Stroke-2013-Ayerbe-1105-10

1105

Although depression is a recognized outcome of stroke,1 most studies investigating depression after stroke have limitations, including selection bias, short follow-up, and small sample size.2,3 The prevalence of depression in the first few years after stroke has been reported in several studies.2 Nonetheless, evidence is poor or lacking on other estimates of the long-term natural history of depression, such as the post-stroke incidence, cumulative incidence, time of onset, dura-tion, and recurrence rate.2 Interventions for depression after stroke only show limited effect. Whether these interventions had been started at the right time after stroke and given for an adequate length of time to obtain maximal sustained response has been questioned.4

In this article, the poststroke incidence, cumulative inci-dence, prevalence, time of onset, duration, and recurrence rate of depression up to 15 years after stroke are estimated in a population-based study.

MethodsFirst in a lifetime stroke patients were recruited from the South London Stroke Register (SLSR), a prospective population-based stroke register covering an inner-city population of 271 817.5 Data from patients, registered in the SLSR between January 1, 1995, and December 31, 2009, and followed up between April 1, 1995 (first 3 months of follow-up assessments), and August 31, 2010, were used (patients at registration, N=4022).

Patients were registered during the acute phase of stroke and were then followed up for 3 months after stroke, 1 year after stroke, and an-nually thereafter. The World Health Organization definition of stroke was used.6 Follow-up was by postal questionnaire or interview, de-pending on the capacity of patient to fill in the questionnaire. Such capacity was judged by the patient, the next of kin, or the field worker in a preceding follow-up assessment. Patients unable to complete the follow-up questionnaire, and those not returning them by post, were telephoned to arrange face-to-face interviews or have another follow-up questionnaire posted. Patients who could not be followed up at one time point remained registered and were contacted again for the following annual assessment. At follow-up, patients were

Background and PurposeEvidence on the natural history of depression after stroke is still insufficient to inform prognosis and treatment strategies. This study estimates the incidence, cumulative incidence, prevalence, time of onset, duration, and recurrence rate of depression up to 15 years after stroke.

MethodsData from patients registered in the South London Stroke Register between 1995 and 2009 were used (N=4022 at registration. Maximum number of participants for these analyses n=1233). Depression was assessed in all patients with the Hospital Anxiety and Depression Scale (scores >7=depression) 3 months after stroke, 1 year after stroke, and annually thereafter up to 15 years after stroke. Inverse probability weighting was used to calculate the estimates accounting for missing data.

ResultsThe poststroke incidence of depression ranged from 7% to 21% in the 15 years after a stroke, with cumulative incidence of 55% and prevalence ranging from 29% to 39%. Most episodes of depression started within a year of stroke, with 33% of the cases starting in the 3 months after a stroke, and none from year 10 onward. Fifty percent of the patients with depression at 3 months had recovered 1 year after stroke. The proportion of recurrent episodes of depression after stroke increased gradually from 38% in year 2 to 100% in years 14 and 15.

ConclusionsThe natural history of depression after stroke is dynamic. Depression affects most of the stroke patients with episodes that have a short duration but a high risk of recurrence in the long term. (Stroke. 2013;44:1105-1110.)

Key Words: cohort studies depression incidence natural history prevalence stroke

The Natural History of Depression up to 15 Years After Stroke

The South London Stroke RegisterLuis Ayerbe, MSc; Salma Ayis, PhD; Siobhan Crichton, MSc;

Charles D.A. Wolfe, FFPH; Anthony G. Rudd, FRCP

Received October 4, 2012; final revision received December 21, 2012; accepted December 28, 2012.From the Division of Health and Social Care Research, Kings College London, London, United Kingdom (L.A., S.A., S.C., C.D.A.W., A.G.R.);

National Institute for Health Research (NIHR) Biomedical Research Centre, Guys and St Thomas NHS Foundation Trust, London, United Kingdom (C.D.A.W.); and Stroke Unit, Guys and St. Thomas NHS Foundation Trust, St. Thomas Hospital, London, United Kingdom (A.G.R.).

The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA. 111.679340/-/DC1.

