Frequency and clinical determinants of poststroke depression

Recent advances in poststroke depression

Depression is the most common psychiatric complication after stroke. Its prevalence varies from 20% to 80%, and it is underdiagnosed and undertreated. It has significant impact on rehabilitation, motor recovery, activities of daily living, social and interpersonal life, and mortality. Several studies have shown that biological and psychosocial factors play significant roles in the development of this disabling disease. Recent research shows that neurochemical processes also may play some role in the pathophysiology of this condition. Several trials have shown evidence that the older, as well as newer antidepressants and psychostimulants may reduce/prevent depressive symptoms after stroke. At this point there are no clear guidelines available to choose safe and effective treatments. Drugs are selected based on their efficacy and side effect profile in these patients. More research is needed to understand the pathophysiology of depression after stroke. There also is a need for more randomized clinical trials to better treat patients with this condition.

[Post-stroke depression: clinical aspects, epidemiology, therapy, and pathophysiology]

Post-stroke depression (PSD) is the most frequent psychiatric complication following ischemic stroke, affecting up to 50% of all such patients. Moreover, PSD is associated with increased morbidity and mortality following ischemic stroke. In clinical practice, PSD is underdiagnosed and many affected patients do not receive adequate treatment. This review article summarizes current knowledge regarding epidemiogy, clinical features, risk factors and predisposition, therapy, and prophylaxis of PSD.

Determinants of depression in chronic stroke: a prospective cohort study

PURPOSE

The aim of the study was to identify factors that are significantly related to depression in chronic stroke patients.

METHODS

Prospective cohort study of stroke patients admitted for rehabilitation. A total of 165 first ever stroke patients over 18 years of age were assessed at one and three years post stroke. Depression was determined by the Centre for Epidemiologic Studies Depression Scale (CES-D). Patients with scores >/=16 were classified as depressed. Bivariate and multivariate logistic regression analyses were used to identify prognostic factors for depression.

RESULTS

At three years post stroke, 19% of the patients were depressed. Bivariate analysis showed significant associations between post-stroke depression and type of stroke, fatigue, motor function of the leg and arm, activities of daily living (ADL) independency and instrumental ADL. Multivariate logistic regression analysis showed that depression was predicted by one-year instrumental ADL and fatigue. Sensitivity of the model was 63%, while specificity was 85%.

CONCLUSIONS

The present prospective cohort study showed that depression three years after stroke can be predicted by instrumental ADL and fatigue one year post stroke. Recognition of prognostic factors in patients at risk may help clinicians to apply interventions aimed at preventing depression in chronic stroke.

Psychiatric and Behavioral Manifestations of Vascular Dementia

Vascular dementia (VaD) is the second most common cause of dementia, accounting for about 20% of all cases. Psychiatric and behavioral problems are at least as common in VaD as in Alzheimer's disease but are very different qualitatively. Patients with VaD, and especially those with small vessel disease, typically manifest symptoms related to damage to the frontal-subcortical system of the brain, including loss of executive function (which is not generally detected with most conventional tests of cognitive function), loss of drive, and disinhibited behaviors. Patients with VaD also commonly develop treatable mood disorders, most commonly depression. Once the symptoms are recognized, the clinician is in an ideal position to manage them and to educate caregivers about their nature.

Is depression different in older adults?

Psychiatric disorders such as depression are common conditions in older adults. Depression presents similarly to younger adults, but with more psychotic symptoms and apathy. Research has suggested that genetics play a less important role in the etiology of depression in the elderly, but that other biological factors may be more significant. Vascular pathology in particular is thought to be especially important. White-matter hyperintensities are found in the frontal lobes and basal ganglia in greater numbers in older adults with depression, with damage to the frontal–subcortical circuits thought to be particularly important. It is associated with treatment resistance. Prognosis is poor if depression is not detected and treated adequately and this may lead to a higher risk of dementia and death. However, treatment with selective serotonin reuptake inhibitors and other antidepressants, plus psychological therapies, are effective in the older depressed patient and reduce morbidity and mortality.

Role of IL-1 in poststroke depressive-like behavior in mice

BACKGROUND

Poststroke depression (PSD) leads to impaired functional recovery and increased mortality, yet physiological mechanisms are unknown. The present study investigates the roles of glucocorticoids and interleukin-1 (IL-1) in poststroke anhedonia.

METHODS

Adult male mice underwent middle cerebral artery occlusion (MCAO), and were recovered 7 days. Mice were treated with metyrapone (100 mg/kg intraperitoneally), mifepristone (50 mg/kg subcutaneously), or vehicle injections on reperfusion days 4-7. A separate cohort of mice was implanted with cannulae and was administered IL-1 receptor antagonist (IL-1ra) or vehicle (6 microg intracerebroventricularly) on reperfusion days 6 and 7. After the final injection or infusion, sucrose consumption was recorded for 6 hours.

RESULTS

Mice in the sham-treated group consumed significantly more sucrose solution than water, whereas MCAO-treated mice consumed similar amounts of each, suggesting anhedonia among MCAO-treated mice. A separate experiment assessed whether stroke-induced increases in corticosteroids or IL-1 contribute to anhedonia. Only IL-1ra restored sucrose consumption in MCAO-treated mice. Vehicle-MCAO-treated mice drank significantly less sucrose solution than did both IL-1ra and vehicle-sham treatment groups, whereas IL-1ra-MCAO-treated mice drank similar amounts to both sham-treated groups.

