Association between dysphagia and symptoms of depression and anxiety after ischemic stroke

Abstract

Background and purpose

Dysphagia is associated with poor outcome, higher mortality, reduced quality of life, and social isolation. We investigate the relationship between swallowing impairment and symptoms of anxiety and depression after ischemic stroke.

Methods

Consecutive patients with ischemic stroke participating in the prospective STROKE‐CARD Registry study from 2020 to 2022 were assessed for dysphagia on hospital admission (clinical swallowing assessment) and for persistence until discharge and 3‐month follow‐up (SINGER Independency Index). Anxiety and depression symptoms were recorded using Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS) at 3‐month follow‐up.

Results

Of 648 patients, 19.3% had dysphagia on admission, persisting in 14.8% at discharge and 6.8% at 3‐month follow‐up. With the presence or duration of dysphagia (no dysphagia, dysphagia at baseline, at discharge, at 3 months), score (mean ± SD) increased on the BDI (7.9 ± 6.7, 12.5 ± 8.7, 13.5 ± 9.0, 16.5 ± 10.2), HADS‐D (4.4 ± 3.7, 7.1 ± 4.2, 7.7 ± 4.4, 9.8 ± 4.3), and HADS‐A (4.4 ± 3.5, 5.4 ± 3.6, 6.0 ± 3.6, 7.0 ± 3.6). In linear regression analysis adjusting for age, sex, diabetes, dementia, and either functional disability or stroke severity, BDI and HADS‐D scores were significantly higher in patients with dysphagia across all points in time (admission, discharge, 3‐month follow‐up). An independent association with HADS‐A scores was only evident in patients with persisting dysphagia after 3 months. Patients with dysphagia were more likely to receive antidepressants, antipsychotics, or benzodiazepines at discharge and 3‐month follow‐up.

Conclusions

Dysphagia after stroke is common and severely affects psychosocial functioning of individuals. Our results highlight swallowing impairment as an independent predictor for poststroke depressive and, to a lesser extent, anxiety symptoms.

INTRODUCTION

Advances in modern health care such as implementation of stroke unit care and reperfusion therapies have increased survival among individuals suffering from ischemic strokes [1, 2]. Despite this progress, a considerable proportion of patients face a wide range of complications and persisting impairments related to cerebral ischemia [3]. Poststroke dysphagia in particular, affecting 21%–32% of patients after ischemic stroke, carries major complications, including increased risk of aspiration, pneumonia, and mortality [4, 5, 6, 7, 8, 9]. Moreover, from a psychosocial perspective, social life‐impairing factors such as reduced quality of life and social isolation emerge in stroke patients with dysphagia, indicating the burden of swallowing impairment experienced by individuals in their daily functioning [6].

Furthermore, oropharyngeal dysphagia, irrespective of etiology, appears to be related to affective symptoms such as anxiety and depression [10]. Whereas prior research examined the relation between dysphagia and affective symptoms in patients with head and neck cancer or Parkinson disease, recent findings indicate that individuals affected by stroke‐related dysphagia might be more likely to develop poststroke depression during hospital stay [10, 11]. Yet, poststroke dysphagia differs from the chronic medical conditions above, as it has the potential to improve swallowing function after a period of time.

AIMS AND HYPOTHESIS

Our study aims to investigate the potential link between poststroke dysphagia and symptoms of depression and anxiety in a large representative ischemic stroke cohort of the STROKE‐CARD Registry within the first 3 months after onset.

