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ORIGINAL ARTICLE
Year : 2015  |  Volume : 18  |  Issue : 3  |  Page : 121-125

Post-stroke depression in a sub-Saharan Africans: Validation of the Japanese Stroke Scale for Depression


Department of Medicine, Neurology Unit, University of Benin Teaching Hospital, Benin City, Nigeria

Date of Web Publication10-Nov-2015

Correspondence Address:
F A Imarhiagbe
Department of Medicine, Neurology Unit, University of Benin Teaching Hospital, P.O. Box 7184, GPO, Benin City
Nigeria
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DOI: 10.4103/1118-8561.169285

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  Abstract 

Background: Japanese Stroke Scale for Depression (JSS-D) is not a validated instrument for post stroke depression (PSD) in sub-Saharan Africans. Methods: Ninety-two subjects on follow-up in a stroke clinic were consecutively assessed for demographic and clinical variables, and all were subsequently assessed for depression with the JSS-D. Functional ability was assessed with Rankin score and good functional recovery was defined as Rankin score of ≤2. Stroke type was determined using cranial computed tomography or magnetic resonance imaging as cerebral infarct or intracerebral hemorrhage. Data was compared between subjects with and without PSD. Symmetric agreement between JSS-D and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria for depression was compared on Cohen's kappa statistics and the sensitivity, specificity of JSS-D was tested on a receiver operated characteristics (ROC) curve. Results: PSD occurred in 17 (18.5%) of study subjects. Mean age was not significantly different between PSD and no PSD, P = 0.226, but there was a difference in the sex distribution (P = 0.034) with a male sex preponderance for both groups. Rankin score was higher in PSD and significantly different both at discharge and the time of evaluation (P = 0.019 and 0.003). JSS-D agreed with DSM IV criteria for mild depression significantly on Cohen's kappa statistics, kappa = 0.69, P < 0.0001. The sensitivity and specificity of JSS-D on ROC curve were 94.1% and 97.2% respectively at a JSS-D cut-off value of 2.37, area under the curve = 0.99, P = < 0.0001. Conclusion: JSS-D could be used for PSD with acceptable sensitivity and specificity in sub-Saharan Africans.

Keywords: Africans depression, Japanese, scale, stroke, validation


How to cite this article:
Imarhiagbe F A, Owolabi A. Post-stroke depression in a sub-Saharan Africans: Validation of the Japanese Stroke Scale for Depression. Sahel Med J 2015;18:121-5

How to cite this URL:
Imarhiagbe F A, Owolabi A. Post-stroke depression in a sub-Saharan Africans: Validation of the Japanese Stroke Scale for Depression. Sahel Med J [serial online] 2015 [cited 2019 Oct 18];18:121-5. Available from: http://www.smjonline.org/text.asp?2015/18/3/121/169285


  Introduction Top


Poststroke depression (PSD) is a relatively common psychological condition occurring after a stroke and it only ranks behind anxiety and the incidence ranges from 5% to 20%; it was found to be as high as 60% in another related study.[1],[2],[3],[4],[5],[6] PSD is considered the most common neuropsychiatric consequence of stroke up to 6–24 months after stroke.[6] Onset of symptoms of PSD may occur as early as few days after a stroke, but more commonly it begins months after the stroke, peak incidence and the greatest severity of PSD commonly occur between 6 months and 2 years.[6] PSD occurring within the first 3 months of stroke is classified as early and is defined as late when the symptoms appear later [5],[7] The PSD that starts within days to few weeks after a stroke usually remits, but later onset PSD tends to last longer.[4],[6] Several factors that have been associated with PSD include age, sex, severity of the stroke and the level of disability, site and side of the stroke, history of previous stroke and previous depression, social distress prestroke among others.[5],[8],[9],[10]

The biologic substrate for PSD is not exactly known, however dominant frontal and basal ganglia infarcts are associated significantly more with PSD than that occurring at other sites.[5] The explanation for PSD has in part been attributed to the psychological effect of the stroke on the one hand as well as the biologic substrate, which is believed to be a disruption of monoaminergic and serotoninergic circuits involved in mood regulation after a stroke.[5] It is also believed to be a complex mixture of prestroke personal and social factors and stroke induced social, emotional and intellectual handicap.[9]

