Soc Psychiatry Psychiatr Epidemiol (1998) 33: 463±470
ORIGINAL PAPER
A.T.F. Beekman á B.W.J.H. Penninx á D.J.H. Deeg
J. Ormel á J.H. Smit á A.W. Braam á W. van Tilburg
Depression in survivors of stroke: a community-based study
of prevalence, risk factors and consequences
Accepted: 5 February 1998
Abstract Depression in survivors of stroke is both
common and clinically relevant. It is associated with
excess su€ering, handicap, suicidal ideation and mor-
tality and it hampers rehabilitation. Most of the data
currently available are derived from clinical studies. The
objective of the present study was to study the preva-
lence, risk factors and consequences of depression in
survivors of stroke, in a large (n ˆ 3050) community-
based study of older (55±85 years) people in three re-
gions of the Netherlands. Depression was measured
using the CES-D scale; histories of stroke were obtained
using self-reports and data from general practitioners.
The study was designed as a case-control study, using
both bivariate and multivariate analyses. The prevalence
of depression in stroke survivors was 27%, which was
signi®cantly higher than the base rate (OR 2.28, 95% CI
1.61±3.24). Both stroke-related disease characteristics
and psychosocial characteristics of the respondents were
predictors of depression. The consequences of depres-
A.T.F. Beekman á D.J.H. Deeg á A.W. Braam á W. van Tilburg
Department of Psychiatry, and Institute for Extramural Medical
Research (EMGO), Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
B.W.J.H. Penninx
Institute for Extramural Medical Research (EMGO),
Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
J. Ormel
Department of Psychiatry, University of Groningen,
Groningen, The Netherlands
J.H. Smit
Department of Sociology and Social Gerontology,
Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
A.T.F. Beekman (&)
Department of Psychiatry, Vrije Universiteit Amsterdam,
PCA Valerius Clinic, Valeriusplein 9,
1075 BG Amsterdam, The Netherlands
Fax: +31-020-6737458
Ó Springer-Verlag 1998
sion were most evident in the realm of disability and
impairment of well-being. The patterns of service
utilization showed that depressed survivors of stroke
are relatively high users of a wide range of health
services.
Introduction
Stroke is one of the most devastating vascular events.
Within the older (65+) population in the Netherlands,
mortality directly attributed to stroke is estimated at
550±600 deaths per 100,000 per year in men, and 600±
625 in women. The point prevalence of stroke survi-
vorship is estimated at 3.7% (Central Bureau of Statis-
tics 1995). While stroke carries a high mortality, there
are substantial numbers of stroke survivors who have to
cope with severe handicaps and who are high utilizers of
medical care (Yearbook Nursing homes 1990). Although
there are several diculties in diagnosing depression
following stroke, the more than chance occurrence of
depression as a sequel to stroke is well established
(House 1987). The prevalence of post-stroke depression
is estimated at 20±50% of survivors of stroke admitted
to hospitals or rehabilitation units (Stevens et al. 1995).
In community-based studies, this ®gure is somewhat
lower, but it remains substantially higher than the base
rate in the community (Burvill et al. 1995).
Knowledge about the risk factors for developing de-
pression after stroke may be used to identify high-risk
groups and may be used in setting up treatment pro-
grammes. Direct biological pathways for the occurrence
of post-stroke depression are strongly suggested by
studies in which the localization of brain lesions corre-
lates with the risk of developing depression (Robinson
et al. 1984; Starkstein et al. 1988). The biological pathways
involved have been hypothesized to involve depletion of
neurotransmitters, such as serotonin, due to the brain
lesions caused by stroke (Bryer et al. 1992). However,
location of the lesion was not correlated with post-stroke
depression in other studies (House et al. 1991; Andersen
464
et al. 1995), leaving this issue unsettled. A second group
of risk factors that have been found to predict depres-
sion after stroke are not speci®c for stroke victims, but
are those factors generally associated with depression.
These factors include female sex, absence of close rela-
tionships or social support and personality characteris-
tics, such as neuroticism (Morris et al. 1991, 1993;
Sharpe et al. 1994). Stroke is a sudden, life-threatening
event, which, depending on the location and magnitude
of the cerebral lesions, may have an impact on virtually
all areas of functioning and totally change the life per-
spective of both the victims and their caregivers.
Through its consequences, stroke may initiate a number
of well-known psychosocial pathways to depression
(Felton and Revenson 1984; Turner and Noh 1988;
Friedland and McColl 1992). Therefore, both the clini-
cal characteristics of stroke and the psychosocial re-
sources of those a‚icted may be expected to predict the
occurrence of depression in survivors of stroke.
