The association between major depression, healthbehaviors, and quality of life in adults with stroke

Charles Ellis1,2*, Anouk L. Grubaugh2,3, and Leonard E. Egede2,4

Aim The study aims to examine the association betweenmajor depression, healthcare behaviors, and quality of lifeindices among adults with stroke.Methods Data from 5869 participants with stroke in the2006 Behavioral Risk Factor Surveillance Survey were exam-ined. Multiple logistic regression was used to assess theindependent association between depression status, self-care and preventive health behaviors, and quality of lifeindices, after accounting for relevant covariates.Results In multivariate models, individuals with majordepression were less likely to engage in physical activity(odds ratio 0·41; 95% confidence interval 0·29, 0·56) thanthose without major depression. Women with major depres-sion were also less likely to have received a mammogram inthe past two-years (odds ratio 0·61; 95% confidence interval0·40, 0·96 for women � age 40 and odds ratio 0·58; 95%confidence interval 0·36, 0·72 for women � age 50) and apap smear in the past three-years (odds ratio 0·40; 95% CI0·22, 0·72). In comparisons of quality of life, individuals withmajor depression were less likely to perceive their health asexcellent/very good/good (odds ratio 0·36; 95% confidenceinterval 0·25, 0·53), to report being satisfied with life (oddsratio 0·13; 95% confidence interval 0·08, 0·20), and to reportreceiving needed social support (odds ratio 0·42; 95% confi-dence interval 0·28, 0·63). Individuals who were depressedwere also more likely to report one or more poor physicaland poor mental health days in the past 30 days (odds ratio

4·56; 95% confidence interval 3·08, 6·76 and odds ratio 10·97;95% confidence interval 7·75, 15·52, respectively).Conclusions In adults with stroke, major depression is asso-ciated with decreased engagement in stroke-specific andgender-specific self-care and preventive health behaviors, aswell as a broad range of quality of life indices.

Key words: depression, quality of life, stroke

Introduction

The World Health Organization estimates that each year 15million people suffer strokes worldwide (1). Stroke claims thelives of 5·8 million individuals each year and another 5 millionare left permanently disabled (2). Stroke survivors are fre-quently left with a range of physical, cognitive, and behavioraldeficits that limit their ability to regain premorbid functioningacross a number of lifestyle domains. Similarly, many indi-viduals experience depression after stroke (3–11). Rates ofpoststroke depression vary significantly across studies.However, depending on the sampling time frame, between20% and 50% of all stroke survivors experience depression(4), either in the short or long term after stroke (5). Forexample, Berg and colleagues found that 29 of 89 patients whowere absent of a severe communication disorder, exhibiteddepression two-weeks after their stroke; however, only 5 of the29 experienced major depression (6). In contrast, Astrom et al.found that 25% of a cohort of 80 patients exhibited majordepression in the acute stage while ~28% exhibited majordepression at three-months post-stroke, 12% at 12 monthsand 25% at 3 years (12).

Depression may be associated with stroke-related out-comes. For example, Goodwin and Devanand found that indi-viduals with stroke and depression had worse and potentiallymore chronic functional health impairment (9). Depressioncan also be a long-term consequence of stroke. Schepers andcolleagues completed a study to predict depressive symptomsup to three-years poststroke and found that 23·7% of thepatients reported symptoms at six-months, 25·2% at 12months, and 16·0% at 36 months (11). Berg and colleaguesfound that 54% of all patients experience depressive symp-toms at some time during the first 18 months after a stroke (6).

Correspondence: Charles Ellis*, Medical University of South Carolina,College of Health Professions, 77 President Street, MSC 700, Charleston,SC 29425, USA.Email: ellisc@musc.edu1Department of Health Sciences & Research, Medical University ofSouth Carolina, Charleston, SC, USA2VA Center for Disease Prevention and Health Interventions for DiversePopulations, Ralph H. Johnson VA Medical Center, Charleston, SC, USA3Department of Psychiatry and Behavioral Sciences, Medical Universityof South Carolina, Charleston, SC, USA4Department of Medicine, Center for Health Disparities Research,Medical University of South Carolina, Charleston, SC, USA

Conflict of interest: None declared.

