Post-stroke depression: Mechanisms and pharmacological treatment

Association between Geriatric Nutritional Risk Index and Depression after Ischemic Stroke

Background: Malnutrition is associated with poor outcomes after stroke. However, the association between malnutrition and post-stroke depression (PSD) remains unelucidated. We aimed to explore the association between geriatric nutritional risk index (GNRI) and depression after ischemic stroke. Methods: In total, 344 patients with ischemic stroke were included in this analysis. The GNRI was calculated from serum albumin level, weight, and height at admission. Malnutrition was defined using the GNRI cutoff points. A lower GNRI score indicates an elevated nutritional risk. The outcome was depression, measured 14 days after ischemic stroke. Logistic regression models were used to estimate the association between the GNRI and risk of PSD. Results: A total of 22.9% developed PSD 14 days after stroke. The mean GNRI was 99.3 ± 6.0, and 53.8% of the patients had malnutrition. After adjusting for covariates, baseline malnutrition was not associated with risk of PSD (OR, 0.670; 95%CI, 0.370–1.213; p = 0.186). The restricted cubic splines revealed a U-shaped association between the GNRI and PSD. Compared to moderate GNRI, higher GNRI (OR, 2.368; 95%CI, 0.983–5.701; p = 0.085) or lower GNRI (OR, 2.226; 95%CI, 0.890–5.563; p = 0.087) did not significantly increase the risk of PSD. Conclusion: A low GNRI was not associated with an increased risk of depression after ischemic stroke.

Peripheral blood and urine metabolites and biological functions in post-stroke depression

Post-stroke depression (PSD) is the most common and severe neuropsychiatric complication after stroke. However, the molecular mechanism of PSD is still unclear. Previous studies have identified peripheral blood and urine metabolites associated with PSD using metabolomics techniques. We searched and systematically summarized metabolites that may be involved in metabolic changes in peripheral blood and urine of patients with PSD from the Metabolite Network of Depression Database (MENDA) and other biomedical databases. MetaboAnalyst5.0 software was used for pathway analysis and enrichment analysis of differential metabolites, and subgroup analyses were performed according to tissue types and metabolomics techniques. We identified 47 metabolites that were differentially expressed between patients with and without PSD. Five differential metabolites were found in both plasma and urine, including L-glutamic acid, pyroglutamic acid, palmitic acid, L-phenylalanine, and L-tyrosine. We integrated these metabolites into metabolic pathways, and six pathways were significantly altered. These pathways could be roughly divided into three modules including amino acid metabolism, nucleotide metabolism, and glucose metabolism. Among them, the most significantly altered pathway was "phenylalanine metabolism" and the pathway containing the most associated metabolites was "aminoacyl-tRNA biosynthesis", which deserve further study to elucidate their role in the molecular mechanism of PSD. In summary, metabolic changes in peripheral blood and urine are associated with PSD, especially the disruption of "phenylalanine metabolism" and "aminoacyl-tRNA biosynthesis" pathways. This study provides clues to the metabolic characteristics of patients with PSD, which may help to elucidate the molecular pathogenesis of PSD.

Symptomatic plaque enhancement is associated with early-onset post-stroke depression

BACKGROUND

The association between imaging features closely associated with symptomatic intracranial atherosclerotic plaques and early-onset post-stroke depression (PSD) is currently unclear.

MATERIALS AND METHODS

76 ischemic stroke patients who underwent high-resolution vessel wall magnetic resonance imaging (HR-VWI) were divided into PSD and non-PSD groups according to their DSM-V diagnoses and HAMD-17 scores at 14 days after onset. Clinical data and the imaging features associated with symptomatic plaques (including the enhancement index (EI), remodeling index, and plaque surface irregularity) were compared between groups. Multifactorial logistic regression analysis was used to find independent predictors of early-onset PSD. Spearman rank correlation analysis explores the association between clinical data, symptomatic plaque imaging features, and HAMD-17 in patients.

