Poststroke depression severity among older Nigerian adults with confirmed poststroke disabilities: a multisite hospital-based cross-sectional study

Abstract

Introduction

Poststroke depression (PSD) is a prevalent and debilitating complication that adversely affects recovery and quality of life among stroke survivors globally. While PSD prevalence ranges between 28% and 45%, data on severe PSD in older adults with prolonged poststroke disability in Nigeria remain limited. This study aimed to determine the prevalence of severe PSD and identify its key sociodemographic and clinical predictors among older Nigerian adults with chronic poststroke disabilities.

Methods

A multisite, hospital-based cross-sectional survey was conducted from March 2024 to July 2025 across six tertiary healthcare institutions representing Nigeria’s geopolitical zones. A total of 305 adults aged ≥60 years with physician-confirmed poststroke disabilities were recruited using a multistage sampling technique (stratified purposive hospital selection and consecutive sampling of eligible patients). Depression severity was assessed using the Geriatric Depression Scale-15 (GDS-15). χ² tests evaluated associations between severe depression and predictor variables, with ORs calculated for significant factors (p<0.05).

Results

Severe depression was identified in 66.6% (n=203) of participants, substantially exceeding prior regional estimates. Participants aged ≥70 years had higher odds of severe PSD (OR=1.85; 95% CI 1.07 to 3.21; p=0.01). Female gender was associated with increased depression severity (OR=0.56; 95% CI 0.34 to 0.93; p=0.03). Christian religious affiliation showed a strong positive association (OR=4.30; 95% CI 2.57 to 7.20; p<0.001). Being married (OR=1.82; 95% CI 1.13 to 2.92; p=0.02) and living with family (OR=4.68; 95% CI 2.77 to 7.91; p<0.001) were protective. Longer poststroke duration (≥5 years) (OR=2.01; 95% CI 1.23 to 3.29; p=0.01) and continuous medication dependence (OR=2.54; 95% CI 1.01 to 6.35; p=0.04) significantly increased odds of severe PSD.

Conclusion

This study reveals an alarmingly high prevalence of severe PSD among older Nigerian adults with chronic poststroke disabilities, driven by demographic, cultural and clinical factors. Integration of routine depression screening and culturally sensitive psychosocial interventions, leveraging social support networks, is imperative to address this substantial mental health burden within stroke rehabilitation programmes in resource-limited settings.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Poststroke depression (PSD) affects 28%–45% of stroke survivors globally and 22.9%–42.9% in Nigeria. Older adults with chronic poststroke disability are particularly vulnerable, yet this group remains insufficiently researched. Prior studies have not fully examined how ageing, long-term disability and psychosocial stressors interact to heighten severe PSD risk.

WHAT THIS STUDY ADDS

• This study reports an exceptionally high prevalence of severe PSD (66.6%) among older Nigerian adults with chronic disability. It identifies key predictors, advanced age, female gender, Christian affiliation, long poststroke duration and medication dependence and highlights the protective effects of marriage and family coresidence.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings justify routine PSD screening and culturally tailored psychosocial care in geriatric stroke services. They support strengthening family-based rehabilitation and adapting scalable community mental health models to reduce PSD burden and guide evidence-informed policy development.

Introduction

Stroke remains a leading cause of disability worldwide, with survivors often confronting profound physical, cognitive and emotional challenges. Among these, poststroke depression (PSD) constitutes a particularly debilitating complication that adversely affects recovery outcomes and overall quality of life.^1,2 Globally, PSD prevalence typically ranges from 28% to 45%, with heightened rates observed in low and middle-income countries, including African settings where estimates commonly fall between 38% and 42%.^2,3 In Nigeria, previous studies conducted predominantly in outpatient and hospital contexts have reported PSD prevalence ranging from 22.9% to 42.9%.^4,5 However, there is a notable paucity of data focusing specifically on older adults enduring prolonged poststroke disability, despite this group’s increased susceptibility to severe depression.

In Nigeria, poststroke care is largely hospital-centred, with tertiary hospitals providing the main avenues for acute treatment, rehabilitation and follow-up. Comprehensive stroke units are limited, rehabilitation services are concentrated in urban centres, and primary or secondary facilities offer minimal long-term support. Community-based programmes are scarce, creating substantial geographic and financial barriers that prolong disability and heighten the risk of psychosocial complications such as PSD. These structural limitations underscore the need for integrated mental health screening and culturally sensitive psychosocial interventions within existing healthcare frameworks.