CONCLUSIONS

Poststroke anhedonia, a symptom of depression in human beings, can be reproduced in a mouse model of stroke and appears to involve altered IL-1 transmission in the brain.

Efficacy of milnacipran on cognitive dysfunction with post-stroke depression: preliminary open-label study

The aim of this study was to assess the therapeutic efficacy of the serotonin norepinephrine reuptake inhibitor (SNRI), milnacipran, on both cognitive impairment and depression in post-stroke depression (PSD) patients. A total of 18 PSD patients, approximately 3 months after stroke, were divided into two groups, milnacipran and control. A total of 10 patients were assigned to the milnaciprane group and eight were assigned to control group. Their cognitive impairment and mood symptoms were measured using the Mini-Mental State Examination (MMSE) and Hamilton Depression Rating Scale (HAM-D) both at the time of admission and at discharge, an interval of approximately 3 months. This study examined the changes in both MMSE and HAM-D scores during the study period. A significant time-by-group interaction for results of the MMSE was observed, although there was no significant difference between the two groups on the HAM-D. Amelioration of cognitive impairment was greater in the milnacipran group than the control group. For PSD patients, milnacipran is effective in improving cognitive dysfunction.

Mood disorders in the elderly

Mood disorders in the elderly are a growing source of morbidity and mortality. Unfortunately, mood disorders in later life frequently are not diagnosed and treated. Appropriate, prompt diagnosis and treatment of late-life mood disorders can significantly improve the quality of life of patients and families and may prove life saving. Current treatments can help most older adults with mood disorders. Future treatments are promising, particularly for those with treatment-resistant depression.

Evidence, education and practice

Stroke causes greater loss of quality-adjusted life years than any other disease and is also one of the most expensive disorders. The burden of stroke will increase in the future due to change in the age structure of populations. We have a vast body of evidence on how to prevent stroke and how to treat stroke patients. Good examples are treatment of hypertension, antithrombotic agents and carotid surgery in stroke prevention, thrombolysis in ischaemic stroke and stroke unit care for all stroke patients. We only have to translate scientific evidence into daily practice. If some pieces are missing, it is our duty to generate them through research. While taking part in randomized clinical trials (RCTs), the discipline, an essential part of RCTs, will improve the daily care of all stroke patients. Besides RCTs there are many other sources of scientific evidence for stroke management, one of which is the European Stroke Initiative (EUSI). The mission of the EUSI is to improve and optimize stroke management in Europe through education and by offering best practice guidelines. Also national and international societies and organizations play an important role in providing education. The human factor is one obstacle to more successful stroke management because to be more effective we must change our own clinical routine. We can make a difference by applying available evidence to our daily practice.

[Relation between certain diseases and frequency of depression in geriatric patients]

The higher prevalence of depression in specific diseases and older persons is discussed. This prevalence varies greatly according to the method used to collect data. A risk group can only be defined if information on diseases and other influencing factors are collected uniformly. The target diagnoses Parkinson's disease, stroke, myocardial infarction, cancer, diabetes mellitus, chronic pain, multiple infarct syndrome, Alzheimer's and other dementia were recorded from 1208 geriatric patients of the ZAGF municipal hospital in Munich, Germany. Logistic regression was used to identify chronic pain as the main cofactor for an association with depression (clinical diagnoses by ICD-10) and depressive symptoms (via GDS [Geriatric Depression Scale]). This association was also found for multimorbid patients with chronic pain. Impairment of the activities of daily living and the clinical setting were important additional cofactors. Pain patients are therefore at higher risk for depression.

Is there improvement of "vascular depression" after carotid artery stent placement?

PURPOSE

To prospectively evaluate if high-grade (> or = 80% luminal narrowing) internal carotid artery stenosis is associated with depressive symptoms and if carotid artery stent placement (CAS) potentially improves depressive symptoms.

MATERIALS AND METHODS

The study was approved by the local ethics committee, and informed consent was obtained from all subjects. One hundred forty-three patients (91 men, 52 women; interquartile range, 63-76 years) undergoing CAS because of asymptomatic high-grade (> or = 80% luminal narrowing) carotid artery stenosis and 102 control subjects (64 men, 38 women; interquartile range, 63-73 years) with advanced peripheral artery disease and without carotid artery stenosis undergoing lower-limb percutaneous transluminal angioplasty were included. Substantial depressive symptoms (defined as a Beck Depression Inventory score of 10 or higher) were recorded at baseline and at 4 weeks (follow-up) after the percutaneous procedures. The chi2 test, Mann-Whitney U test, McNemar test, Wilcoxon rank sum test, and two-group t test were used to check for statistical significance.

RESULTS

A significantly higher prevalence of depressive symptoms was found in patients with carotid artery stenosis than in control subjects with peripheral artery disease at baseline (33.6% vs 16.7%, P = .003). At follow-up, a significant reduction of depressive symptoms was found in patients who underwent CAS (33.6% vs 9.8%, P < .001). The frequency of depressive symptoms remained unaffected in control subjects (16.7% vs 13.0%, P = .1).

CONCLUSION

High-grade carotid artery stenosis is associated with depressive symptoms in patients with atherosclerosis. CAS seems to exert beneficial effects on the course of depressive symptoms in these patients.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.

Emotional symptoms in acute ischemic stroke

BACKGROUND

Anxiety and depressive symptoms encountered in acute stroke influence the patients' neurological outcome and the psychosocial burden of family members. These emotional changes may be caused by the patients' brain damage per se or by psychological reactions. The aims of the present study were to assess the prevalence of anxiety and depressive symptoms in the acute stage of ischemic stroke, and to identify the factors associated with such problems.

