms (PHQ-9 < 10) and 10.3% were considered to have moderate to severe depressive symptoms (PHQ-9 ≥ 10). The regression demonstrated that referral from outpatient, community care access centre, or community settings (OR = 1.89, p=0.04), low RNLI scores (OR = 0.92; p=0.001), and younger age (OR = 0.96; p<0.001) predicted patients having moderate to severe depressive symptoms. Given the impact of poststroke depression on rehabilitation, clinicians should consider the potential impact of referral source, community reintegration, and age when monitoring and treating depressive symptoms.
Worldwide, 15 million individuals have a stroke annually, of which five million are left with permanent deficits [[
Depression is the most common neuropsychiatric disorder occurring after a stroke [[
Most concerning, PSD has been found to negatively impact an individual’s level of disability [[
In general, the literature is conflicting in terms of predictors of PSD. The most commonly examined predictors have been age and gender; however, whether they are associated with depression varies considerably among studies [[
The objective of this study was to evaluate individuals after stroke who participated in a home-based rehabilitation program to identify variables that correlate with depressive symptoms.
This study was granted ethics approval by the Western University Research Ethics Board in London, Ontario.
The Community Stroke Rehabilitation Teams (CSRTs) provide home-based, multidisciplinary care to patients after stroke in Southwestern Ontario. Each patient receives an individualized rehabilitation plan based on their needs; services include physiotherapy (PT), occupational therapy (OT), speech language pathology (SLP), social work (SW), Registered Nursing (RN), therapeutic recreation specialist therapy (TRS), and rehabilitation therapy (RT). To be enrolled in the program, patients must have a stroke diagnosis and exhibit an ongoing need for rehabilitation and show motivation and the physical and cognitive capability to actively participate. Patients may be self-referred or be referred by a clinician or physician from any care setting at any point in the care continuum (e.g., acute, inpatient, and community).
A retrospective review of patients receiving care between January 1, 2009, and September 30, 2015, was conducted. Data from the program was obtained from the CSRT’s central administrative database, which was recorded directly by the program staff and clinicians.
For patients to be included in this retrospective analysis they must have met the following four a priori inclusion criteria: (
Extracted data included demographic variables (e.g., age, gender, marital status, type of stroke, and time after stroke) and program variables (e.g., referral source and number of therapy visits). Referral source was categorized as acute care; inpatient rehabilitation; outpatient, community care access centre (CACC or home care), or Community; and unknown. Admission scores from the following outcome measures were collected on patients during the first therapy visit by the appropriate therapist: PHQ-2 and PHQ-9 (SW and/or OT), Functional Independence Measure (FIM; PT and/or OT), and Reintegration to Normal Living Index (RNLI; OT).
Patient Health Questionnaire (PHQ-2/PHQ-9). The PHQ-9 depression screen includes nine questions centred on a patient’s feelings during a two-week period directly prior to the day of testing [[
Based on an established stepwise screening approach [[
Functional Independence Measure (FIM). The FIM indicates an overall level of independence in activities of daily living (ADLs) using cognitive and motor functioning and measures disability based on burden of care [[
Reintegration to Normal Living Index (RNLI). The RNLI is a measure of a patient’s involvement in normal social activities, such as recreation and community participation, interaction with family or other relationships following a traumatic illness [[
Extracted data was entered into a Statistical Package for Social Sciences (SPSS; IBM, V22) database. Demographic statistics were calculated using frequencies and means with standard deviations. Prior to completing analyses, missing continuous data were analyzed using Little’s Missing Completely at Random (MCAR) test to further determine if multiple imputation would be appropriate to apply in this dataset [[
A binary logistic regression was performed to evaluate the association of independent variables to patients with moderate to severe depressive symptoms. To determine appropriate variables to use within the regression model, preliminary independent sample t-tests were conducted for continuous variables (i.e., age, time post stroke, FIM, and RNLI scores) and chi-square tests of independence were conducted for categorical variables (i.e., gender, referral source, marital status, and type of stroke) to compare patients displaying no symptoms to mild depressive symptoms (PHQ 2 score < 3 or PHQ-9 score of 0–9) against those with moderate to severe depressive symptoms (PHQ-9 score of 10–27).
Based on the preliminary analyses, resultant significant variables were then further analyzed in the regression. Collinearity diagnostics were conducted to ensure that the assumption of multicollinearity was not violated. Independent variables used in logistic regression were age, referral source, and FIM and RNLI scores. The fit of the model was determined through the Hosmer-Lemeshow goodness-of-fit statistic whereby a larger p value indicates a good model fit. The Hosmer-Lemeshow statistic represents the accuracy of the predicted number of cases compared to the true number of cases. Further, the percentage accuracy in classification was an indication of the cases correctly classified by the model. Analysis was conducted using SPSS. Findings have been presented with odds ratios, (OR), 95% confidence interval (CI), and p values where statistical significance was set at p<0.05, two-tailed.