RESULTS

The sample comprised 36 patients with early-onset PSD. The symptomatic plaque EI and infarct volume were significantly higher in depressed patients than in patients without depression (P < 0.05). Multivariate logistic regression showed that symptomatic plaque EI could be used as an independent predictor of early-onset PSD after correcting for the confounding factor of infarct volume (OR = 1.034, 95% CI:1.014-1.055, P = 0.001). In the total sample, symptomatic plaque EI, infarct volume, and HAMD-17 had a significant positive correlation with each other (P < 0.05).

LIMITATIONS

This study focused only on the patients' symptomatic plaques and did not monitor patients' systemic inflammation levels at the time of HR-VWI.

CONCLUSIONS

The degree of symptomatic plaque enhancement is an independent predictive imaging marker of early-onset PSD and can be used the early diagnosis of early-onset PSD.

Natural Products for the Treatment of Post-stroke Depression

Post-stroke depression (PSD) is the most frequent and important neuropsychiatric consequence of stroke. It is strongly associated with exacerbated deterioration of functional recovery, physical and cognitive recoveries, and quality of life. However, its mechanism is remarkably complicated, including the neurotransmitters hypothesis (which consists of a monoaminergic hypothesis and glutamate-mediated excitotoxicity hypothesis), inflammation hypothesis, dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, and neurotrophic hypothesis and neuroplasticity. So far, the underlying pathogenesis of PSD has not been clearly defined yet. At present, selective serotonin reuptake inhibitors (SSRIs) have been used as the first-line drugs to treat patients with PSD. Additionally, more than SSRIs, a majority of the current antidepressants complied with multiple side effects, which limits their clinical application. Currently, a wide variety of studies revealed the therapeutic potential of natural products in the management of several diseases, especially PSD, with minor side effects. Accordingly, in our present review, we aim to summarize the therapeutic targets of these compounds and their potential role in-clinic therapy for patients with PSD.

Efficacy and Safety of Xiaoyao Recipe in the Treatment of Poststroke Depression: A Systematic Review and Meta-Analysis

Background

Poststroke depression (PSD) is a common neuropsychiatric disorder that affects the disability, mortality, functional recovery, and quality of daily life of patients. Xiaoyao Recipe (XYR) is often used to treat PSD and has achieved good clinical effects, but it lacks reliable evidence.

Objective

This study aims to evaluate the effectiveness and safety of XYR on PSD through meta-analysis.

Methods

A comprehensive literature search was carried out in multiple databases, including PubMed, the Cochrane Library, Chinese Biomedical Literature Service System, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and ClinicalTrials, from inception to July 1, 2021, to collect randomized controlled trials that applied XYR for patients with PSD. For a controlled trial, the search time limit was set from the time of the database's establishment to July 2021. Two experienced researchers independently screened the literature according to the inclusion and exclusion criteria, extracted data, evaluated the quality of the literature, and used RevMan 5.3 software for meta-analysis.

Results

A total of 12 studies were included in this study, involving 882 patients with PSD who were hospitalized or outpatients. The meta-analysis results showed that the total effective rate (p < 0.00001) of the test group (XYR or XYR combined with antidepressants) after treatment was high; Hamilton's Depression Scale score (p < 0.000001), Scandinavian Stroke Scale score (p=0.004 < 0.05), and Barthel index (p < 0.00001) were improved; the incidence of adverse reactions (p < 0.00001) was low; and the serum serotonin content (p < 0.00001) was high.

Conclusion

Compared with antidepressant drugs, XYR is more effective and safer in the treatment of PSD patients. However, more high-quality studies are needed to further support the above conclusions.

Alteration of Glycerophospholipid Metabolism in Hippocampus of Post-stroke Depression Rats

Post-stroke depression (PSD) is the most common mental disorder in stroke survivors. However, its specific pathophysiology remains largely unknown. Previous studies suggested a role of hippocampus in PSD. Therefore, we conducted this study to investigate the lipid metabolic signatures in hippocampus of PSD rats. Here, the liquid chromatography mass spectrometry was used to identify the lipid metabolic signatures in the hippocampus of PSD, control and stroke rats. Then, correlations between behavior indices and differential lipid metabolites in PSD rats were explored. Pathway and enrichment analysis were further conducted to uncover the crucial metabolic pathways related to PSD. Finally, we found that the lipid metabolic phenotype in hippocampus of PSD rats was substantially different from that in control and stroke rats, and identified 50 key lipid metabolites that were significantly decreased in PSD rats. These differential metabolites were mainly involved in glycerophospholipid metabolism. Meanwhile, the sucrose preference and immobility time were found to be significantly positively and negatively, respectively, correlated with glycerophospholipid metabolites. The pathway and enrichment analysis showed that the glycerophospholipid metabolism, especially cardiolipin metabolism, was significantly disturbed in PSD rats. These results suggested that the down-regulated glycerophospholipids in hippocampus, especially cardiolipin, might participate in the pathophysiology of PSD. Our findings would be helpful for future exploring the pathophysiology of PSD.

