Patients who become depressed after having had a stroke are four times more likely to die than those who have not had a stroke and who are not depressed.

Results of a large 21-year follow-up study stress the importance of depression screening in poststroke care, according to Dr. Amytis Towfighi, who will present her data in March at the annual meeting of the American Academy of Neurology in San Diego.

“Our research highlights the importance of screening for and treating depression in people who have experienced a stroke,” said Dr. Towfighi, chair of the neurology department at the Rancho Los Amigos National Rehabilitation Center in Downey, Calif. “Given how common depression is after stroke and the potential consequences of having depression, looking for signs and symptoms and addressing them may be key.”

Her study cohort comprised 10,550 people aged 25-74 years who participated in the 1971-1975 National Health and Nutrition Examination Survey. They were interviewed again in 1982-1984 and then followed through 1992. Dr. Towfighi and her colleagues examined the risk of death in four groups: Patients who had a stroke but no depression (73); those who had a stroke and depression (48); those who had neither stroke nor depression (8,138); and those who did not have a stroke but did have depression (2,291).

Subjects with both stroke and depression were about four times more likely to die than those with neither condition in the unadjusted (hazard ratio, 4.06) and adjusted (HR 3.69) analyses.

The multivariate analysis adjusted for age, gender, race, education and income levels, and marital status.

The factors linking stroke, depression, and mortality aren’t fully understood, Dr. Towfighi said in an interview. “However, there are both behavioral and physiological explanations. Behaviorally, individuals who are depressed may be less likely to live healthy lifestyles (abstaining from smoking, exercising regularly, and eating healthy). In addition, they may be less likely to take their medications and go to health care practitioners for routine follow-up. Physiologic processes such as changes in platelet function could also play a role.”

In this study, depression did not seem to be simply a marker of having had a more severe stroke with lasting disability. “While some studies have revealed a link between severity of stroke and depression, others have not. A recent study also showed that transient ischemic attack is associated with depression. Since individuals with TIA do not exhibit any lasting symptoms, this would make the association between depression and stroke severity less likely,” she said.

Checking on a stroke survivor’s psychological well-being can be a fast and easy step to include in stroke follow-up, Dr. Towfighi said. “There are simple tools for quickly screening for depression in a busy ambulatory care setting, including the Patient Health Questionnaires 2 and 9.”

Depression is common after stroke and is treatable, she added. “It is important for patients, family members, and health care practitioners to be aware of the signs and symptoms of depression so that it can be identified and treated promptly.”

Dr. Towfighi had no financial disclosures.