METHODS

Study population

The poststroke disease management program STROKE‐CARD was implemented as a standard of care in December 2020 by the Department of Neurology at the Medical University of Innsbruck and the St. John of God Hospital in Vienna, Austria, after the STROKE‐CARD study (NCT02156778) demonstrated efficacy of this program in reducing the cumulative risk of cardiovascular events and improving health‐related quality of life [12]. All patients with high‐risk transient ischemic attack (TIA; ABCD₂ score ≥ 4) or ischemic stroke living in the catchment area of the respective centers receive a 3‐ and 12‐month in‐person follow‐up visit to identify poststroke complications, assess the patient's need for care services, and support guideline‐based secondary prevention, including lifestyle modifications and achievement of recommended target values. Additionally, besides general measures such as marital status, employment, need for support services, and level of care (care levels according to the Austrian care support plan, which provides financial aid for social care at home), clinical measures of stroke severity (National Institutes of Health Stroke Scale [NIHSS] [13]), disability (modified Rankin Scale [mRS] [14]), dependency (Scores of Independence for Neurologic and Geriatric Rehabilitation [SINGER] [15]), and quality of life (European Quality of Life 5 Dimensions 3 Levels [EQ‐5D‐3L] [16]) are evaluated, along with comorbidities such as dementia (defined as being documented in the digital health record or diagnosed using the Mini‐Mental State Examination with a score < 25 at baseline), depression, and anxiety disorder (measured by Beck Depression Inventory [BDI] [17] and Hospital Anxiety and Depression Scale [HADS] [18]). For those signing an appropriate informed consent, data from baseline (i.e., hospitalization) as well as the 3‐ and 12‐month follow‐up visits are prospectively collected in the STROKE‐CARD Registry.

For the present analysis, data from the study center Innsbruck were used. The Department of Neurology of the Medical University of Innsbruck with its stroke unit is the primary referral hospital for approximately 650,000 inhabitants and the secondary referral hospital for a further 100,000 inhabitants of the county. Between December 2020 and October 2022, 1076 patients fulfilled the inclusion criteria for the STROKE‐CARD Registry. Of those, 749 patients (69.6%) signed the informed consent during hospital stay or at the 3‐month follow‐up visit. After excluding 101 patients presenting with (i) TIA (tissue‐based definition; n = 85), (ii) pre‐existing dysphagia (n = 3), or (iii) early dropout of the study (n = 13), a total of 648 patients remained for the present analysis.

The STROKE‐CARD Registry study has been approved by the local ethics committee (1182/2020) of the Medical University of Innsbruck. The authors confirm that all necessary patient consent has been obtained and the appropriate institutional forms have been archived.

Swallowing assessment

The initial assessment of swallowing function was conducted through a review of clinical records. At the study center, every stroke patient is screened for swallowing difficulties by experienced personnel as part of routine clinical care. Diagnosis of dysphagia was established via clinical examination of swallowing function by language and speech therapists, or using further instrumental diagnostics such as fiberoptic endoscopic evaluation of swallowing if necessary. If dysphagia was diagnosed by clinical or instrumental examination, the patient was assigned to the baseline dysphagia group. The duration of swallowing difficulties was evaluated using logopedic protocols and the “eating/drinking” subitem of the SINGER score [15], which is utilized by therapists to determine whether swallowing issues were still present at hospital discharge or at the 3‐month follow‐up. An experienced therapist performs the standardized assessment with the patient to detect any potential swallowing impairment. Dysphagia signs such as choking or coughing with certain food consistencies and the need for alternative feeding are directly assessed. Therapists can assign scores from 0 to 5, with a score of 5 indicating the absence of a swallowing problem. Patients with a SINGER score < 5 were classified as having persistent swallowing issues.

Evaluation of depression and anxiety

History of depression was defined as intake of antidepressive medication at hospital admission or when documented in the digital health record. Presence of depressive and anxiety symptoms was assessed using the questionnaires (BDI and HADS) and the health‐related quality of life measure EQ‐5D‐3L for the anxiety/depression domain after 3 months [16, 17, 18]. All patients filled in the questionnaires either at home shortly before the 3‐month follow‐up or directly at the follow‐up visit. Both psychiatric questionnaires (BDI and HADS) are validated screening instruments in the context of stroke [19, 20]. The BDI includes 21 items with an overall maximum score of 63 points, and the HADS provides seven items each for anxiety and depression (14 in total) with an overall maximum score of 42 points [17, 18]. Additionally, medications prescribed for depression and anxiety were recorded both at hospital discharge and after 3 months. Psychiatric medication groups prescribed included antipsychotics (typical like haloperidol and atypical like risperidone, olanzapine, and others), antidepressants (tetracyclics, selective serotonin reuptake inhibitors, selective and nonselective serotonin norepinephrine reuptake inhibitors, noradrenergic and specific serotonergic antidepressant), and benzodiazepines (including imidazopyridine derivates).