DOI: 10.1111/j.1747-4949.2011.00708.x

Research

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Aside from being prevalent, depressive symptoms in strokesurvivors have been linked to:

• lower reports of life satisfaction in survivors (13–17) andtheir spouses (18)

• reductions in social activity (19)

• increased family and caregiver stress (19,20), and

• reductions in quality of life (QOL) (21–23)Despite the significant body of literature related to the

prevalence of depression after stroke, little is known about theimpact of depression on general health behaviors importantfor primary and secondary stroke prevention. A recent studyfound that four health behaviors (not smoking, being physi-cally active, moderate consumption of alcohol, and eating fiveportions of fruit and vegetables) substantially lowered the riskof stroke among more than 20 000 men and women with noknown history of stroke (24). These same lifestyle modifica-tions appear key to both primary and secondary stroke pre-vention (25). Studies have not been completed in thepoststroke population to examine the association betweendepression and important health behaviors even though thesefactors are critically important to secondary stroke prevention(26). The relationship between stroke and depression is notentirely clear. For example, there may be a bidirectional rela-tionship between depression and outcomes of debilitatingchronic diseases such as stroke. Few studies have examined therelationship between depression, the aforementioned second-ary stroke prevention behaviors, and a wider range of generalhealth behaviors critical to good health.

The purpose of this study was to examine the associationbetween stroke, major depression, and general health behav-iors and QOL indices in a national sample of adults withstroke. Because this is a cross-sectional study, we will not beable to identify the mechanisms underlying the associationbetween depression and stroke (27). We chose to study theimpact of major depression because little is known about theinfluence of major depression after stroke. To date, few, if any,studies have examined the association between depression andhealth behaviors and QOL among stroke survivors using anationally representative sample. In this study, we used datafrom the 2006 Behavioral Risk Factor Surveillance System(BRFSS) national survey (28) to determine if a broad range ofgeneral and gender-specific health behaviors (i.e. engaging inleisure-time physical activity; not smoking; not drinkingexcessively; and receiving age and gender-appropriate screen-ings for breast, cervical, prostate, and colorectal cancers) andQOL indices (i.e. perceived health status, physical and mentalhealth functioning, life satisfaction, and social support) variedby depression status (i.e. nondepressed vs. major depression).More specifically, we hypothesized that individuals with majordepression would be less likely to engage in general andgender-specific health practices and to report poorer QOLthan nondepressed individuals after controlling for relevantconfounding variables. We recognize a relationship betweenlevel of disability and depression in addition to disability anddecreased levels of physical activity. Consequently, we consider

this examination a critical first step in understanding of thatrelationship with due recognition of the limitations of theavailable data. Future studies should be designed to furtherexamine the causal relationship between stroke anddepression.

Research design and methods

Study setting and sample

We analyzed data from the 2006 BRFSS. The BRFSS is a state-based, random-digit-dialing telephone survey of the US adultpopulation sponsored by the Center for Disease Control (28).The BRFSS uses a complex design involving stratification,clustering, and multistage sampling to yield nationally repre-sentative estimates. The BRFSS includes a range of questions,some of which are single indicator variables, which have beendeemed reliable measures of the general US population (29).

Demographic and socioeconomic characteristics

The BRFSS provides information on a wide range of demo-graphic and background characteristics. For the purposes ofthe current study, we created four age categories: 18–34,35–49, 50–64, and 65+ years. We combined race and ethnicityto create four racial/ethnic groups: non-Hispanic Whites, non-Hispanic Blacks, Hispanics, and non-Hispanic other. We thencreated four levels of education: <high school graduate, highschool graduate, <college graduate, and college graduate; andfour income categories: <$25 000, <$50 000, <$75 000, and$75 000+. We defined marital status as married vs. notmarried; employment status as employed vs. unemployed; andinsurance status as insured vs. uninsured.

Diagnosis of stroke

A diagnosis of stroke was based on self-report. Respondentswere asked ‘Has a doctor, nurse, or other health professionalever told you that you had a stroke?’ We excluded those whoresponded ‘not sure’, ‘don’t know’, ‘refused’, or ‘missing’. Indi-viduals under the age of 18 were also excluded from analyses.

