Prevalence of Depression among post Stroke Patients

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Prevalence of Depression among post Stroke Patients
Depression among stroke patients and
relation with demographic and stroke
characteristics
Zafarullah Khan Qamar
Nr 7/2012
Student Zafarullah Khan Qamar
Umeå International School of Public Health
Epidemiology and Global Health
Autumn 2011
Thesis, 30 ECTS
Degree of Master of Science. Main field of study: Public Health
Specialisation: Epidemiology
120 ECTS
Depression among Stroke Patients and
relation with Demographic and Stroke
Characteristics
Master Thesis in Public Health
Zafarullah Khan Qamar
2011
Supervisor: Marie Lindkvist
Acknowledgement:
I would like to recognize with gratitude the sincere efforts of many people who helped me during
the long journey of materializing my thesis.
First of all I bow my head in front of the “God Almighty” for blessing me with knowledge,
wisdom, and strength at every step of my life. Secondly I am indebted to my parents & whole
family for their sincere prayers, encouragements, eternal support, guidance and unconditional
love which gave me strength to progress in my life and work.
A special debt is owed to Marie Lindkvist, my supervisor for her continuous competent
assistance, dedication and special attention she gave to my thesis work, which enabled me to
complete this thesis in an efficient manner.
I would also like to express my sincere thanks to my friends, professors and colleagues in
Pakistan for their continuous support in the process of data collection.
Finally my special thanks to all the faculty members of the Public Health Department of Umea
University for providing us an enabling environment at university and especially for knowledge
& wisdom, they shared with us.
I dedicate this work to my beloved family.
i
Abstract:
Objective: To identify the prevalence of depression in post stroke patients as well as to access
the relationship between demographic factors, stroke characteristics and post stroke depression.
Design: Cross sectional study.
Setting: Neurology Out Patient Department of the Liaquat University Hospital, Pakistan
Method: We screened stroke survivors (n=81) for depression, visiting the neurology Out
Patient Department of the Liaquat University Hospital, Pakistan using the DSM IV TR criteria.
Data was collected over demographic and stroke related factors. Patients were also asked about
their lifestyle characteristics and their general experiences in life after stroke based on DSM IV
TR symptoms profile. Description of categorical variables like sex, marital status, employment
status, stroke lesion, depression, was presented as numbers and percentages. Analysis to
determine the relationship between post stroke depression and demographic variables and
stroke characteristics were performed by Chi Square (X2) test. P-value < 0.05 was considered
as significantly associated. Further, to examine associations between post stroke depression and
demographic and stroke characteristics simple and multiple logistic regression analysis were
also performed. SPSS 19 version was used to perform statistical analysis.
Results: 31 patients out of 81 were (38%) met the criteria of depression. Demographic variables
like young age, male gender, primary level of education, unemployment and lower level of
monthly income were significantly associated with post stroke depression (P –value < 0.05).
Post Stroke depression was also significantly associated with ischemic stroke type (P-value <
0.05) but was not associated with lesion location.
Conclusion: Post stroke depression occurs in one third of the stroke patients. It is
associated primarily with demographic, socio economic and stroke related factors.
ii
.
Table of Contents
Acknowledgement:...................................................................................................................................... i
Abstract: ...................................................................................................................................................... ii
Abbreviations:............................................................................................................................................. 1
1
Introduction: ....................................................................................................................................... 2
1.1
Stroke: .......................................................................................................................................... 2
1.2
Depression................................................................................................................................... 3
1.3
Prevalence of Post Stroke Depression: .................................................................................... 4
1.4
Course of Post stroke depression: ............................................................................................ 5
1.5
Etiology of Post Stroke Depression: ........................................................................................ 6
1.6
Post Stroke Depression Assessment: ....................................................................................... 8
1.6.1
Method of accessing Post Stroke Depression: ............................................................... 8
1.6.2
Importance of Various Symptoms In Post Stroke Depression: ................................. 8
1.7
Post Stroke Depression and its Related Factors: ................................................................... 9
1.7.1
Post Stroke Depression and Demography: ................................................................... 9
1.7.2
Stroke Characteristics: ................................................................................................... 10
1.8
Country Profile Pakistan: ........................................................................................................ 11
1.8.1
Geography: ....................................................................................................................... 12
1.8.2
Demographic:................................................................................................................... 12
1.8.3
Economy: .......................................................................................................................... 12
1.8.4
Country’s Health Statistics: ........................................................................................... 13
1.8.5
Stroke in Pakistan: .......................................................................................................... 14
1.8.6
Post Stroke Depression: .................................................................................................. 16
2.
Aim of the Study: .............................................................................................................................. 16
3
Method: ............................................................................................................................................. 16
3.1
Study Area: ................................................................................................................................ 16
3.2
Study Design: ............................................................................................................................ 17
3.3
Data collection and Measures: ............................................................................................... 17
i
3.3.1
3.4
4
Study variables: ........................................................................................................................ 19
3.4.1
Demography: ................................................................................................................... 19
3.4.2
Stroke characteristics: .................................................................................................... 19
3.4.3
Depressive Symptom Variables: ................................................................................... 19
3.5
Statistics: ................................................................................................................................... 21
3.6
Ethical Consideration: ............................................................................................................. 21
Results: .............................................................................................................................................. 21
4.1
5
Measurement instrument: ............................................................................................. 18
Baseline Characteristics of Post Stroke Patients: ................................................................ 21
4.1.1
Demography: ................................................................................................................... 21
4.1.2
Stroke Characteristics: ................................................................................................... 23
4.2
Prevalence of Post Stroke Depression: .................................................................................. 23
4.3
Post Stroke Depression and demographic factors: .............................................................. 23
4.4
Post Stroke Depression and Socio Economic variable: ....................................................... 24
4.5
Post Stroke Depression and Stroke Characteristics: ........................................................... 25
4.6
Factors that Differentiate Post Stroke Patients With And Without Depression : ........... 26
4.7
Simple Logistic Regression Analysis: .................................................................................... 27
4.8
Multiple Logistic Regression Analysis: ................................................................................. 29
Discussion: ........................................................................................................................................ 30
5.1
Main Findings:.......................................................................................................................... 30
5.2
Prevalence of Depression: ....................................................................................................... 30
5.3
Associated Factors of Post Stroke Depression: .................................................................... 31
5.3.1
Demographic factors: ..................................................................................................... 31
5.3.2
Stroke characteristics: .................................................................................................... 32
6
Limitations: ....................................................................................................................................... 32
7
Conclusion:........................................................................................................................................ 33
8
Recommendations: .......................................................................................................................... 33
9
References: ........................................................................................................................................ 34
ANNEXURE - I ......................................................................................................................................... 41
ii
Abbreviations:
AIDS:
Acquired Immune Deficiency Syndrome.
BASR:
Board of Advance Studies and Research.
BDI:
Beck Depression Inventory
CI:
Confidence Interval
CNS:
Central Nervous System.
C T Scan:
Computed tomography Scan.
DSM:
Diagnostic and Statistical Manual of Mental Disorders
DSM III:
Diagnostic and Statistical Manual of Mental Disorders. 3rd edition
DSM IV TR: Diagnostic and Statistical Manual of Mental Disorders. 4th edition - Text
Revision
GDP:
Gross Domestic Product.
MADRS:
Montgomery Asberg Depression Rating Scale
OPD:
Out Patient Department.
OR:
Odd Ratio
PSD:
Post Stroke Depression.
SD:
Standard Deviation.
SPSS:
Statistical Packages for the Social Sciences
T.B:
Tuberculosis.
WHO:
World Health Organization.
1
1
1.1
Introduction:
Stroke:
Stroke as defined by the World Health Organization is “a rapidly developed clinical signs of
focal or global disturbance of cerebral function, lasting for more than 24 hours or until death,
with no apparent non-vascular cause. Stroke is caused by the interruption of the blood supply
to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the
supply of oxygen and nutrients, causing damage to the brain tissue”. 1
As per an estimate of WHO every year about 15 million of world population suffers from stroke
out of which around 33% (5 million) die and 33% become disabled permanently. Globally on
every 10th second, a life is taken by stroke and on every ½ second an incident of stroke occurs.
High blood pressure is the major risk factor in stroke which causes more than 80% of stroke
cases (12.7 million) worldwide. Other risk factors of stroke are smoking, atrial fibrillation, heart
failure and heart attack1,2.
In developing countries burden of stroke is increasing rapidly. They borne about 66% of total
stroke burden and rate of stroke in these countries has exceeded the rate of developed countries
by 20% during the period from 2000 to 2008 3. In terms of mortality and morbidity caused by
the stroke globally, stoke found to be the leading cause of death in people of age group of 60
years and above and is the 5th leading cause of death among people of age group 15-59 years4. In
terms of disability as per the Lancet 28 Nov 2009 issue, stroke is found to be the leading cause
worldwide and in developing countries it is the 2nd leading cause of disability.
Around four fifth (> 80%) of stroke cases are caused by ischemic brain infarction5. Ischemic
stroke is caused by obstruction in a blood vessel supplying blood to brain. This blockage in blood
vessel could be caused due to blood clot in the vessel or due to hardening of blood vessel
supplying blood to the brain because of accumulation of fat in vessel walls. Remaining one fifth
(13 % ) of stroke cases are caused by hemorrhagic stroke, which is less frequent and occur due to
rupture or burst of a blood vessel which leads to the bleeding. Accumulation of blood
compresses surrounding brain tissues causing deprivation of oxygen and nutrients to the
surrounding tissues. This type carries higher risk of death6.
In first month after stroke about 80 to 90 % ischemic stroke patients survive while survival rate
drops to 67-80% in one year after stoke7. Rate of stroke mortality is greater than that of other
chronic diseases if all put together (AIDS, TB and Malaria) worldwide8. Major recovery occurs
within first three months after stroke while long term disability often remains for a longer
2
period of time
9,10.
Stroke has major affects on quality of life of its survivors and of their
caregivers of long term durations which require more targeted rehabilitation to avoid further
complications in terms of depression and other allied disabilities.
Incidences of stroke are reducing in the west but reverse is true in case of south Asia. Specifically
in case of Pakistan fewer studies have been conducted on prevalence of stroke and very limited
data on the subject is available. However, prevalence of stroke risk factors in the country is very
high which could be translated into high prevalence of stroke in the country. Estimated
incidences of stroke per year are 250/ 100,000 with 350,000 new cases each year. Prevalence of
stroke in much younger age has been observed in some studies as compare to the west in case of
Pakistan.
