Stroke remains one of the leading causes of morbidity and mortality in the United States, with approximately 795,000 individuals experiencing a new or recurrent stroke annually (Boehme et al., 2017). This translates to a stroke occurring every 40 s, profoundly affecting the lives of individuals and their families (Boehme et al., 2017). The immediate physical consequences of stroke, such as hemiparesis, aphasia, and visual disturbances, are well-recognized and extensively documented (Chohan et al., 2019). However, the neuropsychiatric sequelae, particularly depressive symptoms and suicidal ideation, often remain in the shadows (Towfighi et al., 2017). These psychological outcomes, while less tangible than physical impairments, can significantly impact the quality of life (QoL) of stroke survivors, sometimes even more profoundly than the physical limitations themselves (Kim et al., 2018; Khedr et al., 2020).

Depression is a frequent complication following a stroke, with estimates suggesting that up to one-third of stroke survivors experience post-stroke depression (PSD) (Towfighi et al., 2017). This means that potentially over 260,000 of those who suffer a stroke each year may also grapple with depression (Towfighi et al., 2017). The severity of depressive symptoms can vary, ranging from mild feelings of sadness and hopelessness to severe and debilitating symptoms that can hinder rehabilitation and recovery (Arne et al., 2011). Furthermore, the presence of depressive symptoms post-stroke has been associated with poorer functional outcomes, increased mortality, (Schulz et al., 2000) with rates being 2–3 times higher than stroke survivors without depression, and reduced QoL (Sivertsen et al., 2015). Suicidal ideation, though less frequently studied than PSD, is another concerning psychological outcome among stroke survivors. Preliminary studies have indicated that stroke survivors may be at an increased risk for suicidal thoughts, with rates being up to 25 % in some cohorts, particularly in the early stages following the event (Bartoli et al., 2018; Pompili et al., 2015). The presence of such ideation can further diminish QoL and pose a significant challenge for healthcare providers, caregivers, and the patients themselves (Morimoto et al., 2003).

Depression and suicidal ideation post-stroke have been quantified using the Patient Health Questionnaire-9 (PHQ-9), a validated tool for depression screening (de Man-van Ginkel et al., 2012). The PHQ-9 not only offers a standardized screening tool of depressive symptom but also provides granularity, capturing a spectrum of symptoms from mild to severe (Kroenke et al., 2001). Despite the recognized importance of these psychological outcomes, there remains a gap in the literature regarding the differential impact of mild versus severe depressive symptoms on QoL among US stroke survivors. Moreover, the combined influence of depressive symptoms and suicidal ideation on QoL, as measured by the PHQ-9, has not been extensively explored.

This study aims to bridge this gap by examining the association of mild and severe depressive symptoms and suicidal ideation with QoL in a nationally representative sample of US stroke survivors. Understanding these associations is crucial for tailoring interventions, informing clinical practice, and ultimately improving the overall well-being of this vulnerable population.