Associations of ADL Impairment and Insomnia with Post-Stroke Depression: An Exploratory Mediation Analysis of Neuroticism and Social Support

Associations of ADL Impairment and Insomnia with Post-Stroke Depression: An Exploratory Mediation Analysis of Neuroticism and Social Support | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Associations of ADL Impairment and Insomnia with Post-Stroke Depression: An Exploratory Mediation Analysis of Neuroticism and Social Support Ruike Zhang, Yan Liang, Huiping Peng, Xiaoha Lin, Jiali Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9177408/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Post-stroke depression (PSD) is a common complication after stroke, yet the biopsychosocial mechanisms underlying PSD remain poorly understood. Using the stress–diathesis model, we examined the relationships of activities of daily living (ADL) independence and insomnia with depressive symptoms in stroke patients, particularly focused on the potential mediating roles of neuroticism and social support. Methods This cross-sectional study included 207 stroke patients. Descriptive analyses were conducted using SPSS, and structural equation modeling with the R package 'lavaan' was used to test whether neuroticism and social support mediated the associations of ADL independence and insomnia with PSD. Results The total effect of higher ADL independence on lower PSD symptoms was significant (β = −0.198, 95% CI: [− 0.303, − 0.092]), as was the total effect of insomnia on higher PSD (β = 0.550, 95% CI: [0.453, 0.647]). The association between lower ADL independence and PSD was largely explained by parallel indirect effects via neuroticism (β = −0.034, 95% CI [− 0.064, − 0.004]) and social support (β = −0.046, 95% CI [− 0.089, − 0.003]). For insomnia, significant indirect effects were observed via neuroticism (β = 0.072, 95% CI [0.029, 0.156]) and social support (β = 0.067, 95% CI [0.018, 0.116]), along with a significant serial pathway from neuroticism to social support (β = 0.019, 95% CI [0.001, 0.037]) . Conclusions Lower ADL independence and insomnia appear to be associated with depressive symptoms through distinct psychosocial pathways involving neuroticism and social support. These findings support the development of targeted interventions addressing neuroticism and social support in stroke survivors. Trial registration: Not applicable Post-stroke Depression Activities of Daily Living Insomnia Neuroticism Social Support Mediation Analysis Figures Figure 1 Figure 2 Introduction Stroke is a syndrome of neurological deficits caused by disturbances in cerebral blood circulation. It is clinically manifested as transient or permanent brain dysfunction. In China, stroke has become the leading cause of death and disability. A national epidemiological survey highlighted the substantial burden of stroke: an estimated 11 million stroke survivors currently live with varying degrees of neurological deficits [ 1 ], and the accompanying symptom burden and social disengagement impose additional psychosocial stress that may be associated with post-stroke neuropsychological impairment, ultimately contributing to cognitive and affective dysfunction [ 2 ]. Post-stroke depression (PSD) is among the most common neuropsychiatric complications after stroke, with an estimated prevalence of approximately 33% [ 3 ]. It is characterized by persistent low mood and anhedonia and is associated with delayed rehabilitation, poorer quality of life, and increased suicide risk [ 4 – 5 ]. The etiology of PSD is multifactorial, potentially involving both direct stroke-related damage to specific brain regions (e.g., the frontal lobe and basal ganglia) and substantial illness-related psychosocial stress [ 4 ]. The present study focuses on exploring how functional loss and symptom burden may be linked to depressive symptoms through psychosocial pathways. Although mechanisms underlying PSD have been widely studied [ 4 , 6 ], existing evidence has largely focused on psychological factors, with limited attention to the broader psychosomatic context in which these factors operate. However, stroke is not merely a psychological event but entails profound physiological disruptions, including neurological deficits and circadian rhythm disturbances, that generate significant symptom burden and heightened stress responses [ 7 ]. This interplay between physical and psychological stressors provides a critical backdrop for understanding post-stroke emotional adjustment. According to the stress–diathesis interaction model, depression arises from the joint effects of stress exposure and individual vulnerability [ 8 ]. Within this framework, stroke may be conceptualized as a major stressor that elicits a range of psychosocial reactions, especially among individuals with a predisposition to depression, as it poses significant physical and mental challenges through neurological impairment and disrupted sleep–wake rhythms. However, the associations through which stressors interact with psychological dispositions and external resources in relation to depressive symptoms remain unclear. This gap may partly reflect the tendency of prior research to examine single or relatively homogeneous factors, with limited empirical work adopting an integrated biopsychosocial perspective to systematically identify potential multifactor pathways. To address this gap, we examined neuroticism and social support as psychosocial constructs through which the stress–diathesis interaction may be reflected in depressive symptoms following a stroke. Neuroticism is a stable personality trait characterized by emotional instability and a propensity toward negative affect; it may be associated with more intense negative appraisals of stressors and greater negative emotional reactivity [ 9 – 10 ]. By contrast, social support is a key external protective resource that may alleviate stress-related helplessness and social isolation through instrumental and emotional support, thereby being linked to depressive symptoms and depression risk [ 11 – 12 ]. Within this framework, functional dependence due to neurological deficits (i.e., lower ADL independence) and insomnia related to disrupted sleep–wake rhythms represent distinct post-stroke stressors. These stressors may show differential associations with psychological vulnerability and social resources through pathways involving psychological adaptation to sudden loss of autonomy and affective–cognitive dysregulation, respectively. Specifically, reduced ADL independence is a direct manifestation of motor impairment, may threaten autonomy and self-efficacy for independent living, that linking with negative cognitions and helplessness in individuals high in neuroticism. Furthermore, activity restrictions place patients at a practical disadvantage in mobilizing and maintaining social support, thereby highlighting a neuroticism-mediated pathway [ 7 ]. Insomnia, by contrast, more directly undermines the physiological substrates of emotion regulation and cognitive functioning. By liking with fatigue and emotional vulnerability, insomnia may impair patients' capacity to seek and perceive social support, which could make the protective role of social support especially critical. Accordingly, when stressors from functional dependence and insomnia co-occur with emotion-regulation difficulties associated with high neuroticism and resource scarcity linked to low social support, coping may fail, potentially affecting functional and neurological recovery and ultimately contributing to depressive symptoms [ 8 , 13 ]. Grounded in the stress–diathesis interaction model, we examined how two major post-stroke stressors, reduced ADL independence and insomnia, are associated with depressive symptoms through psychological vulnerability (neuroticism) and protective resources (social support) (see Fig. 1 ). The hypotheses were as follows: (1) Lower ADL independence and insomnia would each show significant total associations with depressive symptoms; (2) neuroticism would mediate these relationships, yielding positive indirect effects; (3) social support would mediate these relationships, yielding negative indirect effects; and (4) neuroticism and social support would form a serial mediation pathway, such that greater stressors are associated with higher neuroticism, which in turn is associated with lower social support and, ultimately, more severe depressive symptoms. By testing this model, we aimed to elucidate potential multifactor pathways linking functional dependence and insomnia to depressive symptoms after stroke, and to inform early identification of high-risk individuals and the development of tailored psychosocial interventions. Materials and Methods Design and Participants This cross-sectional study examined psychosocial pathways associated with PSD, with a particular focus on the differential roles of functional dependence and insomnia. Using convenience sampling, we recruited hospitalized patients after stroke from the Department of Cerebrovascular Disease and the Department of Neurology of a tertiary Grade A hospital in Zhuhai, Guangdong Province, China, between August 2024 and September 2025. Inclusion criteria were: (1) stroke confirmed by brain CT or MRI; (2) age ≥ 18 years; (3) alertness with basic communication ability and the capacity to understand and complete the questionnaires; and (4) provision of written informed consent. Exclusion criteria were: (1) severe aphasia, severe cognitive impairment, or inability to complete the assessment for any reason (e.g., impaired consciousness or severe hearing or visual impairment); (2) a prior diagnosis of depressive disorder or other psychiatric disorders, prior antidepressant use, or a history of severe mental disorders (e.g., schizophrenia or bipolar disorder); and (3) severe end-stage comorbidities that could affect participation or outcomes (e.g., severe cardiac, pulmonary, hepatic, or renal failure, or advanced malignancy). According to requirements for SEM, the sample size should be 5–10 times the number of free parameters to be estimated in the model. The theoretical model in this study contained 29 free parameters; therefore, the required sample size was estimated to be 145–290 participants. Allowing for an approximately 20% invalid response rate, the target sample size was 174–348 participants. In addition, Boomsma and colleagues have recommended a minimum sample size for SEM, with ≥ 200 often considered desirable [ 14 ]. A total of 207 valid questionnaires were ultimately collected, meeting the sample size requirements and the basic criteria for SEM. Measurement tools General Information Questionnaire A self-developed general information questionnaire was used to collect participants’ demographic and clinical characteristics, including age, gender, marital status, occupation status, caregiver status, family income, and negative events. Activities of Daily Living (ADL) Basic self-care ability was assessed using the Barthel Index of Activities of Daily Living (B-ADL). B-ADL was a 10-item scale that developed by Dorothea Barthel and Florence Mahoney in 1965 [ 15 ]. Its items include feeding, bathing, grooming, dressing, bowel and bladder control, toilet use, transfers (bed to chair), ambulation on level surfaces, and stair climbing. Total scores range from 0 to 100, with lower scores indicating poorer independence and greater dependence. The scale has demonstrated good reliability and validity in stroke survivors with the Cronbach’s alpha was 0.908 [ 16 ]. Insomnia Insomnia severity was assessed using the Athens Insomnia Scale (AIS). The AIS was developed and validated by Soldatos et al. [ 17 ] in 2000 based on ICD-10 criteria and assesses insomnia symptoms (e.g., sleep induction, nocturnal awakenings, early morning awakening, and daytime functioning) across eight items. Each item is rated on a 4-point Likert scale (0–3), with total scores ranging from 0 to 24; higher scores indicate more severe insomnia. The AIS has demonstrated acceptable psychometric properties in patients with ischemic stroke, with a Cronbach’s alpha of 0.734 [ 18 ]. Neuroticism Neuroticism was assessed using the neuroticism subscale of the Big Five Inventory (BFI) developed by John et al. [ 19 ]. This 12-item subscale captures negative emotionality and emotional instability. Total scores range from 12 to 60, with higher scores indicating poorer emotional stability and greater neuroticism [ 19 ]. In stroke populations, BFI personality traits have been systematically examined, and neuroticism has been shown to be associated with psychological well-being [ 20 ]. Social Support Perceived social support was measured using the Social Support Rating Scale (SSRS). The SSRS was developed by Xiao [ 21 ], and includes 10 items across three dimensions: subjective support, objective support, and support utilization. Total scores range from 12 to 66, with higher scores indicating greater social support. The scale has demonstrated good reliability and validity, with a Cronbach’s alpha of 0.896 [ 22 ]. Depressive Symptoms Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9). Developed by Kroenke et al.