Correspondence to Luis Ayerbe, 7th Floor, Capital House, 42 Weston Street, London SE1 3QD, United Kingdom. E-mail [email protected]

2013 American Heart Association, Inc.Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.111.679340

2013

8,13,46

Sangeetha

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1106 Stroke April 2013

assessed for depression using the Hospital Anxiety and Depression Scale (HADS).7 Scores >7 in the HADS depression subscale were considered depression. HADS has been validated in stroke patients showing a good performance both when it is used in a face-to-face interview and when it is self-administered8 (Cronbachs alpha > 0.80; optimum performance when HADS subscales scores >7 are used to identify depression, sensitivity: 73.1, and specificity: 81.6).7 Despite its good performance, HADS is not a diagnostic scale but a screening tool that indicates risk of depression. However, the term depression will be used in this article for succinctness in patients with scores >7. HADS was routinely collected between 1997 and 2010. Patients reg-istered in 1995 (n=299) and 1996 (n=350) received their first HADS assessment in 1997. Data on HADS were, therefore, not included from these patients in the respective estimates for early rates of de-pression. Because HADS cannot be answered by proxy, all infor-mation was collected directly from patients. Although patients with some degree of cognitive or communication impairment can respond to HADS, no data could be collected from patients with severe cogni-tive or communication impairment that the field worker, or the pa-tients next of kin in case of postal questionnaire, judged would give invalid responses.

Statistical MethodsThe poststroke incidence of depression was calculated among pa-tients assessed at each time point who were also assessed and not depressed in the previous follow-up. Poststroke incidence of depres-sion 3 months after stroke was not calculated because there were no depression assessments before that point. The cumulative incidence of depression was calculated among patients assessed for depression at any time point. The prevalence of depression was calculated among survivors assessed at each time point. The proportion of patients who became depressed for the first time at each assessment, between 3 months and 15 years after stroke, was calculated among patients with complete follow-up until each time point. The proportion of patients depressed at 3 months who recovered each year was calculated among patients with complete follow-up until each time point. Finally, to es-timate recurrence rate, the proportion of patients not depressed at one time point, becoming depressed in the following one and having a pre-vious episode of depression reported, was calculated among patients who had 3 follow-up assessments. Sociodemographic and clinical characteristics of survivors completing and not completing HADS were compared using 2 test because these variables were categorical.

As a first step, all estimates were obtained only from patients with complete data (ie, complete case [CC] analysis). However, estimates obtained from CC analysis may be biased if the excluded individu-als are systematically different from those included. Therefore, in a second step, estimates were calculated using inverse probability weighting (IPW).9 Using IPW, cases were weighted by the inverse of their probability of being a CC. To weight the probability of being complete, a variable of completeness was created for each estimate. For example, prevalence of depression at 3 months is 1=observed and 0=missing. A logistic regression model was built to identify predic-tors of completeness. Variables included in the models were those considered to be associated with completeness: age, sex, ethnicity, stroke severity measures (Glasgow Coma Scale, incontinence, and paresis), and disability at baseline. The inverse of the probability of being a CC was calculated and applied to individuals with available data. Finally, estimates were calculated on weighted data. Weighted and CC estimates are presented. For cases with weight >25, only CC estimates are presented because IPW can also introduce error when weights are very large.9 IPW was not used to estimate rate of recur-rences because the number of patients available each year was too low, between 1 and 68, to allow for a stable model of completeness to be built.10

Some estimates, particularly those obtained with small number of patients toward the end of the follow-up, had confidence intervals with values >1 or

Ayerbe et al Natural History of Depression After Stroke 1107

stroke patients and a dynamic natural history of depression in the long term after stroke. The cumulative incidence of depression in stroke cohorts has been so rarely reported in previous studies that the overall importance of depression among stroke patients has probably been underestimated.2,3 The duration of the episodes of depression is relatively short. Other studies following stroke patients for up to 3 years published similar results.1214 The increase in recurrent episodes observed during the 15-year follow-up explains

why depression starting shortly after stroke and having short duration has a stable prevalence.