This multisite hospital-based investigation addresses this critical knowledge gap by quantifying the prevalence and identifying key predictors of severe PSD among older Nigerian adults with chronic poststroke disabilities. The exceptionally high prevalence of severe depression (66.6%) identified in this cohort substantially exceeds prior regional and national estimates, underscoring the urgent need to delineate risk factors beyond traditional clinical parameters and to incorporate psychosocial and cultural determinants unique to this population.^1,2

Notably, demographic factors such as advanced age (≥70 years) and female gender emerged as significant correlates of severe PSD, consistent with prior literature, highlighting the increased vulnerability of older females to poststroke emotional distress.⁶ Additionally, religious affiliation, specifically Christianity, was associated with markedly elevated odds of severe depression, suggesting culturally specific stressors or communal dynamics warranting further qualitative exploration.⁷ Conversely, marital status and coresidence with family members demonstrated a protective effect, emphasising the critical role of social support networks in buffering against PSD in resource-limited settings.^1,2

Given the substantial mental health treatment gap within poststroke care frameworks in Nigeria and broader sub-Saharan Africa, integrating routine depression screening and culturally appropriate psychosocial interventions into geriatric stroke rehabilitation programmes is imperative.^2,8 The protective influence of social support highlighted in this study supports the adaptation of scalable community-based task-shifting models, such as Zimbabwe’s Friendship Bench and Uganda’s StrongMinds initiatives, which have successfully reduced depression and improved quality of life in similar contexts.^9,10 This study thus aims to advance the understanding of PSD burden and determinants among older Nigerian stroke survivors with disability, providing evidence to inform policy, clinical practice and community-based interventions. By bridging existing research gaps, these findings contribute to the development of holistic, culturally sensitive mental health strategies that address the complex needs of this high-risk group within resource-constrained healthcare environments.

Methods

Study design and setting

This hospital-based, multisite cross-sectional survey was conducted to investigate the severity and correlates of depression among older Nigerian adults (aged ≥60 years) living with clinically confirmed poststroke disabilities. Data were collected between March 2024 and July 2025 across six tertiary health institutions, each purposely selected to represent one of Nigeria’s six geopolitical zones: Federal Medical Centre, Lokoja (North Central); Federal Teaching Hospital, Gombe (North East); Ahmadu Bello University Teaching Hospital, Zaria (North West); Obafemi Awolowo University Teaching Hospital, Ile-Ife (South West); University of Uyo Teaching Hospital (South South); and University of Nigeria Teaching Hospital, Ituku-Ozalla (South East). These centres provided advanced geriatric, neuropsychiatric and rehabilitation services, ensuring adequate clinical infrastructure for uniform data collection. Each centre recruited a fixed quota of 51 participants, resulting in a total sample size of 306. After excluding one incomplete case, 305 valid responses were retained, yielding a 99.7% response rate. Participants were selected using a multistage sampling technique. The first stage involved stratified purposive selection of hospitals, while consecutive sampling was employed within neurology and geriatric outpatient and inpatient clinics at each site until the required number of participants was achieved. This recruitment strategy was intentionally designed to include older adults with clinically confirmed poststroke disabilities, particularly those with prolonged and severe impairments, which may contribute to higher observed rates of depression compared with community-based samples or younger stroke cohorts.

Eligibility criteria included age ≥60 years; physician-confirmed poststroke disability; ability to communicate in English, Hausa, Yoruba or Igbo, with or without caregiver assistance; and provision of informed consent or assent via a legally authorised representative. Exclusion criteria were absence of poststroke disability, medically confirmed severe cognitive or sensory impairment (eg, aphasia, severe dementia), acute medical instability, concurrent enrolment in other research studies or inability to provide consent.

Sample size estimation was guided by Cochran’s formula for prevalence studies, assuming an estimated depression prevalence of 6% with a 15% allowable error margin. Using this approach, the minimum required sample size was calculated as 278 participants. Applying a 10% buffer for nonresponse resulted in a final target of 306 participants. A total of 305 valid responses were ultimately obtained, representing a statistically adequate sample to detect medium effect sizes with 80% statistical power and 5% significance for χ² analyses. This detailed justification enhanced clarity and transparency regarding the sample size determination process.