1.2
Depression
As per WHO definition “Depression is a common mental disorder characterized by sadness,
loss of interest in activities and by decreased energy. Depression is differentiated from normal
mood changes by the extent of its severity, the symptoms and the duration of the disorder”
According to an estimate, identifiable depression prevalence is 5-10% of the population at any
given point of time which requires psychological treatment. Risk of developing depression in
female during a life time is 10-20% which is comparatively higher than males11.
Post stroke depression is defined/ categorized as mood disorder which occurs due to a general
medical condition12. Post stroke depression in terms of early studies found related with stroke
related factors e.g location of stroke and focal disturbance of neurotransmitter pathways13.
In addition to stroke related factors, patient related factors e.g age, sex, personality, coping
abilities, quality of life, enhanced disability and poor rehabilitation outcomes, extended use of
healthcare, higher rate of mortality, suicidal ideation and social support provided are also
associated with post stroke depression.
Post stroke depression is segregated in to two major types: Major Depression and Minor
Depression. Major depression is the outcome of left interior lesion location of stroke. Risk of
developing cognitive impairment is high among patients suffering from major depression.
Minor or dsythemic depression is the outcome of posterior brain injury. Chance of developing
cognitive impairment in 2nd type of depression is negligible whereas major depression is related
with high functional impairment14-18. Study of post stroke depression (PSD) is of vital
importance to avoid long term unfavorable consequences of post stroke depression. Through
3
early study of PSD, patients could be helped out at an early stage and long term unfavorable
complications could be avoided.
1.3
Prevalence of Post Stroke Depression:
Stroke is significantly associated with high rate of mortality and morbidity. Although a
decreasing trend could be observed in mortality rate from stroke especially in western societies
rate of morbidity is still very high. According to an estimate about one third of the post stroke
patients suffer from substantial depressive symptoms19. WHO has predicted cerebrovascular
disease as the second highest cause of disability worldwide by 2020. Different studies on
prevalence of post stroke depression (PSD) report different frequencies and results vary
considerably across studies. The prevalence as reported in different studies ranges from 9% to
60%. On the basis of population selection we can divide studies on Prevalence of Post Stroke
Depression into three categories: 1) Population based studies, 2) Hospital Based Studies and
3) Community / Rehabilitation based studies. Population based studies usually include all those
stroke patients having most representative depressive symptoms either admitted to hospitals for
extensive care or not. Different population based studies report range of post stroke depression
from 23-40% while using DSM III and IV criteria
19-20.
Hospital base studies recruit those
patients who were admitted in medical wards of general hospitals for intensive care. Different
hospital based studies report range of post stroke depression from 35-53% while using DSM III
and IV criteria 21-25. Community/ rehabilitation based studies recruit patients from rehabilitation
centers, wards, hospitals or stroke units. In community / rehabilitation based studies prevalence
is found from 9-23% range using DSM III and IV criteria 19,26 .
Reported Prevalence Range
9-23%
23-40%
Population based
Hospital Based
Rehabilitation based
35-53%
Figure-1: Showing reported prevalence range of Post stroke depression in various study settings.
4
This large variation in range of depression reported by different studies could be attributed to
variation in population characteristics being studied, different assessment measures/ study
designs used, definition of depression, time of assessment and clinical characteristics.
Stroke progression could be taken as an important risk factor in development of post stroke
depression (PSD) as comparatively less depression is observed in first ever stroke patient as
compare to the patients having recurrent stroke history.. Community base studies which also
include the patients having mild depressive symptoms, show lower frequency of depression as
compare to the hospital based studies. However no big difference in frequencies was observed in
a study in pooled frequencies review of population based and hospital based studies but if DSM
(Diagnostic and Statistical Manual of Mental Disorders) criteria are used for diagnosis of
depression prevalence of depression is found higher in hospital based studies than that of
community based studies 27-29.
In case of Pakistan this area is under researched area and no significant studies/ published
material is available on the subject in Pakistan.
1.4
Course of Post stroke depression:
Persistent prevalence of post stroke depression, which may prolong from a period of weeks to
years, deteriorate the conscious mental activities of patients e.g dysphoric emotions, low
motivation levels, disturbed sleep, appetite, libido and energy. It has negative impact on
functional outcome, quality of life and mortality. Duration over which post stroke depressive
symptoms could prolong may vary in patients from weeks to years.
A stable but high prevalence of depression was observed in 2 years after stroke in a study but
with changes in the composition of patients. Improvement was observed in 100% patients
suffering from major depression in 2 years post stroke. However, rate of improvement among
patients suffering from dysthymic depression was just 30% in same time duration of 2 years and
patients who were having no depressive symptoms developed mood disorders in 2 years after
stroke14. Another study found persistent depressive symptoms among 17% of patients during 1 st
year after stroke and improvement/ recovery after 1st year after stroke was found among those
patients who developed early depressive symptoms (within 3 months after stroke) 29. A study has
found stable prevalence of depression from 6 months to 1 year after stroke with a significant
decline in prevalence by 3rd year after stroke 30.
Literature review on course of depression with respect to study design report contradictory
findings. A hospital based study report decreasing trend in post stroke depression from 6
5
months to 3 years after stroke27. In contrast another hospital based study report decreasing
trend in prevalence of post stroke depression up to 1st year following stroke but increasing trend
in 2nd and 3rd year after stroke31. Likewise, similar trend was reported by a rehabilitation
population based study.
32 Different
studies report different results with respect to assessment
criteria on course of depression. No change in post stroke depression was observed in 12-15
months using Beck Depression Inventory (BDI) criteria33. In contrast using the same BDI
criteria House et al (1991) reported decreasing trend in PSD from 6 th month onwards after
stroke. Likewise, same trend was reported by Verdello et al (2004) using Montgomery Asberg
Depression Rating Scale (MADRS)
26,32.
Mostly Post stroke depression as found in literature
review has an early onset. Andersen et al (1994) and Aben et al (2003) report early inception of
depression in about 50% of stroke patient i.e within 4 weeks after stroke. Mood disorder was
observed during first 6 weeks after stroke in about 60% of post stroke patients who developed
depression subsequently 27,34.
From literature review the early onset of post stroke depression in stroke patients is evident but
consensus on course of depression among different studies has not been found.
1.5
Etiology of Post Stroke Depression:
The subject of etiology of post stroke depression has been addressed by the scientific community
in two different perspectives. Some support the view that post stroke depression is caused by the
brain injury due to the affect of stroke on primary biological mechanism and neural circuits of
the brain, which involved in mood regulation and in turn cause depression in the patients after
stroke. The relation is further explained as below:
Physiological Mechanism of Post Stroke Depression
Stroke
Abnormalities
in production
& Metabolism
of Monomine
transmittors
Disruption
of biogenic
amine
pathways
Post Stroke
Depression
(Ref; 35)
The Endogenous depression as assumed and explained by many researchers is caused due to the
changes in neurotransmitter. Depression may be caused by the paucity of monoamine
transmitters’ dopamine, serotonin and noradrenalin or due to the overall malfunctioning of
monoaminergic neurotransmitter system in different circuits of brain36. However, in studies of
6
both the post stroke depression and endogenous depression the receptors of monoamine
neurotransmitters and the molecular events that these receptors trigger are now been focused
more than that of monoamine neurotransmitters themselves which include regulation of gene
expression and downstream signal transduction. Further, one study has proposed a new
hypothesis for post stroke depression that increased production of pro-inflammatory cytokines
in case of stroke is responsible for pathogenesis of mood disorders 37. The importance of lesion
location in causing post stroke depression has not been proved up till now as different studies
have conflicting results to endorse this relation. Some support the idea that acute depression
may be linked with left hemisphere location of stroke 38. Carson et al 2000 in his study has
found no significant relation between post stroke depression and lesion location39. Structural
and functional abnormalities of limbic system and in prefrontal cortex as identified by
neuroimaging and neuro- pathological studies of endogenous mood disorders are of immense
importance in regulating emotional behaviors and their malfunctioning could be considered as
responsible for causing cognitive emotional expression of long term mood disorders40.
The 2nd group of researchers believes that post stroke depression is the outcome of psychological
and social stressors that emerge as a response to the impairment or loss caused by stroke.
Psychosocial Mechanism of post stroke depression
Stroke
Denial &
rejection
Anger &
frustration
Post Stroke
Depression
In analyzing post stroke depression (PSD) with psychological perspective time passed after
stroke is an important factor. The increasing trend in post stroke depression was followed in
stroke patients’ from 1 to 6 months with post stroke depression at its peak in 6th month and
thereafter decreasing trend was observed till 24th month after stroke 41. The patients develop the
acceptance of loss gradually because they become aware of their injury gradually so post stroke
depression is also developed and intensified gradually with decreasing trend as the time elapsed
since injury with the help of recovery and rehabilitation. Post stroke depression in a study is
categorized as a categorical construct instead of continuous construct. It has been considered as
matter of degree rather than of kind. Another study has considered both major and minor
depression as the outcome of psychological consequence of stroke. Somatic symptoms in stroke
7
patients were found dependent upon presence of depressive mood symptom in stroke
patients. 42-44
1.6
Post Stroke Depression Assessment:
1.6.1
Method of accessing Post Stroke Depression:
Different methods of measuring depression are being used in studies on post stroke depression
due to which reported prevalence rate of depression vary across studies. Most of the recent
studies have used diagnostic definition of major depression in which diagnosis of depression
required to observe a specific criterion, in addition to the psychiatric interviews. Different
criteria’s for diagnosis of depression are being used in studies now out of them one is
Diagnostic and Statistical Manual of Mental Disorders, IV edition, Text Revision (DSM IV TR)
of American Psychiatric Association 2000. The Diagnostic and Statistical Manual of Mental
Disorders, IV edition, Text Revision provides information about each mental health diagnosis
and contains important information and resources for mental health professionals. It is being
commonly used as a guide to communicate mental illness by the physicians, social workers,
psychologists, nurses, family / marriage therapists and by psychiatrists. Multidimensional
approach covering five dimensions of diagnosis is used in DSM IV TR criteria including clinical
disorders, mental retardation, personality disorders, physical health issues that may affect
mental health, psychosocial issues and highest level of functioning. It has a distinguished feature
of classifying mental disorders in different categories of a patient instead of categorizing the
patient itself and thus provides a clear picture of a person’s illness. It is fit for all types of
research e.g prevalence studies, clinical trials and outcome researches45-47.
