Associations between DSM-IV mental disorders and subsequent non-fatal, self-reported stroke
Introduction
Stroke is the leading cause of acquired disability in adults, and also a leading cause of death [1], [2]. Despite the recent advent of improved treatment for survivors of stroke, prevention remains the best approach for reducing the burden of stroke [3], [4]. Recent evidence suggests stroke rates are declining [5], [6] and this has been attributed to increasing success in treating hypertension, in combination with diabetes and high cholesterol control and smoking cessation [7].
Many risk factors for stroke have been studied and quantified. Hypertension accounts for between 52% [8] and 80% of the risk [9] while smoking contributes between 12% [10] and 19% [8] of the risk of stroke. Other contributing factors are: high cholesterol [11], [12], [13], physical activity [8], [9], [1], [12], alcohol [8], [11], [12], heart disease [9], [13], diabetes [8], [9], [12], [13], obesity [9], [11], [13], psychosocial factors [8], [9] and, diet [8], [9], [11].
There is also a well established relationship between depression and incident stroke [14]. Adding to that body of evidence, a recent prospective study found a two-fold increased risk of first ever stroke associated with prior depression, after controlling for confounders [15]. Another recent study reported a 70% increased risk for stroke following depression [16]. There has been limited research into the contribution of anxiety disorders and stroke incidence [17]. A recent review found that while the link between anxiety and heart disease was well established the link between anxiety and stroke was less clear with fewer studies and conflicting results [18]. A key limitation of the majority of prior studies on depression and anxiety is that they have used symptom screening scales rather than diagnostic measures of mental disorders; a review in the area suggests that more research with diagnostic measures of mental disorders is needed [19] in order to establish whether depression and anxiety both contribute to the risk of stroke after controlling for their comorbidity, and whether other mental disorders, including substance use disorders, might also elevate stroke risk.
The rationale for a focus on mental disorders is that like hypertension, they may form a further potentially modifiable group of risk factors for stroke. American Stroke Association Guidelines in the prevention of stroke do not consider mental disorders at all [4]. Treatment of mental disorders may have a direct effect on stroke reduction, and also an indirect effect as they may influence the other known direct modifiable factors. It is possible using the present dataset to examine direct effects of mental health disorders while controlling for known mediators such as smoking, gender and hypertension. Although alcohol consumption is known to influence the risk of stroke, alcohol use disorders have not been studied as risk factors for incident stroke. Evidence regarding alcohol use and stroke suggests that low-level consumption may offer some protection from ischaemic stroke, at the same time increasing the risk of hemorrhagic stroke. Increasing consumption increases all types of stroke risk, as well as other types of cardiovascular disease [20].
The present study uses the cross-national World Mental Health (WMH) Surveys dataset to examine associations between a range of DSM-IV mental disorders and subsequent non-fatal stroke. The WMH surveys are general population surveys that retrospectively assessed lifetime history of DSM-IV mental disorders and also obtained self-report of diagnosis of selected chronic physical conditions including stroke. The surveys are cross-sectional in design, but collected information on onset timing of mental disorders and physical conditions, which allows the use of survival analysis to examine associations between temporally prior mental disorders (retrospectively reported) and the subsequent onset of non-fatal stroke, examining the influence of specific disorders as well as the cumulative influence of multiple disorders.
Section snippets
Samples and procedures
This study uses data from 17 of the WMH surveys (see Table 1). This included all surveys that had included a question specifically on stroke. A stratified multi-stage clustered area probability sampling strategy was used to select adult respondents (18 years +) in most WMH countries. Most of the surveys were based on nationally representative household (or population register) samples while Colombia, and Mexico were based on nationally representative household samples in urbanized areas. All
Results
The survey characteristics are shown in Table 1 together with information about the number of survey respondents reporting a history of non-fatal stroke (n = 714).
Discussion
This study reports on the mental disorders associated with subsequent non-fatal stroke. After controlling for other mental disorders, age, gender, country, smoking, and education, associations remained statistically significant between depression and stroke, and between alcohol abuse and stroke. A general picture emerged that there was a strong joint effect of mental disorders on non-fatal stroke and that the number of mental disorders experienced over the life course was a stronger predictor
Author contributions
Dr. Scott takes full responsibility for the integrity of the data analysis and accuracy of results reported.
Financial disclosure
Dr. Lépine has served on speaker bureaus for Servier, Pfizer-Wyeth, Sanofi and Pierre Fabre. Dr. Kessler has been a consultant for the Analysis Group, GlaxoSmithKline Inc., Kaiser Permanente, Merck & Co., Inc., Ortho-McNeil Janssen Scientific Affairs, Pfizer Inc., Sanofi-Aventis Groupe, Shire US Inc., SRA International, Inc., Takeda Global Research & Development, Transcept Pharmaceuticals Inc., Wellness and Prevention, Inc., and Wyeth-Ayerst; has served on advisory boards for Eli Lilly &
Funding/support
The World Health Organization World Mental Health (WMH) Survey Initiative which is supported by the National Institute of Mental Health (NIMH; R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Squibb. We
Additional funding
Work on this paper was funded by a grant from the Health Research Council of New Zealand (HRC 11/200) to Kate M Scott.
Disclaimer
The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or the U.S. Government.
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