Huiying Zhang, Ting Zhou, Yaqing Zhang, Ying Zhang, Yun Xu

Nursing School of Shanghai Jiao Tong University, Shanghai 200025, China

lNTRODUCTlON

Depression frequently occurs within 6 to 24 months post-stroke[1]. A large number of studies have investigated the correlations of neurotransmitters, social contact, interpersonal relations, family relations and dependence of stroke patients with social support and depression[2-6]. However, results have varied in one-way analyses of age, sex,and lesion site[7-8]. Previous studies have mainly focused on stroke in the acute stage or without considering any stage[8-9]. The Hamilton Depression Scale and the Self-rating Depression Scale, which have been frequently used to assess depression,have high reliability and validity, but are not specific to some populations. Somatic complaints are common in aged people, most of which are normal phenomena for them, but they are often misdiagnosed as depression[10].

Therefore, this study investigated the correlation between social support and depression in elderly stroke patients in the sequelae stage.

RESULTS

Baseline data of participants

A total of 81 patients who were between 6 and 24 months post-stroke, comprising 45 males and 36 females, aged 60-89 years,were selected from five communities of Shanghai, China, between December 2009 and April 2010, using a convenience sampling method. Baseline data of participants are listed in Table 1.

Social support of stroke patients

The social support of the patients was evaluated using the Social Support Rating Scale proposed by Xiao[11]. This scale is composed of three domains (objective support, subjective support, support utilization), and social support total scores. High scores represent high social support (Table 2).

Depressive condition of stroke patients

The Geriatric Depression Scale[10]was used to evaluate the level of depression in the stroke patients: 0-10: normal, i.e. free of depression; 11-20: mild depression; 21-30:moderate and serious depression. The average scores of the patients were 11.49±5.94. The frequency distribution results of the total scores revealed that 54% of patients were free of depression symptoms,35% suffered from mild depression, and 11% from moderate and serious depression(Table 3).

Correlation between social support and depression in stroke patients

Pearson correlation analysis of social support total scores and of the scores of each of the three domains, as well as of depression scores, showed that the degree of depression of stroke patients was significantly negatively correlated with social support total scores, subjective support and utilization (P ＜ 0.01), but not correlated with objective support (Table 4).

Table 1 Baseline data of participants (n=81)

Table 2 Social support of participants (n = 81, score)

Table 3 General frequency distribution of depression scores (n = 81)

Table 4 Correlation between social support, other domains and depression in stroke patients

lnfluence of general data on social support and depression degree in stroke patients

Age

The participants were assigned to three groups according to age. One-way analysis of total social support, each of the three domains, and depression scores showed no differences in objective support among groups. The 60-69 year-old age group exhibited higher subjective support and social support total scores compared with the other two groups (P ＜ 0.05), higher utilization compared with the 80-89 year-old age group, and lower degree of depression compared with the 80-89 year-old age group (P ＜ 0.05; Table 5).

Table 5 Relationship of age with social support and degree of depression

Sex

The independent sample t-tests of sex with total social support, each of the three domains, and depression scores showed that female participants obtained higher scores than male participants in utilization, objective support and social support total scores (P ＜ 0.05 or P ＜0.01), but lower scores in degree of depression (P ＜0.05). No significant differences were detected in subjective support between the two gender groups (P ＞ 0.05;Table 6).

Table 6 Relationship of sex with social support and depression degree

Education

One-way analysis of education with total social support,each of the three domains, and depression scores showed no significant differences in any item among the three groups (P ＞ 0.05).

Family economic status

One-way analysis of family economic status with total social support, each of the three domains, and depression scores showed differences in subjective support,social support total scores and degree of depression between the average income less than 3,000 yuan and the average income more than 5,000 yuan groups (P ＜0.05 or P ＜ 0.01). Moreover, the subjective support and social support total scores were greater, but degree of depression was lower in the average income more than 5,000 yuan group compared with those in the average income more than 3,000 yuan group (Table 7).

Table 7 Relationship of family economic status with social support and degree of depression

Marital status

The participants were assigned to spouse and no spouse groups. The independent sample t-test results of marital status with total social support, each of the three domains and depression scores showed greater subjective support, utilization and social support total scores in the spouse group compared with the no spouse group (P ＜0.01), and lower degree of depression in the spouse group compared with the no spouse group (P ＜ 0.05;Table 8).

Table 8 Relationship of marital status with social support and degree of depression

Disease type

The t-test results of disease type with total social support,each of the three domains and depression scores showed no significant differences except that degree of depression scores were greater in the cerebral hemorrhage group compared with the cerebral infarction group(P ＜ 0.05; Table 9).

Table 9 Relationship of disease type with social support and depression degree

Course of disease

Participants were assigned to three groups according to length of the course of disease. One-way analysis showed no differences in total social support, each of the three domains and depression scores among the three groups (P ＞ 0.05).

DlSCUSSlON

Investigations have shown that the incidence of depression is significantly greater in elderly stroke patients in the sequelae stage compared with other populations[12].