Prediction of Poststroke Depression Based on the Outcomes of Machine Learning Algorithms

Poststroke depression (PSD) is a major psychiatric disorder that develops after stroke; however, whether PSD treatment improves cognitive and functional impairments is not clearly understood. We reviewed data from 31 subjects with PSD and 34 age-matched controls without PSD; all subjects underwent neurological, cognitive, and functional assessments, including the National Institutes of Health Stroke Scale (NIHSS), the Korean version of the Mini-Mental Status Examination (K-MMSE), computerized neurocognitive test (CNT), the Korean version of the Modified Barthel Index (K-MBI), and functional independence measure (FIM) at admission to the rehabilitation unit in the subacute stage following stroke and 4 weeks after initial assessments. Machine learning methods, such as support vector machine, k-nearest neighbors, random forest, voting ensemble models, and statistical analysis using logistic regression were performed. PSD was successfully predicted using a support vector machine with a radial basis function kernel function (area under curve (AUC) = 0.711, accuracy = 0.700). PSD prognoses could be predicted using a support vector machine linear algorithm (AUC = 0.830, accuracy = 0.771). The statistical method did not have a better AUC than that of machine learning algorithms. We concluded that the occurrence and prognosis of PSD in stroke patients can be predicted effectively based on patients' cognitive and functional statuses using machine learning algorithms.

miR-129-5p targets FEZ1/SCOC/ULK1/NBR1 complex to restore neuronal function in mice with post-stroke depression

Post-stroke depression (PSD) seriously affects the normal life of patients. Based on the previous sequencing results, this study selected miR-129-5p as the research object, which was significantly reduced in the PSD model by screening. To clarify the regulatory role of miR-129-5p, this study overexpressed and interfered with miR-129-5p in neuronal cells cultured in vitro, tested its effect on neuronal cell autophagy, and determined expressions of fasciculation and elongation protein zeta-1 (FEZ1), short coiled-coil protein (SCOC), unc-51 like autophagy activating kinase 1 (ULK1) and autophagy cargo receptor (NBR1) autophagy-related proteins. The dual-luciferase reporter system and immunoprecipitation were applied to detect the molecular regulatory mechanism of miR-129-5 and FEZ1, SCOC, ULK1 and NBR1. Findings of the present study revealed that the autophagy of neuronal cells was markedly decreased by overexpressing miR-129-5p (p < 0.05), and expressions of FEZ1, SCOC, ULK1 and NBR1 were substantially reduced (p < 0.05). The dual-luciferase reporter system results indicated that FEZ1, SCOC, ULK1 and NBR1 were all miR-129-5p target genes. Furthermore, immunoprecipitation assay revealed that SCOC, ULK1 and NBR1 could directly bind to the FEZ1 protein. The experiments at an animal level demonstrated that miR-129-5p could effectively alleviate the behavioral indicators of PSD model mice. Taken together, this study testified that SCOC/ULK1/NBR1 proteins could directly bind to FEZ1 to form protein complex, and all of the four proteins FEZ1/SCOC/ULK1/NBR1 were miR-129-5p target genes. miR-129-5p overexpression could effectively restore the behavioral characteristics of model mice, and reduce the autophagy-related proteins FEZ1/SCOC/ULK1/NBR1.