Depression status

Presence of major depression was based on the results of theBRFSS Depression module, which is an eight-item version ofthe Patient Health Questionnaire (PHQ-8). The PHQ-8 is astandardized and validated scale designed to measure theprevalence and severity of depression in the US general popu-lation and in clinical populations (30). The PHQ-8 was stand-ardized to make it comparable with the general format of the2006 BRFSS survey by asking the number of days the respond-ent experienced any of eight depressive symptoms in the past

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two-weeks (30). The PHQ-8 response was converted back tothe original response set as follows:

• 0 to 1 day = ‘not at all’

• 2 to 6 days = ‘several days’

• 7 to 11 days = ‘more than half the days’, and

• 12 to 14 days = ‘nearly every day’ with points (0 to 3)assigned to each category, respectively

The scores for each item were summed to produce a totalscore between 0 and 24 points. No major depression wasdefined as a PHQ-8 score between 0 and 9, and major depres-sion was defined as a PHQ-8 score of 10 or greater. The PHQ-8algorithm has 100% sensitivity and 95% specificity for majordepression (vs. other + none), and 70% sensitivity and 98%specificity for any depressive disorder (30).

Self-care behaviors

Respondents were asked several questions about general pre-ventive care practices, including the following.

Leisure-time physical activityRespondents were asked (yes/no), ‘During the past month,other than your regular job, did you participate in any physicalactivities or exercises such as running, calisthenics, golf, gar-dening, or walking for exercise?’

SmokingRespondents were asked if they were current or formersmokers (every day or some days) or if they never usedtobacco.

Heavy drinkingRespondents were asked, ‘During the past 30 days, on the dayswhen you drank, about how many drinks did you drink on theaverage?’ BRFSS guidelines defined heavy drinking as greaterthan two drinks daily for men and greater than one drink dailyfor women.

General preventive care

Respondents were asked several questions about general pre-ventive care practices.

Flu shotRespondents were asked, ‘During the past 12 months, have youhad a flu shot?’

Pneumonia shotPneumonia shots of pneumococcal vaccines are usually givenonce or twice in a person’s lifetime. Respondents were asked,‘Have you ever had a pneumonia shot?’

Breast cancer screeningWomen were asked whether they had ever received a mam-mogram, as well as how long it had been since their last mam-

mogram (i.e. within the past year, within the past two-years;within the past three-years; within the past five-years; five ormore years ago). For the purposes of the current analyses,women who reported receiving a mammogram in the pasttwo-years received a ‘yes’ for this preventive care variable.Analyses were conducted on women over the age of 50.

Cervical cancer screeningWomen were asked whether they had ever received a pap test(test for cancer of the cervix), as well as how long it had beensince their last pap test (i.e. within the past year, within thepast two-years; within the past three-years; within the pastfive-years; five or more years ago). For the purposes of thecurrent analyses, women aged 18 or older who reportedreceiving a pap test in the past three-years received a ‘yes’ forthis preventive care variable.

Prostate cancer screeningMen who were 40 years of age or older where asked if they hadever received a prostate-specific antigen (PSA) test for prostatecancer, as well as how long it had been since their last PSA test(i.e. within the past year, within the past two-years; within thepast three-years; within the past five-years; five or more yearsago). Men (aged 40 or older) who endorsed receiving a PSAtest in the past two-years received a ‘yes’ for this preventivecare variable.

Colorectal cancer screening

• Colon blood stool test: Participants who were 50 years ofage or older were asked whether they had ever used a homeblood stool test to determine whether they had blood in theirstool, as well as how long it had been since they had used ahome blood tool test (i.e. within the past year, within the pasttwo-years; within the past three-years; within the past five-years; five or more years ago). Men and women (aged 50 orolder) who endorsed using a home blood stool kit in the pasttwo-years received a ‘yes’ for this preventive care variable.

• Sigmoidoscopy/colonoscopy: Participants who were 50years of age or older were asked whether they had ever receiveda sigmoidoscopy or colonoscopy to view the colon for signs ofcancer, as well as how long it had been since they had receiveda sigmoidoscopy or colonoscopy (i.e. within the past year,within the past two-years; within the past five-years; withinthe past 10 years; 10 or more years ago). Men and women(aged 50 or older) who had ever had a sigmoidoscopy orcolonoscopy received a ‘yes’ for this preventive care variable.