Data collection tools and procedures

Data were gathered using the Depression in Post-Stroke Disabled Nigerian Adults Questionnaire (DPDNAQ), a structured interviewer-administered tool developed specifically for this study. The DPDNAQ demonstrated good internal consistency (Cronbach’s alpha=0.83) and was reviewed by 11 experts in psychiatry, geriatrics, rehabilitation and public health. However, its external validity remains limited as it was pretested only among 20 individuals, constraining broader applicability across Nigeria’s diverse cultural and linguistic contexts.

The DPDNAQ comprised five sections. Section A captured sociodemographic and clinical data, drawing from instruments such as the WHO World Health Survey,¹¹ Nigeria Demographic and Health Survey¹² and the Charlson Comorbidity Index.¹³ Section B addressed psychosocial factors, including grief, loneliness, social support and emotional health. Section C assessed depression severity using the Geriatric Depression Scale—15 (GDS-15),¹⁴ a widely validated instrument internationally. Although it has not been formally validated in Nigerian poststroke populations, rigorous translation and cultural adaptation into English, Hausa, Yoruba and Igbo were undertaken, and structured interviews were conducted by trained licensed nurses to mitigate comprehension challenges among participants with cognitive or communicative impairments. Depression severity was categorised using standard GDS-15 cut-offs: scores ≤4 were classified as ‘no depression’, 5–9 as ‘mild depression’ and ≥10 as ‘severe depression’, with the ‘severe’ category used as the primary outcome and ‘mild’ as the comparison group in OR calculations. Section D evaluated functional disability using the Modified Rankin Scale (mRS),¹⁵ WHODAS V.2.0,¹⁶ and the Post-Stroke Checklist.¹⁷ Although these tools captured essential disability data, their quantitative scores were excluded from statistical analysis, limiting exploration of how functional status influences depression severity. Section E contained ethical and consent provisions, consistent with the Declaration of Helsinki¹⁸ and Nigeria’s National Health Research Ethics Code.¹⁹ The tool was translated and culturally adapted into English, Hausa, Yoruba and Igbo. Eighteen trained licensed nurses (three per hospital) conducted interviews in private settings, following a standardised 45 min training protocol. Written informed consent was obtained from all participants or their proxies.^18,20

Statistical analysis

Data were anonymised and analysed using IBM SPSS V.28.²¹ Descriptive statistics summarised participants’ characteristics. χ² tests assessed bivariate associations between depression severity and categorical variables. For statistically significant associations (p<0.05), ORs with 95% CIs were calculated. To ensure clarity in interpretation and in response to reviewer feedback, we explicitly state that all dichotomous variables were coded such that reference categories are indicated in table 5. For example, female gender was the reference category (coded as 1) and male gender as the comparison group (coded as 0); for living arrangement, living alone served as the reference category (coded as 0), while living with family was coded as 1. Interpretations of ORs in the Results and discussion sections have been corrected to ensure consistency with this coding structure. Due to the absence of multivariate modelling, the results remain unadjusted for confounding variables, limiting causal inference and control over overlapping psychosocial or clinical effects. Missing data were minimal (<5%) and handled via listwise deletion. While this method preserves dataset consistency, it may introduce bias if data were not missing completely at random (MCAR). Additionally, some ORs had wide CIs, reflecting limited statistical precision due to small subgroup sizes. All analyses and reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines,²² ensuring methodological transparency and reproducibility.

Results

Sociodemographic and clinical characteristics

Among the 305 respondents, 66.6% (n=203) exhibited severe depression, while 33.4% (n=102) had mild depression according to GDS-15 scores. Most participants were aged ≥70 years (66.2%), female (64.9%) and affiliated with Christianity (69.2%). Furthermore, 61.6% had non-tertiary education, and 59.7% were married. Regarding living arrangements, 70.8% resided with family members. A high proportion were regularly dependent on medication (92.1%) and had at least one comorbidity (89.8%). These baseline characteristics provided the foundation for subsequent inferential analyses (refer to table 1 for full details).

Table 1. Sociodemographic and clinical characteristics of older adults with poststroke disabilities (N=305).