Depression incidence is varied at different stages of stroke[3]. Depression frequently occurs in the 6-24 months after stroke[1,13]. This study investigated stroke patients between 6 and 24 months post-stroke, with results showing that the incidence of depression was 46%This indicates that the metal health of elderly stroke patients in the sequelae stage (6-24 months) requires attention from family and society.

This study showed that the degree of depression of the elderly stroke patients in the sequelae stage was significantly negatively correlated with social support total scores, subjective support, and utilization, but not correlated with objective support. These results are consistent with a previous study by Zhang et al[8], which, however,reported different results from Wu’s study[9]in the correlation between objective support and depression. The differences may be attributed to decreased self-care ability, reduced social activities, and the formation of self-condemning and autistic thoughts, leading to reduced requirements for objective support. Compared with objective support, subjective support and support utilization are more important for improving or preventing depression symptoms in elderly stroke patients. They need care from family, nursing staff, and social service sections to confide depressive emotions. Moreover, they should be encouraged to participate in rehabilitative activities and communicate with friends to arouse passion for life.

Influential factors for social support and degree of depression in stroke patients in the sequelae stage were analyzed. (1) Age: a previous study reported that poststroke depression scores were negatively correlated with age[13], but another study concluded that age was not correlated with poststroke depression[14]. Results from the current study showed decreased scores in subjective support and social support total scores in elderly post-stroke patients with depression compared with those without depression. With aging, activities of daily living are limited and physiological functions such as vision and hearing are decreased. Moreover, stroke patients cannot communicate well with others, resulting in reduced social activities and decreased support utilization, which becomes a risk factor for depression. (2) Sex:in this study, female patients had higher scores in support utilization, objective support, and social support total scores, but lower scores in degree of depression compared with male patients, consistent with previous results[15]. However, some studies have suggested that females are more susceptible to depression compared with males[16-17]. The different results may correlate with varied behaviors, sex role, conventional ideas, and social expectations for Chinese males. (3) Family economic status: this study found that the subjective support and social support total scores were decreased, but degree of depression score was increased in patients with a mean income of less than 3,000 yuan. (4) Marital status:the spouse group exhibited higher scores in subjective support, utilization, and social support total scores, but lower degree of depression scores compared with the no spouse group. One previous study had indicated that spouse status was not correlated with depression[9], but another study suggested that family relations and spouse support are important for mental rehabilitation of patients[4], consistent with results from the present study.

This indicates that loss of spouse and divorce are stressors highly correlated with depression. (5) Disease type: this study showed that cerebral hemorrhage patients suffered from more serious depression than cerebral infarction patients, possibly as a result of the better prognosis and lower mortality of cerebral infarction compared with cerebral hemorrhage[18]. However, some researchers have proposed that poststroke depression is not associated with type of disease, but with lesioned site[19].

This study surveyed social support and depression status in elderly stroke patients in the sequelae stage.

Results revealed that they suffered from a high incidence and serious degree of depression, as well as poor mental health. Social support, especially subjective support and support utilization, is important for the improvement of depression. Older age, male gender, low economic condition, divorce or loss of spouse, and cerebral hemorrhage are risk factors for depression in elderly stroke patients in the sequelae stage.

SUBJECTS AND METHODS

Design

Convenience sampling and cross-sectional study.

Time and setting

The investigation was performed at the Health Service Centers of five communities, Shanghai, China from December 2009 to April 2010.

Subjects

A total of 81 stroke patients between 6 and 24 months post-stroke were included.

Eligible participants were diagnosed in accordance with the standards formulated by the Fourth National Conference on Cerebrovascular Disease[20]; were diagnosed as cerebral infarction or cerebral hemorrhage confirmed by CT or MRI; and were aged 60 years or older, free of serious complications, with stable vital signs following medication or surgery, independent in activities of daily living, free of depression prior to onset, with clear consciousness, and able to give informed consent.

Those with serious organ disease, such as of heart, liver,and kidney, with recurrent attacks of cerebrovascular accident, or with a history of psychosis or aphasia were excluded.

Methods

Evaluation tools

A questionnaire was used for the survey through an interview format. The questionnaire consisted of three aspects. The first was general condition, including age,sex, education, mean income, marital status, disease type and course of disease. The second was social support condition. Social support was investigated using the Social Support Rating Scale proposed by Xiao[11],with a test-retest reliability of 0.92. The scale is composed of 10 items (supplementary Table 1 online), including subjective support (items 1, 3, 4, 5), objective support (items 2, 6, 7) and support utilization (items 8, 9,10). Scoring is as follows: for items 1-4 and 8-10, one option from 1, 2, 3, 4 for each item, respectively, scores 1,2, 3, 4; for item 5, there were four sub-items, A, B, C, D,and each sub-item included four options (1-4 scores); for items 6 and 7, the option “none” scored 0. The final scores were calculated by the sum of the selected options. Total scores of all 10 items were regarded as the total score of the scale. High scores represented high social support. The third was the degree of depression.