DSM IV TR includes nine different depressive symptoms. Out of those nine symptoms if a
patient is having at least five of them (including one of either depressed mood or Loss of interest
or pleasure) he/ she is categorized as suffering from major depression. Nine symptoms of DSM
IV TR criteria are: decrease in weight, decrease in appetite, insomnia, psychomotor agitation or
retardation, fatigue, diminished concentration or decision making, feeling of guilt depressed
mood, loss of interest or pleasure and suicidal ideation 46-47.
1.6.2
Importance of Various Symptoms In Post Stroke Depression:
Different views have been found among different writers/ researchers of Post Stroke Depression
on importance of various symptoms in post stroke depression. Some support the idea of equal
importance of both somatic and psychiatric symptoms irrespective of their origin and support
the use of DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria44, 48. However,
8
stein et al 1996 in their study has found non-somatic symptoms more explicit in post stroke
depression than that of somatic symptoms49. Some studies stressed to consider each symptom
individually instead of grouping them in to somatic and psychological categories and stressed on
use of different symptom profiles for post stroke depression and endogenous depression
Symptom of depressed mood was found as most sensitive symptom in discriminant analysis 50,51.
However, reduced appetite, fatigue, and psychomotor slowing (somatic symptoms) were also
found as having discriminative properties. When symptoms profile was combined with time
factor in different studies it has given conflicting results. As symptoms those categorize a patient
having major depression after stroke tends to change during the period of 24 months following
stroke. 52
1.7
Post Stroke Depression and its Related Factors:
1.7.1
Post Stroke Depression and Demography:
Literature review of post stroke depression mostly found stroke related factors responsible for
creation of post stroke depression to a large extent. However, in addition to those, different
patient related factors are also found equally responsible in causing post stroke depression
like age, gender, education level, income and residence status of the patient.
Studies on association between age and post stroke depression show contradictory findings.
Literature reveals complex relationship between age and post stroke depression which could be
found dependent upon other multiple factors. Some researchers report positive association
between old age group and post stroke depression33,58. In contrast, others suggest positive
relation between post stroke depression and young age group25,32,59. Yet some others report no
relation between age and Post Stroke Depression 31. Therefore, other factors may also be found
responsible in defining relation/ association between age and post stroke depression e.g
gender, race, ethnicity and other socioeconomic factors. Personality traits of a patient may also
play an important role like Rusin M in his study found motivational level of a patient as an
important determinant60. Old patients have tendency to accept their deficiencies more easily as
compare to the young ones and young patients may respond negatively to the deficit occurred
and feel unjustly deprived from a portion of healthy life. Studies on association between Gender
and post stroke depression have found other risk factors of stroke also responsible in
relationship between gender and post stroke depression. In most of the studies, level of
depression was found higher among women61. Contrary to that some found higher rate of
9
depression among male patients62-64 while some suggest no relation between gender and post
stroke depression
24.
One study has found the importance of time factor in association between
gender classification and post stroke depression. As during first year after stroke no association
between gender and post stroke depression was observed but after 18 months post stroke male
were found more depressed as compare to female
64.
One reason of high depression among
working age group of male might be that physical disability in that group is of greater
importance for male as compare to female or another association of higher depression in men
was attributed to their less coping abilities as compare to female64. Various studies have
reported variations in nature of post stroke depression itself with respect to gender. Wade and
Langton in their study found more severe effects of stroke among female and attributed this to
the fact that women usually experience stroke in older age then male65. This finding was
reinforced in a study as they found female more depressed in relatively older age group i.e.
greater than 60 years old. Results on association between post stroke depression and other
demographic and social factors e.g education level and residence status of patients are also
multidirectional. A study has found no association between education level of a patient and post
stroke depression which was conducted on 486 ischemic stroke patients, age from 55 to 85 years
and the same result is reinforced by some other studies. 22,24,37
Inconsistencies persist in literature regarding association of different risk factors with Post
stroke depression which, to some extent, could be minimized by more careful selection of
sample, evaluation criteria used for diagnosis of depression and with more follow up studies.
1.7.2
1.7.2.1
Stroke Characteristics:
Lesion Location
In literature on post stroke depression wide divergence exists on the subject of post stroke
depression association with lesion location of stroke. Three broad views/ researches are: 1. Left
Hemisphere lesion plays a vital role in prevalence of post stroke depression. 2. There is no
association between lesion of stroke and post stroke depression. 3. Right hemisphere lesion is
associated with post stroke depression.
Historically the association of post stroke depression and left hemisphere lesion location was
documented by some of the researches followed by the series of studies which endorse this
finding and reinforce the hypothesis that left hemisphere lesion plays an important role in
creation of post stroke depression 38,53. Severe depression after stroke was found associated with
left interior cerebral lesion while less severity of post stroke depression was found in left
posterior lesion14,38,54. Further, no significant association was found between the post stroke
10
depression and left cortical and sub cortical lesions 55. The researchers who belong to the second
group of thoughts, in contrast, found no relationship between the lesion location and post stroke
depression23,56 as in a systematic review a study has found no significant association between
lesion location and depression after pooling the data of 34 primary studies39. Further, the third
group of thoughts studies found association of depression with right hemisphere lesion
location57.This vide divergence among different studies findings on the subject of Lesion
location association with post stroke depression could be attributed to the methodological
differences among study setting e.g small sample size, sample selection criteria, study site,
different tools used to measure depression, time passed since stroke. Importance of time elapsed
since stroke and study settings in association of depression with lesion location were also proved
by researchers. The involvement of left lesion location in development of depression was found
only in acute depression during first week after stroke. Post stroke depression was found
associated with left hemisphere lesion location in hospital inpatients studies early after stroke
while right hemisphere lesion location and post stroke depression were found associated in
community based population studies within six months after stroke.38, 54
1.8
Country Profile Pakistan:
Pakistan is situated in west of Indian subcontinent. It is a sovereign state in south Asia with
India on the east, Afghanistan and Iran on the west, Arabian Sea on the south and China on
north east.
Map of Pakistan (http://www.worldatlas.com/webimage/countrys/asia/pk.htm)
11
1.8.1
Geography:
Area wise Pakistan is the 36th largest country of the world with an area of 796,095 KM2 (307,374
sq mi). Pakistan is rich with varying nature of landscapes like plains, deserts, forests, hills,
coastal areas and mountains. Its landscape could be divided in to three major geographic areas;
the Northern Highlands include Karakoram, Hindu Kush and Pamir mountain ranges, The
Baluchistan plateau and the Indus river plain.
Pakistan consists of four provinces (Punjab, Sindh, Baluchistan and Khaiber Pakhtoonkah) and
four federal territories (Federal Capital Territory, Federally Administered Tribal Areas, Gilgit
Baltistan and Azad Jammu and Kashmir).
1.8.2
Demographic:
Total population of Pakistan is 180,808,000 (WHO) with an annual growth rate of 1.573%. It is
the sixth most populous country in the world with second highest population of Muslims.
Around 20% of the population lives below poverty line. Crude birth rate is 24.81, crude death
rate is 6.92 per thousand population and dependency ratio is 88.3 %. Adult literacy rate above
15 years is 53.7% and male literacy rate is 66.8% and female is 40 %. About 52% of the total
population is male and 48% is female. More than 50% of the population lived in rural areas.
Pakistan is a country in which more than sixty languages are spoken; Urdu is the national
language while English is being used as official language 66-68.
1.8.3
Economy:
Pakistan is a developing country with an annual GDP growth rate of 4.8% and $2500 per capita
income. Country’s 43% of the labor force is engaged with agriculture. Structure of the economy
has been transformed from an agriculture based to a services based economy. Agriculture
comprises of 21.8% of GDP while industry 23.6% and services 54.6%. Economy of the country is
facing various challenges including poverty, unemployment (15.4%) , high inflation (13.9%), less
foreign investment, and high population growth rate (1.573%). Major industries of the country
are textiles, apparel, food processing, construction materials, pharmaceuticals, paper products
and fertilizer. 66
12
1.8.4
Country’s Health Statistics:
Health system in Pakistan is administered by the Ministry of Health. Like other developing
countries Health care facilities are better in urban areas but in rural areas facilities are very
limited. In 2007-08 Government of Pakistan spent an amount of Rs. 14.272 billion for
development of health sector and current expenditure during the same period in health sector
was 3.791 billion69. Total 2.6 % of GDP is spent on health sector by the Govt. of Pakistan in
2009. Total life expectancy at birth is 65.4 years, for men it is 65.2 years and in female it is 65.6
years. Infant mortality rate per 1000 live births is 76.7 and maternal mortality per 100,000 live
births is 350.
Table-1 showing the detail of health facilities available in Pakistan66,68:
Health Facilities And Human Resources In Pakistan (2009)
Total Health Facilities
13,937 (103,708 beds)
Hospitals
968 (84,257 beds)
Dispensaries
4,813(2,845 beds)
Rural health centers
572 (9,612 beds)
Tuberculosis clinic
293 ( 184 beds)
Basic health units
5,345 (6,555 beds)
M.C.H. centers
906 (256 beds)
Human Resource in 2009
Doctors
139,555
Dentists
9,822
Nurses
69,313
Midwives
26,225
Health visitors
10,731
Registered vets
4,800
Most common infectious diseases which are the main cause of deaths in Pakistan are: acute
respiratory infection, malaria, diarrhea, dysentery, scabies and others (goiter, hepatitis and
13
tuberculosis). Crude rate of mortality due to communicable, non communicable diseases and
from injuries in Pakistan is shown in following figure.
Crude Mortality Rate - Communicable and Non
Communicable Diseases.
8%
46%
Communicable, maternal,
perinatal and nutritional
conditions
Noncommunicable diseases
46%
Injuries
Figure-2 Showing crude mortality rate in Pakistan 67
1.8.5
Stroke in Pakistan:
Incidences of stroke are falling in west but reverse is true in case of south Asia. Fewer studies
have been conducted on prevalence of stroke in Pakistan therefore very limited data on the
subject is available. However, prevalence of stroke risk factors in country is very high which
could be translated into high prevalence of stroke in the country. Estimated incidences of stroke
per year are 250/ 100,000 with 350,000 new cases each year. Prevalence of stroke in much
younger age in Pakistan has been observed in some studies as compare to the west. One study
reported that 26% of the stroke patients belong to age group of 15-45 years. Another study found
one third patients of total sample under the age of 50 years. Similarly 28% frequency of stroke
was reported under age of 55 years and approximately 20% of stroke patients are under the age
of 45 years70,71. In gender classification higher rate of prevalence was found among women of
young age group. However, increasing trend in prevalence rate was observed among male with
increase in age as compare to the female72. According to recent study published by Aga Khan
14
University, one out of four persons in Pakistan suffers from the symptoms of stroke. Stroke now
account for around 41 percent of total disease burden in the country73. Above findings of studies
revealed that demographic of stroke in Pakistan vary from west to a large extent.