The SLSR does not have a control arm, therefore it was not possible to know whether estimates of depression were different from the ones in general population. Two previous studies observed that significantly more stroke survivors were depressed than controls.15,16 Studies observing general population report lower frequency of depression than that observed among stroke patients with a cumulative incidence

Table 1. Poststroke Incidence of Depression up to 15 Years After Stroke

Follow-up, y Patient at Risk Depression Poststroke Incidence (95% CI) Weighted Poststroke Incidence (95% CI)

1 518 85 16.4 (13.219.6) 17.8 (14.021.6)

2 488 93 19.1 (15.622.6) 20.5 (16.624.5)

3 423 69 16.3 (12.819.8) 16.9 (13.020.8)

4 498 85 17.1 (13.720.4) 17.5 (13.721.2)

5 356 58 16.3 (12.420.1) 18.5 (13.823.1)

6 281 42 14.9 (10.719.1) 14.11 (9.518.7)

7 268 52 19.4 (14.624.2) 22.3 (16.128.6)

8 205 27 13.2 (8.517.8) 15.2 (9.421.1)

9 159 27 17.0 (11.122.9) 17.9 (11.024.9)

10 113 22 19.5 (12.026.9) 21.6 (11.931.2)

11 94 15 15.9 (8.423.5) NR

12 66 12 18.2 (8.627.7) NR

13 43 9 20.9 (8.333.6) NR

14 15 1 6.7 (0.226.4)* NR

15 7 1 14.3 (0.350.1)* NR

Because patients who were lost to follow-up for 1 year remained registered and were contacted again the following year, the number of patients at risk may be higher than the number of patients at risk, minus the number of incident cases, in the previous assessment. CI indicates confidence interval; and NR, not reported.

*Proportions calculated using arcsine correction.Weights >25 were considered too high.Estimate not reported as arcsine correction cannot be used, and weighted estimates included CIs with values >1 or


of depression between 13% and 17% during patients lifetime and incidence between 5% and 10%.1719

It has been reported that medical illness, not only stroke, increases the risk of depression.20 The World Health

Organization World Health Survey reported from observations in 60 countries that up to 23% of patients with chronic physical diseases had comorbid depression.21 Life-threatening illness, unpleasant treatments, and drugs causing depression as a side

Table 3. Proportion of Patients (With Complete Follow-up) With New Cases of Depression Annually

Follow-upNumber of Patients With Complete

Follow-up to Each Time Point

Patients With Complete Follow-up and

Depression First Detected

Proportion of Patients With Complete Follow-up and

Depression First Detected

Weighted Proportion of Patients With Complete Follow-up

and Depression First Detected

3 mo 1101 361 32.8 (30.035.6) 33.2 (30.036.4)

1, y 750 85 11.3 (9.013.6) 12.0 (9.414.7)

2, y 450 40 8.9 (6.211.5) 9.4 (6.412.3)

3, y 329 17 5.2 (2.87.6) 5.6 (2.88.3)

4, y 249 16 6.4 (3.39.5) 5.2 (2.58.0)

5, y 154 3 1.9 (0.44.9)* NR

6, y 87 0 0 NR

7, y 44 4 8.3 (0.216.4) NR

8, y 36 0 0 NR

9, y 27 1 3.7 (0.0915.4)* NR

10, y 14 0 0 NR

11, y 11 0 0 NR

12, y 5 0 0 NR

13, y No observations



NR indicates not reported.*Proportions calculated using arcsine correction.Weights >25 were considered too high.Estimate not reported as arcsine correction cannot be used, and weighted estimates included confidence intervals with values >1 or 12 years.

Table 4. Recovery After Depression After Stroke

Recovery Time, y

Patients With Depression at 3 mo With

Complete Follow-up

Patients With Depression at 3 mo

Recovered for the First Time

Proportion of Patients Depressed at 3 mo Recovered

for the First Time (95% CI)

Weighted Proportion of Patients Depressed at 3 mo

Recovered for the First Time (95% CI)

1 232 116 50.0 (43.556.5) 50.3 (43.157.6)

2 139 19 13.7 (7.919.4) 13.9 (7.320.4)

3 92 7 7.6 (2.113.1) 8.1 (1.614.7)

4 74 3 4.0 (0.910.1)* NR

5 41 1 2.4 (0.0610.3)* NR

6 26 1 3.8 (0.115.9)* NR

7 12 0 0 NR

8 9 0 0 NR

9 7 1 14.3 (0.350.1)* NR

10 5 0 0 NR

11 5 0 0 NR

12 2 0 0 NR||

13 0

14 0

15 0

CI indicates confidence interval; and NR, not reported.*Proportions calculated using arcsine correction.Weights >25 were considered too high.Estimate not reported as arcsine correction cannot be used, and weighted estimates included CIs with values >1 or