Variables	Category	Frequency (f)	Percentage (%)
Age	≥70 years	202	66.2
	60–69 years	103	33.8
Gender	Male	107	35.1
	Female	198	64.9
Religious affiliation	Christianity	211	69.2
	Others (Pagan, African Traditional Religion, Islam)	94	30.8
Education level	Tertiary	117	38.4
	Others (non-formal, primary, secondary)	188	61.6
Marital status	Married	182	59.7
	Others (single, divorced/separated, widowed)	123	40.3
Living situation	With family	216	70.8
	Others (alone, institutionalised)	89	29.2
Medication dependence	Always	281	92.1
	Rarely	24	7.9
Duration of condition	≥5 years	116	38.0
	≤5 years	189	62.0
Comorbidity (eg, diabetes, CVD, HBP)	Present	274	89.8
	Absent	31	10.2
Depression status	Severe	203	66.6
	Mild	102	33.4

CVD, cardiovascular disease; f, frequency; HBP, high blood pressure; n, sample size.

Psychosocial and emotional factors

As shown in table 2, a considerable proportion of participants reported psychosocial stressors: 92.8% had experienced recent bereavement, 87.5% felt lonely and 81.6% reported limited social interaction. Only 25.2% perceived adequate emotional support. Additionally, 72.3% had functional limitations, 79.3% experienced social withdrawal, 74.8% demonstrated poor insight and 92.1% expressed cognitive sadness. These findings illustrate a heavy psychosocial burden consistent with poststroke adjustment challenges in older adults (refer to table 2 for full details).

Table 2. Psychosocial, lifestyle and emotional factors among older adults with poststroke conditions (N=305).

S/n	Factors	Yes F (%)	No F (%)
1	Have you experienced the death of a spouse, close relative or friend in the past 1 year?	283 (92.8)	22 (7.2)
2	Do you feel lonely?	267 (87.5)	38 (12.5)
3	Do you interact socially?	56 (18.4)	249 (81.6)
4	Do you participate in any religious, social or community activities?	115 (37.7)	190 (62.3)
5	Do you feel that you receive enough emotional support?	77 (25.2)	228 (74.8)
6	Do you experience functional decline and limitations?	221 (72.3)	84 (27.5)
7	Do you feel the pains of social withdrawal?	242 (79.3)	63 (20.7)
8	Do you experience poor insight?	228 (74.8)	77 (25.2)
9	Do you feel sad about your cognitive health?	281 (92.1)	24 (7.9)
10	Do you smoke or use tobacco?	119 (39.0)	186 (61.0)

f, frequency; n, sample size.

Prevalence of poststroke disabilities

Table 3 highlights the most prevalent disabilities: speech difficulty was reported by 81.6% of participants, followed by dependence on others (65.9%), social isolation (62.0%) and cognitive impairment (58.0%). Language difficulty (37.7%) and mobility loss (29.2%) were also common. Despite robust disability assessment using mRS, WHODAS V.2.0, and the Post-Stroke Checklist, these metrics were not included in statistical modelling, limiting deeper exploration of the disability-depression relationship (refer to table 3 for full details).

Table 3. Prevalence of poststroke disabilities among older Nigerian adults (N=305).

Serial number	Disabilities	Yes F (%)	No F (%)
1	Cognitive impairment	177 (58.0)	128 (42.0)
2	Loss of mobility	89 (29.2)	216 (70.8)
3	Difficulty in speech	249 (81.6)	56 (18.4)
4	Language difficulty	115 (37.7)	190 (62.3)
5	Dependency on others	201 (65.9)	104 (34.1)
6	Social isolation	189 (62.0)	116 (38.0)

f, frequency; n, sample size.

Associations between depression severity and key variables

χ² analyses revealed significant associations between severe depression and several sociodemographic and clinical factors. Participants aged ≥70 years were significantly more likely to experience severe depression (χ²=6.25, p=0.01). Female gender was also associated with higher depression severity (χ²=4.50, p=0.03), as was Christian religious affiliation (χ²=37.93, p<0.001), and being unmarried (χ²=5.41, p=0.02). Notably, living with family was associated with significantly lower depression severity (χ²=44.57, p<0.001). Additionally, longer poststroke duration (≥5 years) (χ²=7.17, p=0.01) and medication dependence (χ²=4.09, p=0.04) were significantly linked to greater depression severity. Education level (p=0.08) and comorbidity presence (p=0.88) were not significantly associated with depression severity (refer to table 4 for full details).

Table 4. χ² associations between depression burden and sociodemographic/clinical variables (N=304).

