Changes in Depressive Symptoms and Incidence of First Stroke Among Middle‐Aged and Older US Adults

• Original Research
  • Epidemiology

Changes in Depressive Symptoms and Incidence of First Stroke Among Middle‐Aged and Older US Adults

1. Paola Gilsanz, ScD; 
2. Stefan Walter, PhD; 
3. Eric J. Tchetgen Tchetgen, PhD;
4. Kristen K. Patton, MD; 
5. J. Robin Moon, DPH; 
6. Benjamin D. Capistrant, ScD;
7. Jessica R. Marden, MPH; 
8. Laura D. Kubzansky, PhD; 
9. Ichiro Kawachi, MD, PhD;
10. M. Maria Glymour, ScD

+Author Affiliations

1. ¹Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA (P.G., J.R.M., L.D.K., I.K., M.G.)
2. ²Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (E.J.T.T.)
3. ³Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (E.J.T.T.)
4. ⁴Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, CA (S.W., M.G.)
5. ⁵Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA (K.K.P.)
6. ⁶Bronx Partners for Healthy Communities, Bronx, NY (R.M.)
7. ⁷Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, MN (B.D.C.)

1. Correspondence to:
   Paola Gilsanz, ScD, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 667 Huntington Avenue, Boston, MA 02115. E‐mail:pgilsanz@mail.harvard.edu

Abstract

Background Although research has demonstrated that depressive symptoms predict stroke incidence, depressive symptoms are dynamic. It is unclear whether stroke risk persists if depressive symptoms remit.

Methods and Results Health and Retirement Study participants (n=16 178, stroke free and noninstitutionalized at baseline) were interviewed biennially from 1998 to 2010. Stroke and depressive symptoms were assessed through self‐report of doctors’ diagnoses and a modified Center for Epidemiologic Studies ‐ Depression scale (high was ≥3 symptoms), respectively. We examined whether depressive symptom patterns, characterized across 2 successive interviews (stable low/no, onset, remitted, or stable high depressive symptoms) predicted incident stroke (1192 events) during the subsequent 2 years. We used marginal structural Cox proportional hazards models adjusted for demographics, health behaviors, chronic conditions, and attrition. We also estimated effects stratified by age (≥65 years), race or ethnicity (non‐Hispanic white, non‐Hispanic black, Hispanic), and sex. Stroke hazard was elevated among participants with stable high (adjusted hazard ratio 2.14, 95% CI 1.69 to 2.71) or remitted (adjusted hazard ratio 1.66, 95% CI 1.22 to 2.26) depressive symptoms compared with participants with stable low/no depressive symptoms. Stable high depressive symptom predicted stroke among all subgroups. Remitted depressive symptoms predicted increased stroke hazard among women (adjusted hazard ratio 1.86, 95% CI 1.30 to 2.66) and non‐Hispanic white participants (adjusted hazard ratio 1.66, 95% CI 1.18 to 2.33) and was marginally associated among Hispanics (adjusted hazard ratio 2.36, 95% CI 0.98 to 5.67).

Conclusions In this cohort, persistently high depressive symptoms were associated with increased stroke risk. Risk remained elevated even if depressive symptoms remitted over a 2‐year period, suggesting cumulative etiologic mechanisms linking depression and stroke.

Key Words:

• depression
• epidemiology
• longitudinal cohort study
• marginal structural model
• stroke

• Received February 23, 2015.
• Accepted March 25, 2015.

• © 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.