As per an estimate of WHO cerebrovascular diseases accounts for 32% of total crude rate of
mortality in Pakistan due to cardiovascular diseases, its classification is as under74:
Crude Rate of Mortality Due to
Cardiovascular Diseases
2%
32%
4%
Rheumatic heart disease
Hypertensive heart disease
62%
Ischaemic heart disease
Cerebrovascular disease
Figure-3: Showing classification of crude mortality rate in Pakistan due to cardiovascular diseases.
Hypertension, smoking and diabetes are the major risk factors of stroke with high prevalence
level in Pakistan. Out of these most preventable cause of stroke is hypertension which, as per an
estimate, is prevailing in 33% of Pakistani population over the age of 43 year75,76.
15
1.8.6
Post Stroke Depression:
Data and research conducted upon post stroke depression in Pakistan is very limited. As this
area is under researched so no significant studies/ published material is available on the subject
in Pakistan. One study conducted in an outpatient clinic at a territory care center report 40%
prevalence rate of post stroke depression in Pakistan71,76,77. Another study conducted at Mayo
Hospital Lahore reported 37.6% prevalence of post stroke depression79.
However, prevalence of general depression in Pakistan is very high. Its level varies with the age
group and during different stages of life. Different studies on the subject have been conducted in
Pakistan. One survey reported 22% prevalence of depression in individuals of the country and
more than 50% experience depression once during their entire life time. 33.7% experience
depression for a shorter period of time, 37.3% experience moderate while 29% experience long
term depression.
2. Aim of the Study:
The aim of this study is:
1. To access the prevalence of depression in post stroke patients.
2. To evaluate the relationship between demographic data and post stroke depression.
3. To evaluate the relationship between stroke characteristics and post stroke depression.
3 Method:
3.1
Study Area:
This Study was conducted at Liaquat University Hospital, Hyderabad Sindh. This Hospital has
two branches, one at Hyderabad and other at Jamshoro and is attached with Liaquat University
of Medical and Health Sciences. This hospital is equipped with modern health care facilities. It
has 1293 beds and is also providing services as teaching and research institute for Graduate and
Post Graduate students. It is the biggest public sector hospital catering with the needs all people
of Sindh province except Karachi. Liaquat University Hospital has four institutes; Nuclear
Institute of Medical radiology, Dentistry Institute, Eye Institute and Psychiatric institute. Its
Psychiatric institute was inaugurated as C.J Mental Hospital in 1871 which became the part of
16
Liqauat University in 1960’s. It is the biggest mental health institute of Sindh province with
sanctioned strength of 496 beds.
Location of Civil Hospital in Hyderabad. (Source: Google Map)
3.2
Study Design:
Cross sectional study.
3.3
Data collection and Measures:
Total 81 patients were recruited in the study that fulfilled the inclusion criteria. This study was
carried out at neurology Out Patient Department of Liaquat University Hospital, Hyderabad,
Pakistan from Feb, 2011 to May, 2011 with the help of trained neurologist and psychiatric. The
consent of patients to participate in study was sought and they were also assured about
confidentiality of the information. We promised not to release the data for any other purpose
apart from the purpose it was meant for. The study’s criteria and purpose was also explained in
detail to all of them and to their relatives/ caregivers.
17
Afterwards, we conducted the interviews of the patients (who fulfilled our inclusion criteria)
using the questionnaire devised for this study, during follow up visits of the post stroke patients
to the neurology Out Patient Department. Questionnaire based interviews were conducted
during the OPD timing (from 10: 00 a.m to 2:00 p.m) in week days. From the response of
patients I personally filled in questionnaires with the help of psychiatric of OPD. Response rate
of patients was 100%.
Patients Inclusion criteria:
a) Male or female of any age.
b) Lesions causing stroke, identified on CT-scan as hypo dense zone in cases of ischemic
stroke and hyper dense zone in cases of hemorrhagic stroke.
c) Sensory/motor impairment.
d) No pre existing disabling condition.
Exclusion criteria:
a) History of any psychotic disorder.
b) Current treatment with antidepressant medication.
c) Language impairment (severe enough to prevent valid neuropsychiatric assessment).
d) History of some other CNS disease (e.g., head trauma, multiple sclerosis).
e) Significant hyponatremia (Na <130meq).
f) Current hypothyroid state.
g) Medically unstable including symptoms of delirium.
Dependent variable of our study was depression while independent were all demographic and
clinical factors such as age, gender, marital status, financial status, residence status, education
level and the clinical variables including stroke type and side of stroke.
3.3.1
Measurement instrument:
The main instrument used for data collection was a questionnaire. It was designed from
Diagnostic and Statistical Manual of Mental Disorders, IV edition, Text Revision (DSM IV TR)
of American Psychiatric Association 2000 to assess depressive symptoms. Questionnaire of the
study was formulated very carefully with multiple choices to get detailed information about
lifestyle characteristics of the patients. Questions were arranged sequentially to study the
depression symptoms. Every patient was evaluated against the list of 9 predefined depressive
symptoms (as per criteria of DSM IV TR) and those patients were identified as depressed who
18
were having at least five or more of the symptoms out of nine and one of those must include
either depressed mood or loss of interest/ pleasure. The other seven symptoms were: decrease
in weight, decrease in appetite, insomnia, psychomotor agitation or retardation, fatigue,
diminished concentration or decision making, feeling of guilt and suicidal ideation.
We have used DSM IV TR as diagnostic criterion because it is being commonly used as a guide
to communicate mental illness by the physicians, social workers, psychologists, nurses, family
and marriage therapists and by psychiatrists. It has a distinguished feature of classifying mental
disorders in different categories of a patient instead of categorizing the patient itself and thus
provides a clear picture of a person’s illness. It is fit for all type of researched e.g prevalence
studies, clinical trials and outcome researches.45,46,47
3.4
Study variables:
3.4.1
Demography:
Age: (25-34 years, 35-44 years, 45-54 years, 55-64 years, 65 years and Above)
Marital Status: (Single, Married, Divorced/ Widow).
Residence Status: (Urban, Rural).
Occupation Status: (Employed, Unemployed).
Education Level: (Illiterate, Primary, Secondary and higher).
Monthly Income: (< 10,000, 10,000 - 40,000, > 40,000).
3.4.2
Stroke characteristics:
Stroke Type: (Ischemic, Hemorrhagic).
Lesion Location: (Right Hemisphere, Left Hemisphere)
3.4.3
Depressive Symptom Variables:
Depressed mood: (Yes, No ).
Feeling sad, down, empty or having physical conditions like headache, aches or pains
continuously for two weeks.
Diminished interest or pleasure: (Yes, No).
Losses interests in those activities which previously were enjoyable to them as going out
to dinner or a movie, visiting with friends, working, or doing hobbies and this symptoms
lasts for at least two weeks continuously.
Significant weight loss or gain: (Yes, No).
19
Either the patient had a change of more than 5% in his/her weight within a month or
there has been a continuous decrease or increase in his/her usual appetite on almost
every day within a two-week period of time.
Insomnia: (Yes, No).
Either not being able to get enough sleep or having disturbed sleep or having difficulty in
falling asleep and these problems are being observed at almost every day during the
period of two weeks.
Psychomotor agitation or retardation: (Yes, No).
Either having symptoms of not being able to sit still (he/she pace the room, twist his/her
hands, or jiggle with clothes or objects) or having symptoms of being slow down in his/
her behavior (may move across a room very slowly, turn away his/her eyes, and sit
slumped in a chair). These symptoms should be present to the extent that they could be
observed by the other person.
Fatigue or loss of energy: (Yes, No).
Feeling tired and fatigued and for diagnosis patient himself reports for experiencing such
feeling.
Feelings of worthlessness or guilt: (Yes, No).
Thinking negatively about them and remained preoccupied with past failures. They also
take minor mistakes as a proof of their worthlessness. He/ she must be having this
feeling continuously for a period of at least two weeks.
Diminished ability to think or concentrate: (Yes, No).
Patients feeling that his/her ability to think, concentrate and of decision making has
become impaired. He/ she must be having this feeling continuously for a period of at
least two weeks.
Suicidal Ideation: (Yes, No).
Having frequent thoughts of death, suicide, or even have made suicide attempts. He/ she
feel that his/ her relatives and family members will be better of with his/ her death.
20
3.5
Statistics:
IBM SPSS Statistics version 19 was used to analyze the collected data. Description of categorical
variables like sex, marital status, employment status, stroke lesion, depression, was presented as
numbers and percentages. Analysis to determine the relationship between post stroke
depression and Demographic variables and stroke characteristics, were performed by Pearson
Chi Square (X2) test at 5% significant level.
A separate logistic regression analysis (simple) was performed to evaluate the strength of
association between post stroke depression and demographic & stroke characteristics. Multiple
logistic regression analysis of all statistically significant demographic & stroke characteristics
was also performed to control for all potential confounders. P-value less than 0.05 were
considered statistically significant. Both simple and multiple regression analysis were expressed
as odd ratios (OR) with 95% confidence interval (CI).
3.6
Ethical Consideration:
Before data collection, formal permission was sought from Board of Advance Studies and
Research (BASR) Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan.
Additionally approval was also solicited from the Ethical Review Committee of Liaquat
University of Medical and Health Sciences. And with respect to patients initially their consent to
participate in study was sought and afterwards study’s criteria and purpose was explained in
detail to all of them and to their relatives/ caregivers.
4 Results:
A total of 81 patients met the eligibility criteria and were enrolled in the study. Baseline
demographic and stroke characteristics are appended:
4.1
Baseline Characteristics of Post Stroke Patients:
4.1.1
Demography:
Demographic characteristics of the sample are provided in Table 2. Out of 81 patients 60.5%
were male and 39.5% female. The mean age of patients was 53.8 (S.D 12.2) years. All patients
were divided into five different age groups ranging from 25-88 years. Highest proportion of the
patients belonged to 45-59 years age group (45.7%) and out of them 40.8% were male and 53.1%
21
were female. The second highest proportion of patients was in the age group 60 years and above
i.e 34.6%. Lowest proportion was in the age group < 45 years (19.8%). Most of the patients
(66.7%) were married (71.4% male and 59.4% female), while only 9.9% were unmarried and
23.5% fall under the category of widowed, divorced or separated. The majority, 48% of patients
had no educational attainment (out of them 57.1% were male and 34.4% female) , while low
proportion, 27.2% of patients (22.4% male and 34.4 % female) were having secondary or higher
level of education whereas 24.7% were educated in primary grade. Most of the patients belong to
low income group 50.6% (46.9% male and 56.3% female) while 49.4 % fall under the category of
higher income group > 10,000 per month (53.1% male & 43.8% female). By classification of
residence status 56.8% patients (67.3% male and 40.6% female) belongs to the urban area while
just 43.2% were living in remote localities (rural areas). Total 37% patients were employed (51%
male and 15.6% female) and majority 63% were unemployed.