A total of 3,227 patients participated in rehabilitation in the CSRT program between January 1, 2009, and September 30, 2015. However, after applying the inclusion criteria, a large proportion of the sample was excluded. A total of 1,725 patients received fewer than four therapist visits and, therefore, were not considered to be receiving active rehabilitation and were excluded. An additional 613 patients did not receive complete PHQ screening and were excluded. Thus, just 889 patients could be included for analysis (Figure 1). There was no significant difference between those meeting or not meeting inclusion criteria on age (p=0.062), gender (p=0.865), type of stroke (p=0.732), admission FIM scores (p=0.389), or HADS scores (p=0.986). The excluded group had fewer total therapy visits than the excluded group (p<0.001) which is consistent with the application of the inclusion criteria.
Patients’ ages ranged from 22 to 98 years (mean = 69.8±13.0) where 53.2% were male and patients were on average 83.6±200.5 days after stroke (median = 53.0). The majority of patients were referred from inpatient rehabilitation (49.6%), were married (61.1%), and had suffered an ischemic stroke (75.9%). Based on the depression screening, 89.7% (n=797) of patients were considered to have had no to mild depressive symptoms and 10.3% (n=92) were considered to have had moderate to severe depressive symptoms (Table 1).
Demographic and program descriptive variables for CSRT patients.
Variables All patients N=889 None to mild depressive symptoms1 N=797 Moderate to severe depressive symptoms2 N=92 Marital status, N (%) Single 97 (10.9%) 84 (10.5%) 13 (14.1%) Married/common law 543 (61.1%) 484 (60.7%) 59 (64.1%) Divorced/separated 47 (5.3%) 41 (5.1%) 6 (6.5%) Widowed 138 (15.5%) 130 (16.3%) 8 (8.7%) Other/unknown 64 (7.2%) 58 (7.3%) 6 (6.5%) Gender, N (%) Male 473 (53.2%) 428 (53.7%) 45 (48.9%) Female 415 (46.7%) 368 (46.2%) 47 (51.1%) Unknown 1 (0.1%) 1 (0.1%) 0 (0.0%) Mean age, years ± SD 69.8 ± 13.0 70.5 ± 12.7 63.4 ± 13.7 Referral source, N (%) Acute 293 (33.0%) 266 (33.4%) 27 (29.3%) Inpatient rehab 441 (49.6%) 402 (50.4%) 39 (42.4%) Outpatient Rehab/community/CCAC 154 (17.3%) 128 (16.1%) 26 (28.3%) Unknown 1 (0.1%) 1 (0.1%) 0 (0.0%) Type of stroke, N (%) Ischemic 675 (75.9%) 600 (75.3%) 75 (81.5%) Hemorrhagic 113 (12.7%) 104 (13.0%) 9 (9.8%) Unknown 101 (11.4%) 93 (11.7%) 8 (8.7%) Mean time following stroke, Days ± SD 83.6 ± 200.5 81.1 ± 206.2 104.8 ± 141.3
Note. PHQ1-9 scores 0–9; PHQ2-9 score ≥ 10; CCAC = community care access centre.
Prior to completing the analyses, Little’s MCAR test was performed to ensure a nonsignificant impact of missing variables, where chi-square results indicated that values were missing completely at random (X
Preliminary analyses of potential predictor variables for inclusion in regression model.
Variables Depressive symptom groups Independent samples t-tests PHQ-9 0–9 (n=797) PHQ-9 ≥ 10 (n=92) t p Mean age, years ± SD 70.5 ± 12.7 63.4 ± 13.7 5.032 0.001 Time post stroke, days ± SD 81.1 ± 206.2 104.8 ± 141.3 −1.063 0.288 FIM, score ± SD 105.8 ± 17.0 99.4 ± 20.1 3.218 0.001 RNLI, score ± SD 15.9 ± 4.2 12.9 ± 4.8 5.233 0.001 Chi-square test of independence X2 p Gender, N males 428 45 0.781 0.377 Referral source, N 8.746 0.013 Acute care 266 27 Inpatient rehab 402 39 Outpatient Rehab/CCAC/community 127 26 Unknown 0 0 Marital status, N 4.475 0.215 Single 84 13 Married 484 59 Divorced/separated 41 6 Widowed 130 8 Type of stroke, N 1.757 0.415 Ischemic 600 75 Hemorrhagic 104 9 Unknown 93 8
Note. CCAC = community care access centre; FIM = Functional Independence Measure; RNLI = Reintegration to Normal Living Index.
Sample size calculations were completed to ensure the sample size was adequate to perform the logistic regression with the specified independent variables (N=10×5/0.10=500) [[
Logistic regression model using pooled data from multiple imputation.
