Neurol Sci (2016) 37:1305–1310
DOI 10.1007/s10072-016-2590-1
ORIGINAL ARTICLE
Association of post stroke depression with social factors, insomnia,
and neurological status in Chinese elderly population
Lingru Wang1 • Yong Tao2 • Yang Chen1 • Hua Wang1
Huadong Zhou1 • Xiaoyan Fu1
Received: 13 October 2015 / Accepted: 19 April 2016 / Published online: 27 April 2016
Ó Springer-Verlag Italia 2016
Abstract The purpose of this study was to investigate the
association of post stroke depression (PSD) with social
factors, insomnia, and neurological status among elderly
Chinese patients with ischemic stroke. Six hundred and
eight patients over 60 years of age, who had suffered from
a first episode of ischemic stroke within 7 days, were
enrolled into the study. They were divided into PSD and
non-PSD groups according to the Self-rating Depression
Scale (SDS) scores. The association of PSD with social
factors, insomnia, and neurological status was analyzed
using multivariable logistic regression analysis. Compared
with the patients who did not develop PSD, those with PSD
reported adverse life events more frequently, and more
subjects with PSD lived alone, had left carotid artery
infarction and cortical infarction (P \ 0.05), history of
insomnia, and high National Institute of Health Stroke
Scale (NIHSS) scores and low Barthel Index (BI) scores
(P \ 0.01). The multivariable logistic regression analysis
showed that the occurrence of PSD was associated with a
history of insomnia (HR = 1.59, 95 % CI 1.12–2.36,
P \ 0.01), NIHSS scores (HR = 2.45, 95 % CI 1.42–3.91,
P \ 0.01) and BI scores (HR = 2.56, 95 % CI 1.39–4.25,
P \ 0.01). Insomnia and the degree of neurological deficit
were associated with PSD in an elderly population of
Chinese people.
& Xiaoyan Fu
fuxiaoyan9527@sina.com
1
Department of Neurology, Daping Hospital, Third Military
Medical University, Chongqing 400042, China
2
Graduate School, Bengbu Medical College,
Bengbu 233030, Anhui, China
•
Keywords Post stroke depression
Insomnia
Ischemic
stroke
Elderly Chinese
Neurological status
Introduction
Many studies show that depression is a common neuro-
psychiatric consequence of stroke, affecting approximately
28–35 % of patients with stroke [1, 2]. In addition to psy-
chosocial stress, history of insomnia and the severity of
neurological deficits might also be related to the develop-
ment of post stroke depression (PSD). PSD shows a series of
symptoms including feeling down, reduced interest, feeling
sorry, self-blaming, and desperation. It severely affects the
quality of daily life and increases the mortality rate of
patients [3]. Some studies have identified specific relation-
ships between the locations of brain injury and PSD [4–6].
There are conflicting results and paucity of data on this issue.
Along with rapid economic development, the number of
elderly Chinese has gradually increased. The morbidity of
stroke and PSD has risen in recent years. Thus, the aim of
this study is to weigh the importance of social factors,
insomnia, and the degree of neurological deficits among a
population of elderly Chinese with ischemic strokes fol-
lowed by PSD.
Subjects and method
Subjects
Consecutive patients with ischemic strokes admitted to
Daping Hospital, Chongqing, China, were registered for the
study that was conducted from January 8, 2013 to December
30, 2014. Six hundred and eight patients (322 males and 286
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females, average age 68.6 ± 9.8 years) agreed to participate
in the study. Patients aged over 60 years who presented
within 7 days of their first ischemic stroke were included.
The exclusion criteria included history of preexisting psy-
chosis, anxiety disorder, and depression according to the data
of medical history or the information provided by family
members, disturbed consciousness, cognitive or visual
impairments, hearing disturbances and severe aphasia.
Demographic data
We collected the following data: age, sex, educational level,
financial situation, living alone (for more than 1 year),
adverse life events (according to Zhang’s life event scale [7]:
the death of a spouse, or offspring, marital separation, theft or
loss of an item of personal value, troubles in a lawsuit, onset
of a serious illness or accident, a serious family dispute, and
financial crisis; these events should have occurred less than
6 months before the stroke), and cigarette smoking and
alcohol drinking (both past and current).
Clinical assessment
(1) Ischemic stroke was diagnosed in accordance with
Oxfordshire Community Stroke Project Classification [8].
CT and MRI scans were used for making the final diag-
nosis. (2) Vascular risk factors included hypertension
(previously diagnosed and treated or systolic pressure
[160 mmHg, and/or diastolic pressure [90 mmHg per-
sistently observed during admission after the acute phase),
diabetes mellitus (previously diagnosed and treated, or
fasting glucose [7 mmol/l in two blood samples after the
acute phase), coronary heart disease (previously diagnosed
and treated). (3) Degree of neurological deficit was
examined by the National Institute of Health Stroke Scale
(NIHSS) on the seventh day after the stroke [9]. (4)
Activities of daily living were examined using the Barthel
index (BI) on the seventh day after the stroke [10]. (5)
Insomnia (anyone of the following three symptoms lasting
more than 3 months: requiring more than 30 min to fall
asleep; waking up more than two times in a night; sleep
less than 6 h, or early awakening; it should have occurred
less than 6 months before the stroke).
Depression screening tools
The following data were collected 3 months after the stroke.
PSD was diagnosed in accordance with ICD-10 criteria [11].
We used the Chinese version of the Self-rating Depression
Scale (SDS) to examine the subjective severity of depression
[12]. The SDS scale consists of 20 items and each has four
categories: always, often, sometimes, or rarely. The total
score ranges from 20 to 80 and is the sum of the individual
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Neurol Sci (2016) 37:1305–1310
item scores. We classified the patients into two groups based
on their score: non-depressed (SDS score \40 points) and
depressed group (SDS score C40 points). The severity of
depression was evaluated using the Hamilton Depression
Rating Scale (HAMD) (17 items) [13]. Mild, moderate, and
severe PSD were defined as scores higher than seven, 17, and
24 points, respectively.
Statistical analysis
Univariate analysis was performed to compare the data of
patients with and without depression, including demo-
graphic data, clinical assessment, and depression screening.
The Chi-square test was used for categorical and student’s
t test for quantitative variables. All the variables with sta-
tistical significance (P \ 0.05) in the univariate analyses
were introduced into logistic regression analyses through a
backward procedure. The exclusion criterion to find inde-
pendent risk factors for the incidence of PSD was
P [ 0.05. All the analyses were performed with SPSS for
Windows, version 19.0 (SPSS Inc.).
Results
A total of 709 patients were enrolled in the study. Only 608
(85.8 %) patients were examined 3 months after the stroke.
The remaining 101 (14.2 %) patients were excluded due to
the following reasons: 21 died, 39 had severe dysphasia,
hearing or visual impairments, and 41 had worsened ill-
ness. The incidence of PSD was 41.1 % (250/608) among
this elderly population.
Characteristics of the patients with and without PSD
When comparing the demographic and clinical character-
istics of patients with and without PSD, there were sig-
nificant differences in a history of insomnia (P \ 0.01),
living alone, and the presence of adverse life events
(P \ 0.05) (Table 1).
Table 2 shows the distribution of stroke features
according to presence or absence of PSD. Comparison
between patients with and without PSD, there were sig-
nificant differences in NIHSS and BI scores (P \ 0.01),
and the presence of left carotid artery and cortical infarc-
tions (P \ 0.05).
Associations of social factors, insomnia, and stroke
features with PSD in multivariable Cox
proportional-hazards models
Multivariable Cox proportional-hazards models were con-
structed to include history of insomnia, adverse life events,
Neurol Sci (2016) 37:1305–1310 1307