Table-2: Demographic Characteristics of Sample:
VARIABLE
MALE
FEMALE
TOTAL
< 45 years
12 (24.5%)
4(12.5%)
16 (19.8%)
45-59
20 (40.8%)
17(53.1%)
37 (45.7%)
60 years and above
17 (34.7%)
11 (34.4%)
28 (34.6%)
Single
4(8.2%)
4(12.5%)
8(9.9%)
Married
35(71.4%)
19(59.4%)
54(66.7%)
Divorced/ widow
10 (20.4%)
9(28.1%)
19(23.5%)
RESIDENCE
STATUS
Urban
33(67.3%)
13(40.6%)
46(56.8%)
Rural
16(32.7%)
19(59.4%)
35(43.2%)
OCCUPATION
STATUS
Employed
25(51%)
5(15.6%)
30(37%)
Unemployed
24 (49%)
27(84.4%)
51(63%)
EDUCATION LEVEL
Illiterate
28(57.1%)
11(34.4%)
39(48.1%)
Primary
10(20.4%)
10(31.3%)
20(24.7%)
11(22.4%)
11(34.4%)
22(27.2%)
23(46.9%)
18 (56.3%)
41 (50.6%)
26 (53.1%)
14 (43.8%)
40 (49.4%)
AGE
MARITAL STATUS
MONTHLY
INCOME
Secondary
higher
<10,000
and
>10000
22
4.1.2
Stroke Characteristics:
Stroke characteristics of the sample are provided in Table-3. Out of total 81 patients 67.9%
(71.4% male and 62.5% female) had Ischemic stroke whereas 32% patients (28.6% male and
37.5% female) had hemorrhagic stroke. The right hemisphere lesion location account for 56.8%
patients (53.1% male and 62.5% female) and 43.2% patients had left hemisphere lesion location
(46.9% male and 37.5% female)
Table-3 Stroke Characteristics of sample
Variable
Stroke Type
Location of
Stroke
4.2
Male
Female
Total
Ischemic
35(71.4%)
20(62.5%)
55(67.9%)
Hemorrhagic
14(28.6%)
12(37.5%)
26(32.1%)
Right Hemisphere
26(53.1%)
20(62.5%)
46(56.8%)
Left Hemisphere
23(46.9%)
12(37.5%)
35(43.2%)
Prevalence of Post Stroke Depression:
The overall prevalence of post stroke depression in sample size was 38% (31 out of 81 patients).
The prevalence in male was found 47% (23 out of 49) whereas in female it was 25% (08 out of
32). This difference was also found statistically significant (Table-4).
4.3
Post Stroke Depression and demographic factors:
Table -4 is showing post stroke depression with reference to demographic factors. If we look at
the age group data, highest depression could be seen in young age group <45 years (68.8%).
However, relatively lower post stroke depression was observed among older age groups, in the
age group 45-59 years (37.8%) and in age group 60 years and above (21.4%). Statistical
significant association has been found between the age group and post stroke depression (PValue < 0.05). Post Stroke Depression was found higher in male as compare to the female in the
sample (Male: 46.9%, Female: 25%), P-value < 0.05. The results reveal a significant association
between post stroke depression and residence status (P-Value < 0.05). Level of depression
among urban population was higher i.e 47.8% as compare to the rural 25.7%.
23
Higher level of post stroke depression was observed among married paitients (42.6%). However,
lower level of Post Stroke Depression was observed among single (25%) and divorced/ widow
(31.6%) patients ( P- Value > 0.05) . (Table-4)
Table 4: Prevalence of Post stroke depression with respect to demography:
Variables
Age
Categories
Marital
Status
4.4
Total
< 45 Years
11(68.8%)
5(31.3%)
16 (100%)
45-59
14(37.8%)
23 (62.2%)
37(100%)
60 & above
6 (21.4%)
22 (78.6%)
28 (100%)
Male
23 (46.9%)
26(53.1%)
49 (100%)
Female
8 (25%)
24 (75%)
32 (100%)
24 (52.2%)
46 (100%)
Rural
22
(47.8%)
9 (25.7%)
26 (74.3%)
35 (100%)
Single
2(25%)
6(75%)
8(100%)
Married
23(42.6%)
31(57.4%)
54(100%)
Divorced/ Widow
6(31.6%)
13(68.4%)
19(100%)
Gender
Residence
Status
Depression
N (%)
Yes
No
31(%)
50 (%)
Urban
P-value
0.008
0.047
0.043
0.051
Post Stroke Depression and Socio Economic variable:
A significant association has also been found between education level and post stroke
depression (P-value < 0.05) showing that post stroke depression was highest among patients
having primary level of education (60%) whereas a decreasing trend was observed in level of
depression with increase in level of education (Secondary and higher level=18.2%).
In data analysis no significant association between Post Stroke Depression and occupation
status of patients was found. Total 46.7% employed patients were found depressed as compare
to a lower level of depression in unemployed (33.3% ) (P-Value > 0.05). In high income group
post stroke patients were less likely to develop depression (only 22.5% were having post stroke
depression) whereas patients with low income group were more likely to develop post stroke
24
depression (53.7% were found depressed) with significant association (P-Value < 0.05). (Table 5)
Table 5: Prevalence of Post stroke depression with respect to Socio Economic Variables:
Variable
Education Level
Occupation
Status
Categories
Total
81 (100%)
Yes
31(%)
No
50 (%)
Illiterate
15 (38.5%)
24(61.5%)
39 (100%)
Primary
12 (60%)
8 (40%)
20 (100%)
Secondary and
higher
4(18.2%)
18 (81.8%)
22 (100%)
Employed
14(46.7%)
16 (53.3%)
30(100%)
Unemployed
17(33.3%)
34(66.7%)
51(100%)
< 10,000
22 (53.7%)
19 (46.3%)
41(100%)
31 (77.5%)
40 (100%)
P-Value
0.021
0.170
Monthly Income
>10,000
4.5
Depression
N (%)
9 (22.5%)
0.004
Post Stroke Depression and Stroke Characteristics:
Table-6 describes the stroke type and localization in patients with and without Post Stroke
Depression. Out of total 81 patients 31 were having post stroke depression. Out of those 31
patients, post stroke depression was found comparatively higher in patients with Ischemic
stroke 47.3% than hemorrhagic stroke (19.2%). Post stroke depression and stroke type had
significant association (P-value <0.05).
Localization of stroke characteristics, which was taken from the CT scan reports of the patients
revealed a higher level of post stroke depression in right hemisphere lesion location (43.5%) as
compared to left hemisphere (31.4%). However, post stroke depression and Stroke localization
had no significant association.
25
Table-6: Stroke type and Localization in patients with and without PSD
Depression
Variable
Categories
N (%)
Total
81 (100%)
Yes
No
31(%)
50 (%)
Ischemic
26 (47.3%)
29 (52.7%)
55 (100%)
Hemorrhagic
5 (19.2%)
21 (80.8%)
26 (100%)
Location of
Right Hemisphere
20 (43.5%)
26 (56.5%)
46 (100%)
Stroke
Left Hemisphere
11 (31.4%)
24(68.6%) 35 35(100%)
Stroke Type
4.6
P-Value
0.015
0.269
Factors that Differentiate Post Stroke Patients With And
Without Depression :
Chart-1 illustrates the factors that differentiate post stroke patients with and without
depression. Some of the demographic factors (e.g age, education level, gender, residence
status and income) were found statistically significant with respect to PSD and differentiated
post stroke patients with and without depression. Further, in our study, for neurological
factors, we found that stroke type had significant association with post stroke depression and
differentiated post stroke patients with and without depression.
26
% of Post stroke patients with & without Depression
Variables that differentiate Post stroke patients with
and without depression
90,00%
80,00%
70,00%
60,00%
50,00%
40,00%
30,00%
20,00%
10,00%
0,00%
Depressive
Variables
Non Depressive
Column1
Chart-1: Showing factors those differentiate Post stroke patients with and without depression.
4.7
Simple Logistic Regression Analysis:
In simple logistic regression analysis Table -7 the age of patients was positively associated
with post stroke depression. Compare to the oldest age group 60 years and above the
youngest age group < 45 years had about 8 times higher odd ratio (8.07) for reporting of
post stroke depression. The residence status of patients was also positively associated with
post stroke depression. The odds for reporting of post stroke depression was high (65%)
among urban resident patients as compare to the rural ones. Education level of the patients
was also positively associated with post stroke depression with highest odd ratio in primary
level of education (6.75) as compare to the higher education. Monthly income was found
27
positively associated with post stroke depression. As compare to the higher income group
the lower income group had four times higher odd ratio. Besides age, residence status,
education level and monthly income, no other demographic and socio economic variable
yielded significant results.
In stroke characteristics, stroke type was positively associated with post stroke depression.
The odds for reporting of post stroke depression was high (76%) among ischemic stroke
patients as compare to the hemorrhagic stroke patients.
Table -7 Simple logistic regression showing the influence of demographic, socio economic
variables and stroke characteristics on post stroke depression among stroke patients.