Quality of life

Perceived health status

Participants were asked to self-report their health status usinga range from excellent to poor. Responses were defined asexcellent/very good/good vs. fair/poor.

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Physical and mental healthPoor physical health was defined as no poor physical healthdays in the past 30 days vs. one or more poor physical healthdays in the past 30 days. Poor mental health was defined in asimilar manner.

Life satisfactionThis variable was defined as very satisfied/satisfied vs.dissatisfied/very dissatisfied in response to: ‘In general, howsatisfied are you with your life?’

Social supportThis variable was defined as always/usually/sometimes vs.rarely/never in response to: ‘How often do you get the socialand emotional support you need?’

Statistical analyses

STATA Version 10·0 (31) was used for all statistical analyses.We performed three types of analyses. First, we compared thedemographic characteristics of our sample by depressionstatus (i.e. nondepressed vs. major depression) using chi-square statistics. Second, we compared a range of general self-care and preventive care behaviors and QOL indicators bydepression status using chi-square statistics. Third, we ranseparate multiple logistic regression models to assess the inde-pendent association between depression status and each self-care and preventive care behavior as well as each QOL variableamong adults with stroke. For each logistic model, we usedeach self-care and preventive care behavior or QOL indicatoras the dependent variable; depression status as the primaryindependent variable; and age, sex, race/ethnicity, education,income, marital status, employment, and insurance status ascovariates. We included all relevant demographic variables inthe adjusted models because they were significantly differentby depression status and were conceptually related to the out-comes of interest. In the selection of key demographic vari-ables, we were unable to include stroke severity andpoststroke-related disability as this information was not avail-able. However, we acknowledge the significance of these issuesand their contribution to lower levels of poststroke activity.Finally, for each logistic model, we assessed goodness of fit andeach model provided an adequate fit for the data.

Results

The 2006 BRFSS sample included 351 411 adults whoresponded ‘yes’ or ‘no’ to the question regarding stroke. Of thisnumber, 9488 (2·7%) reported having a stroke. A final sampleof 5869 participants with stroke and PHQ-8 data was used forstudy analyses. The prevalence of major depression in thestudy sample was 21·6%. The highest prevalence of majordepression by racial/ethnic group was among individuals whoidentified themselves as ‘Other’ (35·8%) compared with 18·6%

for Whites, 24·7% for Blacks, and 26·0% for Hispanics.Females (23·2%) had a higher prevalence than males (20·2%);individuals aged 35–49 (36·8%) had a higher prevalence thanother age groups; and those who reported having less than ahigh school education had a higher prevalence (28·0%) thanthose with a least a high school education. Finally, individualshaving an income <$25 000 had a higher prevalence (29·5%)than those with higher incomes; while those who were notmarried (25·6%), not employed (24·4%), and not insured(32·9%) had a higher prevalence of depression than thosemarried (18·3%), employed (12·5%), and insured (20·3%)(Table 1).

Table 2 compares general self-care and preventive carebehaviors and QOL indicators of adults with stroke by depres-sion status. There were significant differences by depressionstatus based on physical activity participation and smokingstatus. In addition, those with major depression were less likelyto engage in general preventive care behaviors such as receivea flu shot, receive a pneumonia shot, receive a mammogram inthe past two-years, receive a pap test in the past three-years forwomen, receive a prostrate exam in the past two-years formen, and perform a home blood stool exam in the past two-years relative to those without major depression. There werealso significant differences in a number of QOL indicators by

Table 1 Demographic characteristics among adults with stroke bydepression status (n = 5869)

No majordepression

Majordepression

(n = 4688) (n = 1181)% % P value

Race 0·006White 71·6 59·5Black 9·3 11·1Other 6·7 13·6Hispanic 12·4 15·8

Gender: female 51·6 56·0 0·256Age (years) <0·001

18–34 5·5 6·335–49 12·1 25·350–64 28·3 43·265+ 54·2 25·3

Education 0·009<High school graduate 20·6 28·9High school graduate 32·9 34·6<College graduate 24·7 23·1College graduate 21·8 13·4

