The Natural History of Depression up to

15 Years After Stroke

The South London Stroke Register
Luis Ayerbe, MSc; Salma Ayis, PhD; Siobhan Crichton, MSc;
Charles D.A. Wolfe, FFPH; Anthony G. Rudd, FRCP

Background and Purpose—Evidence 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.
Methods—Data 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.
Results—The 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.
Conclusions—The 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
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A lthough 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.
Methods
First 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

Received October 4, 2012; final revision received December 21, 2012; accepted December 28, 2012.
From the Division of Health and Social Care Research, King’s 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, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
(C.D.A.W.); and Stroke Unit, Guy’s 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 luis.ayerbe_garcia-mozon@
kcl.ac.uk
© 2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.111.679340

1105
 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 (Cronbach’s 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-
tient’s next of kin in case of postal questionnaire, judged would give
invalid responses.
Statistical Methods
The 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
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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 χ2 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 <0. In these cases, the arcsine correction was used.11
When this correction was used, IPW was not possible; therefore, only
CC estimates were reported.
Ethics
Patients or their relatives gave written informed consent. The study
was approved by the ethics committees of Guy’s and St Thomas’
Hospital NHS Foundation Trust, King’s College Hospital Foundation,
National Hospital for Neurology and Neurosurgery, Queen’s Square
Hospital, St George’s Hospital, and Chelsea and Westminster
Hospital.
Results
Between 1995 and 2009, the SLSR registered 4022 patients.
When the follow-up period finished in August 2010, the fol-
low-up time for survivors ranged from 3 months to 15 years.
The number of patients registered in each period, assessed
for depression or lost to follow-up, at each time point, is
presented in the online-only Data Supplement I. The maxi-
mum number of participants available for analysis was 1233,
1 year after stroke. Few differences were observed between
sociodemographic characteristics of patients who were and
those who were not assessed for depression (online-only Data
Supplement II). Up to 10 years after stroke, those who had had
more severe strokes were less likely to be assessed (online-
only Data Supplement III).
The poststroke incidence of depression after stroke ranged
between 7% and 21% per year during the 15-year follow-up
(Table 1; online-only Data Supplement III). The proportion
of patients depressed at 3 months, first cases after stroke,
was 33%. The prevalence of depression ranged from 29% to
39% during the follow-up period (Table 2; online-only Data
Supplement IV). Cumulative incidence of depression was
55.4% (53.3%–57.5%) on CC analysis and 58.2% (52.9%–
60.5%) using IPW. Thirty-three percent of the assessed
patients had their first detected episode of poststroke depres-
sion 3 months after the acute event, and this proportion gradu-
ally decreased to 4% in year 9. There were no observations of
patients having their first episode of depression from year 10
onward (Table 3). Half of the patients who were depressed at
3 months had recovered from depression at 1 year. The other
half recovered gradually between years 2 and 9. No cases of
depression at 3 months recovering after year 9 were observed
(Table 4). The proportion of recurrent cases rose from 38% in
year 2 to 100% in years 14 and 15 (Table 5).
Weighted and CC estimates of prevalence, poststroke inci-
dence, cumulative incidence, time of onset, and duration were
consistent at all time points.
Discussion
These analyses and estimates show that the natural history of
depression after stroke is dynamic. Depression affects more
than half of all stroke patients at some point, with a stable
prevalence of ~30% up to 15 years after stroke, with most
patients recovering from depression after a few years and hav-
ing a significant risk of recurrent episodes in the long term.
This study shows a prevalence of depression similar to the
one previously reported in other studies, although the follow-up
is substantially longer.2,3 Poststroke incidence is an estimate
of natural history that has been scarcely investigated.2,12,13
The prevalence and poststroke incidence observed in this
study, which are largely stable throughout the follow-up, are
estimates suggesting a persisting risk of depression among
 Ayerbe et al   Natural History of Depression After Stroke   1107

