Global divergence of stroke and major depressive disorder: unveiling a potential “hidden stagnation” pattern through an integrated medicine perspective
Kui Jia, Ling-Ling Qian, Fu-Cheng Zhao, Qian Sun, Meng-Meng Zhang, Yi-Fan LiAbstract
Background
Major depressive disorder (MDD) is associated with increased stroke risk and can be conceptualized in Traditional Chinese Medicine (TCM) as emotional constraint or “Qi Stagnation” that may contribute to “Blood Stasis.” However, the country-level ecological relationship between stroke burden and MDD prevalence remains unclear, and high-stroke settings may have under-recognized MDD because of differences in data availability, diagnostic practices, mental health services, and cultural symptom expression. This study quantifies this ecological association and interprets it through an Integrated Medicine framework.
Methods
Using Global Burden of Disease (GBD) 2023 data, we analyzed age-standardized stroke Disability-Adjusted Life Year (DALY) rates for all stroke and age-standardized prevalence rates for the GBD cause category of MDD across 204 countries and territories from 1990 to 2023. An exploratory Diagnostic Gap Score (ZStroke—ZMDD) was developed to identify countries and territories with disproportionate stroke burden relative to reported MDD prevalence.
Results
A negative ecological correlation emerged globally and strengthened over time ( r = −0.059 in 1990 versus r = −0.218 in 2023, P = 0.002). The highest stroke burden quartile (Q4) reported lower MDD prevalence (2639.9/100 000) than the lowest quartile (3067.0/100 000; mean difference 427.1/100 000, 95% CI: 121.52 to 732.58), despite an 8.3% increase in stroke burden in Q4. The score identified clusters with disproportionate stroke burden relative to MDD prevalence in Eastern Europe, Southeast Asia, and Pacific Island settings.
Conclusions
Low reported MDD prevalence in high-stroke countries and territories suggests a potential diagnostic, reporting, or data-quality mismatch rather than biological protection. These ecological findings do not prove that undiagnosed MDD causes stroke burden, but they support culturally adapted mental health screening in primary care, stroke-prevention clinics, and community health settings, with referral pathways for those who screen positive.