Nano-Hydrogel for the Treatment of Depression and Epilepsy

This article first combines nano-carrier technology, the electrophysiological mechanism of seizures, and brain targeting technology to prepare new nano-hydrogels. Secondly, through the discharge information generated during the seizure and the electric field responsiveness of the nano-hydrogel, the free drug concentration in the brain area related to the seizure is increased, thereby, limiting the abnormal discharge of the focus to the local area and suppressing it in time. Finally, this article examines the impact of nano-hydrogel on the epilepsy and depression using relevant studies. The experimental observations revealed that the yield of the nano-hydrogel synthesized after 24 h of sapon-free emulsion polymerization was 50 to 70%, the swelling rate was 400 to 1700%, and the viscosity of the 20 mg/mL nano-hydrogel dispersion was 3.9 to 17.0 mPa· s. Furthermore, because the total efficiency was 0.952, the nano-hydrogels have a reduced recurrence rate and a better effect on the depression improvement.

Higher Concentration of Adrenocorticotropic Hormone Predicts Post-Stroke Depression

Background

Post-stroke depression (PSD) is the most common neuropsychiatric complication after stroke, seriously affecting the quality of survivors’ life. As one of the important causes of PSD, neuroendocrine mechanism has been widely studied in recent years. The main objective of this study was to investigate the relationship between adrenocorticotropic hormone (ACTH) on admission and PSD at 3 months.

Methods

This is a hospital-based prospective cohort study, which was conducted at three independent hospitals (Tongji Hospital, Wuhan First Hospital and Wuhan Central Hospital) between August 2018 and June 2019. A total of 768 ischemic stroke patients were finally eligible for analysis and categorized into equal tertiles according to the distribution of ACTH and the number of patients. The χ²-test, Mann–Whitney U-test and Kruskal–Wallis test were used to check for statistical significance. And restricted cubic spline (RCS) regression model was used to explore the non-linear relationship between continuous ACTH levels and PSD at 3 months.

Results

The optimal cut-off points of ACTH were as follows: (T1) 0.32–20.55 pg/mL, (T2) 20.56–39.79 pg/mL, (T3) 39.80–143.40 pg/mL. A total of 305 patients (39.7%) were diagnosed as PSD at 3 months follow-up. Significant differences were found between the PSD and non-PSD groups in ACTH concentration (P = 0.001). After adjustment for all conventional confounders, the odds ratios of PSD were 1.735 (95% CI = 1.176–2.560, P = 0.005) for the highest tertile of ACTH and 1.496 (95% CI = 1.019–2.194, P = 0.040) for the middle tertile of ACTH, as compared with the lowest tertile. In multiple-adjusted RCS regression, continuous ACTH showed saturation effect relation with PSD risk after 31.02 pg/mL (P for nonlinear = 0.0143).

Conclusion

Higher ACTH level on admission is a significant and independent biomarker to predict the development of PSD at 3 months follow-up. Besides, saturation effect was revealed even if the underlying mechanism is unclear. For stroke patients, doctors should pay attention to the baseline ACTH for screening high-risk PSD in clinical practice.

Thyroid Function Affects the Risk of Post-stroke Depression in Patients With Acute Lacunar Stroke

Objective

This study aimed to investigate whether thyroid function profiles are associated with post-stroke depression (PSD) and evaluate the mediation effect of cerebral small vessel disease (cSVD) on the association of thyroid function profiles and PSD in patients with acute ischemic lacunar stroke.

Methods

In this study, 372 patients with confirmed acute ischemic lacunar stroke within 3 days of onset were consecutively recruited. Serum levels of thyroid hormones and thyroid antibodies were detected on admission. Lacunar infarcts, white matter lesions, cerebral microbleeds, and enlarged perivascular spaces were rated using validated scales. The severity of depression was scored with the 24-item Hamilton Depression Scale in the hospital after a week of stroke onset. Multivariate regression was utilized to analyze the association of thyroid function profiles and PSD. Mediation analysis was employed to evaluate the effect of cSVD on the association of thyroid function profiles and PSD.

Results

A total of 87 (23.4%) participants were diagnosed with depression after stroke. Serum thyroid-stimulating hormone (TSH) levels were significantly higher in patients with PSD than in those without PSD, while free triiodothyronine (FT3) and free thyroxine (FT4) were not significantly different between the two groups. After adjusting for potential confounders, serum TSH levels were positively associated with the risk of PSD (OR = 1.228; 95% CI: 1.053–1.431, p = 0.009). A similar association was also found between the total cSVD burden score and PSD (OR = 2.137; 95% CI: 1.634–2.793, p < 0.001). Further mediation analysis indicated that 26.37% of the association between TSH and PSD was mediated by cSVD.