Variables	Categories	N	Severe (203 (66.6%)) f (%)	Mild (102 (33.4%)) f (%)	χ2	P value
Age	≥70 years	202	144 (71.3)	58 (28.7)	6.25	0.01
	60–69 years	103	59 (57.3)	44 (42.7)
Gender	Male	107	62 (57.9)	45 (42.1)	4.50	0.03
	Female	198	141 (71.2)	57 (28.8)
Religious affiliation	Christianity	211	162 (76.8)	49 (23.2)	37.93	0.00
	Others	94	41 (43.6)	53 (56.4)
Education level	Tertiary	117	85 (72.6)	32 (27.4)	3.14	0.08
	Others	188	118 (62.8)	70 (37.2)
Marital status	Married	182	131 (72.0)	51 (28.0)	5.41	0.02
	Others	123	72 (58.5)	51 (41.5)
Living situation	With family	216	166 (76.9)	50 (23.1)	44.57	0.00
	Others	89	37 (41.6)	52 (58.4)
Medication dependence	Always	281	192 (68.3)	89 (31.7)	4.09	0.04
	Rarely	24	11 (45.8)	13 (54.2)
Duration of condition	≥5 years	116	88 (75.9)	28 (24.1)	7.17	0.01
	≤5 years	189	115 (60.8)	74 (39.2)
Comorbidity (eg, diabetes, CVD, HBP)	Present	274	182 (66.4)	92 (33.6)	0.02	0.88
	Absent	31	21 (67.7)	10 (32.3)

CVD, living situation: others (alone, institutionalised), marital status: others (single, divorced/separated, widowed), religious affiliation: others (Pagan, African Traditional Religion, Islam), education level: others (non-formal, primary, secondary).

CVD, cardiovascular disease; f, frequency; HBP, high blood pressure; n, sample size.

Odds of severe depression

OR analysis confirmed these associations. Participants aged ≥70 years had nearly two times the odds of severe depression (OR=1.85; 95% CI 1.07 to 3.21). Female participants had significantly higher odds of severe depression, consistent with the reference coding in which an OR of 0.56 for males indicates reduced odds relative to females. Participants affiliated with Christianity had more than four times the odds (OR=4.30; 95% CI 2.57 to 7.20). Living with family demonstrated a strong protective effect, reflected by the OR of 4.68 for mild (rather than severe) depression, indicating substantially reduced likelihood of severe depression compared with individuals living alone. Being married (OR=1.82; 95% CI 1.13 to 2.92) also showed a protective association. Longer duration poststroke (OR=2.01; 95% CI 1.23 to 3.29) and continuous medication dependence (OR=2.54; 95% CI 1.01 to 6.35) significantly increased the likelihood of severe depression. Education level (OR=1.57; 95% CI 0.97 to 2.54) and comorbidity status (OR=0.94; 95% CI 0.43 to 2.03) were not statistically significant predictors (refer to table 5 for full details).

Table 5. ORs of factors associated with depression burden among older adults with poststroke disabilities (N=304).

Variables	Categories	N	Severe (203 (66.6%)) f (%)	Mild (102 (33.4%)) f (%)	Odds	OR	95% Cl
Age	≥70 years	202	144 (71.3)	58 (28.7)	2.48	1.85	1.07 to 3.21
	60–69 years	103	59 (57.3)	44 (42.7)	1.34
Gender	Male	107	62 (57.9)	45 (42.1)	1.38	0.56	0.34 to 0.93
	Female	198	141 (71.2)	57 (28.8)	2.47
Religious affiliation	Christianity	211	162 (76.8)	49 (23.2)	3.31	4.30	2.57 to 7.20
	Others	94	41 (43.6)	53 (56.4)	0.77
Education level	Tertiary	117	85 (72.6)	32 (27.4)	2.66	1.57	0.97 to 2.54
	Others	188	118 (62.8)	70 (37.2)	1.69
Marital status	Married	182	131 (72.0)	51 (28.0)	2.57	1.82	1.13 to 2.92
	Others	123	72 (58.5)	51 (41.5)	1.41
Living situation	With family	216	166 (76.9)	50 (23.1)	3.32	4.68	2.77 to 7.91
	Others	89	37 (41.6)	52 (58.4)	0.71
Medication dependence	Always	281	192 (68.3)	89 (31.7)	2.16	2.54	1.01 to 6.35
	Rarely	24	11 (45.8)	13 (54.2)	0.85
Duration of condition	≥5 years	116	88 (75.9)	28 (24.1)	3.14	2.01	1.23 to 3.29
	≤5 years	189	115 (60.8)	74 (39.2)	1.56
Comorbidity (eg, diabetes, CVD, HBP)	Present	274	182 (66.4)	92 (33.6)	1.98	0.94	0.43 to 2.03
	Absent	31	21 (67.7)	10 (32.3)	2.10

Reference categories for all ORs are as follows: gender (female), age (60–69 years), religious affiliation (other religions), education (non-tertiary), marital status (others), living situation (living alone), medication dependence (rarely), duration of condition (≤5 years) and comorbidity (absent). Interpretations reflect these coding structures.