METHODS

Anxiety and depressive symptoms were evaluated in 178 patients with acute ischemic stroke using the Hospital Anxiety and Depression Scale (HADS) between day 3 and 7 after admittance to the stroke unit. Factors associated with anxiety and depressive symptoms were identified using logistic regression analyses.

RESULTS

26.4% of the patients suffered from anxiety symptoms, 14.0% from depressive symptoms and 7.9% from both. Anxiety symptoms were associated with single marital state (OR 2.53, 95% CI 1.18-5.41) and a low Mini Mental State Examination (MMSE) score (< 26 points) (OR 0.53, 95% CI 0.31-0.87) whereas depressive symptoms were related to a low Barthel Activities of Daily Living index (BI) (score < 90 points) (OR 0.37, 95% CI 0.15-0.88).

CONCLUSION

The present study indicates that anxiety symptoms are more frequent than depressive symptoms in the acute stage of ischemic stroke. It is important to focus on both anxiety and depressive symptoms throughout the rehabilitation phase in order to ease the patients' personal anguish and improve neurological outcome after stroke.

White matter hyperintensities and depression--preliminary results from the LADIS study

BACKGROUND

White matter hyperintensities have been associated with the development of depression in older subjects, though the details of this relationship are not fully understood.

METHODS

In a pan-European multicentre study of 629 older subjects, we examined the relationship between MRI white matter hyperintensities (WMH), depressive symptoms and self perceived health quality of life (QOL). WMH were rated using a three-point scale.

RESULTS

We found depressive symptoms as assessed by the geriatric depression 15-item scale to be associated with WMH rating (Spearman's rho 0.11, p = 0.008) and also with the Euro-QOL health score (Spearman's rho -0.5, p < 0.001). In a ordinal logistic regression model, QOL was found to strongly predict GDS score (p < 0.001) and severe vs mild WMH were associated with increased depression (p = 0.028). The relationship between history of severe depression and WMH score was examined, but there were no differences either between those with and without a history of severe depression, or those with an early vs late onset of depression.

CONCLUSIONS

The results suggest that WMH play a role in increasing depressive symptoms, even when perceived quality of life is controlled for as a possible mediating factor.

Does rat global transient cerebral ischemia serve as an appropriate model to study emotional disturbances?

We used two validated psychopharmacological methods, the forced swimming test (FST 20 min and 5 min) and the elevated plus-maze (EPM), to quantify depression-like and anxiety-like behavior induced by transient global cerebral ischemia in the rat. We also validated use of these methods for the study of antidepressant (imipramine) and anti-anxiety drugs (diazepam). Twelve days after surgery to provoke transient global ischemia, spontaneous motor activity was 40% higher in ischemic rats than in sham-operated controls. Duration of immobility during the FST 20 min and 5 min was 28 and 30% shorter, respectively, than in controls. Treatment with imipramine (3 x 30 mg/kg i.p.) induced a significantly shorter duration of immobility during the FST 5 min, but with no difference between ischemia and control rats. The EPM demonstrated that ischemia did not induce any change in the six behavior parameters measured. Diazepam (1.5 mg/kg i.p.) induced significant anxiolytic effects which were similar in ischemic and sham-operated animals. Both tests failed to demonstrate perturbed performance but conversely, these findings did disclose the sensitivity of ischemia-exposed rats to the action of imipramine and diazepam, demonstrating the usefulness of these tests as psychopharmocological tools for evaluating the effect of psychotropics in the ischemic rat.

Mild depression in young adults with cerebral infarction at long-term follow-up: A population-based study

We sought to evaluate the prevalence of and risk factors for post-stroke depression (PSD) at long-term follow-up in young adults aged 15-49 years with first-ever cerebral infarction in a population-based study. Scores on Montgomery-Asberg Depression Rating Scale (MADRS) were obtained at follow-up (mean time 6.0 years after the stroke) and analysed in subgroups. MADRS scores were obtained in 196 of 209 surviving patients. PSD (MADRS>or=7) was detected in 56 patients (28.6%). None had severe PSD. Alcoholism (P=0.006), depressive symptoms any time before the index stroke (P=0.016), and severe neurological deficits on admission for the index stroke (P=0.043) were independently associated with PSD. PSD seems milder in young ischaemic stroke patients compared with older patients. Alcoholism, depression any time before the index stroke, and severity of neurological deficits on admission for the stroke increased the risk of developing PSD in the long run.

Poststroke depression in Chinese patients: frequency, psychosocial, clinical, and radiological determinants

This study attempted to evaluate the psychosocial, clinical, and radiological predictors of poststroke depression (PSD) in Chinese patients. One hundred eighty-nine patients participated in the study. Three months after the index stroke, a psychiatrist administered the Structured Clinical Interview for DSM-IV to all of the patients and made a DSM-IV diagnosis of depression. In addition, a host of demographic, clinical, and radiological variables were examined. Thirty-one (16.4%) of the patients had a diagnosis of PSD that included major depression (n=11, 5.8%,), minor depression (n=16, 8.5%), or dysthymia (n=4, 2.1%). Univariate analysis revealed that PSD was associated with female gender, a lower level of education, a lower Lubben Social Network Scale (LSNS) score, subcortical infarcts, and lesions in the anterior cerebral artery (ACA) territory, and the Modified Life Event Scale (MLES) score was borderline for statistical significance. Multivariate logistic regression analysis suggested that female gender, a high MLES score, and subcortical and ACA lesions were independent risk factors for PSD and that a high LSNS score was a protective factor.

