Early screening for post-stroke depression and its effect on functional outcomes, quality of life, and mortality: A meta-analysis

Abstract

BACKGROUND

Post-stroke depression (PSD) is a common and debilitating condition affecting stroke survivors, significantly impacting their recovery and overall quality of life.

AIM

To assess the effects of early PSD screening on functional outcomes, quality of life, and mortality.

METHODS

From an initial pool of 1065 articles, 6 studies met the inclusion criteria and were selected for analysis. Functional outcomes were measured using the functional independence measure (FIM).

RESULTS

The analysis revealed a significant improvement in FIM scores for a PSD screening group compared to controls [standardized mean difference (SMD) = 8.90, 95% confidence interval (CI): 4.65-13.15, P < 0.01]. Quality of life was assessed using the Stroke-Specific Quality of Life Scale, with the screening group showing significantly higher scores (SMD = 20.83, 95%CI: 15.27-26.38, P < 0.01). Mortality analysis indicated a reduction in five-year mortality rates for the PSD screening group.

CONCLUSION

Early PSD screening enhances functional recovery, improves quality of life, and reduces mortality rates in stroke survivors. Thus, integrating PSD screening into routine stroke care improves long-term outcomes for patients.

Key Words: Post-stroke depression; Early screening; Functional outcomes; Quality of life; Mortality

Core Tip: Post-stroke depression (PSD) is a common and debilitating condition affecting stroke survivors, significantly impacting their recovery and overall quality of life. This meta-analysis aimed to assess the effects of early PSD screening on functional outcomes, quality of life, and mortality. The findings of the study highlight the potential benefits of early PSD screening in improving recovery and survival outcomes for patients with stroke. However, further research is necessary to standardize screening protocols and address potential limitations related to heterogeneity.

INTRODUCTION

Post-stroke depression (PSD) is one of the most significant complications following a stroke, yet it is often underdiagnosed. It affects approximately one-third of stroke survivors and is closely associated with poor rehabilitation outcomes, reduced quality of life, and increased mortality[1]. The aggressive nature of PSD, characterized by its profound impact on the neurobiological and psychological health of patients, mirrors the complexities seen in managing severe medical conditions, such as triple-negative breast cancer (TNBC)[2].

Early detection and intervention for PSD are critical in mitigating these adverse outcomes. Current clinical practices emphasize the need for routine early screening to identify depressive symptoms soon after stroke, which allows for timely therapeutic measures that can significantly alter the trajectory of recovery[3].

The choice of screening tools plays a vital role in the clinical management of PSD. Standardized tools like the Patient Health Questionnaire 9 are commonly used, owing to their validated efficacy in detecting early depressive symptoms during the acute phase of stroke rehabilitation[4]. However, like traditional wound dressings in post-mastectomy TNBC care, the effectiveness of such conventional screening tools in different clinical contexts, particularly among diverse stroke populations, is increasingly being questioned[5].

Advanced screening methodologies and integrated care approaches have emerged in response to these challenges[6]. These aim to better manage the complex interplay of symptoms and improve overall outcomes, akin to how silver alginate dressings have revolutionized wound care in patients with TNBC by providing superior infection control and an optimal healing environment.

Nevertheless, transitioning to these advanced methodologies in PSD management is fraught with challenges. Concerns regarding the practicality of their implementation in diverse healthcare settings, cost-effectiveness, and the adaptability of healthcare systems mirror the dilemmas faced in adopting advanced wound care technologies in resource-limited settings[7,8].

Given these parallels, a systematic review and meta-analysis of early screening interventions for PSD is both timely and essential. This analysis will not only clarify the relative benefits and limitations of various screening tools, but also provide evidence-based recommendations for optimizing the management of PSD in stroke survivors, thereby enhancing their recovery and quality of life post-stroke.