[ 23 ], the PHQ-9 is a nine-item self-report measure that assesses the nine DSM-IV symptom criteria for major depressive disorder. Total scores range from 0 to 27, with higher scores indicating more severe depressive symptoms. The PHQ-9 has demonstrated acceptable psychometric properties in stroke populations, with a Cronbach’s alpha of 0.78 [ 24 ]. Data Analysis Data analyses were conducted using IBM SPSS Statistics 25.0 and Mplus 8.3. Given the non-normal distribution of continuous variables, sample characteristics were summarized as medians (interquartile ranges) or frequencies (percentages), as appropriate. Spearman’s rank correlations were used to examine bivariate associations among the primary study variables (activities of daily living, insomnia, neuroticism, social support, and PSD). Structural equation modeling (SEM) was used to test the theoretical model including two independent variables (activities of daily living and insomnia) and two mediators (neuroticism and social support). In light of the cross-sectional design, all references to 'mediation' should be understood as statistical decompositions of associations, which do not imply causal relationships. All path coefficients reported are standardized estimates (β), obtained using maximum likelihood estimation in R package 'lavaan' (version 0.6–15). Social support was specified as a latent variable with three indicators (subjective support, objective support, and support utilization) and all reported path coefficients are standardized estimates (β). The significance of direct, indirect, and serial mediation effects was evaluated using bias-corrected bootstrap confidence intervals with 5,000 resamples. And all effects were considered statistically significant if the 95% confidence interval did not include 0. Overall model fit was assessed using the chi-square/degree of freedom ratio (χ²/df) 0.90, Tucker–Lewis index (TLI) > 0.90, root mean square error of approximation (RMSEA) < 0.08, and standardized root mean square residual (SRMR) < 0.08 [ 25 ]. Results Participants' characteristics Demographic characteristics and univariate analyses of the 207 participants are presented in Table 1 . The mean age was 64.56 ± 12.27 years; 72.46% were male and 85.51% were married. Retired or laid-off participants accounted for 70.53% of the sample, 86.96% had a caregiver, and 2.42% reported recent negative life events. PHQ-9 scores differed significantly by age, marital status, and recent negative life events. AIS scores were significantly higher in female than in male patients. ADL scores were significantly higher among patients without caregivers than among those with caregivers. In addition, SSRS scores were significantly higher among patients aged < 65 years and those who were married. Table 1 Demographic characteristics of the participants and univariate analysis for the research variables. Variables Total ( N = 207) ADL AIS Social support PHQ9 Neuroticism Median [IQR] P -value Median [IQR] P Median [IQR] P Median [IQR] P Median [IQR] P Age (years) 0.072 0.927 0.006 ** 0.006 ** 0.780 < 65 107 90.00 [60.00;100.00] 5.00 [2.00;7.00] 41.00 [36.00;46.00] 4.00 [1.00;6.00] 24.00 [16.00;31.00] ≥ 65 100 82.50 [61.25;95.00] 4.00 [2.00;9.00] 38.00 [31.00;44.00] 5.00 [2.00;8.75] 24.00 [16.00;32.00] Gender 0.756 0.034 * 0.050 0.868 0.952 Male 150 85.00 [60.00;100.00] 4.00 [2.00;8.00] 39.00 [33.00;44.00] 5.00 [2.00;7.00] 23.50 [16.00;32.00] Female 57 85.00 [62.50;100.00] 6.00 [3.00;10.50] 42.00 [35.50;46.50] 4.00 [1.50;7.00] 25.00 [16.00;31.50] Marital status 0.499 0.078 0.000 *** 0.029 * 0.217 Unmarried 4 95.00 [31.25;98.75] 7.00 [1.75;7.00] 27.00 [20.25;40.50] 4.00 [1.25;6.75] 32.00 [19.00;39.00] Married 177 85.00 [65.00;100.00] 4.00 [2.00;8.00] 41.00 [35.50;45.50] 5.00 [2.00;6.00] 23.00 [16.00;31.00] Divorced 12 82.50 [38.75;95.00] 7.00 [4.50;11.25] 33.50 [22.25;38.75] 6.50 [5.00;9.75] 29.00 [24.75;33.50] Widowed 14 75.00 [52.50;95.00] 8.00 [4.25;15.50] 31.50 [26.75;38.00] 6.50 [2.75;9.00] 24.00 [17.25;32.25] Occupation status 0.299 0.950 0.597 0.828 0.394 Be on the job 40 80.00 [51.25;95.00] 4.50 [3.00;7.00] 39.00 [35.00;44.75] 5.00 [2.00;6.00] 24.00 [19.00;31.75] Retired/Layoff 147 90.00 [65.00;100.00] 5.00 [2.00;9.00] 40.00 [33.00;45.00] 5.00 [2.00;7.00] 24.00 [16.00;31.00] Unemployed 20 90.00 [56.25;100.00] 4.50 [3.00;6.75] 42.50 [36.25;45.75] 3.00 [2.00;7.00] 27.50 [17.75;39.50] Caregivers 0.000 *** 0.386 0.291 0.796 0.624 Yes 180 85.00 [60.00; 98.75] 4.50 [2.00;8.00] 40.00 [34.25;45.00] 5.00 [2.00;7.00] 24.00 [16.00;31.00] No 27 100.00 [90.00;100.00] 5.00 [3.00;11.00] 37.00 [26.00;46.00] 5.00 [2.00;7.00] 28.00 [17.00;34.00] Family income (¥) 0.297 0.075 0.157 0.068 0.115 < 5,000 89 80.00 [57.50;100.00] 5.00 [2.50;9.00] 39.00 [32.50;45.00] 5.00 [2.50;7.00] 25.00 [17.50;32.50] 5,000 ~ 9,999 87 90.00 [70.00;100.00] 4.00 [1.00;7.00] 40.00 [37.00;46.00] 4.00 [1.00;6.00] 21.00 [15.00;29.00] ≥ 10,000 31 90.00 [60.00;100.00] 7.00 [2.00;11.00] 37.00 [30.00;42.00] 5.00 [1.00;9.00] 26.00 [17.00;35.00] Negative events 0.238 0.074 0.250 0.004 ** 0.314 Yes 5 55.00 [52.50; 90.00] 15.00 [3.50;18.50] 33.00 [28.00;42.50] 9.00 [9.00;9.50] 27.00 [19.00;43.50] No 202 85.00 [65.00;100.00] 5.00 [2.00;8.00] 40.00 [34.00;45.00] 5.00 [2.00;7.00] 24.00 [16.00;31.25] Bivariate associations among research variable Table 2 presents Spearman’s rank correlations among ADL, insomnia, neuroticism, social support, and depressive symptoms. Higher ADL independence was negatively correlated with insomnia (r = − 0.184, p < 0.01) and PSD (r = − 0.347, p < 0.01) and positively correlated with social support (r = 0.264, p < 0.01). Insomnia was positively correlated with PSD (r = 0.601, p < 0.01), neuroticism (r = 0.432, p < 0.01), and negatively correlated with social support (r = − 0.350, p < 0.01). Neuroticism was negatively correlated with social support (r = − 0.319, p < 0.01) and positively correlated with PSD (r = 0.510, p < 0.01). The SSRS total score was negatively correlated with PSD (r = − 0.486, p 0.05). Table 2 The Spearman correlations between ADL, AIS, BFI-Neuroticism, SSRS, and PHQ9. Correlation 1. 2. 3. 4. 4.1. 4.2. 4.3. 5. 1. ADL 1.000 2. AIS -0.184 ** 1.000 3. BFI Neuroticism -0.276 ** 0.432 ** 1.000 4. Social support 0.264 ** -0.350 ** -0.319 ** 1.000 4.1. Subject support 0.212 ** -0.316 ** -0.265 ** 0.892 ** 1.000 4.2. Object support 0.182 ** -0.203 ** -0.091 0.686 ** 0.445 ** 1.000 4.3. Support utility 0.225 ** -0.272 ** -0.350 ** 0.714 ** 0.468 ** 0.378 ** 1.000 5. PHQ9 -0.347 ** 0.601 ** 0.510 ** -0.486 ** -0.429 ** -0.286 ** -0.428 ** 1.000 Note: ** P < 0.01 Direct effects among variables Path coefficients from the model are presented to depict the direct effects among activities of daily living, insomnia, neuroticism, social support, and PSD (see Fig. 2 ). Higher ADL independence had a significant negative effect on neuroticism (β = −0.156, p = 0.009) and a significant positive effect on social support (β = 0.195, p = 0.007). Insomnia had a significant positive effect on neuroticism (β = 0.329, p < 0.001) and a significant negative effect on social support(β = −0.282, p < 0.001). Neuroticism had a significant negative effect on social support (β = −0.242, p = 0.003). With respect to PSD, neuroticism had a significant positive direct effect (β = 0.219, p < 0.001), whereas social support had a significant negative direct effect (β = −0.237, p = 0.001). The direct effect of insomnia on PSD was significant (β = 0.393, p < 0.001), whereas the direct effect of ADL independence on PSD did not reach statistical significance (β = −0.109, p = 0.050). Total effect and mediating effects among variables Total and indirect effects based on bootstrap resampling (5,000 iterations) are presented in Table 3 . For Hypothesis 1, the total effect of higher ADL independence on PSD was negative and significant (β = −0.198, 95% CI: [− 0.303, − 0.092]), and the total effect of insomnia on PSD was positive and significant (β = 0.550, 95% CI: [0.453, 0.647]). Table 3 Total and indirect effects of activities of daily living (ADL) and insomnia (AIS) on PSD Effects type Hypothesis (path) Estimate SE 95% CI P -value Total Effects H1a X1 → Y -0.198 0.053 [-0.303, -0.092] < 0.001 H1b X2 → Y 0.550 0.049 [0.453, 0.647] < 0.001 Total Indirect Effects X1 → Y -0.089 0.029 [-0.146, -0.032] 0.002 X2 → Y 0.158 0.034 [0.091, 0.224] < 0.001 Specific Indirect Effects H2a X1 → M1 → Y -0.034 0.015 [-0.064, -0.004] 0.025 H2b X2 → M1 → Y 0.072 0.022 [0.028, 0.116] 0.001 H3a X1 → M2 →Y -0.046 0.022 [-0.089, -0.003] 0.036 H3b X2 → M2 →Y 0.067 0.025 [0.018, 0.116] 0.008 H4a X1 → M1 → M2 → Y -0.009 0.006 [-0.020, 0.002] 0.103 H4b X2 → M1 → M2 → Y 0.018 0.009 [0.001, 0.037] 0.038 However, within the mediation model, the mediating roles of neuroticism and social support varied by pathway. Specifically, the effect of ADL on PSD was fully mediated by neuroticism and social support (total indirect effect: β = −0.089, 95% CI: [− 0.146, − 0.032]), whereas the effect of insomnia on PSD was partially mediated (β = 0.158, 95% CI: [0.091, 0.224]). For Hypothesis 2, ADL exerted a significant negative indirect effect on PSD through higher neuroticism (β = −0.034, 95% CI: [− 0.064, − 0.004]); insomnia exerted a significant positive indirect effect through higher neuroticism (β = 0.072, 95% CI: [0.029, 0.116]). For Hypothesis 3, ADL exerted a significant negative indirect effect through lower social support (β = −0.046, 95% CI: [− 0.089, − 0.003]); insomnia exerted a significant indirect effect through lower social support (β = 0.067, 95% CI: [0.018, 0.116]). For Hypothesis 4, insomnia showed a significant positive serial indirect effect on PSD via the pathway neuroticism → social support (β = 0.019, 95% CI: [0.001, 0.037]), whereas the serial mediation effect of ADL via neuroticism → social support was not significant (β = −0.009, 95% CI: [− 0.020, 0.002]). Structural model analysis Overall model fit indices were as follows: the p value for the χ² test was 0.154; χ²/df = 11.927/8 = 1.49; CFI = 0.988; TLI = 0.968; RMSEA = 0.049 (90% CI: 0.000–0.075); and SRMR = 0.028. All indices were within acceptable ranges, indicating a good fit between the hypothesized model and the data. In the measurement model, standardized factor loadings of the latent social support construct on its observed indicators (c1, c2, c3) were 0.763, 0.618, and 0.670, respectively (all p < 0.001), suggesting satisfactory reliability and validity of the measurement