Statistical analysis

Age, sex, and other characteristics were analyzed by presenting descriptive statistics such as mean and SD or median and interquartile range for continuous and ordinal data, and percentage frequencies for binary data. To compare the groups with and without dysphagia, Pearson chi‐squared was used for binary and nominal variables, whereas the Mann–Whitney U‐test was used for ordinal or continuous, nonnormally distributed data. Normal distribution of continuous data was tested using the Shapiro–Wilk test and the Kolmogorov–Smirnov test. To account for multiple testing in univariate comparisons, Bonferroni adjustment was applied. In cases of missing data, the adjusted sample was indicated for each variable. Additionally, multivariate linear regression was conducted to explore the independent association between dysphagia and depression/anxiety, including adjustment for age, sex, diabetes, dementia, and either mRS (model 1) or NIHSS (model 2) at 3 months. The significance level was set at p < 0.05. Statistical analyses were performed using SPSS (version 27.0.1.0; IBM, Armonk, NY, USA).

RESULTS

Baseline analyses were conducted on a cohort of 648 patients diagnosed with acute ischemic stroke, whose mean age was 71.0 years (±13.3 SD, range = 23–101), with 36.6% of the study population being female (detailed cohort prescription is shown in Figure 1).

FIGURE 1.

Study flow chart. TIA, transient ischemic attack.

Poststroke dysphagia

During the initial hospitalization period, dysphagia was observed in 19.3% (125 of 648 patients) of individuals. When limiting the analysis to the residents of Innsbruck and surroundings where our hospital serves as primary care center for stroke patients, a similar proportion showed dysphagia at baseline (18.9%, 82 of 435 patients). Comparing patients with and without dysphagia, those with swallowing difficulties were older (74.7 ± 12.0 vs. 70.2 ± 13.5 years, p < 0.001) and had a higher prevalence of atrial fibrillation (31.2% vs. 17.6%, p < 0.001) and diabetes (30.4% vs. 18.7%, p = 0.004). In addition, they suffered more severe strokes (NIHSS 7 [4–14] vs. 2 [1–4], p < 0.001) and greater disability (mRS 4 [3–5] vs. 2 [2–3], p < 0.001), demonstrated in Table 1.

TABLE 1.

Baseline characteristics of patients with or without dysphagia.

Characteristic	Dysphagia, n = 125, %, mean ± SD or median (IQR)	No dysphagia, n = 523, %, mean ± SD or median (IQR)	p a
Female	36.0%	36.7%	0.882
Age	74.7 ± 12.0	70.2 ± 13.5	<0.001
BMI b	26.8 ± 5.2	26.6 ± 4.4	0.797
Smoker	20.0%	24.6%	0.290
Arterial hypertension	79.2%	75.5%	0.386
Dyslipidemia	76.0%	82.8%	0.079
Atrial fibrillation	31.2%	17.6%	<0.001
Diabetes	30.4%	18.7%	0.004
Cerebrovascular disease history	29.6%	24.1%	0.202
History of depression	9.6%	9.8%	0.959
Dementia	19.2%	16.8%	0.528
NIHSS, baseline	7 (4–14)	2 (1–4)	<0.001
mRS, baseline	4 (3–5)	2 (2–3)	<0.001

Abbreviations: BMI, body mass index; IQR, interquartile range; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale.

^a Adjusted for multiple testing (Bonferroni method), p‐values ≤ 0.005 are considered significant with an alpha error of 0.05.

^b BMI values were missing in eight patients with dysphagia and 22 without dysphagia.

At hospital discharge (median 8 [1–80] days after admission), 14.8% (96/648) of patients had persistent dysphagia, as indicated by SINGER score (Table 2). Patients with dysphagia experienced longer hospital stays (15.6 ± 10.2 vs. 9.9 ± 6.0, p < 0.001) and were more often discharged to a rehabilitation center (56.1% vs. 20.3%, p < 0.001) or nursing home (7.3% vs. 1.9%, p = 0.001). Furthermore, they exhibited higher NIHSS (3 [1–5] vs. 0 [0–1], p < 0.001) and mRS scores (3 [2–4] vs. 1 [1–2], p < 0.001) at discharge.