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 (13.2–19.6) 17.8 (14.0–21.6)
2 488 93 19.1 (15.6–22.6) 20.5 (16.6–24.5)
3 423 69 16.3 (12.8–19.8) 16.9 (13.0–20.8)
4 498 85 17.1 (13.7–20.4) 17.5 (13.7–21.2)
5 356 58 16.3 (12.4–20.1) 18.5 (13.8–23.1)
6 281 42 14.9 (10.7–19.1) 14.11 (9.5–18.7)
7 268 52 19.4 (14.6–24.2) 22.3 (16.1–28.6)
8 205 27 13.2 (8.5–17.8) 15.2 (9.4–21.1)
9 159 27 17.0 (11.1–22.9) 17.9 (11.0–24.9)
10 113 22 19.5 (12.0–26.9) 21.6 (11.9–31.2)
11 94 15 15.9 (8.4–23.5) NR†
12 66 12 18.2 (8.6–27.7) NR†
13 43 9 20.9 (8.3–33.6) NR†
14 15 1 6.7 (0.2–26.4)* NR‡
15 7 1 14.3 (0.3–50.1)* 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 <0.

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
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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

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.12–14 The increase in recurrent
episodes observed during the 15-year follow-up explains
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 2. Prevalence of Depression up to 15 Years After Stroke

Patients Assessed at
Follow-up Each Time Point Patients Depressed Prevalence (95% CI) Weighted Prevalence (95% CI)
3m 1101 361 32.8 (30.0–35.6) 33.2 (30.0–36.4)
1, y 1233 357 28.9 (26.4–31.5) 30.6 (27.7–33.5)
2, y 901 266 29.5 (26.5–32.5) 30.7 (27.4–34.0)
3, y 1100 340 30.9 (28.2–33.6) 31.6 (28.7–34.5)
4, y 890 268 30.1 (27.1–33.1) 31.0 (27.8–34.2)
5, y 658 194 29.5 (26.0–33.0) 30.4 (26.7–34.1)
6, y 600 179 29.8 (26.2–33.5) 29.5 (25.6–33.4)
7, y 475 151 31.8 (27.6–36.0) 32.1 (27.6–36.5)
8, y 392 113 28.8 (24.3–33.3) 29.8 (25.0–34.6)
9, y 296 106 35.8 (30.3–41.3) 37.6 (31.7–43.4)
10, y 234 81 34.6 (28.5–40.1) 34.4 (28.0–40.7)
11, y 183 54 29.5 (22.8–36.2) 30.5 (23.5–37.6)
12, y 116 37 31.9 (23.3–40.5) 31.5 (22.6–40.5)
13, y 72 28 38.9 (27.3–50.4) 35.9 (24.0–47.9)
14, y 46 14 30.4 (16.6–44.2) 34.4 (18.5–50.3)
15, y 16 5 31.2 (5.7–56.8) 32.3 (2.2–62.4)
CI indicates confidence interval.
 1108  Stroke  April 2013

Table 3. Proportion of Patients (With Complete Follow-up) With New Cases of Depression Annually
Patients With Complete Proportion of Patients With Weighted Proportion of Patients
Number of Patients With Complete Follow-up and Complete Follow-up and With Complete Follow-up
Follow-up Follow-up to Each Time Point Depression First Detected Depression First Detected and Depression First Detected
3 mo 1101 361 32.8 (30.0–35.6) 33.2 (30.0–36.4)
1, y 750 85 11.3 (9.0–13.6) 12.0 (9.4–14.7)
2, y 450 40 8.9 (6.2–11.5) 9.4 (6.4–12.3)
3, y 329 17 5.2 (2.8–7.6) 5.6 (2.8–8.3)
4, y 249 16 6.4 (3.3–9.5) 5.2 (2.5–8.0)
5, y 154 3 1.9 (0.4–4.9)* NR‡
6, y 87 0 0 NR†
7, y 44 4 8.3 (0.2–16.4) NR‡
8, y 36 0 0 NR†
9, y 27 1 3.7 (0.09–15.4)* NR†
10, y 14 0 0 NR†
11, y 11 0 0 NR†
12, y 5 0 0 NR†
13, y No observations§ … … …
14, y No observations§ … … …
15, 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 <0.
§No patients had complete follow-up from registration to >12 years.