model. Discussion Overview of the Main Findings Based on the stress–diathesis interaction model, this study examined whether ADL independence and insomnia as two neuropsychological stressors, were associated with PSD, and whether these associations could be mediated by neuroticism and social support respectively. The analysis indicated that stroke patients who exhibited poorer ADL functioning or more severe insomnia had significantly higher levels of PSD. Notably, the association between lower ADL independence and PSD was fully mediated by the psychosocial factors examined, whereas insomnia was indirectly associated with PSD through a serial pathway in which insomnia was related to higher neuroticism, which in turn was related to lower social support. Within an integrated biopsychosocial framework, these results support the applicability of the stress–diathesis model in stroke populations, revealing that lower ADL independence and insomnia may be linked to depressive symptoms through distinct mediation patterns involving neuroticism and social support. The significant total effects of both lower ADL independence and insomnia on PSD confirm their relevance as risk markers, supporting the need for routine screening in stroke settings. Fully Mediated Pathway of lower ADL independence: A Parallel Mediation Pattern Lower ADL independence was indirectly associated with PSD through parallel mediation via neuroticism and social support, with no significant direct effect. This finding underscores the possible role of psychosocial adaptation processes in emotional responses after stroke, yet differs from the findings of Chung et al. [ 26 ]. Specifically, the present study revealed parallel and independent mediation by neuroticism and social support, meaning that depressive symptoms were linked through these two distinct factors rather than through a pathway in which personality vulnerability operated via perceived social support. This pattern of associations suggests that neuroticism, as a stable dispositional vulnerability, is associated with negative emotional experiences and catastrophizing cognitions in response to functional loss [ 27 ], thereby linking functional impairment to depression risk through an internal emotional pathway [ 28 ]. In contrast, as a potential protective resource, the social support may be constrained when stroke-related limitations in activity and shifts in social roles occur during the post-stroke phase, reducing opportunities and capacity for social participation and for obtaining and maintaining effective support. Together, these two paths constitute a potential external pathway through which lower ADL independence may be linked to poorer mental health [ 29 ]. The weak correlation between objective support and neuroticism observed in this study further suggests that perceived rather than actual support may be more relevant to personality-related emotional vulnerability. Therefore, patients with ADL limitations are also subject to attendant psychosocial risks that require clinical attention. We recommend that early rehabilitation of stroke incorporate concurrent screening and intervention targeting both internal cognitive–emotional regulation and external support systems, in order to address these two factors potentially contributing to PSD. Partially Mediated Pathway of Insomnia: A Serial Mediation Mechanism In contrast to the parallel mediation pattern observed for lower ADL independence, insomnia demonstrated a stronger association with PSD, operating through both direct and serial mediation pathways. SEM results identified a chain of associations wherein insomnia was positively associated with neuroticism, which related to lower levels of social support, and this reduced support was further linked to greater severity of depressive symptoms. This serial mediation model supports the theoretical hypothesis that insomnia may exacerbate depressive symptoms through emotional sensitization and subsequent erosion of social support, a aligning with Zhang et al. [ 30 ] finding that neuroticism as a critical bridge between insomnia and social support in stroke patients. This suggests that insomnia-related emotional and social disruptions may contribute not only to depressive symptoms but also to more severe psychiatric outcomes. The clinical relevance of this pathway is underscored by Yang et al. [ 31 ], who found that post-stroke insomnia at various stages was significantly associated with suicidal ideation at one-year follow-up (ORs: 1.9–2.66). Compared with the parallel mediation model for lower ADL independence, this sequential framework offers a distinct pathway for understanding how insomnia may be linked to depression. However, given the very small effect size of the serial pathway (β = 0.019), this pattern should be interpreted as a theoretically plausible but potentially weak statistical association whose robustness requires confirmation in future longitudinal research. Importantly, these findings suggest a potential entry point for clinical intervention. Based on this model, future intervention research in the post-stroke phase may explore integrated approaches that follow the logic of “managing insomnia symptoms—regulating emotional responses—restoring social support,” thereby systematically targeting the sequential components of the model. The potential utility of this sequence is aligned with prior strategies of stepwise support [ 26 ]. Developing and evaluating such strategies may offer new directions for more systematic management of insomnia and its psychosocial sequelae in stroke survivors. Clinical Implications Building on the differential psychosocial pathways identified in this study linking lower ADL independence and insomnia to depressive symptoms, clinical intervention in post-stroke phase may shift from standardized protocols toward individualized strategies informed by precise assessment. Specifically, the parallel mediation pattern observed in patients with prominent ADL limitations suggests the potential value of to a dual-pathway interventional approach. This implies that future interventions may integrate components targeting internal psychological processes and components targeting external environmental resources. Along the internal pathway, cognitive-behavioral approaches (e.g., cognitive restructuring and behavioral activation) could be considered to help patients manage the catastrophizing thoughts triggered by functional loss, as well as enhancing emotion regulation and self-efficacy, thereby addressing emotional vulnerability associated with neuroticism [ 32 – 33 ]. Along the external pathway, strategies such as caregiver skills training, home environment modifications, and linkage to community resources may help proactively build and maintain objective social support networks, compensating for reduced social participation due to functional restrictions and jointly being associated with reducing depression risk through complementary internal and external mechanisms [ 26 , 34 ]. For patients with prominent insomnia symptoms, the serial association model provides a framework for considering a “stepwise integrated intervention” approach. Future research could use this framework to develop a sequential program progressing from symptom management to restoration of social functioning. First, during the sleep management phase, emotion regulation training (e.g., mindfulness practices) could be systematically incorporated to reduce heightened emotional reactivity triggered by insomnia at an early stage [ 35 ]. Second, for activated emotional distress, structured cognitive interventions could be implemented to alleviate catastrophizing thinking and prevent emotional problems from generalizing into the social domain [ 28 ]. Finally, interventions such as family communication training or peer support groups could be used to repair impaired perceived social support and interpersonal connectedness, thereby rebuilding patients’ psychosocial safety net [ 36 – 37 ]. Accordingly, a key implication of this study for clinical practice is the importance of early assessment of ADL limitations and insomnia in stroke survivors. On this basis, future studies may test dual parallel-pathway interventions in patients whose risk profile is dominated by lower ADL independence, and stepwise integrated interventions in those whose risk profile is dominated by insomnia. The clinical effectiveness and contextual feasibility of these theoretically derived interventions in stroke care settings remain to be confirmed in subsequent research. Limitations Several limitations of this study should be noted, which also point to directions for future research. First, although the cross-sectional design enabled the identification of associations and mediating pathways among variables, causal inferences cannot be drawn. The observed relationships require further confirmation through longitudinal studies. In addition, convenience sampling from a single center may limit the generalizability of the findings. Second, the data collection relied primarily on self-report questionnaires, which can capture patients’ subjective experiences but lacked objective indicators such as lesion location and National Institutes of Health Stroke Scale (NIHSS) scores. The omission of these neurological and clinical indices may confound the observed associations, as they could influence both the stressors (ADL, insomnia) and the outcome (depression), potentially leading to an overestimation of the unique contribution of the psychosocial pathways examined. Therefore, subsequent studies should examine the potential moderating or confounding effects of these clinical variables on psychosocial pathways. Based on the above considerations, future research may further validate and extend the differential mediation pathways suggested here by using longitudinal or multicenter designs, integrating multimodal data from both subjective and objective sources, systematically incorporating key clinical covariates, and extending the follow-up period, thereby providing a more comprehensive understanding of psychosocial factors associated with PSD. Conclusions Grounded in the stress–diathesis interaction model, this study examined the associations between functional dependence and insomnia to PSD among stroke survivors. Specifically, lower ADL independence was indirectly associated with PSD through parallel mediation via neuroticism and social support, reflecting two independent transmission pathways. In contrast, insomnia was associated with PSD through a serial mediation pathway of neuroticism to social support. These findings suggest that functional dependence and insomnia may influence emotional health through distinct psychosocial channels. Notably, insomnia as a persistent stressor may progressively erode psychosocial resources through its association with emotional sensitization. By integrating biological, psychological, and social perspectives in the stroke context, this study provides preliminary evidence for differentiated pathways of association in PSD. It also offers empirical evidence for early identification of high-risk patients and the development of integrated mind–body intervention strategies guided by precise assessment. Future research may employ longitudinal designs, control for key clinical variables, and develop operationalized intervention programs targeting the management of emotional responses associated with neuroticism and enhancement of social support to more effectively prevent PSD and promote comprehensive recovery. Declarations Acknowledgements The authors would like to thank all the participants of the study. Authors’ Contributions Jiali Zhang contributed to project conceptualization, study design, academic supervision, and funding acquisition. Ruike Zhang,Yan Liang and Huiping Peng were responsible for data management, manuscript drafting, statistical analyses, visualization and data collection.Xiaoha Lin:Investigation,data collection and statistical analyses. All authors critically reviewed, revised, and approved the final version of the manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The data in this study can be obtained from the corresponding author on reasonable request. Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Medical Ethics Committee of the Fifth Affiliated Hospital of Sun Yat-sen University(Approval No. (2024) K148-1). Written informed consent was obtained from all participants prior to data collection. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Sun, H. X., and W. Z. 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Cha, and R. B. King. 2023. “Linkage of optimism with depressive symptoms among the stroke survivor and caregiver dyads at 2 years post stroke: Dyadic mediation approach.” Journal of Cardiovascular Nursing 38, no. 4: 352-360. https://doi.org/10.1097/JCN.0000000000000920. Aben, I., J. Denollet, R. Lousberg, F. Verhey, F. Wojciechowski, and A. Honig. 2002. “Personality and vulnerability to depression in stroke patients: a 1-year prospective follow-up study.” Stroke 33, no. 10: 2391-2395. https://doi.org/10.1161/01.str.0000029826.41672.2e. Afshar, S., Z. N. Asgharipour, and F. Alidoosti. 2024. “Comparing the effects of the Unified Protocol for transdiagnostic treatment of emotional disorders and the mindfulness-based cognitive therapy on emotional regulation and rumination of depressed people: A randomized clinical trial.” Iranian Journal of Psychiatry and Clinical Psychology 30, no. 1: 1-17. Zhao, L., Q. Sun, Y. Guo, R. Yan, and Y. Lv. 2022. “Mediation effect of perceived social support and resilience between physical disability and depression in acute stroke patients in China: A cross-sectional survey.” Journal of Affective Disorders 308: 155-159. https://doi.org/10.1016/j.jad.2022.04.034. Zhang, N., S. Ma, P. Wang, et al. 2023. “Psychosocial factors of insomnia in depression: a network approach.” BMC Psychiatry 23, no. 1: 949. https://doi.org/10.1186/s12888-023-05454-9. Yang, Y., Y. Z. Shi, N. Zhang, S. Wang, G. S. Ungvari, C. H. Ng, Y. L. Wang, X. Q. Zhao, Y. J. Wang, C. X. Wang, and Y. T. Xiang. 2017. “Suicidal ideation at 1-year post-stroke: A nationwide survey in China.” General Hospital Psychiatry 44, no. 1: 38-42. https://doi.org/10.1016/j.genhosppsych.2016.09.006. Wang, S. B., Y. Y. Wang, Q. E. Zhang, S. L. Wu, C. H. Ng, G. S. Ungvari, L. Chen, C. X. Wang, F. J. Jia, and Y. T. Xiang. 2018. “Cognitive behavioral therapy for post-stroke depression: A meta-analysis.” Journal of Affective Disorders 235, no. 1: 589-596. https://doi.org/10.1016/j.jad.2018.04.011. Yisma, E., S. Walsh, S. Hillier, M. Gillam, R. Gray, and M. Jones. 2024. “Effect of behavioural activation for individuals with post-stroke depression: systematic review and meta-analysis.” BJPsych Open 10, no. 5: e134. https://doi.org/10.1192/bjo.2024.721. Ladwig, S., M. Volz, J. Haupt, A. Pedersen, and K. Werheid. 2025. “Disentangling the relationships of health-related quality of life, depressive symptoms, disability and social support after stroke: A network analysis.” Journal of Affective Disorders Reports 19: 100855. https://doi.org/10.1016/j.jadr.2024.100855. Moghadam, M. S., A. Parvizifard, A. Foroughi, S. M. Ahmadi, and N. Farshchian. 2025. “An examination of the effectiveness of mindfulness-integrated cognitive behavior therapy on depression, anxiety, stress and sleep quality in Iranian women with breast cancer: a randomized controlled trial.” Scientific Reports 15, no. 1: 11041. https://doi.org/10.1038/s41598-025-85745-1. Dhand, A., A. Podury, N. Choudhry, S. Narayanan, M. Shin, and M. R. Mehl. 2022. “Leveraging social networks for the assessment and management of neurological patients.” Seminars in Neurology 42, no. 2: 136-148. https://doi.org/10.1055/s-0042-1744532. Terrill, A. L., S. Gordon, C. Sparks, et al. 2025. “Resilience in Stroke survivor-care-partner Dyads (ReStoreD): a study protocol for a randomized-control trial.” Trials 26, no. 1: 195. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9177408","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":613941844,"identity":"e7561b0c-01be-401b-84a5-76daeeb04852","order_by":0,"name":"Ruike Zhang","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Ruike","middleName":"","lastName":"Zhang","suffix":""},{"id":613941846,"identity":"b3d7289a-b1ab-40b7-a13d-6d8203178fc5","order_by":1,"name":"Yan Liang","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Liang","suffix":""},{"id":613941848,"identity":"2a5b5a4f-c7e9-467d-9950-6ce8a883c131","order_by":2,"name":"Huiping Peng","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Huiping","middleName":"","lastName":"Peng","suffix":""},{"id":613941849,"identity":"5f8103e6-5fd6-417c-8ffb-e1c64addffc6","order_by":3,"name":"Xiaoha Lin","email":"","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoha","middleName":"","lastName":"Lin","suffix":""},{"id":613941851,"identity":"6a04b985-0f70-42a6-b748-ff5d93e49924","order_by":4,"name":"Jiali Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDACCYbEAwkVDAxs7HChBIJaEg4knAFqYSZBC8MBxjYgg2gt8rMbHhx4OG+bPB8zA/Nnnj+HGfjZcwwYfu7ArYVxzoGEA4nbbhu2MTOwSfO2HWaQ7HljwNh7BrcWZokEsBZGkBZm3obDDAY3cgyYwU7FAdjAWubctm+DOcyekBYesJaG24lALQzSPGxAWyQIaJEAaUk4dju5DahMcm5bOo/EmWcFB3vxaJGfkZP48EfNbdv57c2HP7z5Yy3H35688cFPPFqATkuAMhgbmHiAXBDzAD4NDAzsCHnGH/iVjoJRMApGwQgFAD/UT61+6n2LAAAAAElFTkSuQmCC","orcid":"","institution":"The Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Jiali","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-03-20 09:39:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9177408/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9177408/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105843939,"identity":"b0f85cdc-3b18-4e26-a609-e22ab1c3d3d3","added_by":"auto","created_at":"2026-03-31 17:29:08","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103526,"visible":true,"origin":"","legend":"\u003cp\u003eResearch theoretical model\u003c/p\u003e","description":"","filename":"Fig.1.Researchtheoreticalmodel.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9177408/v1/d5a2fbaff631565470348368.jpeg"},{"id":105904756,"identity":"416773a6-b0c8-428b-a625-55eeaa49a476","added_by":"auto","created_at":"2026-04-01 10:10:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":185111,"visible":true,"origin":"","legend":"\u003cp\u003eThe serial multiple mediation role of Neuroticism (M1) and Social support (M2) in the relationship between Activities of Daily Living (X1)/Insomnia (X2) and PSD (Y). Note: *p \u0026lt; 0.05\u003c/p\u003e","description":"","filename":"Fig.2.Mediationmodel.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9177408/v1/bf539cc11311dff231206621.jpg"},{"id":106093016,"identity":"73337dc5-6887-4e62-8f8e-2db12e837e70","added_by":"auto","created_at":"2026-04-03 11:32:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1435920,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9177408/v1/a354283b-a2b6-4a85-8baa-f388653af9f0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations of ADL Impairment and Insomnia with Post-Stroke Depression: An Exploratory Mediation Analysis of Neuroticism and Social Support","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke is a syndrome of neurological deficits caused by disturbances in cerebral blood circulation. It is clinically manifested as transient or permanent brain dysfunction. In China, stroke has become the leading cause of death and disability. A national epidemiological survey highlighted the substantial burden of stroke: an estimated 11\u0026nbsp;million stroke survivors currently live with varying degrees of neurological deficits [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and the accompanying symptom burden and social disengagement impose additional psychosocial stress that may be associated with post-stroke neuropsychological impairment, ultimately contributing to cognitive and affective dysfunction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePost-stroke depression (PSD) is among the most common neuropsychiatric complications after stroke, with an estimated prevalence of approximately 33% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is characterized by persistent low mood and anhedonia and is associated with delayed rehabilitation, poorer quality of life, and increased suicide risk [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The etiology of PSD is multifactorial, potentially involving both direct stroke-related damage to specific brain regions (e.g., the frontal lobe and basal ganglia) and substantial illness-related psychosocial stress [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The present study focuses on exploring how functional loss and symptom burden may be linked to depressive symptoms through psychosocial pathways.\u003c/p\u003e \u003cp\u003eAlthough mechanisms underlying PSD have been widely studied [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], existing evidence has largely focused on psychological factors, with limited attention to the broader psychosomatic context in which these factors operate. However, stroke is not merely a psychological event but entails profound physiological disruptions, including neurological deficits and circadian rhythm disturbances, that generate significant symptom burden and heightened stress responses [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This interplay between physical and psychological stressors provides a critical backdrop for understanding post-stroke emotional adjustment. According to the stress\u0026ndash;diathesis interaction model, depression arises from the joint effects of stress exposure and individual vulnerability [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Within this framework, stroke may be conceptualized as a major stressor that elicits a range of psychosocial reactions, especially among individuals with a predisposition to depression, as it poses significant physical and mental challenges through neurological impairment and disrupted sleep\u0026ndash;wake rhythms. However, the associations through which stressors interact with psychological dispositions and external resources in relation to depressive symptoms remain unclear.