Prevalence, Severity, and Predictors of Poststroke Depression in a Prospective Cohort of Jordanian Patients

Poststroke depression (PSD) is common and remains a significant risk factor for poor outcomes. This prospective study is aimed at assessing the prevalence, severity, and predictors of PSD among Jordanian stroke survivors. A total of 151 patients who were consequently admitted to a tertiary teaching hospital with ischemic or hemorrhagic strokes were enrolled. Participants were screened on admission for premorbid depression using the PHQ-9 questionnaire; then, screening for PSD was repeated one and three months after stroke using the same tool. Depression prevalence at each screening was reported, and logistic regression analysis was conducted to evaluate for significant predictors. PHQ-9 scores suggestive of depression were reported by 15%, 24.83%, and 17.39% of respondents on admission and after one and three months, respectively. Scores suggesting severe depression were reported by 0.71%, 2.13%, and 6.52% of respondents, respectively. Significant predictors of PSD were having chronic kidney disease, current smoking status, moderate or severe disability (mRS score) at stroke onset, and severe dependence (BI) after one month ( values 0.007, 0,002, 0.014, and 0.031, respectively). Patients with secondary and high school education levels were less likely to get depression compared with illiterate patients ( 0.042). This study showed that nearly one in four Jordanian stroke survivors experienced PSD after one month. In contrast, while the overall PSD prevalence declined towards the end of follow-up period, patients who remained depressed showed a tendency towards higher PSD severity.

1. Introduction
Stroke is a significant cause of morbidity and mortality globally [1]. It is the second leading noncommunicable cause of death in Jordan and a considerable source of complications and physical disability [2, 3]. Stroke survivors are liable to a multitude of physical, psychiatric, social, and functional impacts. Poststroke depression (PSD) is the most frequent and a very important neuropsychiatric complication. Stroke survivors who develop PSD are at a greater risk of poor functional outcomes, lower quality of life, increasing cognitive impairment, recurrent vascular events, and higher mortality than those without depression [4–6].

The DSM-V defines poststroke mood disorders as mood disorders due to stroke, with the specifiers of depressive features, major depressive-like episode, or mixed mood features [6]. Studies evaluating PSD have reported varying findings owing to heterogeneous settings, populations, and methodologies. Also, several studies suggested that PSD prevalence differs with the time interval between stroke and depression assessment [7]. Additionally, some neurological symptoms such as aphasia and cognitive impairment may conceal mood abnormalities, and there is a lack of consensus over the best screening tool for case-finding [7, 8]. Subsequently, the range of estimated PSD prevalence is wide [9, 10]. However, meta-analyses with large databases reported that approximately one-third of survivors developed PSD at any time point up to 5 years following stroke [11–13]. Surveys from the Middle East and North Africa (MENA) region also reported a wide prevalence of PSD (17-73%) [10], while previous surveys from Jordan reported a range from 25% to 76% [14–17]. Studies aiming to identify risk factors predisposing to PSD have also been inconsistent. The most frequently identified risk factors include the level of physical disability, stroke severity, and history of mental illness [7, 18].

Different instruments have been used to screen stroke survivors for PSD [19]. The Patient Health Questionnaire-9 (PHQ-9) is a self-administered tool that employs nine standard questions to score each of the nine DSM criteria as zero (not at all) to three (nearly every day) [20]. It has been well-validated in different settings as a brief screener for PSD [19, 21, 22]. A meta-analysis found that PHQ-9 had a summary sensitivity of 0.77 and a specificity of 0.94 (0.90–0.97) [23]. Cut-off PHQ-9 scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively [20]. This study is aimed at determining the prevalence and severity of PSD at one and three months after stroke and at investigating PSD predictors among Jordanian stroke survivors.