A further area of clinical interest concerns the con-
sequences of depression in stroke. Knowledge of the
excess su€ering, disability, mortality and service utili-
zation caused by depression in survivors of stroke may
help in designing strategies to mitigate these conse-
quences and may be used in the rehabilitation of stroke
patients. Clinical studies suggest that post-stroke de-
pression is associated with excess su€ering, handicap,
suicidal ideation and mortality (Astrom et al. 1992;
Schubert et al. 1992; Angeleri et al. 1993; Morris et al.
1993; Kishi et al. 1996). While depression hampers the
rehabilitation of survivors of stroke, various e€ective
treatment modalities are available (Masand et al. 1991;
Currier et al. 1992; Andersen et al. 1994a). Community-
based data on the consequences of depression in survi-
vors of stroke are needed to estimate its public health
importance and the impact systematic treatment of de-
pression may have.
The primary objectives of the present study were to
explore the prevalence, risk factors and potential con-
sequences of depression in a community-based sample of
stroke survivors.
Methods
Sampling and response
The Longitudinal Aging Study Amsterdam (LASA) is a 10-year
longitudinal study on predictors and consequences of changes in
well-being and autonomy in the elderly (Deeg et al. 1993). Details
on the methodology and results of the sampling strategy are re-
ported elsewhere (Beekman et al. 1995). In brief, a random sample
of older (55±85 years) men and women was drawn from the pop-
ulation registers of 11 municipalities in three regions of the Neth-
erlands. In order to be able to study age and sex di€erences, the
sample was strati®ed for age and sex. Persons aged 85 and above
were excluded, because the attrition rate of this age group was
expected to be too high over the 10-year study period. For reasons
of economy the sample was used in two studies: NESTOR-LSN
(van Tilburg 1995) and LASA. Respondents were ®rst interviewed
by the NESTOR-LSN team and, about 10 months later, by one of
the LASA interviewers. The response rate for the NESTOR-LSN
interview was 62.3%. As expected, non-response was associated
with age (P < 0.05), sex (P < 0.05) and urbanicity (P < 0.05).
The more elderly, females and those living in more urbanized areas
were less likely to respond. For LASA, all 3805 respondents to
NESTOR-LSN were approached, of whom 3107 (81.7%) took part
(Smit and de Vries 1994). Of the non-participants, 394 (10.4%)
refused to participate due to lack of interest; 134 (3.5%) were too ill
or cognitively impaired to be interviewed; 126 (3.3%) died before
being interviewed and 44 (1.2%) could not be contacted. Attrition
was related to age (P < 0.001), but not to sex. As expected, the
more elderly were more often found to be too ill or cognitively
impaired to participate (P < 0.05). Due to item non-response a
further 57 subjects were lost, leaving a study sample of 3050.
All interviews were conducted in the homes of respondents by
specially trained and intensively supervised interviewers. The in-
terviews were tape-recorded in order to control the quality of the
data. Interviewers worked with laptop computers and were en-
couraged to record any disturbance in the course of the interview.
Interviews were conducted between October 1992 and September
1993.
Measures
Depression
Depression was measured using the Center for Epidemiologic De-
pression Scale (CES-D, Radlo€ 1977). This is a 20-item self-report
scale, developed to measure depressive symptoms in the commu-
nity. It has been widely used in older community samples, and has
good psychometric properties in elderly samples (Himmelfarb and
Murrell 1983; Hertzog et al. 1990; Radlo€ 1986). The Dutch
translation had similar psychometric properties in three previously
studied samples of elderly in the Netherlands (Beekman et al.
1994). Moreover, criterion validity for major depression was very
satisfactory (sensitivity 100%, speci®city 88%, Beekman et al.
1997a). The overlap with symptoms of physical illness has been
shown to be minimal in a number of studies (Berkman et al. 1986;
Foelker and Shewcheck 1992). The CES-D generates a total score
which can range from 0 to 60. In order to identify respondents with
levels of depression that are clinically relevant, we used the gener-
ally used cut-o€ score of ³ 16 (Beekman et al. 1994, 1997a). As this
level of depressive symptomatology is comparable to what has been
called `pervasive depression' in previous studies (Gurland 1983;
Beekman et al. 1995), the term `pervasive depression' was adopted
for the present study also.
Stroke
Stroke was assessed using both self-reports and data supplied by
general practitioners (GPs). The self-reports included questions on
the history of stroke, speci®cally excluding transient ischaemic at-
tacks. In subjects with a positive history, additional questions were
asked regarding the number of stroke episodes, the date of the last
stroke, the severity of stroke (motor impairment of arms and legs,
visual impairment, problems with speech, problems understanding
text) and whether the subject was currently under treatment of a
physician or using medication speci®cally in relation to stroke
(Kriegsman et al. 1996). Moreover, questions were asked regarding
current functional limitations (van Sonsbeek 1988) and comorbid
chronic physical illnesses (Central Bureau of Statistics 1989).
Cognitive functioning was assessed using the Mini-Mental Status
Examination (MMSE, Folstein et al. 1975).