\u003c/p\u003e \u003cp\u003eThis gap may partly reflect the tendency of prior research to examine single or relatively homogeneous factors, with limited empirical work adopting an integrated biopsychosocial perspective to systematically identify potential multifactor pathways. To address this gap, we examined neuroticism and social support as psychosocial constructs through which the stress\u0026ndash;diathesis interaction may be reflected in depressive symptoms following a stroke. Neuroticism is a stable personality trait characterized by emotional instability and a propensity toward negative affect; it may be associated with more intense negative appraisals of stressors and greater negative emotional reactivity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. By contrast, social support is a key external protective resource that may alleviate stress-related helplessness and social isolation through instrumental and emotional support, thereby being linked to depressive symptoms and depression risk [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithin this framework, functional dependence due to neurological deficits (i.e., lower ADL independence) and insomnia related to disrupted sleep\u0026ndash;wake rhythms represent distinct post-stroke stressors. These stressors may show differential associations with psychological vulnerability and social resources through pathways involving psychological adaptation to sudden loss of autonomy and affective\u0026ndash;cognitive dysregulation, respectively. Specifically, reduced ADL independence is a direct manifestation of motor impairment, may threaten autonomy and self-efficacy for independent living, that linking with negative cognitions and helplessness in individuals high in neuroticism. Furthermore, activity restrictions place patients at a practical disadvantage in mobilizing and maintaining social support, thereby highlighting a neuroticism-mediated pathway [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Insomnia, by contrast, more directly undermines the physiological substrates of emotion regulation and cognitive functioning. By liking with fatigue and emotional vulnerability, insomnia may impair patients' capacity to seek and perceive social support, which could make the protective role of social support especially critical. Accordingly, when stressors from functional dependence and insomnia co-occur with emotion-regulation difficulties associated with high neuroticism and resource scarcity linked to low social support, coping may fail, potentially affecting functional and neurological recovery and ultimately contributing to depressive symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGrounded in the stress\u0026ndash;diathesis interaction model, we examined how two major post-stroke stressors, reduced ADL independence and insomnia, are associated with depressive symptoms through psychological vulnerability (neuroticism) and protective resources (social support) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The hypotheses were as follows: (1) Lower ADL independence and insomnia would each show significant total associations with depressive symptoms; (2) neuroticism would mediate these relationships, yielding positive indirect effects; (3) social support would mediate these relationships, yielding negative indirect effects; and (4) neuroticism and social support would form a serial mediation pathway, such that greater stressors are associated with higher neuroticism, which in turn is associated with lower social support and, ultimately, more severe depressive symptoms. By testing this model, we aimed to elucidate potential multifactor pathways linking functional dependence and insomnia to depressive symptoms after stroke, and to inform early identification of high-risk individuals and the development of tailored psychosocial interventions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Participants\u003c/h2\u003e \u003cp\u003eThis cross-sectional study examined psychosocial pathways associated with PSD, with a particular focus on the differential roles of functional dependence and insomnia. Using convenience sampling, we recruited hospitalized patients after stroke from the Department of Cerebrovascular Disease and the Department of Neurology of a tertiary Grade A hospital in Zhuhai, Guangdong Province, China, between August 2024 and September 2025.\u003c/p\u003e \u003cp\u003eInclusion criteria were: (1) stroke confirmed by brain CT or MRI; (2) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (3) alertness with basic communication ability and the capacity to understand and complete the questionnaires; and (4) provision of written informed consent. Exclusion criteria were: (1) severe aphasia, severe cognitive impairment, or inability to complete the assessment for any reason (e.g., impaired consciousness or severe hearing or visual impairment); (2) a prior diagnosis of depressive disorder or other psychiatric disorders, prior antidepressant use, or a history of severe mental disorders (e.g., schizophrenia or bipolar disorder); and (3) severe end-stage comorbidities that could affect participation or outcomes (e.g., severe cardiac, pulmonary, hepatic, or renal failure, or advanced malignancy).\u003c/p\u003e \u003cp\u003eAccording to requirements for SEM, the sample size should be 5\u0026ndash;10 times the number of free parameters to be estimated in the model. The theoretical model in this study contained 29 free parameters; therefore, the required sample size was estimated to be 145\u0026ndash;290 participants. Allowing for an approximately 20% invalid response rate, the target sample size was 174\u0026ndash;348 participants. In addition, Boomsma and colleagues have recommended a minimum sample size for SEM, with \u0026ge;\u0026thinsp;200 often considered desirable [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A total of 207 valid questionnaires were ultimately collected, meeting the sample size requirements and the basic criteria for SEM.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurement tools\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Information Questionnaire\u003c/h2\u003e \u003cp\u003eA self-developed general information questionnaire was used to collect participants\u0026rsquo; demographic and clinical characteristics, including age, gender, marital status, occupation status, caregiver status, family income, and negative events.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eActivities of Daily Living (ADL)\u003c/h3\u003e\n\u003cp\u003eBasic self-care ability was assessed using the Barthel Index of Activities of Daily Living (B-ADL). B-ADL was a 10-item scale that developed by Dorothea Barthel and Florence Mahoney in 1965 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Its items include feeding, bathing, grooming, dressing, bowel and bladder control, toilet use, transfers (bed to chair), ambulation on level surfaces, and stair climbing. Total scores range from 0 to 100, with lower scores indicating poorer independence and greater dependence. The scale has demonstrated good reliability and validity in stroke survivors with the Cronbach\u0026rsquo;s alpha was 0.908 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eInsomnia\u003c/h3\u003e\n\u003cp\u003eInsomnia severity was assessed using the Athens Insomnia Scale (AIS). The AIS was developed and validated by Soldatos et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] in 2000 based on ICD-10 criteria and assesses insomnia symptoms (e.g., sleep induction, nocturnal awakenings, early morning awakening, and daytime functioning) across eight items. Each item is rated on a 4-point Likert scale (0\u0026ndash;3), with total scores ranging from 0 to 24; higher scores indicate more severe insomnia. The AIS has demonstrated acceptable psychometric properties in patients with ischemic stroke, with a Cronbach\u0026rsquo;s alpha of 0.734 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNeuroticism\u003c/h2\u003e \u003cp\u003eNeuroticism was assessed using the neuroticism subscale of the Big Five Inventory (BFI) developed by John et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This 12-item subscale captures negative emotionality and emotional instability. Total scores range from 12 to 60, with higher scores indicating poorer emotional stability and greater neuroticism [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In stroke populations, BFI personality traits have been systematically examined, and neuroticism has been shown to be associated with psychological well-being [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSocial Support\u003c/h3\u003e\n\u003cp\u003ePerceived social support was measured using the Social Support Rating Scale (SSRS). The SSRS was developed by Xiao [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and includes 10 items across three dimensions: subjective support, objective support, and support utilization. Total scores range from 12 to 66, with higher scores indicating greater social support. The scale has demonstrated good reliability and validity, with a Cronbach\u0026rsquo;s alpha of 0.896 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eDepressive Symptoms\u003c/h3\u003e\n\u003cp\u003eDepressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9). Developed by Kroenke et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], the PHQ-9 is a nine-item self-report measure that assesses the nine DSM-IV symptom criteria for major depressive disorder. Total scores range from 0 to 27, with higher scores indicating more severe depressive symptoms. The PHQ-9 has demonstrated acceptable psychometric properties in stroke populations, with a Cronbach\u0026rsquo;s alpha of 0.78 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData analyses were conducted using IBM SPSS Statistics 25.0 and Mplus 8.3. Given the non-normal distribution of continuous variables, sample characteristics were summarized as medians (interquartile ranges) or frequencies (percentages), as appropriate. Spearman\u0026rsquo;s rank correlations were used to examine bivariate associations among the primary study variables (activities of daily living, insomnia, neuroticism, social support, and PSD). Structural equation modeling (SEM) was used to test the theoretical model including two independent variables (activities of daily living and insomnia) and two mediators (neuroticism and social support). In light of the cross-sectional design, all references to 'mediation' should be understood as statistical decompositions of associations, which do not imply causal relationships. All path coefficients reported are standardized estimates (β), obtained using maximum likelihood estimation in R package 'lavaan' (version 0.6\u0026ndash;15). Social support was specified as a latent variable with three indicators (subjective support, objective support, and support utilization) and all reported path coefficients are standardized estimates (β). The significance of direct, indirect, and serial mediation effects was evaluated using bias-corrected bootstrap confidence intervals with 5,000 resamples. And all effects were considered statistically significant if the 95% confidence interval did not include 0. Overall model fit was assessed using the chi-square/degree of freedom ratio (χ\u0026sup2;/df)\u0026thinsp;\u0026lt;\u0026thinsp;3, comparative fit index (CFI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, Tucker\u0026ndash;Lewis index (TLI)\u0026thinsp;\u0026gt;\u0026thinsp;0.90, root mean square error of approximation (RMSEA)\u0026thinsp;\u0026lt;\u0026thinsp;0.08, and standardized root mean square residual (SRMR)\u0026thinsp;\u0026lt;\u0026thinsp;0.08 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eParticipants' characteristics\u003c/h2\u003e \u003cp\u003eDemographic characteristics and univariate analyses of the 207 participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age was 64.56\u0026thinsp;\u0026plusmn;\u0026thinsp;12.27 years; 72.46% were male and 85.51% were married. Retired or laid-off participants accounted for 70.53% of the sample, 86.96% had a caregiver, and 2.42% reported recent negative life events. PHQ-9 scores differed significantly by age, marital status, and recent negative life events. AIS scores were significantly higher in female than in male patients. ADL scores were significantly higher among patients without caregivers than among those with caregivers. In addition, SSRS scores were significantly higher among patients aged\u0026thinsp;\u0026lt;\u0026thinsp;65 years and those who were married.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the participants and univariate analysis for the research variables.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;207)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eADL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eAIS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003ePHQ9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003eNeuroticism\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian [IQR]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian [IQR]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMedian [IQR]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMedian [IQR]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMedian [IQR]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.006\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.006\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.780\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.00 [60.