Table 1 Comparison between patients with PSD and without PSD in demographic and clinical characteristics
Variables Non-depressed group N = 358 Depressed group N = 250 P value

Average age, years x ± SD 68.3 ± 7.8 69.1 ± 8.2 0.23

Female n (%) 168 (46.9) 118 (47.2) 0.95
Illiteracy or elementary school n (%) 157 (43.9) 115 (46.0) 0.61
Financial situation
B2000 RMB/month n (%) 138 (38.5) 82 (32.8) 0.15
[2000 RMB/month n (%) 220 (61.5) 168 (67.2)
Family history of depression n (%) 29 (8.1) 21 (8.4) 0.84
History of insomnia n (%) 126 (35.2) 114 (45.6) \0.01
Living alone n (%) 35 (9.8) 42 (16.8) \0.05
Adverse life events n (%) 14 (3.9) 19 (7.6) \0.05
Vascular risk factors
Hypertension n (%) 162 (45.3) 111 (44.4) 0.81
Diabetes mellitus n (%) 78 (21.8) 58 (23.2) 0.67
Coronary heart disease n (%) 62 (17.3) 46 (18.4) 0.73
Smoking n (%) 90 (25.1) 68 (27.2) 0.42
Alcohol drinking n (%) 96 (26.8) 72 (28.8) 0.59

Table 2 Comparison between patients with and without PSD in stroke features
Variables Non-depressed group N = 358 Depressed group N = 250 P value