TABLE 2.

Frequency of dysphagia at baseline, discharge, and 3‐month follow‐up.

	n	Dysphagia, % (n)
Baseline	648	19.3% (125)
Discharge	648	14.8% (96)
Follow‐up	527	6.8% (36)

At 3‐month follow‐up (median 3 [1–6] months after discharge), 121 of 648 patients (18.7%) were lost to follow‐up, 37 of 125 (29.6%) with dysphagia and 84 of 523 (16.1%) without dysphagia. Reasons were death in 18 patients (13 with dysphagia, five without dysphagia), withdrawal of consent in 32 patients (nine with dysphagia, 23 without dysphagia), visit via telephone call in 20 patients (three with dysphagia, 17 without dysphagia), and missed appointments in 51 patients (12 with dysphagia, 39 without dysphagia). Eighty‐eight of 125 patients presenting with dysphagia initially underwent follow‐up. Among those, 36 patients reported ongoing dysphagia, representing 6.8% of the follow‐up cohort (36/527) and 40.9% of initially dysphagic patients (36/88; Table 2). Similar proportions of stroke patients residing in Innsbruck and surroundings (5.1%, 22/435) showed swallowing problems at follow‐up.

Patients with dysphagia at hospitalization were more likely to live in nursing homes (20.2% vs. 2.8%, p < 0.001), required more external support services (32.9% vs. 9.9%, p < 0.001), had higher levels of care (46.8% vs. 15.6%, p = 0.001), and exhibit higher NIHSS (2 [1–4] vs. 0 [0–1], p < 0.001) and mRS scores (3 [2–3] vs. 1 [0–2], p < 0.001) at 3 months. Furthermore, EQ‐5D‐3L scores were significantly lower in patients with dysphagia at baseline (59.1 ± 23.6 vs. 71.9 ± 21.3, p < 0.001) and follow‐up (67.1 ± 19.2 vs. 76.9 ± 17.2, p < 0.001). Patients with dysphagia had lower body mass index (BMI) at 3 months (median BMI drop 1.2, p < 0.001), whereas those without dysphagia remained the same (median drop 0.01, p = 0.630).

Depression and anxiety

At the 3‐month follow‐up, 389 questionnaires (73.8%) were collected, including 50 from patients with initial dysphagia (56.2%). Patients who attended follow‐up and submitted questionnaires were younger than those without questionnaires (68.5 ± 13.1 vs. 75.0 ± 12.7 years, p < 0.001) and had lower NIHSS (0 [0–1] vs. 1 [0–2], p < 0.001) and mRS (1 [0–2] vs. 2 [1–3], p < 0.001) scores at follow‐up.

Patients with initial dysphagia had higher scores than patients without dysphagia on all questionnaires at 3 months, which was statistically significant for the HADS‐D (7.1 ± 4.2 vs. 4.4 ± 3.7, p < 0.001) and the BDI (12.5 ± 8.7 vs. 7.9 ± 6.7, p < 0.001), but not for the HADS‐A (5.4 ± 3.6 vs. 3.3 ± 3.5, p = 0.051; Table 3).

TABLE 3.

Mean scores on HADS‐A, HADS‐D, and BDI at 3‐month follow‐up dependent on presence or persistence of dysphagia.

	No dysphagia at baseline, n = 339	Dysphagia at baseline, n = 50	Dysphagia at discharge, n = 39	Dysphagia at follow‐up, n = 17
HADS‐A, mean ± SD	4.4 ± 3.5	5.4 ± 3.6	6.0 ± 3.6	7.0 ± 3.6
Unadjusted p	—	0.051	0.006	0.003
Adjusted p, model 1	—	0.652	0.203	0.121
Adjusted p, model 2	—	0.350	0.070	0.045
HADS‐D, mean ± SD	4.4 ± 3.7	7.1 ± 4.2	7.7 ± 4.4	9.8 ± 4.3
Unadjusted p	—	<0.001	<0.001	<0.001
Adjusted p, model 1	—	0.024	0.006	<0.001
Adjusted p, model 2	—	0.022	0.004	0.001
BDI, mean ± SD	7.9 ± 6.7	12.5 ± 8.7	13.5 ± 9.0	16.5 ± 10.2
Unadjusted p	—	<0.001	<0.001	<0.001
Adjusted p, model 1	—	0.037	0.019	0.006
Adjusted p, model 2	—	0.049	0.021	0.016