MATERIALS AND METHODS

Search strategy

To evaluate the effect of early screening for PSD on functional outcomes, quality of life, and mortality, a rigorous search strategy was employed, which adhered to the PRISMA guidelines. Systematic searches were conducted across several databases, including PubMed, Embase, Web of Science, and Cochrane Library. Key terms used in the search included “Post-Stroke Depression,” “Early Screening,” “Functional Outcomes,” “Quality of Life,” “Mortality,” and related terms. The search was limited to studies published in English up to May 2024. Initial screening involved assessing titles and abstracts for relevance, followed by full-text reviews of the selected studies.

Selection criteria for studies

This meta-analysis included studies that specifically investigated the effects of early PSD screening on subsequent health outcomes. Eligible studies were randomized controlled trials, cohort studies, and controlled observational studies. Studies not directly addressing the research question, as well as reviews, case reports, and editorial pieces were excluded. The selection process involved a detailed examination of study titles and abstracts first, followed by a full-text review where necessary. Any disagreements in the study selection were resolved through discussion within the research team.

Data extraction protocol

Data extraction was conducted systematically, which included crucial information, such as study author, publication year, study location, study design, participant demographics, details of the screening method used, and primary outcomes related to PSD. A pre-designed data extraction form was utilized to standardize this process.

Statistical analysis

Statistical analysis was performed using the Review Manager (RevMan) software. Continuous outcomes, such as quality of life scores and functional recovery metrics, were analyzed using standardized mean difference (SMD), each with 95% confidence interval (CI). Dichotomous outcomes, such as mortality rates, were assessed using risk ratios or odds ratios, also with 95%CI. Heterogeneity among studies was evaluated using the I² statistic, with values > 50% indicating substantial heterogeneity. Depending on the degree of heterogeneity identified, either a fixed-effect or random-effects model was applied. Statistical significance was determined at a P value < 0.05.

Bias assessment

The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. Two team members independently reviewed each study, classifying the risk of bias as low, high, or unclear. Discrepancies were resolved by consensus. Additionally, publication bias was evaluated using funnel plots, sensitivity analysis, and Egger’s regression test, to ensure the reliability of the meta-analysis findings.

RESULTS

Our exhaustive literature search initially identified 1065 studies. After the rigorous removal of duplicates and initial screenings based on titles and abstracts, 98 studies remained for detailed full-text assessment. Following a stringent two-tiered exclusion process, we further excluded 92 studies that did not meet the inclusion criteria. This process resulted in the final selection of six studies[9-14] for inclusion in our meta-analysis, as illustrated in Figure 1. A detailed overview of the study characteristics is presented in Table 1.

Figure 1  Flow diagram of the study selection process.

Table 1 Characteristics of included studies, mean ± SD.

Ref.	Year	Country	Sample size	Age	Gender (Male %)	Screening tool	Outcome measures
Thomas et al[9]	2019	United Kingdom	48	68.45 ± 3.51	52.7	PHQ-9	FIM, SS-QoL, mortality
Almeida et al[10]	2021	Australia	607	70.12 ± 2.83	49.3	HADS	FIM, SS-QoL, mortality
Gao et al[12]	2017	China	274	69.33 ± 3.24	47.5	CES-D	FIM, SS-QoL, mortality
Hackett et al[13]	2010	Australia	200	71.29 ± 2.65	55.4	PHQ-9	FIM, SS-QoL, mortality
Almeida et al[11]	2022	Australia	1221	67.84 ± 3.10	50.6	HADS	FIM, SS-QoL, mortality
Trompetto et al[14]	2013	Italy	110	72.40 ± 3.79	53.1	GDS	FIM, SS-QoL, mortality

FIM: Functional independence measure; SS-QoL: Stroke-Specific Quality of Life Scale.

Risk of bias assessment

The risk of bias was meticulously evaluated across the selected studies. Figure 2, a traffic light plot, and Figure 3, a bar graph summarizing the bias in various domains, indicate a generally low risk of bias in the included studies. Specifically, the domains of randomization, protocol adherence, completeness of outcome data, and accuracy of outcome measurement demonstrated low bias. Although minor issues of selective reporting were noted in two studies, the overall risk of bias was considered minimal.

Figure 2  Traffic light plot showing the risk of bias assessment.