Relationship between post-stroke depression and lesion location: a meta-analysis

Our understanding of the relationship between the neuroanatomic loci of brain damage and the incidence of post-stroke depression (PSD) is not complete. Many studies have investigated this relationship and the evidence is conflicting. With the purpose of gaining a consistent, strong, and credible conclusion on the relationship between PSD and the loci of brain damage, a meta-analysis was used in this study to systematically reanalyze the findings of related studies and to investigate the sources of heterogeneity among study results. The key words "stroke or cerebrovascular" and "depression or mood or affective" were entered into the MEDLINE, PsycINFO, and EMBASE databases to search for relevant studies. The references cited in the studies found were also used to locate additional studies. For each eligible study, the important study characteristics were recorded, and the effect sizes of the relationship between PSD and lesion location were computed. Furthermore, we conducted subgroup analyses to explore the heterogeneity among study results. A total of 3,668 patients participating in 52 studies were included in this meta-analysis. There was a weak relationship between PSD and right hemisphere lesion. The major sources of heterogeneous study results included systematic exclusion of patients with language dysfunction and use of different assessors and instruments for diagnosing depression. Future efforts should aim to enhance standards for reporting studies, improve assessment tools for assessing depression of aphasic patients, and adopt appropriate study methodologies for investigating the relationship between PSD and lesion location.

Persistent Severe Depressive Episode with Mood-Congruent Psychotic Features Associated with Left Temporal Ischemia

OBJECTIVE

The authors describe the case of a patient suffering from a persistent severe depressive episode with mood-congruent psychotic features following left temporal ischemia.

BACKGROUND

Depression is a frequent disorder that may stem from psychosocial factors or occur after brain damage. Cases of poststroke depression with associated psychotic symptoms are rarely described in the literature, and, to our knowledge, no case of depression with psychotic symptoms in the presence of a focal lesion has yet been reported.

METHOD

History included psychiatric, neurologic, and neuropsychological as well as EEG data and CT scan and magnetic resonance images.

RESULTS AND CONCLUSIONS

Neurologic and psychiatric dimensions may be associated and difficult to disentangle, even when the patient presents the classic symptoms of a depressive disorder. This case underlines the importance of investigating possible neurologic signs or symptoms, even when the psychiatric presentation is prototypical of a determined mental disorder. This may be crucial for the patient's evolution.

Depression in the elderly. Tailoring medical therapy to their special needs

Depression is often overlooked as a clinical diagnosis in older patients because it is assumed to be a normal response to aging, physical losses, or other life events. However, medical intervention for depression is appropriate in this population, especially those patients with severe chronic disease. In this article, Dr Raj discusses the prevalence of depression in the elderly, the role of cognitive impairment, the risk factors for first onset in old age, typical presentations in this age-group, and the response to treatment.

The effect of poststroke cognitive impairment on rehabilitation process and functional outcome

OBJECTIVES

To determine whether cognitive impairment affects access to, or quality of, rehabilitation services, and to examine the effects of functional outcomes in stroke patients.

DESIGN

Secondary analysis of prospective cohort of stroke patients followed for 6 months after stroke.

SETTINGS

Eleven large-volume US Department of Veterans Affairs hospitals nationwide.

PARTICIPANTS

Stroke patients (N=272) who were candidates for rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation process variables were examined for patients assessed as cognitively impaired or unimpaired according to education-adjusted Mini-Mental State Examination score. Functional outcomes were performance of activities of daily living (ADLs), measured by the FonFIM, and instrumental activities of daily living (IADLs), measured by Lawton, at 6-month follow-up.

RESULTS

Compliance with guidelines and receipt of and interval to postacute treatment initiation did not differ between cognitively impaired and unimpaired patients. Although most cognition-related treatment elements were similar for both groups, cognitive goals were more frequently charted in impaired patients. Controlling for baseline function and rehabilitation process, cognitively impaired patients had worse IADL performance at 6 months than did unimpaired patients; cognition did not significantly influence ADL performance.

CONCLUSIONS

Quality of, and access to, rehabilitative care was equivalent for patients with and without cognitive impairment. Despite a similar rehabilitation process, cognitively impaired stroke patients experienced worse recovery of IADLs.

Depression After Stroke: A Prospective Epidemiological Study

OBJECTIVES

To elucidate the relationship between stroke and depressive symptoms and to determine whether disability or cerebrovascular risk factors mediate that relationship.

DESIGN

A prospective longitudinal epidemiological survey.

SETTING

The mid-Monongahela Valley, a rural, nonfarm, low-socioeconomic-status community.

PARTICIPANTS

Random sample of 1,134 subjects aged 65 and older.

MEASUREMENTS

The dependent variable was clinically significant depressive symptoms, as defined by five or more symptoms on the modified Center for Epidemiological Studies Depression scale. The independent variables were demographics (age, sex, education), stroke, number of impaired instrumental activities of daily living (IADLs), diabetes mellitus, hypertension, atherosclerotic heart disease, and smoking. Logistic regression analyses were conducted for cross-sectional and longitudinal models examining whether stroke was associated with or predicted depressive symptoms, with other associated factors included as covariates.