Note: p‐values for the difference between patients without dysphagia at baseline and those who recovered to discharge and follow‐up (unadjusted and adjusted for age, sex, diabetes, dementia, and either modified Rankin Scale [model 1] or National Institutes of Health Stroke Scale [model 2] at 3 months using linear regression analysis).

Abbreviations: BDI, Beck Depression Inventory; HADS, Hospital Anxiety and Depression Scale.

There were no significant differences in mean scores of HADS‐A, HADS‐D, and BDI between women and men (data not shown). Subgroup analysis revealed that individuals had higher scores on all questionnaires based on the duration of dysphagia (from hospital discharge to 3‐month follow‐up; Table 3).

In a linear regression analysis adjusting for age, sex, diabetes, dementia, and functional disability (mRS; model 1) or stroke severity (NIHSS; model 2) at 3 months, patients with initial dysphagia had significantly higher HADS‐D and BDI scores at 3 months compared to those without dysphagia. However, there was no significant difference in HADS‐A scores at 3 months. The same results were observed for HADS‐D and BDI comparing patients who had persistent dysphagia until hospital discharge (n = 39) or follow‐up (n = 17) with those who never had dysphagia or recovered from dysphagia until hospital discharge (n = 349) or follow‐up (n = 371), respectively (Table 3). Merely those patients with persistent dysphagia showed a significant correlation with higher HADS‐A scores after 3 months, independent of stroke severity (NIHSS).

These findings fit with the results from EQ‐5D‐3L subdomain “anxiety/depression,” which were available in 92.1% of the study population. Whereas 45.6% of patients with initial dysphagia reported anxiety/depression after 3 months, only 24.6% of patients without dysphagia did. Figure 2 illustrates the distribution of reported symptoms in patients with and without dysphagia.

FIGURE 2.

Comparison of European Quality of Life 5 Dimensions 3 Levels “anxiety/depression” subitem between patients with or without initial dysphagia at 3‐month follow‐up.

Assessment of newly initiated psychiatric medications (antipsychotics, antidepressants, benzodiazepines) prescribed at discharge and after 3 months indicated that patients with dysphagia had a higher frequency of prescriptions compared to those without dysphagia, both at discharge and after 3 months (Table 4). Prescription of antidepressants increased after 3 months, whereas prescriptions of antipsychotics and benzodiazepines decreased compared to discharge. Women were significantly more likely to receive antidepressants at discharge and at 3 months (13.5% vs. 6.3%, p = 0.004 and 22.8% vs. 9.6%, p < 0.001). At hospital admission, 9.7% of patients (63/648) had pre‐existing psychiatric medications (9.6% vs. 9.8% of patients with vs. without dysphagia, respectively), all of which were excluded in the subsequent analysis.

TABLE 4.

Prescription of novel psychiatric medications at hospital discharge and 3‐month follow‐up.

	n	Dysphagia % (n)	No dysphagia % (n)	p
Discharge medication
Antipsychotics	585	17.7% (20)	3.8% (18)	<0.001
Antidepressants		28.3% (32)	4.2% (20)	<0.001
Benzodiazepines		20.4% (23)	6.6% (31)	<0.001
Follow‐up medication
Antipsychotics	429	19.0% (15)	3.3% (13)	<0.001
Antidepressants		44.3% (35)	8.3% (33)	<0.001
Benzodiazepines		12.7% (10)	5.5% (22)	0.020

DISCUSSION

In the present analysis of the STROKE‐CARD Registry study—a large representative cohort of consecutive ischemic stroke patients—we report the prevalence of poststroke dysphagia in the acute phase and its recovery within the first 3 months as well as its association with symptoms of anxiety and depression.