Concordance between GP and self-reported data on stroke
histories was fairly good (kappa 0.60) and not dependent on the
level of depressive symptomatology (Kriegsman et al. 1996).
Therefore, as misclassi®cation was nondi€erential with respect to
depressive status, any bias in the associations found between self-
reported histories of stroke and depression are in the direction of
underestimating the true associations (Rothman 1986). However,
as avoiding bias due to relying on self-reports was considered
 465

crucial for the present study, stroke was de®ned in two ways: (1) on was the dependent variable. The third step involved analyses re-
the basis of self-report and (2) on the basis of consensus between garding the consequences of depression. Here, separate analyses
respondent and GP. The disadvantage of the latter was that the were carried out, with each potential consequence of depression as
quality of the data supplied by the GPs could not be ascertained the dependent variable. Depression was one of a set of independent
and that there was a sizable non-response in the gathering of GP variables. Again, the sample was restricted to only the survivors of
data (Kriegsman et al. 1996). In the analyses, both de®nitions of stroke, and odds ratios were used to express the strength of asso-
stroke were used. As the di€erences in the results were small, and as ciations.
the numbers were reduced when using the GP data, all analyses
reported will rely on self-reported data on stroke.
Results
Psychosocial resources
Description of the sample
Psychosocial resources include the presence of a partner, the size of
the contact network, the amount of both emotional and instru- Table 1 shows the characteristics of the sample. The
mental support received by the subject, and a dimension of per-
sonality (locus of control). The network-related variables were
even representation of men and women, the high pro-
constructed from a questionnaire which included detailed questions portion of more elderly subjects and of subjects without
on both the number and the quality of contacts with members of a partner or with chronic diseases re¯ect the strati®ed
the social network (van Tilburg 1995). Locus of control was mea- sampling procedure. The prevalence of stroke was 5.7%.
sured using the scale developed by Pearlin and Schooler (1978). This is considerably higher than what is usually found in
the general population in the Netherlands (3.7%, Cen-
Consequences of depression tral Bureau of Statistics 1995). The relatively high ®gure
is the result of oversampling among the more elderly. It
A number of potential consequences of depression in survivors of also shows that attrition has not caused the study sample
stroke were studied. Disability was assessed using items regarding
bed-days and disability-days during the past month, derived from to become a sample of healthy elderly, and that the
the Medical Outcome Study (Anderson et al. 1990). Well-being was variables under study are well-represented.
assessed using a question on general satisfaction with life (Central
Bureau of Statistics 1989). Data on mortality were prospectively
assessed, using data supplied by the community registries of the
municipalities in which the respondents lived. The data on mor-
tality span on average 2‰ years from the interview. The use of a Table 1 Characteristics of the study sample (n = 3050)
wide range of health services, generally available in the Nether-
lands, was assessed using a questionnaire previously developed for Variable n %
use in community-based studies among the elderly in the Nether-
lands (Bosma 1988). Measures were based on self-reports and in- Sex
clude questions on admittances to general hospitals, consulting Men 1476 48.4
GPs, medical specialists, physiotherapy, social work, home nursing, Women 1574 51.6
professional home help, and ancillary services (meals on wheels and Age (years)
transport facilities). Finally, age, sex and the level of education 55±64 963 31.6
were included as control variables . All scales were previously val- 65±74 951 31.2
idated either in comparable samples in the Netherlands or in LASA 75±85 1136 37.2
pilot studies (Deeg et al. 1993).
Education (years)
5±8 1336 43.9
9±13 1362 44.7
Data analysis 14±18 347 11.5
The data were analysed in three steps. First, to assess the associa- Partner status
tion between stroke and depression in the sample (n ˆ 3050), Partner 1017 33.3
respondents with stroke were contrasted with those without stroke. No partner 2033 66.7
In these analyses, the control group may be varied. One option is to Number of chronic diseases
have subjects without any chronic disease constitute the control 0 1026 33.6
group. This seems the most precise contrast, as the presence of 1 1118 36.7
other diseases in the control group cannot confound the results. 2 573 18.8
However, subjects with stroke may also have comorbid chronic 3 or more 333 11.0
physical illnesses, the in¯uence of which will be attributed to stroke
when this contrast is used. The other option is, therefore, to use all Stroke
respondents without a history of stroke as the control group. Here No 2877 94.3
the presence of other chronic illnesses in the control group may Yes 173 5.7
confound the results of the comparison. To circumvent this prob- Functional limitations
lem, the results of analyses using both de®nitions of the control None 1785 59.1
group will be presented. Moreover, stroke was de®ned using both One or more 1235 40.9
self-reported data and data supplied by GPs. The depressive
symptom levels of subjects with and without stroke were compared, Subjective health
using analysis of variance. In analyses pertaining to pervasive Good 1909 62.6
depression, odds ratios with 95% con®dence intervals were calcu- Fair to poor 1139 37.4
lated. Pervasive depression
The second step involved analyses regarding the predictors of No 2599 85.2
depression in survivors of stroke. Here the study sample was re- Yes 451 14.8
duced to only the survivors of stroke (n ˆ 173), while depression
466
Stroke and depression
In Table 2, data concerning the association between
stroke and depression are shown. On the symptom level,
stroke is strongly associated with depression. Whichever
way stroke is de®ned, it is associated with approximately
a 50% increase in depressive symptoms. Within the
group of stroke survivors, the prevalence of pervasive
depression was 27.2% when relying on self-reported
data, and 27.3% when strict criteria for stroke were
adopted (concordance between self-reports and GP da-
ta). As would be predicted, de®ning stroke strictly leads
to a slightly higher odds ratio for depression (2.53 vs
2.28). This di€erence is small, and well within the 95%
con®dence limits of both odds ratios. The above results
may be in¯uenced by the presence of other physical ill-
nesses in the sample. In additional analyses, the odds of
depression in stroke survivors was contrasted with the
odds in those without any chronic disease. These data
are also summarised in Table 2. Due to the control
group being free of any chronic diseases, the contrast
with the group of stroke survivors is greater (OR 3.88,
95% CI 2.60±5.78).