RESULTS

Clinically significant depressive symptoms were cross-sectionally associated with stroke (odds ratio (OR)=3.5, 95% confidence interval (CI)=1.4-8.3), diabetes mellitus (OR=2.8, 95% CI=1.7-4.6; P</=.05), and IADL impairment (OR=1.6, 95% CI=1.4-1.8; P<.05). Longitudinal analysis demonstrated that stroke (OR=6.3, 95% CI=1.7-23.2) and depressive symptoms at baseline (OR=15, 95% CI=7.7-29.5) predicted subsequent clinically significant depressive symptoms measured 2 years later, whereas education was protective (OR=0.4, 95% CI=0.2-0.8).

CONCLUSION

Stroke survivors have a greatly elevated risk for clinically significant depressive symptoms even 2 or more years after index stroke, independent of functional disability, cerebrovascular risk factors, and previous depressive symptoms.

Clinical features of MRI-defined subcortical vascular disease

BACKGROUND AND PURPOSE

Vascular cognitive impairment and vascular dementia are now seen to extend much beyond the traditional multi-infarct dementia.A more homogeneous subtype is the subcortical ischemic vascular disease (SIVD). We applied magnetic resonance imaging (MRI) criteria based on research criteria for SIVD in a large cohort of patients with ischemic stroke. We compared clinical features of patients with SIVD and patients with other stroke type.

SUBJECT AND METHODS

The study group comprised 337 of 486 consecutive patients aged 55 to 85 years who 3 months after ischemic stroke completed a comprehensive neuropsychological test battery and MRI, including structured medical, neurologic, and laboratory evaluations; clinical mental status examination; interview of a knowledgeable informant; detailed history of risk factors; and evaluation of stroke type, localization, and syndrome.

RESULTS

Patients with SIVD (n = 86) more often had a history of progressive cognitive decline (22.8% vs. 6.9%, P = 0.0002), walking disorder before stroke (27.9% vs. 2.0%, P = 0.02), and urinary difficulties (12.8% vs. 5.6%, P = 0.028) in comparison with patients with other stroke type (n = 251). Of the study population, 107 (31.8%) had DSM-III dementia. The patients with SIVD more often had DSM-III dementia (40.7% vs. 28.7%, P = 0.04), had less severe stroke as measured by Scandinavian Stroke Scale (56.6 vs. 55.1, P = 0.03), were more dependent in activities of daily living (ADL) functions as measured by FAQ scale (8.9 vs. 5.4, P = 0.001), were more dependent in instrumental activities of daily living (IADL) functions as measured by the Lawton scale (5.5 vs. 6.3, P = 0.01), and were more depressed as measured by the Beck Depression Inventory (11.8 vs. 8.4, P = 0.0003) poststroke than the patients without SIVD. The main cognitive domain that differentiated the patients with SIVD from those without was executive dysfunction (51.2% vs. 38.7%, P = 0.04). According to multiple regression model, apractic-atactic gait disorder (odds ratio 2.82, 95% confidence interval 1.21-6.53), ADL functions (odds ratio 1.04, 95% confidence interval 1.01-1.08), and the Beck Depression Inventory (odds ratio 1.05, 95% confidence interval 1.02-1.09) related to SIVD.

CONCLUSIONS

The most significant clinical features of MRI-defined SIVD were found to be apractic-atactic gait, impaired ADL functions, and depression.

MRI correlates of executive dysfunction in patients with ischaemic stroke

Executive dysfunction (ED) may lead to problem behaviour and impaired activities of daily living in many neuropsychiatric disorders, but the neuroanatomical correlates of ED are still not well known. Different aspects of executive functions were studied by widely used neuropsychological tests in 214 elderly patients 3 months after ischaemic stroke, and a sum score of eight different measures was counted in each patient. The number and site of brain infarcts as well as severity and location of white matter lesions (WMLs) and brain atrophy on magnetic resonance imaging were recorded and compared between patients with and without ED. ED was present in 73 (34.1%) of the 214 patients. The mean frequency of brain infarcts in the brain and in the left hemisphere was higher in the patients with ED. Lesions affecting the frontal-subcortical circuits (e.g. pallidum, corona radiata or centrum semiovale) were more frequent in patients with ED than in those without. Also, patients with pontine brain infarcts frequently had ED, but this may have been due to more extensive ischaemic changes in these patients in general. Mean number of brain infarcts affecting the pons and posterior centrum semiovale on the left side, moderate to severe medial temporal atrophy, the Fazekas white matter score, the Mini-Mental State Examination score and low education were independent correlates of ED. Brain infarcts and WML affecting the frontal-subcortical circuits or the pons may increase risk for ED in stroke patients.

Focal and lateralized subcortical abnormalities in unipolar major depressive disorder: an automated multivoxel proton magnetic resonance spectroscopy study

BACKGROUND

The results of prior proton magnetic resonance spectroscopy ((1)H-MRS) studies in unipolar major depressive disorder (MDD) evaluating choline (Cho)/creatine (Cr) and N-acetyl-L-aspartate (NAA)/Cr ratios are mixed. These single-voxel or one-dimensional chemical-shift imaging (CSI) nonautomated (1)H-MRS studies has been unable to evaluate global or lateralized abnormalities in neuronal or membrane function. Using automated multivoxel two-dimensional CSI (1)H-MRS techniques, we tested the hypothesis that patients with MDD have focal neuronal and membrane abnormalities localized in the subcortical region.