VARIABLE
OR
CI (95%)
P-Value
DEMOGRAPHIC VARIABLES
AGE
<45 Years
45-59
Gender
MARITAL STATUS
2.01-32.39
0.003
2.23
0.73-6.85
0.160
0.99-7.05
0.050
0.72
0.11-4.69
0.733
1.61
0.53-4.87
0.401
1.02-6.87
0.045
2.81
0.79-9.92
0.108
6.75
1.66-27.51
0.008
0.69-4.41
0.235
1.52-10.45
0.005
60 Years & Above
1.0
Male
2.65
Female
1.0
Single
Married
RESIDENCE
STATUS
8.07
Divorced/ widow
1.0
Urban
2.65
Rural
1.0
SOCIO ECONOMIC VARIABLES
EDUCATION LEVEL
Illiterate
Primary
OCCUPATION
STATUS
MONTHLY
INCOME
Secondary
higher
Employed
and
1.0
1.75
Unemployed
1.0
<10,000
3.99
>10000
1.0
28
STROKE CHARACTERISTICS
Stroke Type
Ischemic
Location Of Stroke
4.8
3.77
Hemorrhagic
1.0
Right Hemisphere
1.68
Left Hemisphere
1.0
1.24-11.42
0.019
0.67-4.28
0.271
Multiple Logistic Regression Analysis:
The results obtained in multiple logistic regression analysis (Table-8) shows the influence of
demographic, socio economic & stroke variables on post stroke depression. The multiple logistic
regression analysis was performed on all statistically significant variables of simple logistic
regression model. In adjusted multiple logistic regression positive relationship was observed
between post stroke depression and age, education level, monthly income and stroke type. Odd
ratio for age was 10.98 & is still significant. Odd ratio for education level (primary level) was
5.44, for monthly income it was 3.65 & for stroke type it was 3.62 and they all remained
significant. However, no statistical significance was observed between residence status and post
stroke depression (P Value > 0.05).
Table-8: Multiple logistic regression showing the influence of demographic, socio economic variables
and stroke characteristics on post stroke depression among stroke patients.
VARIABLES
AGE
RESIDENCE STATUS
EDUCATION LEVEL
MONTHLY INCOME
STROKE TYPE
<45 Years
45-59
60 Years & Above
Urban
Rural
Illiterate
Primary
Secondary and
higher
< 10,000
>10,000
Ischemic
OR
C.I (95%)
P-VALUE
10.98
3.47
2.152 -56.019
.970 -12.441
0.004
0.056
1.0
2.49
0.815-7.585
0.109
1.0
3.83
0.910-16.141
0.067
5.44
1.063-27.807
0.042
1.171-11.426
0.026
1.05-14.487
0.048
1.0
3.66
1.0
3.62
Hemorrhagic
1.0
29
5 Discussion:
5.1
Main Findings:
Post stroke depression was diagnosed using DSM IV TR criteria. Our study endorsed the fact
that depression is a common outcome of stroke. In this study we found more than one third of
the stroke patients depressed. Depression was found more frequent in our sample in young age
group and for males.
Post stroke depression was found significantly related and more frequent among primary
educated, unemployed patients with lower level of monthly income. However, in terms of
residence status depression among urban population was found more frequent as compare to
the rural ones. No significant relation was found between the marital status of the patients and
depression.
In terms of stroke related factors, ischemic stroke type was found statistically associated with
depression while no significant relation was observed between lesion location of stroke and
depression.
Multiple logistic regression analysis was used to eliminate the potential confounders.
To sum up factors contributing to increased risk of depression after stroke include advancement
in age, male sex, primary level of education, urban residence, unemployment, lower income
levels and Ischemic stroke type.
5.2
Prevalence of Depression:
Prevalence of depression among Pakistani population is reported to be very high and found
among one third of the population
78.
Risk of developing depression in stroke survivors is also
very high which affect their recovery after stroke. Depression after stroke was found very
frequent in our sample and more than one third of the sample was found depressed which was
found related with many other studies
78,79,80,81
. The presence of depression in our patients was
high as compared with that in studies conducted in developed countries but this is in line with
studies conducted in developing countries and in South East Asia. Our results reflect the
dilemma of Pakistan and of most developing countries. It shows the picture of sociodemographic profile of a developing country, where very low per capita expenditure is made on
health and few, if any, benefits provided to the disabled population.
30
5.3
Associated Factors of Post Stroke Depression:
5.3.1 Demographic factors:
Demographic variables are important determinants of post stroke depression. Depressive
symptoms were found statistically associated with young age group in our study. Our result has
similarity with previous studies
25,32,59,82.
However, most of the studies on significance between
age and post stroke depression show contradictory findings and reveals complex relationship
between age and post stroke depression which could be found dependent upon other multiple
factors.
Post stroke depression was found significantly associated with male sex in this study. This is in
accordance with many other studies
62-64,83.
One reason of high depression among working age
group of male might be that physical disability in that group is of greater importance for male as
compare to female or another explanation of higher depression in men was attributed to their
less coping abilities as compare to female64. In specific case of Pakistan high post stroke
depression among male could also be attributed to the cultural norms as high level of
responsibilities and expectations are attached with male gender. Males are responsible to earn
bread and butter for large families. Joint family system in the country adds fuel to the fire and in
such scenario physical impairment by stroke carries a higher risk of developing depression.
Similarly, our study found education level, employment status, monthly income and residence
status as the other most important demographic determinants of post stroke depression. We
have found our study unique in exploring these factors as determinants of post stroke
depression. As per our knowledge no previous study in Pakistan has explored association of
above mentioned four demographic factors in developing post stroke depression. In our study
post stroke depression was found significantly associated with primary level of education,
unemployment, lower monthly income and urban residence locality. The significant association
of urban locality in post stroke depression has also been proved by other studies83. Logic of
above four factors as being determinant of post stroke depression in particular case of Pakistan,
as found in our study, could be traced out behind culture, economic, socio economic and
political conditions of the country. Pakistani population since last three decades is experiencing
sociopolitical instability, economic uncertainty, violence, terrorism, regional conflict, and
dislocation. Pakistan is facing biggest problems of poverty, unemployment and illiteracy. Very
31
little resources are devoted to socio-economic development of the country which in addition to
high birth rate contributes to persistence of poverty. Currently 32% of Pakistani population is
living below poverty line
84
and Unemployment rate is 15.4% with 49.9% literacy rate
66.
All
these factors are interlinked and produce synergy affect in causing post stroke depression when
combined in a stroke patient.
5.3.2 Stroke characteristics:
A significant association was found between post stroke depression and Ischemic stroke type in
our study. This finding is in congruence with other studies
24,81,85,86.
An earlier study reported
high depression among patients having ischemic stroke in the left hemisphere as compare to
those having it in the right hemisphere85. However, many studies do not agree with this and
report contradictory results33,56.
No significant association was found between stroke localization and post stroke depression in
the study and this finding is in line with many other studies23, 24,39,56,83. In a systematic review a
study has found no significant association between lesion location and depression after pooling
the data of 34 primary studies39. However, some studies disagree with this finding and report
significance of left lesion location in causing post stroke depression 14,38,53,54 and some other in
contrast to this report significance of right lesion location in causing post stroke depression 57.
This vide divergence among different study findings on the subject of Lesion location association
with post stroke depression could be attributed to the methodological differences among study
settings e.g sample size, sample selection criteria, study site, different tools used to measure
depression and time passed since stroke.
6 Limitations:
Our study has several potential limitations. First being a cross sectional study, this study
inherits in itself the limitation to test the temporal sequence of these events. Secondly our study
was limited to one public sector hospital which might be biased in stroke type, stroke severity
and demographic characteristics of the patients. Thirdly, our entire sample was based on those
who had no cognitive and psychiatric impairment. Therefore, the results cannot be generalized
to those stroke patients who have any cognitive and psychiatric impairment.
32
7 Conclusion:
It is concluded that prevalence of post stroke depression is high and frequent. It usually
remained under recognized. Demographic and Stroke variables are associated with post stroke
depression and are the most important determinants of post stroke depression. Young patients
with male sex are more vulnerable to develop depression. Those who usually have primary level
of education, low monthly income, urban residence, unemployed and having Ischemic stroke are
at higher risk of developing depression after stroke.
8 Recommendations:
As to our knowledge this study is unique of its type and has evaluated the relationship between
demographic factors, stroke factors and post stroke depression in Pakistan. We recommend that
the population which has been identified in this study requires immediate attention of the
health care providers with respect to post stroke care. Well planned training sessions for
dissemination information about stroke and its related risk factors are suggested for health
professionals. At community level awareness sessions for general public are recommended.
Further, a community based study is also recommended on the subject. In addition more studies
using detailed information about sample like time elapsed after stroke, severity of stroke and
type of medical services used may also be explored in further studies which may help to enhance
the interpretation of the study findings.
33
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40
ANNEXURE - I
QUESTIONNAIRE
PREVALENCE OF DEPRESSION AMONG POST STROKE PATIENTS IN LIAQUAT
UNIVERSITY HOSPTIAL HYDERABAD
Name: ____________________________________________________________
Age : ______________.
Sex:
Male
Female.
Marital Status:
Single.
Married.
Divorced/Widow
OPD Registration No._________________
Residence Status:
Rural
Employment Status:
Education Level:
Urban.
Employed
Illiterate.
Monthly Income:
< 10,000.
Unemployed.
Primary
Secondary and Higher
10,000 - 40,000.
> 40,000.
Assessment of Stroke Characteristics:
1. Type of Stroke:
Hemorrhagic.
2. Anatomical site of Stroke lesion:
Ischemic
Right hemisphere.
Left hemisphere.
Assessment of Depressive symptoms:
1. Depressed mood:
YES
2. Loss of interest in activities previously enjoyed:
YES
NO
NO
3. Significant weight loss/ gain:
a) Weight loss of 5% when not dieting
YES
NO
b) Weight gain of 5% when not overeating.
YES
NO
4. Sleep disturbance (Insomnia)
41
a) Late onset sleep
YES
b) Feels un-fresh in the morning.
YES
NO
NO
5. Psychomotor agitation or retardation:
a) Agitation
YES
NO
b) Retardation
YES
NO
6. Loss of energy:
YES
7. Feelings of worthlessness:
YES
NO
NO
8. Diminished ability to concentrate:
YES
NO
9. Recurrent thoughts of death or suicidal ideation
YES
NO
Number of factors presents: _____
DEPRESSION:
YES
42
NO
A list of master theses from previous years, 1996-2007, is available at:
www.phmed.umu.se/english/divisions/epidemiology/research/publications
Centre for Public Health Report Series
(ISSN 1651-341X)
2009
2009:1
Anne Neumann. Assessing the cost-effectiveness of the Saxon Diabetes Type 2 Prevention Program
Using a Markov Model. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:2
Yien Ling Hii. Climate variability and increase in intensity and magnitude of dengue incidence in
Singapore. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:3
Agnes Mbabaali Nanyonjo. Knowledge, attitude and practices of young people, regarding HIV
positive prevention - a mixed method study of the Infectious Diseases Institute Kampala Uganda.