Predictors of depression in survivors of stroke
Table 3 summarises the association between clinical
characteristics of stroke and pervasive depression. The
number of stroke episodes, the years since the last
stroke, having visual problems due to stroke, problems
understanding written text, comorbidity with other
chronic diseases, and currently being under treatment of
a physician or using medication speci®cally in relation to
stroke were not associated with higher risks of depres-
sion. In contrast with this, motor limitations in the use
of upper or lower limbs, problems with speech, func-
tional limitations and cognitive impairment were strong
predictors of post-stroke depression. Table 4 shows that
the size of the social network and the amount of both
emotional and instrumental support received were not
associated with depression. The absence of a partner and
Table 2 Stroke and depression:
bivariate associations (CES-D n CES-D score
center for Epidemiologic De-
pression scale, OR odds ratio,
CI con®dence interval)
Self reported data
No stroke 2877
Stroke 173
Concordance GP
No stroke 2230
Stroke 77
Stroke versus no
chronic diseases
No chronic diseases 1026
Stroke 173
* P < 0.001
a more external locus of control were both associated
with higher risks of depression.
Consequences of depression
Table 5 shows the results of a series of analyses, in which
the various consequences were the dependent variable,
and depression was one of a set of independent vari-
ables. Controlling for other variables which may cause
disability, depression appeared to carry an independent,
increased risk of disability and impaired well-being,
while it was not associated with excess mortality 2‰
years prospectively.
As would be expected, the base rate of service utili-
zation was quite high. Within the group of stroke sur-
vivors, depression was associated with more admittances
to general hospitals, and more use of physiotherapy,
social work, home help and medically subsidized trans-
port. Depression was not associated with more contacts
with GPs, medical specialists, use of home nursing or
meals on wheels. Results of bivariate analyses may be
confounded by a number of variables that are associated
both with depression and the use of services. Examples
are the level of functional limitation, cognitive decline,
the number of comorbid physical illnesses and other
variables, such as age, sex, the level of education and the
availability of a partner. In the last column of Table 5,
results are shown of multivariate analyses, controlling
for these potential confounders. Variables not associated
with depression in previous analyses, such as the time
since the last stroke and the number of strokes, were not
controlled for. As expected, some of the bivariate asso-
ciations were weakened by instigating controls. How-
ever, both the associations with disability and impaired
well-being remained virtually unchanged. Although the
odds ratio was only slightly lower, the association with
admissions to general hospitals was no longer signi®-
cant, nor were the associations with physiotherapy, so-
cial work, home help and using transport facilities.