of depression between 13% and 17% during patient’s lifetime Organization World Health Survey reported from observations
Downloaded from http://ahajournals.org by on February 10, 2021

and incidence between 5% and 10%.17–19 in 60 countries that up to 23% of patients with chronic physical
It has been reported that medical illness, not only stroke, diseases had comorbid depression.21 Life-threatening illness,
increases the risk of depression.20 The World Health unpleasant treatments, and drugs causing depression as a side

Table 4. Recovery After Depression After Stroke

Patients With Patients With Proportion of Patients Weighted Proportion of
Depression at 3 mo With Depression at 3 mo Depressed at 3 mo Recovered Patients Depressed at 3 mo
Recovery Time, y Complete Follow-up Recovered for the First Time for the First Time (95% CI) Recovered for the First Time (95% CI)
1 232 116 50.0 (43.5–56.5) 50.3 (43.1–57.6)
2 139 19 13.7 (7.9–19.4) 13.9 (7.3–20.4)
3 92 7 7.6 (2.1–13.1) 8.1 (1.6–14.7)
4 74 3 4.0 (0.9–10.1)* NR‡
5 41 1 2.4 (0.06–10.3)* NR‡
6 26 1 3.8 (0.1–15.9)* NR‡
7 12 0 0 NR†
8 9 0 0 NR†
9 7 1 14.3 (0.3–50.1)* 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 <0.
||Number of observations too low to build a model of completeness.
 Ayerbe et al   Natural History of Depression After Stroke   1109

Table 5. Proportion of Recurrent Cases of Depression After Stroke these limitations are common in large epidemiology studies,
such as the SLSR. The HADS shows a good performance
No. of Incident No. of Cases With
Cases With ≥3 ≥1 Previous Episode Proportion of detecting depression in patients with no psychiatric conditions
Follow-up, y Assessments of Depression Recurrent Cases according to a systematic review.7 The SLSR is probably the
largest population-based cohort of stroke patients followed up
2 65 25 38.5 (26.3–50.6)
for so long. It provides the least biased sampling frame and
3 57 26 45.6 (32.3–58.9)
good statistical power in the analyses of data collected in the
4 68 29 42.6 (30.6–54.7) long term after stroke, in contrast with previous studies.2 A
5 54 31 57.4 (43.8–71.0) capture–recapture analysis conducted with the data on inci-
6 40 27 67.5 (52.3–82.7) dent strokes registered in the SLSR concluded that 88% of
7 51 31 60.7 (46.9–74.6) the strokes occurring in the study area were being registered.24
8 26 20 76.9 (59.6–94.3) Clinicians should acknowledge that depression remains a
9 27 17 63.0 (43.5–82.4) frequent active problem long after stroke, even when stroke
seems to be completely settled and many other medical issues
10 22 17 77.3 (58.2–96.3)
may have presented. With the exception of those patients who
11 15 12 80.0 (55.0–100.0)*
do not become depressed shortly after stroke, who seem to
12 12 10 83.3 (56.7–100.0)* be at lower risk, depression requires periodic clinical atten-
13 8 7 87.5 (54.9–99.7)* tion in the long term. The high rate of recurrence of depres-
14 1 1 100 sion should be noted. Assuming that a patient recovering from
15 1 1 100 depression is a closed case could lead to a late diagnosis or an
*Proportions calculated using arcsine correction. overlooking of a further episode.

effect may explain this association.20 Most of these apply to

stroke patients. However, the increased prevalence of depres- Acknowledgments
sion specifically among stroke patients may also be attribut- We thank all patients and healthcare professionals involved. Particular
able to other causes, including the following: (1) depression thanks to field workers and the team working since 1995 for the South
London Stroke Register and the Stroke Research Team at King’s
is a risk factor for stroke, therefore the proportion of patients College London.
at risk of depression may be increased among stroke patients;
(2) depression and stroke have risk factors in common, such
Sources of Funding
Downloaded from http://ahajournals.org by on February 10, 2021

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,
The study was funded by Guy’s 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 Guy’s
and St Thomas’ NHS Foundation Trust in partnership with King’s
College London.
Disclosure
Charles 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.
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