METHODS

Whole brain and subcortical measures of Cho, NAA, Cr, and myo-inositol (mI) were obtained in 18 patients with MDD and 20 control subjects using automated two-dimensional CSI (1)H-MRS.

RESULTS

Compared with control subjects, MDD patients had a significantly lower mean NAA/Cr amplitude in the caudate and a significantly higher mean Cho/Cr amplitude in the putamen, particularly on the right side. No differences were observed for global whole brain measurements.

CONCLUSIONS

The findings support reduced neuronal viability or function in the caudate and altered membrane phospholipid metabolism in the putamen for patients with MDD. Our results are consistent with prior magnetic resonance imaging, positron emission tomography, and postmortem reports of focal and lateralized abnormalities of the basal ganglia in MDD.

Poststroke depression: prevalence, diagnosis, treatment, and disease progression

In recent years, poststroke depression has attracted worldwide interest. This review focuses on the major research themes that have emerged. Pooled data from studies conducted throughout the world have found prevalence rates for major depression of 19.3% among hospitalized patients and 23.3% among outpatient samples. The diagnosis of poststroke depression is most appropriately based on a structured mental state exam and DSM-IV criteria for depression due to stroke with major depressive-like episode or depressive features. Rarely, poststroke patients may also develop bipolar mood disorder. The treatment of poststroke depression has been examined in several placebo-controlled randomized clinical trials with both nortriptyline and citalopram showing efficacy. The progression of recovery following stroke can be altered by treating depression, which has been shown to improve recovery in activities of daily living and cognitive impairment and to decrease mortality. In addition, two studies have demonstrated that poststroke depression can be prevented using antidepressant medication, which also decreases the frequency of associated physical illness. Furthermore, two studies have shown that premorbid depression can significantly increase the risk of stroke over the subsequent 10-15 years. The mechanisms underlying the association of cerebrovascular diseases and mood disorder are important areas for future investigation.

[Health-related quality of life assessed by EuroQol in caregivers of home care stroke patients]

The purpose of this study was to identify significant factors influencing health-related quality of life (HRQOL) of caregivers for home care patients with stroke. Subjects were 150 caregivers and 167 stroke patients who required help in activities of daily living (ADL) after discharge. HRQOL of caregivers and patients was assessed using a EuroQol utility score obtained by mailed questionnaire. The questionnaire also included the following items; caregiver's relationship to the patient, age, nursing care hours, family support, patient's functional changes after discharge, stroke recurrence, ADL, public nursing care insurance, care levels, and number of services patients received. The mean QOL score of 0.82 +/- 0.18 for caregivers was significantly higher than that of 0.57 +/- 0.20 for patients. Multiple regression analysis revealed that the significant factors influencing caregiver's QOL were caregiver's age and family support for caregivers, and anxious/depressed state, pain/discomfort state, and failure of memory of the patients. In addition, a significant correlation of QOL score was observed between patients and caregivers in the pain/discomfort and anxious/depressed states. The results of our study suggested that the alleviation of the patient's depressive state after stroke and the family's active support to caregivers played an important role for improving caregiver's QOL.

[Neurorehabilitation after stroke]

After stroke most patients need to undergo extensive neurological and neuropsychological rehabilitation (neurorehabilitation). It is important to have an individual treatment programme that takes into account that the stroke patient is impaired in terms of his receptive skills, his capacity to act and his personal integrity. Based on the "phase model" of the Austrian Society for Neurological Rehabilitation (OGNR) individual goals have to be agreed and measures have to be taken. After maintaining the vital functions and a stable vegetative state, the remaining abilities have to be stimulated, functions have to be regained and deficits have to be compensated. An interdisciplinary neurological rehabilitation team has, for example, the following responsibilities: treatment of impaired motor skills and balance, treatment of swallowing and breathing impairments, training of activities of daily living, and special concepts for the treatment of cognitive deficits and impaired behaviour. A decisive factor for rehabilitation success is the relationship between therapists and patients and their relatives/carers. Preparation for independent or care-managed life after inpatient rehabilitation is of paramount importance, this means organization of continuing out-patient treatment, out-patient care management, as well as measurement and documentation of rehabilitation success. Regaining quality of life is an active process of analysing and working on the remaining activity limitations and participation restrictions in society. The work of the interdisciplinary neurological rehabilitation team contributes decisively to this process.

[Post-stroke depression]

The frequency of post-stroke depression (PSD) was evaluated in an ischemic stroke cohort four weeks after onset, and the relationship between self-rating depression scale (SDS)/and infarct size, number and location of the ischemic brain lesions was also studied. The effects of a newly developed antidepressant SSRI (selective serotonin reuptake inhibitor), fluvoxamine maleate, on PSD and cerebral blood flow (CBF) was investigated in other ischemic stroke patients. The frequency of patients who had more than 40 on SDS score was 46% (18/39), and that of patients who had more than 50 was 13% (5/39). There were no differences in SDS score in infarct size, number and location of ischemic brain lesions, however there were significant differences in the lesion side. The score of the patients who had lesions in the left hemisphere was significantly higher than that of those who had them in the right. Administration of fluvoxamine maleate for four weeks improved the score on the Hamilton rating scale for depression (HAM-D) from 16.6 +/- 4.7 (n = 5) to 8.4 +/- 4.3 (n = 5), however it did not influence the mean cortical CBF. This study shows that the patients frequently had depression after ischemic stroke, and that left side lesion had a significant relationship with PSD. Therefore it is important that psychiatric examination of post-stroke patients is conducted. This study also shows that a newly developed antidepressant, fluvoxamine maleate, was effective for PSD.