Finally, a number of other services were used infre-
quently, yielding odds ratios with very wide con®dence
limits. The results are mentioned here, because of their
Pervasive depression
n (%) OR (95%CI)
7.79 * 404 (14.0) 2.28 (1.61±3.24)
11.08 47 (27.2)
7.50 * 288 (12.96) 2.53 (1.51±4.24)
10.75 21 (27.3)
5.99 * 90 ( 8.8) 3.88 (2.60±5.78)
11.08 47 (27.2)
 467

Table 3 Associations between

disease characteristics and de- Disease characteristic nb Pervasive depression
pression in the 173 survivors of
stroke (MMSE Mini-Mental % OR (95% CI)
State Examination)
No. of stroke episodes
1 121 28.1 0.79 (0.37±1.68)
2 51 23.5
Years since last strokea
0±2 59 32.6 1.02 (1.00±1.05)
3±7 51 30.4
³7 60 37.0
Treatment by physician
No 76 23.7 1.32 (0.66±2.64)
Yes 93 29.0
Use of speci®c medication
No 60 25.0 1.16 (0.57±2.38)
Yes 111 27.9
Limited use of arms or legs
No 70 11.4 3.01 (1.23±7.36)
Yes 75 28.0
Visual problems
No 113 17.7 1.82 (0.73±4.52)
Yes 32 28.1
Problems with speech
No 110 15.5 2.85 (1.20±6.80)
Yes 35 34.3
Problems understanding text
No 119 17.6 2.07 (0.80±5.40)
Yes 26 30.8
Comorbid chronic illness
No 36 30.6 0.81 (0.36±1.81)
Yes 137 26.3
Functional limitation
No 37 13.5 2.95 (1.07±8.12)
Yes 133 31.6
a
Odds ratio calculated per year Cognitive impairment
since last stroke (MMSE £ 23)
b
Numbers do not add to 173 in No 113 19.5 2.60 (1.28±5.28)
all cases due to item non-re- Yes 57 28.6
sponse

Table 4 Associations between psychosocial resources and depres- these, two were depressed. That is, 4.3% of the de-
sion in survivors of stroke (n = 173) pressed versus 0.8% of the non-depressed received
treatment in a nursing home (OR 5.56, 95% CI 0.49±
Psychosocial resource Bivariate analyses 62.76). Similarly, only ten (5.8%) of the survivors of
OR (95% CI)
stroke used the facilities of residential homes for the
Absent partner 2.38 (1.21±4.76) elderly. Of these, 40% were depressed. That is, 8.5% of
Smaller social network 1.05 (0.99±1.12) the depressed versus 4.8% of the non-depressed
Instrumental support 1.20 (0.72±2.00) used residential home facilities (OR 1.86, 95% CI
Emotional support 0.97 (0.59±1.61)
External locus of control 1.28 (1.14±1.45) 0.50±6.91).

economic impact. There was only one subject with a Discussion

psychiatric hospitalisation in the 6 months previous to
the interview. This subject was depressed. Only four
subjects (2.4% of total) were seen by local `indication
committees' for admittance to nursing homes. Of these,
three were depressed. That is, 6.5% of the depressed
subjects, versus 0.8% of non-depressed were admitted to
hospital (OR 8.30, 95% CI 0.84±82.0). Only three people
(1.7% of total) received treatment in a nursing home; of
The association between stroke and depression was
con®rmed in the present, community-based study.
Whichever way stroke was de®ned, it was associated
with about a 50% increase of depressive symptoms. The
prevalence of pervasive depression in survivors of stroke
was 27%, which is very similar to what was found in
other community-based studies (Burvill et al. 1995). The
468

Table 5 The consequences of depression in survivors of stroke (n = 173)

Consequence Occurrence in all Bivariate analysis Multivariate analysisa

stroke survivors OR (95% CI) OR (95% CI)
(n = 173)

Disability
Bed-days past month 12.8% 3.94 (1.57±9.90) 3.28 (1.21±8.93)
Days limited activities 18.7% 2.95 (1.33±6.56) 2.79 (1.13±6.90)
Impairment of well-being 24.5% 7.03 (2.64±18.70) 7.24 (2.37±22.14)
Mortality 16.2% 1.09 (0.44±2.67) 0.57 (0.19±1.66)
Services used past 6 months
Hospital admission 20.9% 2.72 (1.16±6.44) 2.57 (0.98±6.69)
General practitioner 82.4% 0.57 (0.24±1.32) 0.78 (0.27±2.18)
Medical specialists 65.2% 0.99 (0.45±2.13) 0.67 (0.25±1.73)
Physiotherapy 21.8% 2.64 (1.22±5.72) 2.21 (0.93±5.22)
Social work 4.2% 7.13 (1.33±38.20) 3.85 (0.50±29.62)
Home nursing 9.7% 2.19 (0.77±6.29) 1.88 (0.54±6.58)
Home help 11.5% 2.65 (1.01±7.03) 2.15 (0.76±6.10)
Ancillary services used past 6 months
Meals on wheels 6.7% 1.52 (0.42±5.47) 0.91 (0.22±3.79)
Transport 5.4% 5.85 (1.40±24.86) 4.47 (0.83±24.18)
a
Stepwise logistic regression analyses. In each service under study, depressed, controlling for age, sex, level of education, partner
service utilization was the dependent variable. Odds ratios were status, functional limitations, comorbid chronic diseases and cog-
calculated contrasting depressed survivors of stroke with the non- nitive decline

odds for being depressed varied between 2.28 and 3.88,
depending on the de®nition of stroke and with which
control group the stroke survivors were contrasted. Both
stroke-related disease characteristics (functional limita-
tions, limitations in the use of arms or legs, cognitive
impairment and problems with speech) and psychosocial
characteristics of the respondents (absence of a partner,
external locus of control) were predictors of depression
in stroke.