Master thesis in public health. Umeå International School of Public Health, Epidemiology and
Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:4
Raman Preet. Tobacco control and prevention: Need for commitment from oral health
professionals. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:5
Erika Viklund. A struggle for health against all odds. Women`s experiences from a refugee camp in
Ghana. Master thesis in public health. Umeå International School of Public Health, Epidemiology
and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:6
Veneranda Masatu Bwana. Pulmonary tuberculosis among human immunodeficiency virus (HIV)
infected patients in the era of highly active antiretroviral therapy (Haart) in Dar Es Salaam
municipal, Tanzania. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:7
Kwabena Titi Ofei. Nutrient intakes and vitamin supplements in early pregnancy in relation to
maternal age and body mass index in Umeå, Sweden. Master thesis in public health. Umeå
International School of Public Health, Epidemiology and Public Health Sciences, dept of Public
Health and Clinical Medicine, Umeå University, 2009.
2009:8
Bege Dauda. Antimalarial drug prescriptions and doctors perception on malaria in hospitals of
Kaduna State, Nigeria. A pilot study. Master thesis in public health. Umeå International School of
Public Health, Epidemiology and Public Health Sciences, dept of Public Health and Clinical
Medicine, Umeå University, 2009.
2009:9
Nurul Kodriati. Economic modelling of the impact of work site cardiovascular screening in
Indonesia. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:10
Trisasi Lestari. Burden of childhood TB in hospitals in Java Island: Challenge for DOTS program.
Master thesis in public health. Umeå International School of Public Health, Epidemiology and
Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:11
Ziaul Islam Chowdhury. The effect of antenatal care on infant malnutrition in Bangladesh:
Secondary analysis of Demographic and Health Survey data. Master thesis in public health. Umeå
International School of Public Health, Epidemiology and Public Health Sciences, dept of Public
Health and Clinical Medicine, Umeå University, 2009.
2009:12
Mojgan Padyab. Factor structure of the Iranian version of Ways of Coping questionnaire. Master
thesis in public health. Umeå International School of Public Health, Epidemiology and Public Health
Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:13
Hana Kolac. Studying abroad: Changes in sexual behaviour and access to sexual health services.
Master thesis in public health. Umeå International School of Public Health, Epidemiology and
Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:14
Xueyan Bai. Cost-effectiveness analysis on the use of Peripheral Intravenous Catheter (PIV) and
Peripherally Inserted Central Catheter (PICC) in hospitalized old tumor patients in China. Master
thesis in public health. Umeå International School of Public Health, Epidemiology and Public Health
Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:15
Andinet Worku. Pattern and determinants of survival in adult HIV patients on antiretroviral
therapy, Ethiopia. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:16
Ailiana Santosa. Sexual dysfunction and quality of life among older people in Purworejo district,
Indonesia. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:17
Cynthia Anticona Huaynate. Heavy metal levels and nutritional status in two indigenous
communities of the Corrientes river- Loreto- Peru. Master thesis in public health. Umeå
International School of Public Health, Epidemiology and Public Health Sciences, dept of Public
Health and Clinical Medicine, Umeå University, 2009.
2009:18
Arash Safaverdi. Oral health in Iran. A comparison between Tehran and Pardis. Master thesis in
public health. Umeå International School of Public Health, Epidemiology and Public Health
Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:19
Angelica Lahid Barragan Romero. Forgotten people in the programs of sexual and reproductive
health. Master thesis in public health. Umeå International School of Public Health, Epidemiology
and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:20
Anna Stecksén. Physical activity habits, Body Mass Index, general health, screen-time and
education in families within the SALUT Child Health Promoting Intervention Programme in
Västerbotten – results from a pilot study. Master thesis in public health. Umeå International School
of Public Health, Epidemiology and Public Health Sciences, dept of Public Health and Clinical
Medicine, Umeå University, 2009.
2009:21
Yared Woldemariam Habtewold. Preference for health care financing options and willingness to
pay for compulsory health insurance among government employees in Ethiopia. Master thesis in
public health. Umeå International School of Public Health, Epidemiology and Public Health
Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:22
Irina V. Pecheykina. Comprehensive social and psycho-pedagogical assistance to singe-parent
families in Russia. A study protocol for cost-effectiveness analysis. Master thesis in public health.
Umeå International School of Public Health, Epidemiology and Public Health Sciences, dept of
Public Health and Clinical Medicine, Umeå University, 2009.
2009:23
Irina Popova. Teenage boys and girls with asthma in the Arkhangelsk city, Russia: Self-reported
health and coping strategies. A study protocol. Master thesis in public health. Umeå International
School of Public Health, Epidemiology and Public Health Sciences, dept of Public Health and Clinical
Medicine, Umeå University, 2009.
2009:24
Ulla-Greta Rönnqvist. The face of a woman. A study of the roles of socio-cultural norms and values
in the planning of sexual and reproductive health, gender, HIV and AIDS strategies in Mozambique.
Master thesis in public health. Umeå International School of Public Health, Epidemiology and
Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:25
Yihuai Liang. Parental corporal punishment and emotional maltreatment (PCPEM) in childhood,
mental health and risk behaviors among youth students in Beijing and Hebei, China. Master thesis
in public health. Umeå International School of Public Health, Epidemiology and Public Health
Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:26
Bahar Aghaie Nia. Causes and consequences of fleeing from home. An elaborative effort to
present the lived-experience of young women living in welfare shelters in Tehran, Iran. Master
thesis in public health. Umeå International School of Public Health, Epidemiology and Public Health
Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:27
Dao Dinh Sang. Injecting drug users: Their processes of being addicted and their lives in a rural
area in Vietnam. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:28
Dang The Hung. Health effects related to second hand smoke in children. Preliminary study in
Vietnam. Master thesis in public health. Umeå International School of Public Health, Epidemiology
and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:29
Hideyuki Kobayashi. Well-being and freedom of patients. Comparison of nursing service between
Sweden and Japan. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:30
Asiya Abuliekemu. A literature review of cost-effectiveness analysis on rotavirus vaccine. Umeå
Master thesis in public health. International School of Public Health, Epidemiology and Public
Health Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:31
Nighat Farooqi. Can dietary advice improve the energy intake and physical performance in
patients with Chronic Obstructive Pulmonary Disease. Master thesis in public health. Umeå
International School of Public Health, Epidemiology and Public Health Sciences, dept of Public
Health and Clinical Medicine, Umeå University, 2009.
2009:32
Phan Minh Trang. Chronic respiratory function and symptoms among workers in rubber industry
at Ho Chi Minh City. Master thesis in public health. Umeå International School of Public Health,
Epidemiology and Public Health Sciences, dept of Public Health and Clinical Medicine, Umeå
University, 2009.
2009:33
Xiaohong Gu. Insulin resistance: an important risk marker for the development of silent cerebral
infarction in Chinese middle-age patient with hypertension. Master thesis in public health. Umeå
International School of Public Health, Epidemiology and Public Health Sciences, dept of Public
Health and Clinical Medicine, Umeå University, 2009.
2009:34
Anneli Thylin. Utdelning av läkemedel inom missbruksvård till misshandlade kvinnor – en
journalstudie vid Renforsens behandlingshem. Master thesis in public health. Umeå International
School of Public Health, Epidemiologi och folkhälsovetenskap, Institutionen för folkhälsa och klinisk
medicin, Umeå Universitet, 2009.
2009:35
Zohreh Sadeghkhani. Depression and unequal rights among women and men. Master thesis in
public health. Umeå International School of Public Health, Epidemiology and Public Health
Sciences, dept of Public Health and Clinical Medicine, Umeå University, 2009.
2009:36
Michaela Zenek. Organic Farming- Beneficial to the 3rd world farmer? Bridging sustainable farming
and healthier communities in Sub Saharan Africa. Master thesis in public health. Umeå
International School of Public Health, Epidemiology and Public Health Sciences, dept of Public
Health and Clinical Medicine, Umeå University, 2009.
2010
2010:1
Osama Ahmed Hassan Ahmed. Rift Valley Fever. A Resurgent Threat. Case Studies from Sudan and
the Kingdom of Saudi Arabia. Master thesis in public health. Umeå International School of Public
Health, Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå
University, 2010.
2010:2
Oziegbe Paul Akhigbe. Motorcycle related maxillofacial injuries in a semi-urban town in Nigeria. A
four year review of cases in Irrua Specialist Teaching Hospital. Master thesis in public health. Umeå
International School of Public Health, Epidemiology Global Health, Department of Public Health
and Clinical Medicine, Umeå University, 2010.
2010:3
Eyerusalem Dagne. Role of socio-demographic factors on utilization of maternal health care
services in Ethiopia. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2010.
2010:4
Yalem Tsegay Assfaw. Determinants of Antenatal Care, Institutional Delivery and Skilled Birth
Attendant Utilization in Samre Saharti District, Tigray, Ethiopia. Master thesis in public health.
Umeå International School of Public Health, Epidemiology Global Health, Department of Public
Health and Clinical Medicine, Umeå University, 2010.
2010:5
Stefanie Butz. Bangladeshi girl: “My parent’s didn´t allow me to learn to swim, so I drowned”. A
gender theoretical perspective on environmental migration by applying Connells hegemonic
masculinity theory in the field of Public Health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2010.
2010:6
Huo Jinhai. The economic burden of occupational asthma in Europe. Master thesis in public health.
Umeå International School of Public Health, Epidemiology Global Health, Department of Public
Health and Clinical Medicine, Umeå University, 2010.
2010:7
Ernest Njoh Malange. The Cholera Epidemic and Barriers to Healthy Hygiene and Sanitation in
Cameroon. A Protocol Study. Master thesis in public health. Umeå International School of Public
Health, Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå
University, 2010.
2010:8
Shabnam Salimi. Association of severe periodontitis with microalbuminuria and chronic kidney
disease. Master thesis in public health. Umeå International School of Public Health, Epidemiology
Global Health, Department of Public Health and Clinical Medicine, Umeå University, 2010.
2010:9
Tewodros Bizuwork. Risk factors and causes of mortality among HIV/AIDS patients receiving
antiretroviral therapy; Zomba central hospital; Zomba, Malawi. A study protocol. Master thesis in
public health. Umeå International School of Public Health, Epidemiology Global Health,
Department of Public Health and Clinical Medicine, Umeå University, 2010.
2010:10
Michael Tesfamariam. Salutogenic perspective and it´s contribution to improve the care of
orphans in Eritrea. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2010.
2010:11
Agegnehu Tesfaye Abdeberhan. Risk factors for (predictors of) loss to antiretroviral therapy in
Oromia, Ethiopia. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2010.
2010:12
Masoud Waazghasemi. Overweight and lifestyle characteristics among Swedish adolescents. A
study in four pilot areas of Västerbotten. Master thesis in public health. Umeå International School
of Public Health, Epidemiology Global Health, Department of Public Health and Clinical Medicine,
Umeå University, 2010.