Income ($) <0·001<25 000 47·3 69·1<50 000 30·2 18·2<75 000 10·6 7·575 000+ 11·8 5·2

Married 55·5 44·8 0·004Employed 24·9 12·8 <0·001Insured 90·0 82·4 0·003

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depression status. Those who were depressed were less likely toperceive their health status as excellent/very good/good, toreport being very satisfied/satisfied with life, and to reportalways/usually/sometimes receiving needed social supportrelative to individuals without major depression. Finally, indi-viduals who were depressed were also more likely to have oneor more poor physical and poor mental health days in the past30 days relative to nondepressed individuals.

Table 3 presents the adjusted odds of general self-care andpreventive care behaviors and QOL indicators by depressionstatus using nondepressed individuals as the reference groupand controlling for clinically relevant variables. After control-ling for clinically relevant background and demographic vari-ables, individuals with major depression were less likely toengage in leisure-time physical activity (odds ratio (OR) 0·41;95% confidence interval (CI) 0·29, 0·56) than individualswithout major depression. Women with major depressionwere also less likely to have received a mammogram in the pasttwo-years (OR 0·58; 95% CI 0·36, 0·93 for women aged 50 andolder) and receive a pap smear (OR 0·40; 95% CI 0·22, 0·72) inthe past year relative to their nondepressed counterparts.

With regard to QOL indices, individuals with major depres-sion were less likely to perceive their health as excellent/verygood/good (OR 0·36; 95% CI 0·25, 0·53), to report being verysatisfied/satisfied with life (OR 0·13; 95% CI 0·08, 0·20), and toreport always/usually/ sometimes receiving needed socialsupport (OR 0·42; 95% CI 0·28, 0·63) relative to nondepressedindividuals. Individuals who were depressed were also morelikely to report one or more poor physical and poor mentalhealth days in the past 30 days (OR 4·56; 95% CI 3·08, 6·76 andOR 10·97; 95% CI 7·75, 15·52, respectively) relative to nonde-pressed individuals.

Discussion

The current study examined the association between majordepression, general self-care and preventive health behaviors,and QOL indicators among adults with stroke. There were fourmajor findings in this study.

Table 2 Self-care, preventive care, and quality of life indicators among adults with stroke by depression status

No majordepression

Majordepression

(n = 4688) (n = 1181)% % P value

Physical activity (yes) 62·59 38·54 <0·001Current smoker (yes) 19·22 33·23 <0·001Heavy drinking (yes) 3·06 4·36 0·303Flu shot (yes) 54·94 41·47 <0·001Pneumonia shot (yes) 53·27 45·53 0·042Mammogram past two-years – women over 50 (n = 2462 not depressed; 593 depressed) (yes) 77·58 62·08 <0·001Pap smear (yes) (n = 1264 not depressed; 320 depressed) 78·84 66·94 0·014Prostate-specific antigen – men over 40 (yes) (n = 1742 not depressed; 333 depressed) 64·76 43·71 0·004Colon blood stool test – adults over 50 (yes) (n = 4142 not depressed; 906 depressed) 28·28 28·83 0·875Colon sigmoidoscopy – adults over 50 (yes) (n = 4174 not depressed; 908 depressed) 63·32 56·99 0·100Perceived health status – excellent/very good/good 52·48 23·12 <0·001Poor physical health – past 30 days

1+ days poor physical health in past 30 days 55·87 88·01 <0·001Poor mental health – past 30 days

1+ days poor mental health in past 30 days 27·85 81·07 <0·001Life satisfaction – very satisfied/satisfied 95·26 67·14 <0·001Social support – always/usually/sometimes 86·70 74·06 <0·001

Table 3 Adjusted odds of self-care, preventive care, and quality of lifeindicators among adults with stroke and major depression