Ayerbe et al Natural History of Depression After Stroke 1109

effect may explain this association.20 Most of these apply to stroke patients. However, the increased prevalence of depres-sion specifically among stroke patients may also be attribut-able to other causes, including the following: (1) depression is a risk factor for stroke, therefore the proportion of patients at risk of depression may be increased among stroke patients; (2) depression and stroke have risk factors in common, such as sedentary lifestyle; (3) depression is a secondary psycho-logical reaction to stroke; (4) depression is secondary to other outcomes of stroke, such as cognitive impairment; and (5) stroke has a direct pathophysiological effect on the brain (eg, increase of cytokine levels).22

As in almost all cohort studies, there are some missing data in this study. This was not only attributable to the difficulty in following up patients for so long but also to the difficulty of some patients in responding to the HADS. The exclusion of patients with cognitive and communication impairment is a limitation affecting most studies of depression in stroke cohorts.2 Nonetheless, missing data were handled using IPW, and to obtain maximum robustness, both the results of IPW and CC analysis are presented. Although IPW adjusts for differences in characteristics of patients with complete and incomplete follow-up, it cannot adjust for unmeasured fac-tors, which may result in some patients being more likely to have incomplete follow-up. However, it should be acknowl-edged that weighted and CC estimates were always consis-tent. This suggests that although part of the sociodemographic groups are more likely to be missing than others, this had little impact on the estimates of the natural history of depression after stroke. Therefore, the validity of results from CC analy-sis should be considered.

To assess the natural history of depression, it would have been ideal to followup patients more frequently because the average duration of episodes of depression is shorter than 1 year.19 It would have also been better to assess depression with a diagnostic tool as well, such as the Diagnostic and Statistical Manual of Mental Disorders-IV criteria.23 However,

these limitations are common in large epidemiology studies, such as the SLSR. The HADS shows a good performance detecting depression in patients with no psychiatric conditions according to a systematic review.7 The SLSR is probably the largest population-based cohort of stroke patients followed up for so long. It provides the least biased sampling frame and good statistical power in the analyses of data collected in the long term after stroke, in contrast with previous studies.2 A capturerecapture analysis conducted with the data on inci-dent strokes registered in the SLSR concluded that 88% of the strokes occurring in the study area were being registered.24

Clinicians should acknowledge that depression remains a frequent active problem long after stroke, even when stroke seems to be completely settled and many other medical issues may have presented. With the exception of those patients who do not become depressed shortly after stroke, who seem to be at lower risk, depression requires periodic clinical atten-tion in the long term. The high rate of recurrence of depres-sion should be noted. Assuming that a patient recovering from depression is a closed case could lead to a late diagnosis or an overlooking of a further episode.

AcknowledgmentsWe thank all patients and healthcare professionals involved. Particular thanks to field workers and the team working since 1995 for the South London Stroke Register and the Stroke Research Team at Kings College London.

Sources of FundingThe study was funded by Guys and St Thomas Hospital Charity, The Stroke Association, Department of Health HQIP grant, UK, National Institute for Health Research Program Grant (RP-PG-0407-10184). Charles D.A. Wolfe acknowledges financial sup-port from the Department of Health via the National Institute for Health Research (NIHR) Biomedical Research Center award to Guys and St Thomas NHS Foundation Trust in partnership with Kings College London.

DisclosureCharles D.A. Wolfe is an NIHR Senior Investigator. This article pres-ents independent research commissioned by the National Institute for Health Research (NIHR) under its Program Grants for Applied Research funding scheme (RP-PG-0407-10184). The views ex-pressed in this article are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health. The other authors have no conflicts to report.

References 1. Wolfe CD, Crichton SL, Heuschmann PU, McKevitt CJ, Toschke AM,

Grieve AP, et al. Estimates of outcomes up to ten years after stroke: analysis from the prospective South London Stroke Register. PLoS Med. 2011;8:e1001033.

2. Ayerbe L, Ayis S, Wolfe C, Rudd A. A systematic review and meta-analysis of depression after stroke, its natural history, predictors, and outcomes. Br J Psychiatry. 2013;202:1421.

3. Hackett ML, Yapa C, Parag V, Anderson CS. Frequency of depres-sion after stroke: a systematic review of observational studies. Stroke. 2005;36:13301340.

4. Hackett ML, Anderson CS, House A, Xia J. Interventions for treating depression after stroke. Cochrane Database Syst Rev. 2008:CD003437.

5. Heuschmann PU, Grieve AP, Toschke AM, Rudd AG, Wolfe CD. Ethnic group disparities in 10-year trends in stroke incidence and vas-cular risk factors: the South London Stroke Register (SLSR). Stroke. 2008;39:22042210.