Poststroke depression takes its toll on the overall recovery of stroke survivors and early identification and treatment should be part of the management of stroke.[5],[11] In a large related study, nutrition, cognition and motor functional recovery were hampered by PSD and the risk of fatality is higher in PSD than in nondepressed stroke patients.[4],[6]

The clinimetric tools used in the assessment of PSD so far are tools developed for depression in general and are usually matched against the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for depression as gold standard and many of these tools have proven sensitivity and specificity.[11],[12] However, the Japanese Stroke Scale for Depression (JSS-D) is a simple tool that was originally designed and validated for depression in stroke survivors among Japanese, which somewhat introduces some specificity in its use when compared with other depression assessment tools such as Beck's Depression Inventory, Hamilton Depression Instrument, MINI and Montgomery Asberg.[13],[14] The JSS-D has been found to perform acceptably well when compared with other well-known scales for depression.[12]

This study used the JSS-D in a cohort of stroke survivors in sub-Saharan Africa, a clime different from where it was originally developed, to characterize PSD and validate the JSS-D.


  Methods Top


Ninety-two subjects on follow-up in a stroke clinic were consecutively assessed for demographic and clinical variables of age, gender, marital status, educational attainment, duration in months since the last stroke occurred, number of stroke(s) ever suffered, most important informal caregiver at home, functional ability at the time of discharge from in-patient care and at the time of evaluation in clinic and type of stroke with a study questionnaire and all were subsequently assessed for depression with the JSS-D instrument. Functional ability was assessed with modified Rankin score, and Rankin gain was the difference between modified Rankin score at discharge and at the time of evaluation in the clinic for PSD. Good functional recovery was defined as Rankin score of ≤2. Stroke type was determined by cranial computed tomography or magnetic resonance imaging as cerebral infarct or intracerebral hemorrhage. Subjects with Ahasia were excluded from the study. Study was approved by the Institutional Review Board (Ethics Committee) at the study center.

Data were presented as mean and standard deviation, median and percentages as appropriate and compared between subjects with and without PSD with Chi-square and independent t-test.

Symmetric agreement between JSS-D and DSM IV criteria for depression was compared on Cohen's kappa statistics and the sensitivity, specificity of JSS-D was tested on a receiver operated characteristics (ROC) curve or c statistics. Inter- and intra-rater reliability in the use of JSS-D between a specialist neurologist and a trainee neurologist was tested on Pearson's correlation. Analysis was performed with IBM SPSS ® version 20 (SPSS Inc., Chicago IL) and P < 0.05 was considered to be significant.


  Results Top


A total of 92 participants were studied, mean age 63.79 ± 13.36 years, median 64 years, age range 27–97, comprising 31 (33.7%) females and 61 (66.3%) males. Seventeen (18.5%) had PSD while 75 (81.5%) did not using the JSS-D. Median duration between time of last stroke and time of evaluation was 10 months, (range 0.5–65) and median number of strokes suffered was 1, (range 1–3) out which 74 (80.4%) had a first ever stroke, 17 (18.5%) had a second stroke and only 1 (1.1%) a third stroke. 71 (77.17%) had cerebral infarct, and 21 (22.83%) had intracerebral hemorrhage. Median Rankin score at discharge was 3 (range 0–5) and median Rankin score at the time of evaluation was 2 (range 0–5) and median Rankin difference (gain) was 1 (range 2–3). Median JSS-D score was 0.73 (range 0.46–13.12), mean JSS-D score was 1.63 ± 1.99. These and some other summary statistics are shown in [Table 1].
Table 1: Comparing basic summary statistics of study subjects between PSD and non-PSD

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Data were subsequently analyzed between the 2 groups of those with and without PSD using the JSS-D. Mean age was not significantly different between the two groups, 64.60 ± 14.85 (n = 75) versus 60.24 ± 15.95 (n = 17) years P = 0.226, there was however a significant difference in the sex distribution (P = 0.034) with a male sex preponderance for both groups (15 vs. 2 and 46 vs. 29 for PSD and non-PSD respectively). Marital status, educational attainment, informal caregivers were not significantly different (P = 0.093, 0.591, 0.253, respectively). Mean duration of stroke (P = 0.305), mean number of strokes suffered (P = 0.782), mean Rankin difference (P = 0.874) were also not significantly different. However, mean Rankin score at discharge from the hospital (P = 0.019), mean Rankin score at the time of evaluation in clinic (P = 0.003), mean JSS-D score (P < 0.001) were significantly different [Table 1].

