Exploring the risk-factor association between depression and incident stroke: a systematic review and meta-analysis

Abstract

There is growing evidence that depression increases the risk of incident stroke. However, few studies have considered possible residual confounding effects by preexistent cerebrovascular and cardiac diseases. Therefore, we synthesized data from cohort studies to explore whether depressed individuals free of cerebrovascular and cardiac diseases are at higher risk of incident stroke. We searched the electronic databases PubMed and Medline for eligible cohort studies that examined the prospective association between depression and first-ever stroke. A random-effects model was used for quantitative data synthesis. Sensitivity analyses comprised cohort studies that considered a lag period with exclusion of incident strokes in the first years of follow-up to minimize residual confounding by preexistent silent strokes and excluded cardiac disease at baseline. Overall, we identified 28 cohort studies with 681,139 participants and 13,436 (1.97%) incident stroke cases. The pooled risk estimate revealed an increased risk of incident stroke for depression (relative risk 1.40, 95% confidence interval [CI] 1.27-1.53; P<0.0001). When we excluded incident strokes that occurred in the first years of follow-up, the prospective association between depression and incident stroke remained significant (relative risk 1.64, 95% CI 1.27-2.11; P<0.0001). This positive association also remained after we considered only studies with individuals with cardiac disease at baseline excluded (relative risk 1.43, 95% CI 1.19-1.72; P<0.0001). The prospective association of depression and increased risk of first-ever stroke demonstrated in this meta-analysis appears to be driven neither by preexistence of clinically apparent cerebrovascular and cardiovascular diseases nor by silent stroke.

Keywords: depression; prestroke; risk factor; stroke.

Figure 1

Flow diagram of study selection for the quantitative data synthesis. Abbreviation: TIA, transient ischemic attack.

Figure 2

Forest plot showing the pooled adjusted risk estimates for first-ever stroke in depressed individuals. Note: Weights are from random effects analysis. Abbreviations: ES, effect size; CI, confidence interval; HR, hazard ratio; OR, odds ratio; RR, relative risk.

Figure 3

Forest plot showing the pooled adjusted risk estimates for first-ever stroke in depressed individuals according to the analytic approach used in the included study. Lag period indicates that stroke cases that occurred in the first years of follow-up were excluded from the analysis to minimize the possibility of reverse causality. Note: Weights are from random effects analysis. Abbreviations: ES, effect size; CI, confidence interval.