Table 5. Proportion of Recurrent Cases of Depression After Stroke

Follow-up, y

No. of Incident Cases With 3 Assessments

No. of Cases With 1 Previous Episode

of DepressionProportion of

Recurrent Cases

2 65 25 38.5 (26.350.6)

3 57 26 45.6 (32.358.9)

4 68 29 42.6 (30.654.7)

5 54 31 57.4 (43.871.0)

6 40 27 67.5 (52.382.7)

7 51 31 60.7 (46.974.6)

8 26 20 76.9 (59.694.3)

9 27 17 63.0 (43.582.4)

10 22 17 77.3 (58.296.3)

11 15 12 80.0 (55.0100.0)*

12 12 10 83.3 (56.7100.0)*

13 8 7 87.5 (54.999.7)*

14 1 1 100

15 1 1 100

*Proportions calculated using arcsine correction.

by guest on August 23, 2015http://stroke.ahajournals.org/Downloaded from


6. Hatano S. Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ. 1976;54:541553.

7. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002;52:6977.

8. Aben I, Verhey F, Lousberg R, Lodder J, Honig A. Validity of the beck depression inventory, hospital anxiety and depression scale, SCL-90, and Hamilton depression rating scale as screening instruments for depression in stroke patients. Psychosomatics. 2002;43:386393.

9. Seaman SR, White IR. Review of inverse probability weighting for deal-ing with missing data. Stat Methods Med Res. 2011.

10. Counsell C, Dennis M. Systematic review of prognostic models in patients with acute stroke. Cerebrovasc Dis. 2001;12:159170.

11. Gleason J. Improved confidence intervals for binomial proportions. Stata Tech Bull. 1999:1618.

12. Farner L, Wagle J, Engedal K, Flekky KM, Wyller TB, Fure B. Depressive symptoms in stroke patients: a 13 month follow-up study of patients referred to a rehabilitation unit. J Affect Disord. 2010;127:211218.

13. Wade DT, Legh-Smith J, Hewer RA. Depressed mood after stroke. A community study of its frequency. Br J Psychiatry. 1987;151:200205.

14. Astrm M, Adolfsson R, Asplund K. Major depression in stroke patients. A 3-year longitudinal study. Stroke. 1993;24:976982.

15. Kase CS, Wolf PA, Kelly-Hayes M, Kannel WB, Beiser A, DAgostino RB. Intellectual decline after stroke: the Framingham Study. Stroke. 1998;29:805812.

16. House A, Dennis M, Mogridge L, Warlow C, Hawton K, Jones L. Mood disorders in the year after first stroke. Br J Psychiatry. 1991;158:8392.

17. Nabi H, Chastang JF, Lefvre T, Dugravot A, Melchior M, Marmot MG, et al. Trajectories of depressive episodes and hypertension over 24 years: the Whitehall II prospective cohort study. Hypertension. 2011;57:710716.

18. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al.; National Comorbidity Survey Replication. The epide-miology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). J Am Med Assoc. 2003;289: 30953105.

19. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62:10971106.

20. Peveler R, Carson A, Rodin G. Depression in medical patients. BMJ. 2002;325:149152.

21. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007;370:851858.

22. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54:216226.

23. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington DC: American Psychiatric Association; 1994.

24. Tilling K, Sterne JA, Wolfe CD. Estimation of the incidence of stroke using a capture-recapture model including covariates. Int J Epidemiol. 2001;30:13519; discussion 1359.


SUPPLEMENTAL MATERIAL

Follow up time Registration period

since stroke

3 months 1995-2009 N=4022

1 year 1995-2009 N=3957

2 year 1995-2008 N=3740

3 year 1995-2007 N=3524

4 year 1995-2006 N=3287

5 year 1995-2005 N=3065

6 year 1995-2004 N=2807

7 year 1995-2003 N=2562

8 year 1995-2002 N=2288

9 year 1995-2001N=2018

10 year 1995-2000 N=1726

11 year 1995-1999 N=1502

12 year 1995-1998 N=1193

13 year 1995-1997 N=863

14 year 1995-1996 N=542

15 year 1995-1996 N=204

Supplement 1. Number of participants included in the analysis at each follow up time point

N= number of patients registered.

Dead

HADS=number of patients completing the depression scale.

