The high rate of major depression after stroke in Nigeria may be the result of high cumulative morbidity burden: a call for greater efficiency in the management of stroke in developing countries

Authors


Dear editor,

Stroke remains the most common cause of medical death in Nigeria [1]. Although recent improvement in the management of the accident has led to a decline in mortality, there are paradoxical increases in the number of survivors left with morbidity. Much of this results from depression [2].

The present study sought to determine the frequency and predictors of major depressive disorder (MDD) meeting criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders in a sample of 130 stroke survivors using standardized assessments. They were recruited from two outpatient settings in southwestern Nigeria. Along with historical details, an exploration for MDD was carried out using a semistructured interview. Cognition was assessed using both the Mini Mental State Examination and the modified Indiana University Token test, whereas disability was assessed using the modified Rankin Scale.

The diagnosis of MDD was present in 41·5% of the survivors (Table 1). It was strongly associated with female gender [P < 0·0001, odds ratio (OR) = 3·77, 95% confidence interval (CI) = 1·78–8·00], disability (P = 0·001, OR = 3·27, 95% CI = 1·57–6·83), and cognitive dysfunction (P < 0·0001, OR = 5·28, 95% CI = 2·25–12·41).

Table 1. Clinical characteristics of stroke survivors
CharacteristicsNumber (n)Percentage (%)
Side of weakness  
Right5844·5
Left7255·5
Physical disability  
No disability1310·0
Slight disability3526·9
Moderate disability5139·2
Moderately severe disability2216·9
Severe disability43·1
Time since stroke  
3–9 months3930·0
10–16 months3123·9
17–24 months6046·2
Medical history  
Hypertension10782·3
Diabetes2418·5
Other physical condition (e.g, obesity and heart diseases)43·1
History of medication use (antihypertensives, antidiabetics, anticoagulant, etc.)9976·2
Family history (stroke, hypertension, diabetes)4937·7
Alcohol use3426·2
Psychosocial stressors10278·5
DSM IV depression (MDD)5441·5

The high rate of MDD reported in this sample is likely to have been influenced by contextual factors affecting the management of stroke in Nigeria. For instance, it has previously been observed that the acute phase of stroke is often inefficiently managed in many of the facilities where biomedical treatments are provided [3]. Also, a large proportion of patients may present initially to traditional or faith healers because of sociocultural beliefs about stroke [4]. Moreover, as only a small percentage of the population has access to health insurance, the cost of health care may prevent many patients from seeking treatment in the early stages of stroke [5].

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