To the best of our knowledge, this is the first study to report a clear association between poststroke dysphagia and symptoms of depression and anxiety. The respective scores were higher with persistence of dysphagia and were associated with increased prescription of antipsychotics, antidepressants, or benzodiazepines. When adjusting for age, sex, diabetes, dementia, and either general functional recovery or stroke severity, the association with depressive symptoms remained statistically significant, whereas a significant correlation with symptoms of anxiety independent of stroke severity was only evident in patients with persistent dysphagia after 3 months.

Our observation is supported by a recent analysis of administrative data demonstrating an increased incidence of in‐hospital depression in patients with stroke and dysphagia [11]. On the other hand, in a cohort of in‐hospital rehabilitation patients, those with poststroke depression were more likely to have dysphagia [21]. Yet, neither study was adjusted for potential confounders.

Various studies have found a strong correlation between depressive symptoms and factors such as stroke severity, functional disability in general, and cognitive decline in the context of stroke [22, 23]. Our results nevertheless demonstrate further evidence for an association between dysphagia and the occurrence of depressive symptoms after stroke irrespective of these potential confounders.

The etiology and underlying principles of poststroke dysphagia and poststroke depression have been thoroughly studied in the past, including their pathogenesis and pathophysiology. Both conditions were linked to a variety of brain regions, yet no clear lesion pattern can be established [24, 25]. An alternative possible pathophysiologic connection between both entities is a disturbance of the neuronal network connectivity that has been linked to both poststroke dysphagia and poststroke depression separately [10, 25, 26].

There are numerous reports that link oropharyngeal dysphagia as a consequence of other conditions, like Parkinson disease or oropharyngeal cancer, to affective symptoms (systematically reviewed Verdonschot et al. [10]). Therefore, it can be assumed that not only neurobiological factors but also psychosocial factors lead to an increase of depressive symptoms in patients with poststroke dysphagia. The inability to have a regular meal leads to a substantial loss of pleasure, self‐esteem, and social withdrawal [27]. As social isolation has been identified as a major contributor to the development of poststroke depression [28], a possible relation between these two factors appears to be plausible.

Even though our data show a clear relationship between the duration of dysphagia and the severity of depressive symptoms, it is unclear whether appropriate treatment and management of dysphagia decrease mood disturbances. Only a small study found improved BDI scores in 25 patients with an intensified dysphagia exercise program, compared to 25 age‐ and sex‐matched controls on standard care [29]. Yet, as poststroke depression is a relevant problem leading to substantial adverse effects on functional recovery, quality of life, and mortality [30, 31], intensified treatment and management of dysphagia might offer additional benefits in poststroke depression treatment.

A second important finding in our large representative cohort of patients with ischemic stroke is the prevalence and prognosis of poststroke dysphagia. In our sample—which also included very mild strokes—poststroke dysphagia was still a prevalent condition, affecting approximately 20% of patients in the acute phase and persisting in almost 80% at hospital discharge and 40% at 3‐month follow‐up. The frequency of dysphagia in the acute phase of stroke is similar with other studies reporting frequencies ranging from 21% to 32% [4, 5, 6, 7, 8, 9], but considerably lower than cohorts excluding patients with very mild strokes [32]. There are diverging reports about recovery during follow‐up, with persistent dysphagia in the first few weeks in 51% [4], 17.5% [33], 2% [34], or at least 50% (exact proportion of initially dysphagic patients unknown) [35] at 3‐ or 6‐month follow‐up. When using videofluoroscopic assessment, swallowing difficulties were found in 80% of patients during follow‐up [35]. These differences in reported prognosis of dysphagia among studies can be explained by variations in assessment of dysphagia and patient populations (also including patients with hemorrhagic stroke [33, 34, 35]). Our study has utilized the “eating and drinking” item of the SINGER Independency Index, a well‐established, standardized tool that effectively examines a patient's independency status during neurorehabilitation, involving a multidisciplinary approach [15].

The proportion of women is low in this cohort (38.7%), yet this closely reflects the prevalence of ischemic stroke in women in the Tyrolean population (41.5% in the population‐based Tyrolean Stroke Pathway database in 2021–2022).