FU= Number of patients followed up at each time point.

LTF=Number of patients lost to follow up at each time point.

# Note that some patients who were followed up could not be assessed with HADS due to cognitive or communication impairment.

**The 649 patients registered in 1995 and 1996 were not assessed for depression at this point as HADs was routinely collected from 1997.

Proportion of patients assessed with HADS over the total patients followed up and lost to follow up

##The 299 patients registered in 1995 were not assessed for depression at this time point as HADs was routinely collected from 1997.

HADS completed / HADS not completed

Age>65(%) Female gender (%) White ethnicity (%) Black ethnicity (%)

3m 64.3/64.9 46.0/47.4 71.1/70.1 22.7/23.2

1y 61.0/65.3 44.6/46.2 71.1/68.3 22.7/24.8

2y 59.3/59.5 44.9/44.1 66.7/69.3 26.1/24.0

3y 57.4/55.6 42.6/45.2 70.5/62.8 23.4/27.7

4y 54.0/55.4 45.6/40.7 68.6/62.6 24.7/28.2

5y 49.8/55.3 41.6/43.8 68.3/64.5 23.8/27.3

6y 50.7/50.7 43.8/42.4 69.2/61.5 24.2/29.4

7y 49.3/48.2 42.5/40.7 68.9/59.9 25.2/31.7

8y 44.1/47.2 38.8/44.2 64.2/63.8 29.4/28.0

9y 38.8/46.9 41.2/39.8 67.9/60.3 25.6/30.7

10y 37.6/44.4 41.4/41.8 67.9/58.1 24.8/33.5

11y 44.8/35.7 38.8/42.2 69.6/61.4 23.8/30.7

12y 39.7/35.1 36.2/43.2 70.7/56.0 22.4/38.5

13y 33.3/40.2 36.1/44.8 68.1/61.2 27.8/30.6

14y 37.0/39.1 39.1/37.0 66.7/63.0 31.1/30.4

15y 43.7/50 56.2/25.0 66.7/56.2 26.7/37.5

Supplement 2 Comparison of sociodemographic characteristics of the survivors assessed, and

not assessed, with the HADS at each time point

p

HAD completed / HADS not completed

GCS>12

(%)

Urine continence

(%)

No paresis

(%)

Barthel Index=20

(%)

3m 90.0/84.3 73.3/64.0 26.8/24.9 32.5/29.1

1y 90.7/84.1 75.0/65.2 30.2/22.3 37.8/26.3

2y 89.5/86.8 77.2/68.6 30.7/24.5 41.2/28.7

3y 88.7/86.5 75.3/68.2 28.9/26.0 37.0/32.7

4y 90.6/86.3 76.6/69.1 30.8/25.4 40.6/33.7

5y 89.7/88.4 78.7/71.3 33.1/25.4 41.9/36.9

6y 90.6/85.8 81.8/69.3 32.2/25.7 44.4/34.3

7y 90.2/86.1 80.0/72.6 33.9/25.6 43.1/36.3

8y 90.1/85.7 79.9/72.8 32.9/28.3 42.1/38.0

9y 89.4/87.1 83.0/71.1 33.6/27.6 46.4/32.4

10y 87.9/87.8 80.2/72.2 33.5/27.4 44.3/32.9

11y 88.9/85.2 79.8/67.6 33.7/29.3 41.0/28.2

12y 85.1/86.2 74.3/71.3 27.8/28.2 38.2/29.9

13y 81.7/88.4 70.4/71.8 18.1/25.6 25.7/35.8

14y 87.0/91.3 73.9/78.3 17.4/19.6 31.8/35.6

15y 93.7/93.7 81.2/75.0 18.7/18.7 40.0/56.2

Supplement 3. Comparison of the stroke clinical characteristics of survivors assessed, and not assessed, with HADS at each time point

p

Post stroke Incidence (%)

0

10

20

30

40

50

60

Time (years) 1 3 6 9 12 15

Supplement 4. Incidence of Depression up to 15 years after stroke

Prevalence %

0

10

20

30

40

50

60

Time (years)

1 3 6 9 12 15

Supplement 5. Prevalence of Depression up to 15 years after stroke

Luis Ayerbe, Salma Ayis, Siobhan Crichton, Charles D.A. Wolfe and Anthony G. RuddRegister

The Natural History of Depression up to 15 Years After Stroke: The South London Stroke

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