Conclusions

Serum TSH levels on admission can probably predict depression after acute ischemic lacunar stroke.

The association between depression and chronic lower back pain from disc degeneration and herniation of the lumbar spine

Chronic lower back pain induced by lumbar disc degeneration or herniation exerts a great impact on patients' daily lives. Depression and anxiety often exist among patients with lower back pain. Some studies mentioned about mechanisms, such as inflammatory biomarkers, which are commonly seen in herniated intervertebral disc (HIVD) and major depressive disorder (MDD). Method: Our study used a large database from the National Health Insurance to explore the incidence rate of MDD in patients with HIVD and correlated risk factors. A total of 41,874 patients with HIVD were included in this work. The control group was matched by using propensity scores. Results: The results showed a temporal association between prior HIVD and subsequent MDD after adjusting for potential confounding factors. Patients with HIVD were at high risk of developing MDD (hazard ratio, HR: 9.00, 95% confidence interval, CI: 7.196-11.257) even after adjusting for demographic characteristics and comorbidities (HR: 8.47, 95% CI: 6.84-10.49, p < 0.0001). Conclusions: The combination of HIVD and MDD represents an important health problem that is associated with higher disability rates, socioeconomic disadvantage, and greater utilization of health care resources. Early detection and combined treatment of depressive symptoms may benefit patients with HIVD.

Effect of immediate blood pressure reduction on post-stroke depression in ischemic stroke patients: A substudy of CATIS trial

BACKGROUND

Several prospective studies have identified that hypertension is an important risk factor of post-stroke depression (PSD). However, the effect of immediate antihypertensive treatment on the risk of PSD in patients with acute ischemic stroke remains unknown.

METHODS

In this prespecified depression substudy of the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) randomized clinical trial, a total of 642 patients with acute ischemic stroke within 48 h of onset and elevated systolic BP at 7 sites of CATIS were included. Patients were randomly assigned to receive antihypertensive treatment (n = 318) or to control group (n = 324). The primary outcome was depression (Hamilton Rating Scale for Depression score≥8) at 3-month posttreatment follow-up.

RESULTS

At 24 h after randomization, the mean systolic BP was reduced by 21.6 mm Hg (12.5%) in the treatment group and 13.9 mm Hg (7.9%) in the control group (difference, -7.7 mm Hg [95% CI, -10.2 to -5.2]; P<0.001). The mean systolic BP levels at 7 days (P<0.001) and 14 days (P<0.001) after randomization in treatment group were also significantly lower than those in control group. At 3-month posttreatment follow-up, 122 patients (38.4%) in antihypertensive treatment group and 131 patients (40.4%) in control group developed PSD (odds ratio, 0.92 [95% CI, 0.67 to 1.26]; P = 0.59).

LIMITATIONS

All patients in the CATIS trial were Chinese, which might limit the generalizability of our findings to other populations.

CONCLUSIONS

Early antihypertensive treatment had no effect on the risk of PSD at 3 months among patients with acute ischemic stroke and elevated BP.

Intimate Relationships and Stroke: Piloting a Dyadic Intervention to Improve Depression

Stroke affects not only the survivor but also their romantic partner. Post-stroke depression is common in both partners and can have significant negative consequences, yet few effective interventions are available. The purpose of this study was to pilot test a novel 8-week remotely administered dyadic intervention (ReStoreD) designed to help couples better cope with stroke-related changes and reduce depressive symptoms. Thirty-four cohabitating survivor–partner dyads at least 3 months post-stroke and reporting some changes in mood were enrolled. Depressive symptoms were assessed pre- and post-intervention and at 3-month follow-up. Repeated measures analysis of variance was used to assess the effects of ReStoreD over time on depressive symptoms in stroke survivors and their partners. Twenty-six dyads completed the study. Although statistical significance was not reached, there was a large effect size for improvements in depressive symptoms for stroke survivors. There was no significant improvement for partners, and the effect size was minimal. Those with more significant depressive symptoms at baseline were more likely to benefit from the intervention. This pilot study established proof-of-concept by demonstrating that depressive symptoms can be lessened in stroke survivors and partners with more severe depressive symptoms. Future research will establish the efficacy of the intervention in a fully powered study.

