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Review
. 2011 Sep 21;306(11):1241-9.
doi: 10.1001/jama.2011.1282.

Depression and risk of stroke morbidity and mortality: a meta-analysis and systematic review

An Pan  1 , Qi Sun, Olivia I Okereke, Kathryn M Rexrode, Frank B Hu
Affiliations
Review

Depression and risk of stroke morbidity and mortality: a meta-analysis and systematic review

An Pan et al. JAMA. .

Erratum in

  • JAMA. 2011 Dec 21;306(23):2565

Abstract

Context: Several studies have suggested that depression is associated with an increased risk of stroke; however, the results are inconsistent.

Objective: To conduct a systematic review and meta-analysis of prospective studies assessing the association between depression and risk of developing stroke in adults.

Data sources: A search of MEDLINE, EMBASE, and PsycINFO databases (to May 2011) was supplemented by manual searches of bibliographies of key retrieved articles and relevant reviews.

Study selection: We included prospective cohort studies that reported risk estimates of stroke morbidity or mortality by baseline or updated depression status assessed by self-reported scales or clinician diagnosis.

Data extraction: Two independent reviewers extracted data on depression status at baseline, risk estimates of stroke, study quality, and methods used to assess depression and stroke. Hazard ratios (HRs) were pooled using fixed-effect or random-effects models when appropriate. Associations were tested in subgroups representing different participant and study characteristics. Publication bias was evaluated with funnel plots and Begg test.

Results: The search yielded 28 prospective cohort studies (comprising 317,540 participants) that reported 8478 stroke cases (morbidity and mortality) during a follow-up period ranging from 2 to 29 years. The pooled adjusted HRs were 1.45 (95% CI, 1.29-1.63; P for heterogeneity <.001; random-effects model) for total stroke, 1.55 (95% CI, 1.25-1.93; P for heterogeneity = .31; fixed-effects model) for fatal stroke (8 studies), and 1.25 (95% CI, 1.11-1.40; P for heterogeneity = .34; fixed-effects model) for ischemic stroke (6 studies). The estimated absolute risk differences associated with depression were 106 cases for total stroke, 53 cases for ischemic stroke, and 22 cases for fatal stroke per 100,000 individuals per year. The increased risk of total stroke associated with depression was consistent across most subgroups.

Conclusion: Depression is associated with a significantly increased risk of stroke morbidity and mortality.

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Conflict of interest statement

Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Figures

Figure 1
Figure 1
Flowchart of the Meta-analysis
Figure 2
Figure 2
Adjusted Hazard Ratios of Total Stroke for Depressed Participants Compared with Non-depressed Individuals The summary estimates were obtained using a random-effects model. The data markers indicate the adjusted hazard ratios (HRs) in depressed participants compared with non-depressed individuals. The size of the data markers indicates the weight of the study, which is the inverse variance of the effect estimate. The diamond data markers indicate the pooled HRs. CI indicates confidence interval.
Figure 3
Figure 3
Adjusted Hazard Ratios of (A) Fatal Stroke and (B) Ischemic Stroke for Depressed Participants Compared with Non-depressed Individuals The summary estimates were obtained using a fixed-effect model. The data markers indicate the adjusted hazard ratios (HRs) in depressed participants compared with non-depressed individuals. The size of the data markers indicates the weight of the study, which is the inverse variance of the effect estimate. The diamond data markers indicate the pooled HRs. CI indicates confidence interval.
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