However, we found no significant differences between patients with non-persistent depression and those with no depression with respect to proportion of women (29.6% vs. 28.7%, P = 0.792), rate of ischemic stroke (80.4% vs. 81.3%, P = 0.802), age (57.7 ± 10.1 vs. 56.7 ± 11.2, P = 0.248), NIHSS scores (3.5 [1.0–6.0] vs. 3.0 [1.0–5.0], P = 0.183), PCS scores (36.9 [23.9–52.6] vs. 40.3 [28.2–53.9], P = 0.111), and MCS scores (40.5 [25.6–48.4] vs. 41.7 [30.6–49.2], P = 0.063).
The risk factors associated with QoL assessed at the 5-year follow-up model are shown in Table 3. Even after adjusting for age, sex, marital status, education level, diagnosis, NIHSS score on admission, comorbidities, disability at 5 years, and stroke recurrence within 5 years, multivariable ordinal logistic regression revealed that persistent depression at the 1-year follow-up (odds ratio [OR]: 0.48; 95% confidence interval [CI]: 0.29–0.81) and disability at the 5-year follow-up (OR: 0.34; 95% CI: 0.23–0.49) were both independently associated with poor MCS scores at the 5-year follow-up. The variables associated with low PCS scores at the 5-year follow-up were as follows: age (OR: 0.97; 95% CI: 0.96–0.99), high NIHSS score at admission (OR: 0.94; 95% CI: 0.90–0.98), disability at the 5-year follow-up (OR: 0.19; 95% CI: 0.13–0.27), and stroke recurrence at the 5-year follow-up (OR: 0.53; 95% CI: 0.34–0.85).
Previous studies have observed that the baseline characteristics of patients with stroke are associated with the subsequent development of depression symptoms: for example, female stroke survivors are reportedly more likely to be dead or dependent at 12 months following stroke onset, and high baseline NIHSS scores are associated with an increased risk of neurological and medical complications. Some authors have postulated that such characteristics at baseline might, therefore, predict poor outcomes of patients following stroke.
To the best of our knowledge, this study is the first nationwide longitudinal multi-center prospective cohort study to study the effect of the time course of PSD on the QoL of stroke survivors. PSD is a long-term problem that can occur in the sub-acute and acute hospitalization phases as well as in later stages. While previous research has indicated a link between persistent depression and a high risk of poor prognosis and that recovery from depression after stroke might reduce the negative impact of the disease on QoL,[10,32–34] only three longitudinal studies have thus far reported that depression in the acute and sub-acute phases independently predicts poor QoL among stroke patients. Of these investigations, two have reported that PSD was independently associated with poor QoL at 1 year,[32,35] while one reported that PSD at 3 months could predict poor QoL at 5 years after stroke.
While some investigations have reported that most cases of PSD recover spontaneously within a few months without any treatment,[17,37] others have reported that PSD might remain persistent in some cases.[11,33,38] In the present study, 10.0% (80/801) of stroke survivors exhibited persistent depression, and this result is consistent with a previous study, which reported 9.2% of stroke survivors had persistent depression in the 1-year follow-up.
In agreement with our study, a previous investigation found that psychiatric symptoms affected MCS scores, while neurological conditions influenced PCS scores; specifically, the investigators found that persistent depression could predict low MCS scores but could not predict long-term PCS scores. However, several cross-sectional studies have reported that PSD adversely affects both the physical and psychological dimensions of QoL.[5,8] This discrepancy in findings may indicate that patterns of MCS and PCS differ among various stroke conditions: for example, in cross-sectional studies, depression symptoms coexisted with neurological impairment, which may have impeded the rehabilitation of physical function in stroke patients; and while depression may limit gait recovery after stroke, poor physical health may negatively affect the mental dimensions of QoL in stroke patients.
This study is subject to several limitations. First, due to the absence of certain assessment scales, patients with aphasia who were unable to complete the self-rating scales were excluded; reliably measuring depression in these patients was thought to have been overly challenging. Second, mood was continuously assessed only in the first year but not thereafter. Third, although we performed a comparison between the baseline characteristics of the included patients and those who did not complete the 5-year follow-up, and did not find significant difference, however, no comparison has been made between the baseline characteristics of the patients lost at 1-year follow-up and those of the included patients.
This work was supported by grants from the National Key Research & Development Program of China (No. 2016YFC1307200), Beijing Brain Research (No. Z161100000216131), and Beijing Municipal Science & Technology Commission (No. Z151100004015127).
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