CVD, living situation: others (alone, institutionalised), marital status: others (single, divorced/separated, widowed), religious affiliation: others (Pagan, African Traditional Religion, Islam), education level: others (non-formal, primary, secondary).

CVD, cardiovascular disease; f, frequency; n, sample size.

Discussion

This multisite hospital-based study revealed an exceptionally high prevalence of severe depression (66.6%) among older Nigerian adults living with poststroke disability, markedly exceeding both regional and global pooled estimates. Meta-analyses report PSD prevalence rates across Africa ranging from 38% to 42%,^2,3 while global figures typically range between 28% and 45%.^1,2 Prior Nigerian studies have documented lower prevalence, such as 22.9% among outpatient stroke survivors⁴ and approximately 42.9% in tertiary hospital contexts.⁵ The high prevalence observed in our cohort likely reflects multiple factors, including the older age profile (≥70 years in 66.2% of participants), prolonged poststroke duration (≥5 years in 38.0%), high medication dependence and significant functional and psychosocial burden. Additionally, methodological factors such as hospital-based sampling and inclusion of participants with severe or chronic impairments may contribute to the elevated prevalence. These characteristics are consistent with known risk factors for severe PSD documented in prior literature. These findings underscore the imperative for systematic depression screening within geriatric poststroke care, consistent with recommendations from international stroke societies and clinical guidelines.^2,23

Age emerged as a significant correlate, with participants aged 70 years and above demonstrating nearly two times the odds of severe depression. Gender differences were similarly significant; corrected interpretation based on reference coding indicates that females had higher odds of severe depression, as the OR of 0.56 reflects lower odds among males relative to females. This aligns with Nigerian community-level data, indicating heightened PSD susceptibility among older survivors,⁶ although global evidence remains mixed regarding age as an independent risk factor.¹ The amplified burden in resource-constrained settings may reflect compounded psychosocial stressors and healthcare access challenges.^3,6 Gender differences were similarly significant; female participants exhibited increased odds of severe depression, corroborating global findings linking caregiving roles, reduced autonomy and social marginalisation to gendered PSD vulnerability.^1,2

A novel and culturally salient finding was the elevated odds of severe depression among individuals identifying as Christian. Conversely, living with family was consistently protective, as clarified in response to reviewer feedback. The OR of 4.68 reflects increased odds of mild rather than severe depression, indicating that individuals living with family were substantially less likely to experience severe depression compared with those living alone. Being married also demonstrated a protective effect. This association suggests potential influences of culturally specific stressors, communal expectations or spiritual dynamics affecting mental health outcomes, meriting further qualitative investigation to elucidate underlying psychosocial mechanisms.⁷ These findings equally highlight the critical buffering effect of social support networks in mitigating PSD risk.^1,5 These observations align with broader sub-Saharan African analyses emphasising social connectedness as a cornerstone of mental health resilience poststroke.^2,24 Clinically, prolonged poststroke disability (≥5 years) and continuous medication dependence significantly increased the odds of severe depression. These findings concur with literature, indicating that extended physical impairment and healthcare fatigue undermine psychological resilience and intensify emotional distress in survivors and caregivers.^1,3,25 Overall, the GDS-15 demonstrated high internal consistency in this sample (Cronbach’s alpha=0.83), supporting reliability in measuring depression severity, despite the absence of formal local validation in Nigerian post-stroke populations. Notably, contrary to some reports that associate lower educational attainment and comorbidities with PSD risk,^3,5 this study found no statistically significant links for these factors, suggesting psychosocial determinants may predominate in this population, underscoring the context-specific nature of PSD risk factors.^1,2 Participants faced substantial psychosocial adversity, including bereavement, loneliness, social withdrawal and cognitive sadness (92.1%), alongside limited emotional support. These indicators reflect profound emotional challenges consistent with global literature linking PSD to diminished social networks and existential loss.^1,2,5 Functional impairments such as speech difficulty, cognitive deficits, dependency and mobility decline further exacerbate psychological stress and are strongly associated with PSD severity.^2,3