Controlling for confounding factors, the conse-
quences of depression in stroke-survivors were most
evident in the realm of well-being and disability. The
2‰-year mortality, assessed prospectively, was not pre-
dicted by depression in either bivariate or multivariate
analyses. In bivariate analyses it appeared that depressed
survivors of stroke are a group of relatively high utilizers
of medical care. This shows that providers of care for
stroke patients are highly likely to encounter patients
with comorbid depression. As depression may interfere
with key aspects of delivering adequate medical care,
such as building a lasting working alliance with both
patients and their caregivers, patient-compliance and
prevention of further adverse consequences of stroke,
these bivariate results are important. Previous analyses
of the LASA material suggested that depressed elderly
have more contacts with GPs and medical specialists
(Beekman et al. 1997b). The lack of association between
depression and visits to GPs or medical specialists
among survivors of stroke may be explained by their
very high base-rate of consulting GPs and medical spe-
cialists. In multivariate analyses, the odds of service
utilization remained fairly high in most instances, but
were no longer statistically signi®cant. The use of in-
tramural facilities has the greatest impact, both on the
lives of patients and from an economic perspective. Al-
though the low numbers do not allow drawing any ®rm
conclusions, the results suggest that comorbid depres-
sion may be associated with a relatively high risk of
admittances to general hospitals, or using the facilities of
nursing and residential homes.
A strong point of the present study was that it was
community based, thereby avoiding the selection bias
inherent in clinical studies. Through this bias, clinical
studies include patients with more severe and more
complex symptomatology. This explains why the prev-
alence of depression in survivors of stroke is somewhat
lower in community-based studies. It may also explain
why community-based studies generally suggest a
greater heterogeneity of risk factors of depression and
weaker associations when consequences of depression
are studied. However, the current study certainly has
methodological limitations. First, there was consider-
able non-response. Attrition was highest among the
more elderly, especially among the least healthy. The
sampling strategy was designed with the speci®c aim to
include sucient of the more elderly people to allow a
longitudinal study. As was shown, this strategy was
successful, in that the more elderly were well-repre-
sented. The high prevalence of chronic illnesses and
functional limitations shows that attrition had not led
the sample to become a sample of `healthy elderly'.
Paradoxically, the sampling strategy has led to a good
representation of all the variables under study, but also
to a lower response. As most analyses were based on
relative risks, representation of variables is more im-
portant than actual response rates. However, it is al-
most certain that people su€ering the most severe
symptoms of stroke, especially those that interfere with
memory and communication, were not able to con-
tribute to the study. As this is the most impaired group,

who probably use services intensively, data concerning
prevalence and consequences of concurrent depression
are most relevant. However, diagnosing depression in
this group is beset with diculties. Clearly, the present,
survey-type methodology is inadequate to study de-
pression in the most severely handicapped survivors of
stroke. This limits the generalizability of the results. A
second limitation is that most variables were measured
relying on self-reports. With regard to the identi®cation
of stroke survivors, self-reports could be compared with
data supplied by GPs. Concordance between respon-
dents and GPs was reasonably good and not dependent
on the level of depressive symptoms (Kriegsman et al.
1996). Therefore, as misclassi®cation was non-di€eren-
tial with respect to depressive status, any bias in the
associations found between self-reported histories of
stroke and depression are in the direction of underes-
timating the true associations (Rothman 1986). This is
demonstrated in Table 2, where the odds ratio is higher
when the analyses are restricted to subjects in which the
GP data are in agreement with the self-reports. More-
over, additional analyses, including only subjects in
which there was concordance between the GP and the
self-reports, yielded essentially the same results. Access
to hospital records or results of special investigations,
such as CT scans, would have strengthened the data,
but was not available. A third methodological point is
that the data are cross-sectional. The survivors of
stroke are therefore heterogeneous with regard to the
time since their last stroke. Clinical studies typically
include subjects at admission, that is, shortly after an
episode of stroke. The prevalence of depression after
stroke may be expected to drop after the ®rst months
(Andersen et al. 1994b). Moreover, there is evidence
that depression in stroke is more biologically deter-
mined in the ®rst months, psychosocial factors becom-
ing more important later on (Iacoboni et al. 1995). This
is an additional explanation of the lower prevalence of
depression and the more heterogeneous distribution of
risk factors in studies such as ours. Finally, drawing
causal inferences on the basis of cross-sectional data is
hazardous. Although multivariate controls were insti-
gated, the results should be interpreted with due cau-
tion.
Bearing the above limitations in mind, the results
suggest that depression is both common and clinically
relevant in survivors of stroke. The distribution of risk
factors underscores the necessity to integrate the bio-
logical and psychosocial paradigms when studying de-
pression in stroke. Moreover, although most of the
damage done by an episode of stroke cannot be mended,
most of the risk factors for depression can be targeted
for intervention. Examples are physiotherapy and sup-
portive measures to ameliorate the e€ects of functional
limitations, providing social support in patients without
a partner, and cognitive therapy for those with an ex-
ternal locus of control (Gurland et al. 1988). Finally, the
data suggest that training non-psychiatric providers of
469
medical care for stroke patients in recognizing and
working with depressed patients may help improve well-
being and prevent excess disability.