Major depression

Odds ratio 95% CI

Physical activity 0·41 0·29–0·56*Smoker 1·37 0·96–1·96Heavy drinking 1·34 0·58–3·13Flu shot 0·83 0·60–1·16Pneumonia shot 1·09 0·82–1·46Mammogram past two years –

women over 500·58 0·36–0·93*

Pap smear 0·40 0·22–0·72*Prostate-specific antigen 0·69 0·42–1·16Colon blood stool test 1·16 0·85–1·64Colon sigmoidoscopy 0·99 0·68–1·44Health status 0·36 0·25–0·53*Poor physical health – past 30 days 4·56 3·08–6·76*Poor mental health – past 30 days 10·97 7·75–15·52*Life satisfaction 0·13 0·08–0·20*Social support 0·42 0·28–0·63*

Reference group: no depression.Adjusted for race, gender, age, education, income, marital status,employment status, and insurance.*Significant at P < 0·05.

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First, the prevalence of major depression in this nationallyrepresentative sample of approximately 6000 stroke survivorswas 21·6%. These findings are supported by at least two pre-vious studies examining the prevalence of major depression instroke survivors (8,12). Unfortunately in this study, we werenot able to determine when participants experienced theirstrokes to examine the relationship between prevalence ofmajor depression relative to stroke onset. However, it is likelythat this large national sample included a significant numberof individuals in the latter phases of stroke recovery, therebyhighlighting the long-term impact of depression in stroke sur-vivors (3,11).

Our second major finding was that after controlling forrelevant covariates, major depression was highly associatedwith reduced participation in physical activity. Individualswith stroke and major depression were almost 2·4 times lesslikely (OR 0·41) than stroke survivors without major depres-sion to engage in physical activity. These findings are impor-tant because participation in regular physical activity is one ofseveral activities important for secondary stroke preventionand general cardiovascular health (25,32). Regular exercise isbelieved to reduce a range of cardiovascular risk factors whilealso providing physiological, psychological, and sensorimotorbenefit to stroke survivors (32). It is also important to note apotential bidirectional causal link between depression andbehavioral risk factors such as exercise. For example, Joubertand colleagues found that when patients receiving integratedstroke care, which included specialized stroke care andprimary care, were monitored regularly via the telephone formanagement of stroke risk factors and depression, they expe-rienced fewer depressive symptoms than there matched con-trols (33). These findings suggest that an integrated caremodel for stroke provides the appropriate support for detect-ing and monitoring depression, thereby resulting in decreasedpoststroke depression. We recognize that a range of factorsassociated with stroke can preclude regular exercise includingstroke severity and physical deficits, comorbidities, familysupport, fatigue, and cultural factors (32). However, the dra-matic differences by depression status point to the magnitudeof depression as a condition that can significantly impact adiverse range of stroke-related outcomes. Interestingly, twoother commonly recommended lifestyle changes (smokingand alcohol reduction) were not significantly different bydepression status in this study. These findings suggest thatmajor depression has a more dramatic impact on participa-tion in physical activity than lifestyle changes that are moresedentary in nature.

Our third major finding was that participation in twogender-specific health behaviors (receipt of regular mammo-grams and pap smears) differed by depression status. Morethan 3500 women were included in our sample of stroke sur-vivors with a major depression prevalence rate of 23%.Depressed women with a history of stroke were approximately1·5 times (OR 0·61 women over 40 and OR 0·58 women over50) less likely to receive a mammogram in the past two-years

and 2·5 times (OR 0·40) less likely to receive a pap smear in thepast three-years than nondepressed female stroke survivors.These findings are important because they suggest thatdepression has a major influence on stroke-specific as well asgender-specific preventive health behaviors. The presence ofmajor depression appears to be associated with gender-specific prevention strategies that can have a devastating andcostly effect on the long-term health status of female strokesurvivors (34). To our knowledge, this is the first study toexamine the association between individuals with stroke,major depression, and such health behaviors.