The Geriatric Depression Scale[10]comprises 30 items for a total of 30 scores (supplementary Table 2 online). The scale is highly sensitive to social support and is used for people aged more than 56 years old. The test-retest reliability was 0.85. Of the 30 items, 10 were of reverse scoring, i.e., “No” represented existence of depression,and 20 were of positive order, i.e., “Yes” represented existence of depression. Each option for depression was scored 1.

Statistical analysis

Data were analyzed using SPSS17.0 software (SPSS,Chicago, IL, USA) and expressed as mean±SD. Paired comparison of multi-sample means was performed using independent sample t-tests, one-way analysis of variance, and the Scheffe test. The correlation between social support and depression was analyzed using Pearson correlation analysis. A value of P ＜ 0.05 was considered statistically significant.

Author contributions:Huiying Zhang conceived and designed this study, was in charge of funds, and wrote and revised the manuscript. Ting Zhou conducted experiments. Yaqing Zhang participated in study design, was responsible for support and also revised the manuscript. Ying Zhang guided the statistical analysis. Yun Xu provided support for psychological information.

Conflicts of interest:None declared.

Funding:This study was supported by the Science and Technology Foundation Program of Shanghai Jiao Tong University Medical School (Influence of clinical nursing rehabilitative training on self-care ability of stroke patients), No.YZ1048.

Supplementary information:Supplementary data associated with this article can be found, in the online version, by visiting www.nrronline.org, and entering Vol. 6, No. 19, 2011 after selecting the “NRR Current Issue” button on the page.

[1]Zhang XP. Diagnosis of elderly depression. Shiyong Laonian Yixue. 2001;15(1):8-9.

[2]Sun FZ, Su JF, Yuan YP, et al. Analysis on related factors about post-stroke depression. Zhongxiyi Jiehe Xin Nao Xueguanbing Zazhi. 2008;6(1):122-123.

[3]Martín-González R, Ortiz de Salazar A, Peris-Martí A, et al. Life events, quality of life and social support prior to acute cerebral vascular disease, as predictive factots of the quality of life and functional state following stroke. Rev Neurol. 2000;30(8):707-711.

[4]Berg A, Palomäki H, Lehtihalmes M, et al. Poststroke depression:an 18-month follow-up. Stroke. 2003;34(1):138-143.

[5]Mant J, Winner S, Roche J, et al. Family support for stroke: one year follow up of a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2005;76(7):1006-1008.

[6]Wang SA, Luo YW. Post-stroke Depression. Zhongguo Kangfu Yixue Zazhi. 2009;24(6):407-409.

[7]Yan H. Analysis on related factors about post-stroke depression.Zhongxiyi Jiehe Xin Nao Xueguan Bing Zazhi. 2009;7(11):1373-1374.

[8]Zhang XM, Qi FS, Li HF, et al. The relationship between social supports and post-stroke depression. Zhongguo Jiankang Xinlixue Zazhi. 2004;12(5):351-352.

[9]Wu SF. Relevant analysis of the depression and the relationship with social supports for patients with post-stroke. Hushi Jinxiu Zazhi. 2009;24(1):10-12.

[10]Mei JR. Reliability and validity of GDS and GHQ short form for the aged. Zhonghua Xinli Xuekan. 1999(1):41-43.

[11]Xiao SY. Theoretical basis and research applications for “social support rating scale”. Linchuang Jingshen Yixue Zazhi. 1994;4(2):98-100.

[12]Jiang KD. Psychiatry. Beijing: People's Medical Publishing House.2006:123.

[13]Khan F. Poststroke depression. Aust Fam Physician. 2004;33(10):831-834.

[14]Hsieh LP, Kao HJ. Depressive symptoms following ischemic stroke: a study of 207 patients. Acta Neurol Taiwan. 2005;14(4):187-190.

[15]Qiao AP, Wei ZJ. Geriatric Depression and Analysis of the Influential. Shanxi Yike Daxue Xuebao: Yixue Ban. 2002;33(6):24-25.

[16]Herrmann N, Black SE, Lawrence J, et al. The sunnybrook stroke study: a prospective study of depressive symptoms and functional outcome. Stroke. 1998;29(3):618-624.

[17]Paolucci S, Gandolfo C, Provinciali L, et al. The Italian multicenter observational study on post-stroke depression (DESTRO). J Neurol. 2006;253(5):556-562.

[18]Li GH, Liu B. 251 cases of cerebral hemorrhage and cerebral infarction prognosis. Zhongguo Chuji Weisheng Baojian. 2001;15(9):58.

[19]Du GP. Discussion the relationship between post-stroke depression and stroke location. Zhongguo Shiyong Shenjing Jibing Zazhi. 2009;12(23):39-40.

[20]Fourth National Conference on Cerebrovascular Disease.Zhonghua Shenjingke Zazhi. 1996;29(6):379-380.