Acknowledgements This study was conducted in the context of the
Longitudinal Aging Study Amsterdam, which is largely funded by
the Dutch Ministry of Health, Welfare and Sports.
References
Andersen G, Vestergaard K, Lauritzen L (1994a) E€ective treat-
ment of post-stroke depression with the selective serotonin re-
uptake inhibitor citalopram. Stroke 25: 1099±1104
Andersen G, Vestergaard K, Riis J, Lauritzen L (1994b) Incidence
of post-stroke depression during the ®rst year in a large unse-
lected stroke population determined using a valid standardized
rating scale. Acta Psychiatr Scand 90: 190±195
Andersen G, Vestergaard K, Ingemann-Nielsen M, Lauritzen L
(1995) Risk factors for post-stroke depression. Acta Psychiatr
Scand 92: 193±198
Anderson JST, Sulivan F, Usherwood TP (1990) The Medical
Outcome Study Instrument (MOSI). Use of a new health status
measure in Britain. Fam Pract 7: 205±218
Angeleri F, Angeleri VA, Foschi N, Giaquinto S, Nolfe G (1993)
The in¯uence of depression, social activity and family stress on
functional outcome after stroke. Stroke 24: 1478±1483
Astrom M, Asplund K, Astrom T (1992) Psychosocial functioning
and life satisfaction after stroke. Stroke 23: 527±531
Beekman ATF, van Limbeek J, Deeg DJH, Wouters L, van Tilburg
W (1994) Screening for depression in the elderly in the com-
munity: using the Center for Epidemiologic Studies Depression
scale (CES-D) in the Netherlands. Tijdschr Gerontol Geriatr
25: 95±103
Beekman ATF, Deeg DJH, van Tilburg T, Smit JH, Hooijer Ch,
van Tilburg W (1995) Major and minor depression in later
life: a study of prevalence and risk factors. J A€ect Disord 36:
65±75
Beekman ATF, Deeg DJH, van Limbeek J, Braam AW, de Vries
MZ, van Tilburg W (1997a) Criterion validity of the Center for
Epidemiologic Studies Depression scale (CES-D): results from a
community-based sample of older subjects in the Netherlands.
Psychol Med 27: 231±235
Beekman ATF, Deeg DJH, Braam AW, Smit JH, van Tilburg W
(1997b) Consequences of major and minor depression in later
life: a study of disability, well-being and service utilization.
Psychol Med 27: 1397±1409
Berkman LF, Berkman CS, Kasl SV, Freeman DH, Leo L, Ostield
AM, Coroni-Huntly J, Brody JA (1986) Depressive symptoms
in relation to physical health and functioning in the elderly. Am
J Epidemiol 124: 372±388
Bosma A (1988) Health of persons in the third phase of life: a study
of physical and mental aspects. Gemeentelijke Gezondheids
Dienst, Eindhoven
Bryer JB, Starkstein SE, Votypka V, Parikh RM, Price TR, Rob-
inson RG (1992) Reduction of CSF monoamine metabolites in
post-stroke depression: a preliminary report. J Neuropsychiatry
Clin Neurosci 4: 440±442
Burvill PW, Johnson GA, Jamrozik KD, Anderson CS, Stewart-
Wynne EG, Chakera TM (1995) Prevalence of depression after
stroke: the Perth community stroke study. Br J Psychiatry 166:
320±327
Central Bureau of Statistics (1989) Health Interview Questionnaire.
CBS, Heerlen
Central Bureau of Statistics (1995) Vademecum of health statistics
in the Netherlands 1995. CBS, The Hague, p 119
Currier MB, Murray GB, Welch CC (1992) Electroconvulsive
therapy for post-stroke depressed geriatric patients. J Neuro-
psychiatry Clin Neurosci 4: 140±144
470
Deeg DJH, Knipscheer CPM, van Tilburg W (1993) Autonomy
and well-being in the aging population: concepts and design of
the Longitudinal Aging Study Amsterdam. NIG Trendstudies
no. 7. Netherlands Institute of Gerontology, Bunnik
Felton BJ, Revenson TA (1984) Coping with chronic illness: a
study of illness controllability and the in¯uence of coping
strategies on psychological adjustment. J Consult Clin Psychol
52: 343±353
Foelker GA, Shewchuk RM (1992) Somatic complaints and the
CES-D. J Am Geriatr Soc 40: 259±262
Folstein MF, Folstein SE, Mc Hugh PR (1975) `Mini-mental state'.