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.00 [2.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e41.00 [36.00;46.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4.00 [1.00;6.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24.00 [16.00;31.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.50 [61.25;95.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.00 [2.00;9.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e38.00 [31.00;44.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;8.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24.00 [16.00;32.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.034\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.952\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.00 [60.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.00 [2.00;8.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e39.00 [33.00;44.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e23.50 [16.00;32.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.00 [62.50;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.00 [3.00;10.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e42.00 [35.50;46.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4.00 [1.50;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e25.00 [16.00;31.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.000\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.029\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95.00 [31.25;98.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.00 [1.75;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e27.00 [20.25;40.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4.00 [1.25;6.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e32.00 [19.00;39.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.00 [65.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.00 [2.00;8.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e41.00 [35.50;45.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;6.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e23.00 [16.00;31.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.50 [38.75;95.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.00 [4.50;11.25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e33.50 [22.25;38.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6.50 [5.00;9.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e29.00 [24.75;33.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.00 [52.50;95.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.00 [4.25;15.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e31.50 [26.75;38.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6.50 [2.75;9.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24.00 [17.25;32.25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.950\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.394\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBe on the job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.00 [51.25;95.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.50 [3.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e39.00 [35.00;44.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;6.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24.00 [19.00;31.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired/Layoff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.00 [65.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.00 [2.00;9.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e40.00 [33.00;45.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24.00 [16.00;31.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.00 [56.25;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.50 [3.00;6.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e42.50 [36.25;45.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3.00 [2.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e27.50 [17.75;39.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaregivers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.624\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.00 [60.00; 98.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.50 [2.00;8.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e40.00 [34.25;45.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24.00 [16.00;31.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.00 [90.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.00 [3.00;11.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e37.00 [26.00;46.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e28.00 [17.00;34.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily income (\u0026yen;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.00 [57.50;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.00 [2.50;9.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e39.00 [32.50;45.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.50;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e25.00 [17.50;32.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5,000\u0026thinsp;~\u0026thinsp;9,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.00 [70.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.00 [1.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e40.00 [37.00;46.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4.00 [1.00;6.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e21.00 [15.00;29.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.00 [60.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.00 [2.00;11.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e37.00 [30.00;42.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [1.00;9.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e26.00 [17.00;35.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative events\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.004\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.00 [52.50; 90.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.00 [3.50;18.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e33.00 [28.00;42.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e9.00 [9.00;9.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e27.00 [19.00;43.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.00 [65.00;100.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.00 [2.00;8.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e40.00 [34.00;45.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5.00 [2.00;7.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24.00 [16.00;31.25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBivariate associations among research variable\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents Spearman\u0026rsquo;s rank correlations among ADL, insomnia, neuroticism, social support, and depressive symptoms. Higher ADL independence was negatively correlated with insomnia (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.184, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and PSD (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.347, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and positively correlated with social support (r\u0026thinsp;=\u0026thinsp;0.264, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Insomnia was positively correlated with PSD (r\u0026thinsp;=\u0026thinsp;0.601, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), neuroticism (r\u0026thinsp;=\u0026thinsp;0.432, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and negatively correlated with social support (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.350, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Neuroticism was negatively correlated with social support (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.319, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and positively correlated with PSD (r\u0026thinsp;=\u0026thinsp;0.510, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The SSRS total score was negatively correlated with PSD (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.486, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Notably, the objective support dimension was not significantly correlated with neuroticism (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.091, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Spearman correlations between ADL, AIS, BFI-Neuroticism, SSRS, and PHQ9.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.1.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.2.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.3.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. AIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.184\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. BFI Neuroticism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.276\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.432\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.264\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.350\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.319\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.1. Subject support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.212\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.316\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.265\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.892\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.2. Object support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.182\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.203\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.686\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.445\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.3. Support utility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.225\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.272\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.350\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.714\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.468\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.378\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. PHQ9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.347\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.601\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.510\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.486\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.429\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.286\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.428\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote: ** \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDirect effects among variables\u003c/h2\u003e \u003cp\u003ePath coefficients from the model are presented to depict the direct effects among activities of daily living, insomnia, neuroticism, social support, and PSD (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Higher ADL independence had a significant negative effect on neuroticism (β = \u0026minus;0.156, p\u0026thinsp;=\u0026thinsp;0.009) and a significant positive effect on social support (β\u0026thinsp;=\u0026thinsp;0.195, p\u0026thinsp;=\u0026thinsp;0.007). Insomnia had a significant positive effect on neuroticism (β\u0026thinsp;=\u0026thinsp;0.329, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a significant negative effect on social support(β = \u0026minus;0.282, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Neuroticism had a significant negative effect on social support (β = \u0026minus;0.242, p\u0026thinsp;=\u0026thinsp;0.003). With respect to PSD, neuroticism had a significant positive direct effect (β\u0026thinsp;=\u0026thinsp;0.219, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas social support had a significant negative direct effect (β = \u0026minus;0.237, p\u0026thinsp;=\u0026thinsp;0.001). The direct effect of insomnia on PSD was significant (β\u0026thinsp;=\u0026thinsp;0.393, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas the direct effect of ADL independence on PSD did not reach statistical significance (β = \u0026minus;0.109, p\u0026thinsp;=\u0026thinsp;0.050).