2010:13
Julia Schröders. Are we running with the wrong fuel? A study protocol quantitatively and
qualitatively assessing short-term effects of a paleolithic diet on healthy German men and women.
Master thesis in public health. Umeå International School of Public Health, Epidemiology Global
Health, Department of Public Health and Clinical Medicine, Umeå University, 2010.
2010:14
Ediri Brume. Obesity in low income African American adults. A New York City Literature Review.
Master thesis in public health. Umeå International School of Public Health, Epidemiology Global
Health, Department of Public Health and Clinical Medicine, Umeå University, 2010.
2010:15
Bruno Guerreiro Semedo. A Review of the State of Chronic Obstructive Pulmonary Disease in
Portugal. Master thesis in public health. Umeå International School of Public Health, Epidemiology
Global Health, Department of Public Health and Clinical Medicine, Umeå University, 2010.
2010:16
Janna Maria Brouwer. Cheap doesn’t always mean better. Anaesthesia in cataract extractions in
the normal eye in the Netherlands; a deterministic cost utility analysis using a Markov Model.
Master thesis in public health. Umeå International School of Public Health, Epidemiology Global
Health, Department of Public Health and Clinical Medicine, Umeå University, 2010.
2010:17
Manuel Krone. Is it efficient to vaccinate girls against HPV? A cost-utility analysis of HPVvaccination in Germany using a Markov-Model. Master thesis in public health. Umeå International
School of Public Health, Epidemiology Global Health, Department of Public Health and Clinical
Medicine, Umeå University, 2010.
2010:18
Ali Mohammed Abbas. Western Moist Snuff and Oropharyngeal Cancer. A Systematic Review.
Master thesis in public health. Umeå International School of Public Health, Epidemiology Global
Health, Department of Public Health and Clinical Medicine, Umeå University, 2010.
2010:19
Marwan Shehda Salama Mosleh. Awarness of anaemia among pregnant women at UNRWA clinics
in Gaza strip. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2010.
2010:20
Tariq Feroz Memon. The potential risk factors of stroke and their frequencies among stroke
patients admitted in Liaquat University Hospital, Hyderanad, Pakistan Master thesis in public
health. Umeå International School of Public Health, Epidemiology Global Health, Department of
Public Health and Clinical Medicine, Umeå University, 2010.
2011
2011:1
Therese Kardakis, Linda Sundberg, Monica E. Nyström, Rickard Garvare, Lars Weinehall.
Utveckling och implementering av kliniska riktlinjer för hälso- och sjukvården – En
litteraturöversikt. Epidemiologi och global hälsa, Umeå universitet, 2011.
2011:2
Rathi Ramji. Assessing the Relationship between Occupational Stress and Periodontitis in Industrial
Workers. Master thesis in public health. Umeå International School of Public Health, Epidemiology
Global Health, Department of Public Health and Clinical Medicine, Umeå University, 2011.
2011:3
Waseem Akhtar Choudhary. Barriers to voluntary counselling and testing (VCT) among HIV/AIDS
patients. A Study Protocol for the Punjab Province of Pakistan. Master thesis in public health.
Umeå International School of Public Health, Epidemiology Global Health, Department of Public
Health and Clinical Medicine, Umeå University, 2011.
2011:4
Joseph S. Bukalasa. Indoor Air Pollution, Social Inequality and Acute Respiratory Diseases in
Children in Tanzania. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2011.
2011:5
Shijun Wang. Health systems in rural areas: A comparative analysis in financing mechanisms and
payment structures between China and India. Master thesis in public health. Umeå International
School of Public Health, Epidemiology Global Health, Department of Public Health and Clinical
Medicine, Umeå University, 2011.
2011:6
Nguyen Thi Minh Thoa. Health care utilization and economic growth of households in Ba Vi,
Vietnam. Master thesis in public health. Umeå International School of Public Health, Epidemiology
Global Health, Department of Public Health and Clinical Medicine, Umeå University, 2011.
2011:7
Nazgul Mussanova. Efficiency Analysis of the Health Centres in Karaganda oblast, Kazakhstan. Data
envelopment and Malmquist index analysis. Master thesis in public health. Umeå International
School of Public Health, Epidemiology Global Health, Department of Public Health and Clinical
Medicine, Umeå University, 2011.
2011:8
Medet Ospanov. Cost effectiveness analysis of lifestyle intervention in primary health care. Master
thesis in public health. Umeå International School of Public Health, Epidemiology Global Health,
Department of Public Health and Clinical Medicine, Umeå University, 2011.
2011:9
Haleema Masud. Health Policy: What does it mean in Pakistan? Policy Actors’ Perspectives. Master
thesis in public health. Umeå International School of Public Health, Epidemiology Global Health,
Department of Public Health and Clinical Medicine, Umeå University, 2011.
2011:10
George Downward. Diabetes among the Sami population of Sweden. Master thesis in public
health. Umeå International School of Public Health, Epidemiology Global Health, Department of
Public Health and Clinical Medicine, Umeå University, 2011.
2011:11
Fauhn C Minvielle. Women’s right to health in the Anglo-Caribbean. Intimate partner violence,
abortion and the State. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2011.
2011:12
Andrea Linander. Explicit Health Care Priority Setting in Practice. -Clinical managers’ views of
performing vertical prioritization in Västerbotten County Council. Master thesis in public health.
Umeå International School of Public Health, Epidemiology Global Health, Department of Public
Health and Clinical Medicine, Umeå University, 2011.
2011:13
Petronella Sevelius. Breastfeeding in rural Eritrea: a qualitative study of factors influencing
women’s decision to exclusive or non exclusive breastfeeding. Master thesis in public health. Umeå
International School of Public Health, Epidemiology Global Health, Department of Public Health
and Clinical Medicine, Umeå University, 2011.
2011:14
Yehualashet Tadesse. Cervical cancer: Analysis of diagnostic and therapeutic facility in public
health institutions in Addis Ababa, Ethiopia. Master thesis in public health. Umeå International
School of Public Health, Epidemiology Global Health, Department of Public Health and Clinical
Medicine, Umeå University, 2011.
2011:15
Muhammad Talha Khan. Diabetes mellitus and sugar consumption; an ecological study. Master
thesis in public health. Umeå International School of Public Health, Epidemiology Global Health,
Department of Public Health and Clinical Medicine, Umeå University, 2011.
2011:16
Hina Khuram. Effect of aerobic physical training on stroke survivors. Master thesis in public health.
Umeå International School of Public Health, Epidemiology Global Health, Department of Public
Health and Clinical Medicine, Umeå University, 2011.
2011:17
Batholomew Chireh. Knowledge, attitude and practices (KAP) concerning Hepatitis B among
adolescents in the upper West Region of Ghana. The rural-urban gradient. Master thesis in public
health. Umeå International School of Public Health, Epidemiology Global Health, Department of
Public Health and Clinical Medicine, Umeå University, 2011.
2011:18
Tom Nick Adie. Cost-effectiveness of community-based HIV/AIDS Management program:
Implications for Kenya. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2011.
2011:19
Henrietta Opoku. Self-reported vision health status among older people in the Kassena-Nankana
District, Ghana. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2011.
2011:20
Arnold Nyiegwen Muweh. Modernity in traditional medicine. Women’s experiences and
perceptions in the Kumba health district, SW region Cameroon. Master thesis in public health.
Umeå International School of Public Health, Epidemiology Global Health, Department of Public
Health and Clinical Medicine, Umeå University, 2011.
2011:21
Nazib Uz Zaman Khan. Husbands perceptions about their wives’ long term maternal morbidity:
findings from interviews in rural Bangladesh. Master thesis in public health. Umeå International
School of Public Health, Epidemiology Global Health, Department of Public Health and Clinical
Medicine, Umeå University, 2011.
2011:22
Abraham Tsegay. Knowledge, attitude and practice of public health practitioners towards safe
abortion care services in Tigray regional state, Ethiopia. Master thesis in public health. Umeå
International School of Public Health, Epidemiology Global Health, Department of Public Health
and Clinical Medicine, Umeå University, 2011.
2012:1
Md. Muradul Islam. Married men’s views on gender rights and sexuality in a northwest
Bangladesh village. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2011.
2012:2
Sundip Gurung. Silent sufferers. Street children, drugs, and sexual abuse in Kathmandu, Nepal.
Master thesis in public health. Umeå International School of Public Health, Epidemiology Global
Health, Department of Public Health and Clinical Medicine, Umeå University, 2012.
2012:3
Parshin Yousefi. Overweight/obesity and lifestyle. Characteristics among Iranian pre-school
children. Master thesis in public health. Umeå International School of Public Health, Epidemiology
Global Health, Department of Public Health and Clinical Medicine, Umeå University, 2012.
2012:4
Nguyen Van Hiep. Sexual risk behaviors among male sex workers in Ho Chi Minh City, VietnamImplications for HIV prevention. Master thesis in public health. Umeå International School of Public
Health, Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå
University, 2012.
2012:5
Shufen Cao. The home-based elderly care system analysis: An illustration from Hangzhou, China.
Master thesis in public health. Umeå International School of Public Health, Epidemiology Global
Health, Department of Public Health and Clinical Medicine, Umeå University, 2012.
2012:6
Mona Mohamed Ali. Food-and sun habits with a specific focus on vitamin D among pregnant
Somali women living in Sweden. A study protocol. Master thesis in public health. Umeå
International School of Public Health, Epidemiology Global Health, Department of Public Health
and Clinical Medicine, Umeå University, 2012.
2012:7
Zafarullah Khan Qamar. Depression among stroke patients and relation with demographic and
stroke characteristics. Master thesis in public health. Umeå International School of Public Health,
Epidemiology Global Health, Department of Public Health and Clinical Medicine, Umeå University,
2012.
2012:8
Dina Vemming Oksen. An epidemiological overview on oral outbreaks of Chagas disease in South
America. Master thesis in public health. Umeå International School of Public Health, Epidemiology
Global Health, Department of Public Health and Clinical Medicine, Umeå University, 2012.
2012:9
Bong Ngeasham Collins. Assessing the outcome of tuberculosis treatment in the Cameroon Baptist
convention health board tuberculosis treatment centers. Master thesis in public health. Umeå
International School of Public Health, Epidemiology Global Health, Department of Public Health
and Clinical Medicine, Umeå University, 2012.
Umeå International School of Public Health
Epidemiology and Global Health
SE-901 85 Umeå, Sweden
Phone +46 90 785 27 29
www.phmed.umu.se/english/divisions/epidemiology
ISSN 1651-341X