Mean Rankin score in good functional recovery (≤2) and poor functional recovery (>2) were comparatively higher in subjects with PSD than in non-PSD though the difference was not significant (P = 0.247 and 0.432) respectively [Table 1].

Japanese Stroke Scale for Depression agreed with DSM-IV criteria for mild depression significantly on Cohen's kappa statistics, kappa = 0.69, P < 0.0001. The sensitivity and specificity of JSS-D on ROC curve (C statistics) were 94.1% and 97.2% respectively at a JSS-D cut-off value of 2.37, area under the curve = 0.99, P = <0.0001 [Figure 1] and [Figure 2].
Figure 1: The receiver operated characteristics curve, with sensitivity and specificity values and the area under the curve (AUC) statistics. AUC = 0.997 (0.99–1.003), P < 0.001. At Japanese Stroke Scale for Depression cut-off value of 2.37, sensitivity = 0.941 (94.1%), 1-specificity = 0.028 (specificity = 97.2%). (a) The smallest cut-off value is the minimum observed test value minus 1, and the largest cut-off value is the maximum observed test value plus 1. All the other cut-off values are the averages of two consecutive ordered observed test values

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Figure 2: Japanese Stroke Scale for Depression circle the appropriate response from the options

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Inter- and intra-rater reliability correlated significantly between a specialist neurologist and a junior trainee (resident) in the administration of JSS-D, r = 0.95 and 0.95, P < 0.0001 and 0.0001 respectively.


  Discussion Top


The mean age of study subjects in this study is similar to what has been described, and the preponderance of the male gender is also in consonance with what was found in related studies on stroke survivors.[14],[15] The almost 19% frequency of PSD is within the range described earlier.[1],[2],[3] Male gender was associated more with PSD in this study, and this may be due to the larger proportion of males in the study population and in both subgroups of PSD and non-PSD. Some other studies have not identified any significant effect of gender in PSD, but a large majority have associated PSD more with the female gender.[8],[16] Marital status and educational attainment were not significantly different between the groups as in some other studies.[16],[17] Informal caregivers of depressed subjects have been shown to be influential in their care and in the frequency of PSD, however informal caregivers were not associated with PSD in this study.[18] The duration of stroke and the number of strokes suffered did not significantly differentiate between PSD and non-PSD in this work apparently because the large majority (80.4%) had a first ever stroke and the relatively long median duration of 10 months at the time of evaluation for this study may be responsible. Most stroke survivors enter a chronic recovery phase, which improves over time particularly if they undergo active therapeutic exercises and functional improvement as measured by Rankin score reduces the frequency of PSD as shown as shown in this work and in an earlier one.[19] We also noted that the pathologic type of stroke did not associate significantly with PSD. PSD is associated more with the disruption of the neural substrate for mood regulation after stroke than the type of injury that engendered it.[16],[20],[21] Remarkably the mean Rankin score at evaluation in the clinic was significantly higher in those with PSD than in those without PSD. PSD is known to be associated with functional disability particularly at the time of evaluation as evident in this study and in several others.[8],[16],[21],[22],[23] The almost 70% symmetric agreement between JSS-D and DSM IV criteria for mild depression in the assessment of PSD is remarkable. This in our opinion is high. The sensitivity and specificity values are also considered high. The inter- and intra-rater reliability of JSS-D between two different cadres of medical staff is also high, and it is suggestive of the user-friendly components of the JSS-D. A small number of study subjects and the paucity of references with JSS-D are obvious limitations of this study. We can safely conclude that the JSS-D could as well be used in other climes outside its provenance with acceptable sensitivity and specificity at a derived cut-off similar to the original value and its wider use in the evaluation of PSD is therefore recommended.[12]


  Acknowlegedgments Top


We appreciate the contribution of the support staff of the stroke out-patient clinics in the University of Benin Teaching Hospital.

 
  References Top

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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[Pubmed] | [DOI]



 

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