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTotal effect and mediating effects among variables\u003c/h2\u003e \u003cp\u003eTotal and indirect effects based on bootstrap resampling (5,000 iterations) are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. For Hypothesis 1, the total effect of higher ADL independence on PSD was negative and significant (β = \u0026minus;0.198, 95% CI: [\u0026minus;\u0026thinsp;0.303, \u0026minus;\u0026thinsp;0.092]), and the total effect of insomnia on PSD was positive and significant (β\u0026thinsp;=\u0026thinsp;0.550, 95% CI: [0.453, 0.647]).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal and indirect effects of activities of daily living (ADL) and insomnia (AIS) on PSD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffects type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eHypothesis (path)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Effects\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eH1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eX1 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[-0.303, -0.092]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eH1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eX2 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.550\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.453, 0.647]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Indirect Effects\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eX1 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[-0.146, -0.032]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eX2 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.091, 0.224]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecific Indirect Effects\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eX1 \u0026rarr; M1 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[-0.064, -0.004]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eX2 \u0026rarr; M1 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.028, 0.116]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eX1 \u0026rarr; M2 \u0026rarr;Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[-0.089, -0.003]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH3b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eX2 \u0026rarr; M2 \u0026rarr;Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.018, 0.116]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eX1 \u0026rarr; M1 \u0026rarr; M2 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[-0.020, 0.002]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH4b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eX2 \u0026rarr; M1 \u0026rarr; M2 \u0026rarr; Y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e[0.001, 0.037]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHowever, within the mediation model, the mediating roles of neuroticism and social support varied by pathway. Specifically, the effect of ADL on PSD was fully mediated by neuroticism and social support (total indirect effect: β = \u0026minus;0.089, 95% CI: [\u0026minus;\u0026thinsp;0.146, \u0026minus;\u0026thinsp;0.032]), whereas the effect of insomnia on PSD was partially mediated (β\u0026thinsp;=\u0026thinsp;0.158, 95% CI: [0.091, 0.224]).\u003c/p\u003e \u003cp\u003eFor Hypothesis 2, ADL exerted a significant negative indirect effect on PSD through higher neuroticism (β = \u0026minus;0.034, 95% CI: [\u0026minus;\u0026thinsp;0.064, \u0026minus;\u0026thinsp;0.004]); insomnia exerted a significant positive indirect effect through higher neuroticism (β\u0026thinsp;=\u0026thinsp;0.072, 95% CI: [0.029, 0.116]). For Hypothesis 3, ADL exerted a significant negative indirect effect through lower social support (β = \u0026minus;0.046, 95% CI: [\u0026minus;\u0026thinsp;0.089, \u0026minus;\u0026thinsp;0.003]); insomnia exerted a significant indirect effect through lower social support (β\u0026thinsp;=\u0026thinsp;0.067, 95% CI: [0.018, 0.116]). For Hypothesis 4, insomnia showed a significant positive serial indirect effect on PSD via the pathway neuroticism \u0026rarr; social support (β\u0026thinsp;=\u0026thinsp;0.019, 95% CI: [0.001, 0.037]), whereas the serial mediation effect of ADL via neuroticism \u0026rarr; social support was not significant (β = \u0026minus;0.009, 95% CI: [\u0026minus;\u0026thinsp;0.020, 0.002]).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStructural model analysis\u003c/h2\u003e \u003cp\u003eOverall model fit indices were as follows: the p value for the χ\u0026sup2; test was 0.154; χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;11.927/8\u0026thinsp;=\u0026thinsp;1.49; CFI\u0026thinsp;=\u0026thinsp;0.988; TLI\u0026thinsp;=\u0026thinsp;0.968; RMSEA\u0026thinsp;=\u0026thinsp;0.049 (90% CI: 0.000\u0026ndash;0.075); and SRMR\u0026thinsp;=\u0026thinsp;0.028. All indices were within acceptable ranges, indicating a good fit between the hypothesized model and the data. In the measurement model, standardized factor loadings of the latent social support construct on its observed indicators (c1, c2, c3) were 0.763, 0.618, and 0.670, respectively (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting satisfactory reliability and validity of the measurement model.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eOverview of the Main Findings\u003c/h2\u003e \u003cp\u003eBased on the stress\u0026ndash;diathesis interaction model, this study examined whether ADL independence and insomnia as two neuropsychological stressors, were associated with PSD, and whether these associations could be mediated by neuroticism and social support respectively. The analysis indicated that stroke patients who exhibited poorer ADL functioning or more severe insomnia had significantly higher levels of PSD. Notably, the association between lower ADL independence and PSD was fully mediated by the psychosocial factors examined, whereas insomnia was indirectly associated with PSD through a serial pathway in which insomnia was related to higher neuroticism, which in turn was related to lower social support. Within an integrated biopsychosocial framework, these results support the applicability of the stress\u0026ndash;diathesis model in stroke populations, revealing that lower ADL independence and insomnia may be linked to depressive symptoms through distinct mediation patterns involving neuroticism and social support. The significant total effects of both lower ADL independence and insomnia on PSD confirm their relevance as risk markers, supporting the need for routine screening in stroke settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFully Mediated Pathway of lower ADL independence: A Parallel Mediation Pattern\u003c/h2\u003e \u003cp\u003eLower ADL independence was indirectly associated with PSD through parallel mediation via neuroticism and social support, with no significant direct effect. This finding underscores the possible role of psychosocial adaptation processes in emotional responses after stroke, yet differs from the findings of Chung et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Specifically, the present study revealed parallel and independent mediation by neuroticism and social support, meaning that depressive symptoms were linked through these two distinct factors rather than through a pathway in which personality vulnerability operated via perceived social support. This pattern of associations suggests that neuroticism, as a stable dispositional vulnerability, is associated with negative emotional experiences and catastrophizing cognitions in response to functional loss [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], thereby linking functional impairment to depression risk through an internal emotional pathway [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In contrast, as a potential protective resource, the social support may be constrained when stroke-related limitations in activity and shifts in social roles occur during the post-stroke phase, reducing opportunities and capacity for social participation and for obtaining and maintaining effective support. Together, these two paths constitute a potential external pathway through which lower ADL independence may be linked to poorer mental health [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The weak correlation between objective support and neuroticism observed in this study further suggests that perceived rather than actual support may be more relevant to personality-related emotional vulnerability. Therefore, patients with ADL limitations are also subject to attendant psychosocial risks that require clinical attention. We recommend that early rehabilitation of stroke incorporate concurrent screening and intervention targeting both internal cognitive\u0026ndash;emotional regulation and external support systems, in order to address these two factors potentially contributing to PSD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePartially Mediated Pathway of Insomnia: A Serial Mediation Mechanism\u003c/h2\u003e \u003cp\u003eIn contrast to the parallel mediation pattern observed for lower ADL independence, insomnia demonstrated a stronger association with PSD, operating through both direct and serial mediation pathways. SEM results identified a chain of associations wherein insomnia was positively associated with neuroticism, which related to lower levels of social support, and this reduced support was further linked to greater severity of depressive symptoms. This serial mediation model supports the theoretical hypothesis that insomnia may exacerbate depressive symptoms through emotional sensitization and subsequent erosion of social support, a aligning with Zhang et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] finding that neuroticism as a critical bridge between insomnia and social support in stroke patients. This suggests that insomnia-related emotional and social disruptions may contribute not only to depressive symptoms but also to more severe psychiatric outcomes. The clinical relevance of this pathway is underscored by Yang et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], who found that post-stroke insomnia at various stages was significantly associated with suicidal ideation at one-year follow-up (ORs: 1.9\u0026ndash;2.66). Compared with the parallel mediation model for lower ADL independence, this sequential framework offers a distinct pathway for understanding how insomnia may be linked to depression. However, given the very small effect size of the serial pathway (β\u0026thinsp;=\u0026thinsp;0.019), this pattern should be interpreted as a theoretically plausible but potentially weak statistical association whose robustness requires confirmation in future longitudinal research. Importantly, these findings suggest a potential entry point for clinical intervention. Based on this model, future intervention research in the post-stroke phase may explore integrated approaches that follow the logic of \u0026ldquo;managing insomnia symptoms\u0026mdash;regulating emotional responses\u0026mdash;restoring social support,\u0026rdquo; thereby systematically targeting the sequential components of the model. The potential utility of this sequence is aligned with prior strategies of stepwise support [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Developing and evaluating such strategies may offer new directions for more systematic management of insomnia and its psychosocial sequelae in stroke survivors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eBuilding on the differential psychosocial pathways identified in this study linking lower ADL independence and insomnia to depressive symptoms, clinical intervention in post-stroke phase may shift from standardized protocols toward individualized strategies informed by precise assessment.