Figure 3  Bar graph summarizing bias across various domains.

Functional outcomes

The forest plot in Figure 4A compares the functional independence measure (FIM) scores between patients who underwent PSD screening and those in the control group. The analysis revealed a significant improvement in FIM scores for the PSD screening group (SMD = 8.90, 95%CI: 4.65-13.15, P < 0.01), indicating that early screening for PSD is associated with better functional recovery post-stroke.

Figure 4 Functional outcomes, quality of life, and mortality in post-stroke depression screened patients compared to controls. A: Forest maps compared functional independence measure scores between patients screened for post-stroke depression (PSD) and control patients; B: The forest plots of stroke-specific quality of life scale scores were compared between PSD screening group and control group; C: The forest map shows the mortality rates within five years of stroke in patients screened for PSD versus those who were not screened.

Quality of life

Figure 4B presents a forest plot comparing the Stroke-Specific Quality of Life Scale (SS-QoL) scores between the PSD screening and control groups. The results showed a significant enhancement in SS-QoL scores for the PSD screening group (SMD = 20.83, 95%CI: 15.27-26.38, P < 0.01), suggesting that early PSD screening significantly improves the quality of life for stroke survivors.

Mortality

The forest plot in Figure 4C illustrates the mortality rates within five years post-stroke for patients who underwent PSD screening compared to those who did not. The findings indicate that PSD screening significantly reduces the five-year mortality rate (SMD = -47.13, 95%CI: -60.08 to -34.18, P < 0.01).

Publication bias

Figure 5 presents the funnel plot and Egger’s regression test for five-year mortality outcome. The funnel plot showed no significant asymmetry, and Egger’s regression test confirmed the absence of significant publication bias (P = 0.67), affirming the reliability of our meta-analysis results.

Figure 5  Funnel plot and Egger's regression test assessing publication bias for five-year mortality rates.

DISCUSSION

The findings of this meta-analysis underscore the significant benefits of early screening for PSD on functional outcomes, quality of life, and mortality in stroke survivors. The inclusion of seven studies provides a robust dataset that enhances the reliability of these conclusions.

The significant improvement in functional outcomes among patients who underwent PSD screening suggests that early detection and management of depression can facilitate better neurological and physical recovery post-stroke. These results align with existing literature that highlights the positive effect of early psychological interventions on functional recovery and cognitive outcomes in patients with stroke[15,16].

Furthermore, the enhancement in quality of life for those screened for PSD underscores the broader impact of mental health on overall quality of life. Stroke survivors often face significant psychological challenges that can adversely affect their social interactions, emotional well-being, and activities of daily living[17,18]. Early PSD screening facilitates timely psychological and psychiatric interventions, which can mitigate these adverse effects and enhance the overall quality of life.

The reduction in mortality rates among the PSD screening group highlights the critical role of mental health in survival outcomes. Depression is a well-established predictor of increased mortality in patients with stroke due to its association with poorer adherence to medical treatments and rehabilitation protocols, as well as its effect on biological processes, such as inflammation and neuroplasticity[19].

Risk of bias was assessed across the included studies using standardized tools. Our analysis confirms a generally low risk of bias, particularly in randomization, protocol adherence, and completeness of outcome data. Although minor issues of selective reporting were noted in some studies, the overall risk of bias was minimal. The absence of significant publication bias, as indicated by the funnel plot and Egger’s regression test, further supports the reliability of our findings.

Despite these promising findings, this study had several limitations. The heterogeneity in study designs, sample sizes, and screening tools used across the included studies could introduce variability in the results[20]. Additionally, the exclusion of non-English language studies may have led to a selection bias, potentially overlooking relevant research published in other languages. Future research should aim to standardize screening protocols and explore the effect of early PSD screening in diverse populations and healthcare settings[21].

CONCLUSION

This meta-analysis demonstrates that early screening for PSD significantly enhances functional outcomes, improves quality of life, and reduces mortality in stroke survivors. These findings advocate for the integration of routine early PSD screening into post-stroke care protocols to facilitate timely intervention and optimize overall patient outcomes.