Vascular territory
Left carotid artery infarction n (%) 154 (43.0) 128 (51.2) \0.05
Right carotid artery infarction n (%) 122 (34.1) 63 (25.2) \0.05
Vertebrobasilar artery infarction n (%) 82 (22.9) 59 (23.6) 0.84
Localization
Cortical infaction n (%) 190 (53.2) 155 (62.0) \0.05
Subcortical infaction n (%) 168 (46.8) 95 (38.0) \0.05
NIHSS x ± SD 6.5 ± 0.9 9.2 ± 1.1 \0.01
Barthel index x ± SD 71.5 ± 6.5 44.2 ± 5.2 \0.01

living alone, presence of left carotid artery and cortical
infarctions, NIHSS and BI scores. After adjusting for
potential confounders,we found that history of insomnia
(HR = 1.59; 95 % CI 1.12–2.36; P \ 0.01), NIHSS
(HR = 2.45; 95 % CI 1.42–3.91; P \ 0.01), and BI scores
(HR = 2.56; 95 % CI 1.39–4.25; P \ 0.01) were signifi-
cantly associated with the occurrence of PSD (Table 3).
Relationship between severity of PSD
and insomnia, NIHSS, and BI scores
Among the 608 patients with PSD, 132 (52.8 %) had mild,
82 (32.8 %) had moderate, and 36 (14.4 %) had severe
PSD. Figure 1 shows the incidence of insomnia, NIHSS
and BI scores across the three groups according to the
severity of PSD. The patients with severe PSD had higher
insomnia incidence (P \ 0.05), higher NIHSS scores
(P \ 0.05) and lower BI scores (P \ 0.05) than those with
mild and moderate PSD.
Discussion
According to our research, the multivariable logistic
regression analysis showed that a history of insomnia was
associated with the occurrence of PSD (HR = 1.59, 95 %
CI 1.12–2.36, P \ 0.01). There were 114 (45.6 %) patients
with a history of insomnia prior to the stroke in the
depression group. As we know, insomnia is likely to lead to
various psychological problems, and depression is one of
the most common mental disorders [14, 15]. Few studies
have reported on the association of insomnia with PSD was
limited. Fernandez M et al. [16] investigated 1137 adults
without depression who were followed up with a structured