Behavioral symptoms in vascular cognitive impairment and vascular dementia

Noncognitive or behavioral and psychological symptoms (BPSD) are common in vascular dementia. Many occur with the same frequency as in Alzheimer's disease, though depression, emotional lability, and apathy may be more common and psychosis less so. There is a particularly strong relationship between cerebrovascular disease and depression.

Post stroke depression: epidemiology, pathophysiology, and biological treatment

Depression is a common occurrence after stroke and is associated with excess disability, cognitive impairment, and mortality. The authors undertook a systematic review of the English language literature to review several aspects of this illness, including the prevalence of this disorder, the debate on its etiology, and the current understanding of the biological treatment of poststroke depression. Methodological problems encountered in the study of poststroke depression are highlighted throughout the manuscript. The authors conclude that the available evidence supports poststroke depression as being multifactorial in origin and consistent with the biopsychosocial model of mental illness.

Previous stroke but not vascular risk factors are associated with depression in a cognitively impaired older Korean population

BACKGROUND

Depression is frequently associated with dementia and mild cognitive impairment. Cerebrovascular disease may be an important aetiological factor for depression in the context of cognitive impairment but has received little investigation in population-based research.

OBJECTIVES

To investigate the association between vascular disease/risk and depression in an older Korean population with cognitive impairment.

METHODS

The sample consisted of 341 persons, drawn from a community study in Kwangju, South Korea, all aged 65 or over and with scores of 24 or below on the Korean version of the Mini-Mental State Examination. Depression (Hamilton Rating Scale for Depression), vascular disease/risk (interview, examination and blood tests), and disablement were ascertained.

RESULTS

Previous stroke was associated with depression (Odds Ratio 3.4, 95% Confidence Intervals 1.6-7.4). This association was weaker in the presence of more severe cognitive impairment and higher levels of dependency. No associations were found between depression and any other measures of vascular risk.

CONCLUSIONS

In the absence of previous stroke, a role of vascular disease/risk was not supported in the aetiology late-life depression.

Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 1: Diagnosis, frequency and impact

BACKGROUND

Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to explore the available evidence on which to base an integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting. It is divided into two parts.

AIMS AND OBJECTIVES

In part 1 we review the frequency of depression in stroke and its impact on functional recovery. Also the different methods for diagnosis and measurement.

METHODS

Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews.

MAIN FINDINGS

PSD is common and is associated with cognitive, functional and social deficits which potentially limit the outcome from rehabilitation. However, diversity of assessment tools and diagnostic criteria confound assimilation of the available literature. The Beck Depression Inventory (BDI), Hamilton Depression Rating Scale and Zung Self-rating Depression Scale were most commonly used and have demonstrable validity in stroke patients but tend to exclude those with aphasia. Instruments developed specifically to include aphasic patients, such as the Stroke Aphasic Depression Scale, are promising but have yet to be fully evaluated.

CONCLUSIONS

Further work is required to adapt and evaluate instruments to measure depression in the context of stroke. Development of an integrated care pathway may help to establish a more consistent approach to assessment and diagnosis of PSD.

Post-stroke depression, executive dysfunction and functional outcome

The early diagnosis of vascular cognitive impairment has been challenged and executive control function has been suggested to be a rational basis for the diagnosis of vascular dementia. We sought to examine the correlates of executive dysfunction in a well-defined stroke cohort. A group of 256 patients from a consecutive cohort of 486 patients with ischaemic stroke, aged 55-85 years, was subjected to a comprehensive neuropsychological examination 3-4 months after ischaemic stroke and 188 of them in addition to detailed psychiatric examination. Basic and complex activities of daily living (ADLs) (bADLs and cADLs) post-stroke were assessed. The DSM-III-R criteria were used for the diagnosis of the depressive disorders. Altogether 40.6% (n=104) of the patients had executive dysfunction. The patients with executive dysfunction were older, had lower level of education, were more often dependent, did worse in bADLs and cADLs, had more often DSM-III dementia, had worse cognition as measured by Mini Mental State Examination (MMSE) and were more depressed as measured by the BECK depression scale, but not with the more detailed psychiatric evaluation. They had more often stroke in the anterior circulation and less often in the posterior circulation. The independent correlates of executive dysfunction were cADLs (OR 1.1, 95% CI 1.03-1.16), each point of worsening in cognition by MMSE (OR 1.7, 95% CI 1.42-1.97) and stroke in the posterior circulation area (OR 0.4, 95% CI 0.18-0.84). Clinically significant executive dysfunction is frequent after ischaemic stroke and is closely connected with cADLs and to overall cognitive status but could be distinguished from depression by detailed neuropsychological examination. Executive measures may detect patients at risk of dementia and disability post-stroke.

Psychosocial risk factors in poststroke depression: a systematic review

OBJECTIVE

To review systematically the psychosocial risk factors for poststroke depression.

METHODS

Medline was searched using the key words "poststroke depression" (PSD) for the period January 1, 1966, to June 30, 2000; using the key words "cerebrovascular disease" and "depression" it was searched from June 1, 1996, to June 30, 2000. Corollary articles were obtained from the bibliographies. Inclusion criteria were as follows: original research in French or English; prospective, case-control or cross-sectional study design; assessment of PSD in the first 6 months following the stroke; an acceptable definition of depression; an acceptable definition of stroke; and at least one psychosocial risk factor. Interrater reliability was tested for the selection and quality of the articles. A qualitative risk factor analysis was conducted.