\u003c/p\u003e \u003cp\u003eSpecifically, the parallel mediation pattern observed in patients with prominent ADL limitations suggests the potential value of to a dual-pathway interventional approach. This implies that future interventions may integrate components targeting internal psychological processes and components targeting external environmental resources. Along the internal pathway, cognitive-behavioral approaches (e.g., cognitive restructuring and behavioral activation) could be considered to help patients manage the catastrophizing thoughts triggered by functional loss, as well as enhancing emotion regulation and self-efficacy, thereby addressing emotional vulnerability associated with neuroticism [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Along the external pathway, strategies such as caregiver skills training, home environment modifications, and linkage to community resources may help proactively build and maintain objective social support networks, compensating for reduced social participation due to functional restrictions and jointly being associated with reducing depression risk through complementary internal and external mechanisms [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor patients with prominent insomnia symptoms, the serial association model provides a framework for considering a \u0026ldquo;stepwise integrated intervention\u0026rdquo; approach. Future research could use this framework to develop a sequential program progressing from symptom management to restoration of social functioning. First, during the sleep management phase, emotion regulation training (e.g., mindfulness practices) could be systematically incorporated to reduce heightened emotional reactivity triggered by insomnia at an early stage [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Second, for activated emotional distress, structured cognitive interventions could be implemented to alleviate catastrophizing thinking and prevent emotional problems from generalizing into the social domain [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Finally, interventions such as family communication training or peer support groups could be used to repair impaired perceived social support and interpersonal connectedness, thereby rebuilding patients\u0026rsquo; psychosocial safety net [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccordingly, a key implication of this study for clinical practice is the importance of early assessment of ADL limitations and insomnia in stroke survivors. On this basis, future studies may test dual parallel-pathway interventions in patients whose risk profile is dominated by lower ADL independence, and stepwise integrated interventions in those whose risk profile is dominated by insomnia. The clinical effectiveness and contextual feasibility of these theoretically derived interventions in stroke care settings remain to be confirmed in subsequent research.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSeveral limitations of this study should be noted, which also point to directions for future research. First, although the cross-sectional design enabled the identification of associations and mediating pathways among variables, causal inferences cannot be drawn. The observed relationships require further confirmation through longitudinal studies. In addition, convenience sampling from a single center may limit the generalizability of the findings. Second, the data collection relied primarily on self-report questionnaires, which can capture patients\u0026rsquo; subjective experiences but lacked objective indicators such as lesion location and National Institutes of Health Stroke Scale (NIHSS) scores. The omission of these neurological and clinical indices may confound the observed associations, as they could influence both the stressors (ADL, insomnia) and the outcome (depression), potentially leading to an overestimation of the unique contribution of the psychosocial pathways examined. Therefore, subsequent studies should examine the potential moderating or confounding effects of these clinical variables on psychosocial pathways.\u003c/p\u003e \u003cp\u003eBased on the above considerations, future research may further validate and extend the differential mediation pathways suggested here by using longitudinal or multicenter designs, integrating multimodal data from both subjective and objective sources, systematically incorporating key clinical covariates, and extending the follow-up period, thereby providing a more comprehensive understanding of psychosocial factors associated with PSD.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGrounded in the stress\u0026ndash;diathesis interaction model, this study examined the associations between functional dependence and insomnia to PSD among stroke survivors. Specifically, lower ADL independence was indirectly associated with PSD through parallel mediation via neuroticism and social support, reflecting two independent transmission pathways. In contrast, insomnia was associated with PSD through a serial mediation pathway of neuroticism to social support. These findings suggest that functional dependence and insomnia may influence emotional health through distinct psychosocial channels. Notably, insomnia as a persistent stressor may progressively erode psychosocial resources through its association with emotional sensitization. By integrating biological, psychological, and social perspectives in the stroke context, this study provides preliminary evidence for differentiated pathways of association in PSD. It also offers empirical evidence for early identification of high-risk patients and the development of integrated mind\u0026ndash;body intervention strategies guided by precise assessment. Future research may employ longitudinal designs, control for key clinical variables, and develop operationalized intervention programs targeting the management of emotional responses associated with neuroticism and enhancement of social support to more effectively prevent PSD and promote comprehensive recovery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the participants of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJiali Zhang contributed to project conceptualization, study design, academic supervision, and funding acquisition. Ruike Zhang,Yan Liang and Huiping Peng were responsible for data management, manuscript drafting, statistical analyses, visualization and data collection.Xiaoha Lin:Investigation,data collection and statistical analyses. All authors critically reviewed, revised, and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data in this study can be obtained from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the Medical Ethics Committee of the Fifth Affiliated Hospital of Sun Yat-sen University(Approval No. (2024) K148-1). Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSun, H. X., and W. Z. Wang. 2018. \u0026ldquo;A nationwide epidemiological sample survey on cerebrovascular disease in China.\u0026rdquo; \u003cem\u003eChinese Journal of Contemporary Neurology and Neurosurgery\u003c/em\u003e 18, no. 2: 83-88. https://doi.org/10.3969/j.issn.1672-6731.2018.02.002.\u003c/li\u003e\n\u003cli\u003eHe, Y., S. Q. Shi, Y. D. 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Mehl. 2022. \u0026ldquo;Leveraging social networks for the assessment and management of neurological patients.\u0026rdquo; \u003cem\u003eSeminars in Neurology\u003c/em\u003e 42, no. 2: 136-148. https://doi.org/10.1055/s-0042-1744532.\u003c/li\u003e\n\u003cli\u003eTerrill, A. L., S. Gordon, C. Sparks, et al. 2025. \u0026ldquo;Resilience in Stroke survivor-care-partner Dyads (ReStoreD): a study protocol for a randomized-control trial.\u0026rdquo; \u003cem\u003eTrials\u003c/em\u003e 26, no. 1: 195.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Post-stroke Depression, Activities of Daily Living, Insomnia, Neuroticism, Social Support, Mediation Analysis","lastPublishedDoi":"10.21203/rs.3.rs-9177408/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9177408/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePost-stroke depression (PSD) is a common complication after stroke, yet the biopsychosocial mechanisms underlying PSD remain poorly understood. Using the stress\u0026ndash;diathesis model, we examined the relationships of activities of daily living (ADL) independence and insomnia with depressive symptoms in stroke patients, particularly focused on the potential mediating roles of neuroticism and social support.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study included 207 stroke patients. Descriptive analyses were conducted using SPSS, and structural equation modeling with the R package 'lavaan' was used to test whether neuroticism and social support mediated the associations of ADL independence and insomnia with PSD.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe total effect of higher ADL independence on lower PSD symptoms was significant (β = \u0026minus;0.198, 95% CI: [\u0026minus;\u0026thinsp;0.303, \u0026minus;\u0026thinsp;0.092]), as was the total effect of insomnia on higher PSD (β\u0026thinsp;=\u0026thinsp;0.550, 95% CI: [0.453, 0.647]). The association between lower ADL independence and PSD was largely explained by parallel indirect effects via neuroticism (β = \u0026minus;0.034, 95% CI [\u0026minus;\u0026thinsp;0.064, \u0026minus;\u0026thinsp;0.004]) and social support (β = \u0026minus;0.046, 95% CI [\u0026minus;\u0026thinsp;0.089, \u0026minus;\u0026thinsp;0.003]). For insomnia, significant indirect effects were observed via neuroticism (β\u0026thinsp;=\u0026thinsp;0.072, 95% CI [0.029, 0.156]) and social support (β\u0026thinsp;=\u0026thinsp;0.067, 95% CI [0.018, 0.116]), along with a significant serial pathway from neuroticism to social support (β\u0026thinsp;=\u0026thinsp;0.019, 95% CI [0.001, 0.037]) .\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eLower ADL independence and insomnia appear to be associated with depressive symptoms through distinct psychosocial pathways involving neuroticism and social support. These findings support the development of targeted interventions addressing neuroticism and social support in stroke survivors.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Associations of ADL Impairment and Insomnia with Post-Stroke Depression: An Exploratory Mediation Analysis of Neuroticism and Social Support","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-31 17:29:04","doi":"10.21203/rs.3.rs-9177408/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-27T04:22:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T03:55:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-25T12:10:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T11:24:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2026-03-25T10:38:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b32c863b-f4fe-4f31-ad63-827e6ada43c2","owner":[],"postedDate":"March 31st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-31T17:29:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-31 17:29:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9177408","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9177408","identity":"rs-9177408","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}