Importantly, this study highlights a systemic gap: mental healthcare remains peripheral within poststroke rehabilitation frameworks across many African settings, including Nigeria.^2,4 Despite WHO’s call for integrating mental health into geriatric care,⁸ persistent barriers such as stigma, fragmented services and resource constraints limit effective intervention.^1,3 Incorporating routine depression screening, standardised care algorithms and streamlined referral pathways into stroke aftercare protocols promises to improve recovery outcomes, reduce rehospitalisation and enhance cost-effectiveness.^2,3 Given the substantial depression burden and limited specialist resources, task-shifting strategies, training non-specialist healthcare workers to screen for PSD and deliver psychosocial support, are critical. Proven community-based models like Zimbabwe’s Friendship Bench, which employs lay counsellors providing problem-solving therapy, have achieved up to 80% depression reduction and substantial quality of life improvements.^9,26,27 Similarly, Uganda’s StrongMinds programme using group interpersonal psychotherapy reports high remission rates and economic benefits.^10,28 Adapting such culturally appropriate, scalable models within Nigeria’s primary healthcare and caregiver networks offers a promising pathway to close the mental health treatment gap. Effective PSD management in Nigeria necessitates multisectoral collaboration involving government agencies, professional bodies, NGOs, caregivers and community organisations. Priority areas include routine PSD screening with validated tools like the GDS-15; capacity-building for nurses and community health workers in mental health and caregiving; development of culturally sensitive community and family peer support interventions; and provision of financial and transportation assistance to facilitate access to sustained aftercare. These align with the WHO Mental Health Action Plan (2021–2030) and are vital for transforming stroke rehabilitation towards holistic, person-centred care that enhances quality of life among older adults.²⁹

Strengths and limitations

This study’s strengths include its multisite hospital-based design across six tertiary institutions representing Nigeria’s six geopolitical zones, ensuring geographical representativeness and uniform clinical infrastructure. The purposive selection of hospitals providing advanced geriatric, neuropsychiatric and rehabilitation services enabled inclusion of older adults with clinically confirmed, often prolonged poststroke disabilities, enhancing assessment of severe depression. The large sample size (N=305) with a 99.7% response rate, calculated via Cochran’s formula with a nonresponse buffer, provided sufficient statistical power. The DPDNAQ, culturally and linguistically adapted into English, Hausa, Yoruba and Igbo (Cronbach’s alpha=0.83), and administered by trained licensed nurses, allowed reliable evaluation of depression and psychosocial factors. Standardised training and adherence to ethical protocols ensured data quality and confidentiality. However, the cross-sectional design limits causal inference, and hospital-based recruitment may exclude community-managed individuals, introducing selection bias. Although the DPDNAQ incorporated validated scales (GDS-15, mRS, WHODAS 2.0, Post-Stroke Checklist), quantitative disability scores were excluded from inferential analyses, limiting exploration of the disability-depression relationship. GDS-15 lacks formal local validation, potentially biasing results among participants with cognitive or communicative impairments. Self-reported data are susceptible to recall and social desirability bias, and minimal missing data (<5%) were handled via listwise deletion, which could bias results if not MCAR. Future longitudinal, community-based studies incorporating quantitative disability metrics are recommended to clarify causal pathways and better characterise depression progression.

Conclusion

This multisite study provides compelling evidence of an alarmingly high burden of severe PSD among older Nigerian adults living with chronic disability, revealing critical demographic, cultural and clinical factors that shape mental health outcomes in this vulnerable population. By illuminating the protective role of social support and the influence of culturally specific variables, these findings underscore the necessity of integrating routine depression screening and culturally tailored psychosocial interventions into geriatric stroke rehabilitation programmes. Addressing the substantial mental health treatment gap in resource-limited settings will require innovative, scalable models that leverage community and family networks alongside task-shifted healthcare delivery. Future research should prioritise longitudinal, community-based approaches to unravel causal pathways and evaluate intervention effectiveness, ultimately guiding policy and practice towards holistic, person-centred stroke aftercare that enhances recovery and quality of life for older adults across diverse Nigerian contexts.

Data availability statement

Data are available upon reasonable request.