RESULTS

The risk factors most consistently associated with PSD are a past history of depression, past personal psychiatric history, dysphasia, functional impairments, living alone, and poststroke social isolation. Risk factors not associated with PSD are dementia and cognitive impairment. Controversial risk factors are age, socioeconomic status (SES), prior social distress, dependency in regard to activities of daily living (ADL), and sex.

CONCLUSIONS

Over approximately 30 years, some 25 qualitative studies have addressed psychosocial risk factors for PSD. Further studies should aim for quantitative analysis. The results suggest that identifying psychiatric history and preventing social deterioration and impairment should be part of multidisciplinary efforts to care for poststroke patients.

Abulia and cognitive impairment in two patients with capsular genu infarct

BACKGROUND

An internal capsule genu infarct has been rarely reported to cause cognitive impairment and behavioral changes. This clinical picture can be explained on anatomical and functional basis because important subcortical-cortical pathways traverse the internal capsule genu. We report 2 previously non-demented patients who developed acute confusional state, abulia, and moderate cognitive decline after the occurrence of an infarct in the capsular genu.

METHODS

Clinical, neuropsychological, and MRI evaluation at baseline and 12-month follow-up.

RESULTS

Abulia and cognitive impairment were still present 1 year after stroke. In 1 patient there were associated multiple lacunar infarcts and leukoaraiosis. In the other an old small left frontal infarct was also present. In both moderate cortical atrophy co-existed.

CONCLUSIONS

We hypothesize that co-existing lesions, possibly associated with a sub-clinical reduction of cognitive functions, facilitate the development of a persistent clinically evident mental deficit after the occurrence of an infarct in the capsular genu.

Depression is an independent predictor of poor long-term functional outcome post-stroke

The influence of depression on the long-term outcome of stroke patients was examined among 390 of 486 consecutive patients aged 55-85 years. They completed, at 3 months after ischaemic stroke, a detailed medical, neurological, and radiological stroke evaluation, structured measures of emotion (Beck's Depression Inventory, BDI), handicap (Rankin scale, RS), and assessment of activities of daily living (Barthel Index, BI). Further RS and BI was evaluated at 15-month follow-up from these 390 patients and BDI in 276 patients. A group of 256 patients completed, in addition to the 15-month follow-up, a comprehensive psychiatric evaluation, including the Present State Examination 3 months after stroke. The DSM-III-R criteria were used for diagnosis of the depressive disorders. BDI identified depression (cut-off point > or = 10 for depression) in 171 (43.9%) of 390 and in 123 (44.6%) of 276 patients at 3- and 15-month follow-up. DSM-III-R major depression was diagnosed in 66 (25.8%), and minor depression in 32 (12.5%), of 256 patients 3 months after stroke. Patients with BDI > or = 10, or major, but not minor, depression more often had poor functional outcome (RS > II and BI < 17) at 15 months. Poor functional outcome at 3 months also correlated with depression at 15 months. In logistic regression analysis, depression at 3 months (Beck > or = 10) correlated with poor functional outcome at 15 months (RS > II) (OR 2.5, 95% CI 1.6-3.8). More careful examination and treatment of depression in stroke patients is emphasized.

Post stroke depression

Depression following stroke is common. Although it is highlighted as an issue in stroke guidelines, guidance on diagnosis or management is not given. This paper presents the original research from a literature review of Medline and the Cochrane Database on stroke and depression, and discusses some of the clinical implications of the findings.

Research into the specificity of depression after stroke: a review on an unresolved issue

Iwo decades of research have failed to generate consistent insight into the specificity of poststroke depression (PSD). This is, at least in part, caused by methodological difficulties. Differences in symptom profile between PSD and depression with no or another medical cause were described, but no specific and unequivocal clinical picture has been established so far. Prevalence rates of PSD varied largely between studies. In community based studies using standardised diagnostic instruments for depression, relatively low prevalence rates were reported compared to inpatient or rehabilitation studies. PSD occurs most frequently in the first few months after stroke, while a new incidence peak may occur 2-3 years after stroke. Two systematic reviews on the relation between lesion location and depression did not support the claim that left hemisphere lesions are a risk factor for PSD. A new concept of vascular depression has been proposed, which relates depression in the elderly to acute or chronic damage to the cerebral vascular system. Future efforts should aim at increasing the uniformity of study designs, assessment tools should be further improved for use in cognitively impaired patients and appropriate control groups should be defined to study the characteristic features of PSD.

Stroke, vascular risk factors and depression: Cross-sectional study in a UK Caribbean-born population

BACKGROUND

Stroke, hypertension and diabetes are common in older Caribbean-born populations in the UK who may be at risk of depression secondary to vascular disease.

AIMS

We examined the association between stroke, vascular risk factors and depression in a community-based Caribbean-born population aged 55-75 years.

METHOD

Vascular risk factors were identified by interview, examination and blood tests. Depression was categorised using the Geriatric Depression Scale. Disablement was assessed as a potential mediating factor.

RESULTS

Physical illness and disablement were strongly associated with depression, independent of disablement. Previous stroke was associated with depression, independent of disablement. No vascular risk factors were associated with depression.

CONCLUSIONS

The risk of depression associated with stroke was not explained by disablement. However, the hypothesis that vascular risk factors are important in the genesis of depression was not supported.