The particular strength of our study is the inclusion of consecutive ischemic stroke patients, including the whole spectrum of ischemic stroke. Furthermore, we assessed symptoms of depression and anxiety using different scales validated in the context of stroke. Even though our assessment of dysphagia at discharge and follow‐up (SINGER) does not replace standardized swallowing examinations, the evaluation was done according to the standardized assessment of a well‐established rehabilitation scale by experienced personnel addressing the presence of specified symptoms of dysphagia and the requirement for alternative feeding [15].

When interpreting our results, one has to keep in mind that the BDI and HADS questionnaires were completed in 73.8% of the whole cohort. Those providing the questionnaires tended to be younger and less severely affected by their stroke. However, this selection bias is likely to attenuate our observed effect. In addition, a sensitivity analysis of the EQ‐5D‐3L “anxiety/depression” subitem that was available in >90% of our studied cohort also strongly links dysphagia to affective symptoms. The high level of prescribed psychiatric medications (which were available in every single patient) also indicates a strong correlation; moreover, despite the prevalence of prescribed antidepressants among individuals with dysphagia, our findings continue to demonstrate a strong association with depressive symptoms. A further limitation is the rate of patients lost to follow‐up (30% in the dysphagia group vs. 16% in the nondysphagia group). Additionally, concerning prescribed benzodiazepines, we cannot rule out that some patients receive benzodiazepines solely as a sleeping aid instead of a psychiatric disorder.

CONCLUSION

Poststroke dysphagia is a prevalent complication among patients with ischemic stroke and has a major impact on psychosocial functioning, due to its association with depressive and anxiety symptoms. Moreover, our results highlight dysphagia as a potential independent predictor in the development of depressive symptoms after ischemic stroke. Screening for poststroke depression is crucial in all stroke patients, especially in those with dysphagia.

AUTHOR CONTRIBUTIONS

Anel Karisik: Writing – original draft; investigation; conceptualization; methodology; data curation; formal analysis; visualization; writing – review and editing. Benjamin Dejakum: Conceptualization; data curation; investigation; writing – review and editing. Kurt Moelgg: Writing – review and editing; data curation; conceptualization. Silvia Komarek: Writing – review and editing; data curation; conceptualization. Thomas Toell: Writing – review and editing; data curation; supervision. Lukas Mayer‐Suess: Data curation; supervision; writing – review and editing. Raimund Pechlaner: Writing – review and editing; supervision; data curation. Stefanie Kostner: Supervision; data curation; writing – review and editing. Simon Sollereder: Data curation; supervision; writing – review and editing. Sophia Kiechl: Data curation; supervision; writing – review and editing; formal analysis. Sonja Rossi: Supervision; writing – review and editing. Gudrun Schoenherr: Data curation; supervision; writing – review and editing. Wilfried Lang: Writing – review and editing; supervision. Stefan Kiechl: Writing – review and editing; supervision; project administration. Michael Knoflach: Project administration; writing – review and editing; supervision; data curation; formal analysis; methodology; conceptualization; writing – original draft. Christian Boehme: Writing – review and editing; data curation; supervision; formal analysis; project administration; methodology; conceptualization; writing – original draft.

FUNDING INFORMATION

This study is supported by VASCage—Research Center on Clinical Stroke Research. VASCage is a Competence Centers for Excellent Technologies (COMET) Center within the COMET program and funded by the Federal Ministry for Climate Action, Environment, Energy, Mobility, Innovation, and Technology, the Federal Ministry of Labor and Economy, and the federal states of Tyrol, Salzburg, and Vienna. COMET is managed by the Austrian Research Promotion Agency (Österreichische Forschungsförderungsgesellschaft). FFG Project number: 898252.

CONFLICT OF INTEREST STATEMENT

The authors report no disclosures relevant to this research.

Karisik A, Dejakum B, Moelgg K, et al. Association between dysphagia and symptoms of depression and anxiety after ischemic stroke. Eur J Neurol. 2024;31:e16224. doi: 10.1111/ene.16224

DATA AVAILABILITY STATEMENT

The data collected within this study can be accessed upon request.