Our fourth finding was that multiple indices of QOL weresignificantly associated with the presence of major depression.Stroke survivors with major depression were almost 2·8 times(OR 0·36) more likely to report fair or poor health status,more than 4·5 times more likely to report poor physical healthin the past 30 days, almost 11 times more likely to report poormental health in the past 30 days, almost 8 times (OR 0·13)more likely to report not being satisfied with life, and 2·4 times(OR 0·42) more likely to report rarely or never receivingneeded social support than nondepressed stroke survivors.These findings are supported by previous studies that high-light the impact of depression on QOL. Carod-Artal andEgido noted that depression affects QOL in addition to func-tional recovery, cognitive function, and utilization of health-care services (35). Similarly, Kim and colleagues found thatdepression was the strongest predictor of QOL and that theQOL of most stroke survivors in their study was low (23).They added that adaptation to stroke involves more thanrecovery of physical function, thereby highlighting the impor-tance of depression on poststroke QOL. Finally, Kwok andcolleagues argued that depression has a generalized adverseeffect on QOL and that health professionals should stronglyemphasize the treatment of depression among stroke survi-vors to improve stroke-related outcomes (36). In summary, itis also possible that a bidirectional causal link exists betweendepression and QOL.

It is noteworthy with regard to QOL that we examined lifesatisfaction separate from perceived health status and physicaland mental health in the current study. Life satisfaction candiffer across domains as evidenced by the notion that patientswith chronic diseases such as stroke may be dissatisfied withtheir health condition (stroke) while concurrently experienc-ing satisfaction in other domains of life (financial stability,education, marriage, etc.) (37). Therefore, it is possible thatmajor depression is a primary contributor to reduced life sat-isfaction rather than the specific disabling consequences ofstroke. However, because indices of QOL differed betweenadults with major depression relative to those without majordepression, these findings suggest that major depression hasan adverse impact on all aspects of QOL in adults with stroke.

Despite what we believe are interesting and novel findings,this study has some limitations. First, telephone surveys canyield biased estimates because of exclusion of householdswithout telephones. However, many published studies have

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established the validity and reliability of the BRFSS telephonesurvey (38,39). The BRFSS also has the potential for recallbias. It is important to note, however, that recall bias is small inepidemiological studies of major life events such as stroke. Forexample, Howard and colleagues note that while recall bias isa potential limitation, the stroke event itself is reasonably sig-nificant to result in high recall of the event for accurate self-report (40).

Second, depression was not assessed using a ‘gold standard’psychiatric interview, which could have resulted in some falsepositive or negative diagnoses. However, the PHQ-8 is a validand reliable measure of depression in the general US popula-tion (30). We also recognize that the BRFSS does not askparticipants about depression prior to stroke, which would beimportant to the likelihood of experiencing poststroke depres-sion. Third, because this is a cross-sectional study, we arelimited in our ability to test for and adequately account forcausal relationships in our analyses. For example, individualswith aphasia and other cognitive impairments that can occurafter stroke are typically underrepresented in national surveys.Additionally, because information related to type and severityof disability and the time since the stroke onset was not avail-able, we were limited in our ability to determine how thesefactors may have contributed to the completion of healthbehaviors, which are critical to secondary stroke prevention.Similarly, we do not know how the presence and level of dis-ability influenced reports of QOL, and it is impossible to drawconcrete conclusions regarding the independent associationbetween depression, health behaviors, and QOL.

In spite of these limitations, this study provides newinsights into the relationship between depression, healthcarebehaviors, and QOL among adults with stroke. These findingssuggest that major depression can be associated with and havesignificant and detrimental influences on the health status ofindividuals with stroke via multiple causeways. In addition,when considering life satisfaction as an individual measure ofwell-being, adults with stroke and major depression are lesslikely to report being satisfied with life relative to thosewithout major depression. These data suggest that there is aneed to recognize depression early after stroke onset anddevelop strategies to effectively manage depression in adultsduring the short- and long-term recovery phases. Addition-ally, future studies are needed to further clarify the mechanismby which depression impacts both health behaviors and QOLamong individuals with stroke.

Acknowledgements

(1) This work represents work supported by the use of facili-ties at the Charleston, SC HSR&D Funded Center for DiseasePrevention and Health Interventions for Diverse Populations(REA 08-261).(2) Dr Ellis is supported by a career development award(CDA# 07-012-3) from the Veterans Health AdministrationHealth Services Research and Development program.

(3) Dr Grubaugh is supported by a career development award(CDA2 # 07-015-2) from the Veterans Health AdministrationHealth Services Research and Development program.

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