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Table 3 Hazard ratios for PSD,
Variables
according to Cox proportional-
hazards models Insomnia
Adverse life events
Living alone
Left carotid artery infarction
Cortical infarction
NIHSS
Barthel index
* Adjustment were included for history of insomnia, adverse life events, living alone, the left carotid artery
infarction, the cortical infarction, NIHSS, and BI scores
telephone interview for seven and a half years. They found
that insomnia was significantly associated with the inci-
dence of depression (OR = 1.9, P = 0.031). Further, the
study of Hayley AC et al. [17] demonstrated that insomnia
was associated with significant depressive symptomatology
among a large population-based sample of 11,329 adults
2005–2008 (OR = 6.57, 95 % CI 3.89–11.11).
Severe physical disability after stroke has been found to
be consistently associated with increased risk of develop-
ing PSD [18]. It is thought that moderate or severe dis-
abilities might increase the risk of developing PSD by
20 %. Further, severe disability might be linked to large
lesions involving brain regions that process mood. Patients
with severe disabilities might develop depression due to
concern over the social consequences of the stroke [19].
Our results indicated that NIHSS and BI scores were
associated with the occurrence of PSD. Azra A et al. [20]
investigated 210 patients with stroke (105 each of males
and females, age were 67.12 ± 9.5 years) in 2012, and
demonstrated that the occurrence of depression was asso-
ciated with NIHSS scores. Furthermore, Ning S et al. [21]
reported that the degree of neurological deficit score was an
important risk factor for the development of PSD, in a
survey on 465 patients in China. According to the study of
Nys GM et al. [22] the severity of depressive symptoms
was related to functional impairment, as measured by the
modified Barthel Index (P = 0.004).This study was per-
formed 126 patients 3 weeks after their first-ever symp-
tomatic stroke. In a cross sectional study of 40 patients (21
men and 19 women, mean age 61.5 ± 3.5 years, average
time period post stroke 8.7 ± 3.5 months), Hojjat AH et al.
[23] found that there was a significant negative correlation
between the performance of activities of daily living and
the degree of post stroke depression (r = -0.81). In
addition, Mihajlo G et al. [24] investigated 80 patients
(mean age 56.8 ± 12.5 years) three to 6 months after the
stroke in Malaysia, and suggested that the occurrence of
depression significantly correlated with poor performance
in activities of daily living (P = 0 0.001).
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Neurol Sci (2016) 37:1305–1310
Crude HR (95 % CI) P value Adjusted HR (95 % CI)* P value
1.61 (1.14–2.38) \0.01 1.59 (1.12–2.36) \0.01
1.15 (0.91–1.67) 0.08 1.13 (0.94–1.61) 0.07
1.03 (0.96–1.25) 0.14 1.02 (0.95–1.28) 0.12
1.09 (0.92–1.31) 0.17 1.07 (0.93–1.34) 0.18
1.12 (0.89–1.43) 0.23 1.13 (0.90–1.39) 0.24
2.72 (1.48–3.56) \0.01 2.45 (1.42–3.91) \0.01
2.84 (1.43–4.33) \0.01 2.56 (1.39–4.25) \0.01
Further, our study showed that infarction of the left
carotid artery was associated with PSD. Robinson RG et al.
[25] investigated patients over 2 to 6 weeks after the
stroke, and reported that PSD was associated with lesions
in the left hemisphere of the brain (P \ 0.01). In a longi-
tudinal study of 81 patients with new-onset unilateral
hemispheric stroke, Singh A et al. [26] suggested that
lesions close to the frontal pole of the left hemisphere had a
specific correlation with the degree of PSD (P \ 0.0005).
Yasuhiro N et al. [27] found that left sided lenticulocap-
sular infarcts were independent predictors for the devel-
opment of depressive symptoms, in a research performed
on 134 patients 1 month after an ischemic stroke
(OR = 4.303, 95 % CI 1.095–16.904). Some scholars
believe that post stroke left frontal lobe and basal ganglia
lesions were obviously associated with the occurrence of
PSD [28, 29]. However, Hsieh LP et al. [30] researched
207 patients with ischemic stroke (mean age of 64 years),
and suggested that there was no association between the
location of lesions and depression (P [ 0.05). Therefore,
further studies are needed to confirm this conclusion.
Our study found that living alone and a history of
adverse life events were not associated with the occurrence
of PSD, and such associations were rarely reported. How-
ever, association of living alone and adverse life events
with depression has been demonstrated. Fukunaga R et al.
[31] investigated the factors associated with depression
among the elderly (1552 cases, aged [65 years) in rural
Japan and confirmed that living alone was an important
factor in the development of depression (P \ 0.01). Chou
KL et al. [32] reported that living alone was an independent
risk factor contributing to depression among Chinese
women aged [60 years. In addition, Kraaij V et al. [33]
suggested that the total number of negative life events had
the strongest relationship with depression in a meta-anal-
ysis of 25 studies (r = 0.15, n = 5,037).
The etiology of the development of PSD is complex and
not fully understood. At present, some scholars believe that
PSD is directly caused by the stroke that disrupts neural
Neurol Sci (2016) 37:1305–1310 1309

80.00% because the destruction of 5-HT neurons of the raphe system

A
70.00% induced a severe insomnia [37, 38]. Therefore, a substantial
Percentage of insomnia (%)

decrease in 5-HT in patients with insomnia may be related to

60.00%
the occurrence of PSD.
50.00% Our study has some limitations: (1) we only focused on
40.00% patients with ischemic stroke, those with hemorrhagic
stroke were not included, (2) our study group included
30.00%
patients C60 years of age and did not include those that
20.00% were middle-aged, (3) we followed up patients with PSD
10.00% 3 months after the stroke, while patients with PSD 6 to
0.00%
12 months after the stroke were not discussed. If the fol-
low-up had been done for a longer period of time, the
relation between insomnia, neurological deficits, and PSD
25
B could have been studied more meaningfully, (4) polymor-
phisms in the 5-HTT and BDNF genes are shown to be
NIHSS scores ( Mean ± SD)

20 associated with genetic risk of PSD [39, 40]. However, we

did not introduce genetic factors into our study. These
15 limitations should be considered carefully while the
applicable range of our conclusions is discussed.
10 In conclusion, our study showed that a history of
insomnia and the degree of neurological deficit were
5
associated with the development of PSD in a group of
elderly Chinese. Therefore, improved treatment of insom-
nia is recommended for patients with ischemic stroke to
0
reduce the incidence of depression. Further, early psycho-
logical interventions for depression might be considered
Barthel Index scores ( Mean ± SD )

70 for those patients with high NIHSS and low BI scores after
C
60
an ischemic stroke.

50 Compliance with ethical standards

40 Conflicts of interest The authors declare that they have no conflicts

of interest concerning this article.
30

20
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