A practical method for grading the cognitive state of patients
for the clinician. J Psychiatr Res 12: 189±198
Friedland J, McColl M (1992) Disability and depression: some
etiological considerations. Soc Sci Med 34: 395±403
Gurland BJ (1983) The mind and mood of aging. Haworth Press,
New York
Gurland BJ, Wilder DE, Berkman C (1988) Depression and dis-
ability in the elderly: reciprocal relations and changes with age.
Int J Geriatr Psychiatry 3: 163±179
Hertzog C, van Alstine J, Usala PD, Hultsch DF, Dixon R (1990)
Measurement properties of the Center for Epidemiological
Studies Depression Scale (CES-D) in older populations. Psy-
chol Assess 2: 64±72
Himmelfarb S, Murrell SA (1983) Reliability and validity of ®ve
mental health scales in older persons. J Gerontol 38: 333±339
House A (1987) Mood disorders after stroke: a review of the evi-
dence. Int J Geriatr Psychiatry 2: 211±221
House A, Dennis M, Mogridge L (1991) Mood disorders in the
year after ®rst stroke. Br J Psychiatry 158: 83±92
Iacoboni M, Padovani A, Di Piero V, Lenzi GL (1995) Post-stroke
depression: relationships with morphological damage and cog-
nition over time. Ital J Neurol Sci 16: 209±216
Kishi Y, Kosier JT, Robinson RG (1996) Suicidal plans in patients
with acute stroke. J Nerv Ment Dis 184: 274±280
Kriegsman DMW, Penninx BWJH, van Eijk JThM, Boeke AJP,
Deeg DJH (1996) Self reports and general practitioner infor-
mation on the presence of chronic diseases in community-
dwelling elderly: a study of the accuracy of patients' selfreports
and of determinants of inaccuracy. J Clin Epidemiol 49: 1407±
1417
Masand P, Murray GB, Pickett P (1991) Psychostimulants in post-
stroke depression. J Neuropsychiatry Clin Neurosci 3: 23±27
Morris PL, Robinson RG (1995) Personality neuroticism and de-
pression after stroke. Int J Psychiatry Med 25: 93±102
Morris PLP, Robinson RG, Raphael B, Bishop D (1991) The re-
lationship between the perception of social support and post-
stroke depression in hospitalized patients. Psychiatry 54: 306±
315
Morris PL, Robinson RG, Andrzejewski P, Samuels J, Price TR
(1993) Association of depression with 10-year poststroke mor-
tality. Am J Psychiatry 150: 124±129
Pearlin LJ, Schooler C (1978) The structure of coping. J Health Soc
Behav 19: 2±21
Radlo€ LS (1977) The CES-D scale: a self-report depression scale
for research in the general population. Appl Psychol Meas 1:
385±401
Radlo€ LS, Teri L (1986) Use of the CES-D with older adults. Clin
Gerontol 5: 119±36
Robinson RG, Kubos KL, Starr LB, Rao K, Price TR (1984)
Mood disorders in stroke patients: importance of location of
lesion. Brain 107: 81±93
Rothman KJ (1986) Modern epidemiology. Little Brown, Boston
Schubert DS, Burns R, Paras W, Sioson E (1992) Increase of
medical hospital length of stay by depression in stroke and
amputation patients: a pilot study. Psychother Psychosom 57:
61±66
Sharpe M, Hawton K, Seagroatt V, Bamford J, House A, Mo-
lyneux A, Sandercock P, Warlow C (1994) Depressive disorders
in longterm survivors of stroke. Br J Psychiatry 164: 380±386
Smit JH, de Vries MZ (1994). Procedures and results of the ®eld
work. In: Autonomy and well-being in the aging population:
report from the Longitudinal Aging Study Amsterdam 1992±
1993. VU University Press, Amsterdam, pp 7±13
Starkstein SE, Robinson RG, Berthier ML, Price TR (1988) De-
pressive disorders following posterior circulation as compared
with middle cerebral artery infarcts. Brain 111: 375±387
Stevens DE, Merikangas KR, Merikangas JR (1995) Comorbidity
of depression with other medical conditions. In: Beckham EE,
Leber WR (eds) Handbook of depression. Guilford Press, New
York, pp 147±199
Turner RJ, Noh S (1988) Physical disability and depression: a
longitudinal analysis. J Health Soc Behav 29: 23±37
van Sonsbeek JLA (1988) Methodological and substantial aspects
of the OECD indicator of chronic functional limitations. Ma-
andbericht Gezondheid (CBS) 88: 4±17
van Tilburg TG (1995) Delineation of the social network and dif-
ferences in network size. In: Knipscheer CPM, de Jong Gierveld
J, van Tilburg T, Dijkstra PA (eds) Living arrangements and
social networks of older adults. VU University Press, Amster-
dam, pp 83±97
Yearbook Nursing Homes (1990) Den Haag
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