Variable B SE p Odds ratio 95% CI for odds ratio Lower Upper Age −0.044 0.009 0.001 0.957 0.941 0.973 Referral source (reference = acute) Inpatient rehab −0.252 0.283 0.372 0.777 0.446 1.352 Outpatient Rehab/CCAC/community 0.646 0.314 0.039 1.909 1.032 3.531 Admission FIM −0.013 0.007 0.065 0.987 0.974 1.000 Admission RNLI −0.106 0.032 0.001 0.899 0.845 0.957
Note. CCAC = community care access centre; FIM = Functional Independence Measure; RNLI = Reintegration to Normal Living Index.
The regression demonstrated that demographic factors and reintegration into normal living were independently associated with greater depressive symptoms. First, younger age was significantly associated with moderate to severe depressive symptoms (OR 0.96, C.I. 95%, 0.94, 0.97, p<0.001). The referral source also impacted reports of depressive symptoms whereby those referred from outpatient/CCAC/community settings were more likely to have depressive symptoms (PHQ > 10) than those referred from an acute setting (OR 1.87, C.I. 95%, 1.02, 3.50, p=0.04). There were no significant differences between referral groups for gender (p=0.337) or time after stroke (p=0.708). However, mean age (p<0.001) and admission FIM scores (p<0.001) were significantly different between referral groups. Those referred from outpatient settings were younger (66.0 years) compared to those from the community (67.9 years), acute care (68.4 years), inpatient rehabilitation (70.6 years), and CCAC (73.4 years). Those referred from CCAC had the lowest mean admission FIM scores (99.0) compared to those from inpatient rehabilitation (101.8), outpatient rehabilitation (106.7), the community (107.2), and acute care (110.8). Furthermore, patients’ ability to reintegrate into normal life (RNLI) was significantly related to depressive symptoms; lower reintegration scores (OR = 0.90, C.I. 95%, 0.85, 0.96, p=0.001) were associated with a greater odds of reporting depressive symptoms.
Among a large sample of individuals receiving home-based stroke rehabilitation, this study found that the majority of people had no or mild depressive symptoms (~90%), as determined by the PHQ-2/PHQ-9. Individuals who were referred from outpatient/CCAC/community settings (p=0.04), were younger (p<0.001), or had lower RNLI scores on admission (p=0.001) were more likely to have moderate to severe depressive symptoms (~10%). There was no difference between groups in gender, marital status, or type of stroke. Most notably, the logistic regression model was able to correctly classify 89% of depressive symptom cases.
PSD is a significant problem for many individuals. Prevalence rates are highly variable and have been shown to be correlated with several patient sociodemographic and clinical characteristics including timing, setting, and method of assessment after stroke, stroke type, and lesion side. The time at which patients are assessed and the setting in which they are assessed influence the extent to which depression is reported. For example, Matsuzuki et al. [[
Depression rate variability may also relate to method of screening and/or assessment. There are a plethora of depressive symptom screens and assessments, many of which have been used to evaluate the presence of PSD including the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Hopelessness Scale, Hospital Depression and Anxiety Scale, and “clinical judgement” [[
The current study reported that individuals who had moderate to severe depressive symptoms were younger than those with mild or no symptoms. These findings are in contrast to a recent systematic review which reported that, among sixteen studies, thirteen found no association between PSD and age whereas the remaining three reported a higher prevalence of PSD among older adults [[
Despite the fact that some studies have found no association between PSD and functional recovery [[
Functional ability and one’s ability to reintegrate into their community are tightly linked. Murtezani et al. [[
There are limitations to the current study that warrant mentioning. First, this study used retrospective data from a large administrative database; the large number of missing PHQ screens and its impact on study outcomes demonstrate the limitations of using such a database. Second, depression screen scores were collected on patients at a single point in time during the home-based rehabilitation program. Since cross-sectional analysis does not allow for one to draw longitudinal conclusions, this is a potential avenue for future research. Finally, the PHQ-2/PHQ-9 was used to identify patients with no to mild depressive symptoms versus moderate to severe depressive symptoms. This tool does not formally diagnose patients with depression. However, a significant study performed by Williams et al. [[
This study demonstrated that individuals with younger age, lower RNLI scores, or being referred from outpatient/CCAC/community settings were at increased odds of reporting moderate to severe depressive symptoms; these findings are in alignment with other studies. This research demonstrates the need for clinicians to continuously screen patients for depressive symptoms so that they are appropriately managed, given the functional and social ramifications of PSD.
The authors declare that they have no conflicts of interest.
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PHOTO (COLOR): Depression screening flow diagram.
By Julianne Vermeer; Amanda McIntyre; Shannon Janzen; Danielle Rice; Laura Allen; David Ure and Robert Teasell