Longitudinal assessment of depression during the first year after stroke: Dimensionality and measurement invariance

OBJECTIVE

Repeated measurement of depression using summative scores of commonly used depression scales assumes that the construct is unidimensional and invariant across time, but little is known about the validity of these assumptions in stroke patients. The study examined the assumptions during the first year after mild to moderate stroke using the 8-item Patient Health Questionnaire (PHQ-8).

METHODS

Data were obtained from the 2014-2016 Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study with longitudinal follow-up in Texas, United States. Depressive symptoms were assessed with the PHQ-8 at 3, 6, and 12 months post-stroke (n = 648, 542, 533, respectively). Dimensionality of the PHQ-8 was examined using exploratory bifactor analysis and confirmatory factor analysis (CFA). Based on a one-factor CFA model, longitudinal measurement invariance was examined by fitting configural, weak, strong and strict invariance models sequentially.

RESULTS

Mean age was 65.6 (SD = 11.2), half were women, and 56.7% were Mexican American. Reliability measures suggested a generally unidimensional construct (Omega Hierarchical: 0.79-0.86), good internal consistency (Cronbach's alpha: 0.84-0.88) and good temporal stability (intraclass correlation coefficient: 0.838). Configural invariance for equality of item-factor structure (RMSEA = 0.038, CFI = 0.982, WRMR = 0.970) was supported. Partial weak invariance for equality of factor loadings (p = 0.11) was supported by chi-square difference tests, whereas full longitudinal invariance was supported by changes in comparative fit index and root mean square error of approximation.

CONCLUSIONS

The findings suggest the PHQ-8 may be a reasonable tool for repeated measurement of depression in stroke patients, and more research on its longitudinal psychometric properties is needed.

Efficacy of acupuncture on cognitive function in poststroke depression: study protocol for a randomized, placebo-controlled trial

INTRODUCTION

Poststroke depression (PSD) is the most common mental complication after stroke and has a serious impact on functional outcomes and quality of life. Antidepressants are the first-line treatment for PSD, but many reported side effects remain. Clinical research has shown that acupuncture has a positive effect on PSD. This trial aims to study the efficacy and safety of acupuncture for PSD and to explore its effect on cognitive function. It is hypothesized that acupuncture treatment improves depressive symptoms, cognitive behavior, and negative emotion processing bias in PSD.

METHODS

In this randomized, placebo-controlled, single-blinded trial, fifty-six people with PSD will be randomly allocated into the intervention (n=28) or control (n=28) groups. The intervention group will receive acupuncture treatment, and the control group will receive sham acupuncture treatment, in 20 sessions over 4 weeks. The primary outcome is the change from baseline in the Hamilton Depression Scale-17 (HAMD-17) scores at week 4. Secondary outcomes include the Wisconsin Card Sorting Test (WCST) and latency and amplitude of P1, N170, and P3 of the event-related potentials (ERPs) components to assess the changes in cognitive function and electroencephalography. Outcomes are assessed at baseline and post intervention.

DISCUSSION

Acupuncture therapy could become an alternative treatment for PSD, and it is expected that this trial will provide reliable clinical evidence for the future use of acupuncture for the treatment of PSD.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900026948 . Registered on 27 October 2019.

Shugan Jieyu Capsule in Post-Stroke Depression Treatment: From Molecules to Systems

Post-stroke depression (PSD) is the most common non-cognitive neuropsychiatric complication after stroke, and about a third of patients with stroke have depression. Although a great deal of effort has been made to treat PSD, the efficacy thereof has not been satisfactory, due to the complex pathological mechanism underlying PSD. In Traditional Chinese Medicine (TCM) theory, PSD is considered to be a combination of “stroke” and “Yu Zheng.” The holistic, multi-drug, and multi-objective nature of TCM is consistent with the treatment concept of systems medicine for PSD. TCM has a very long history of being used to treat depression, and various TCM prescriptions have been clinically proven to be effective in improving depression. Among the numerous prescriptions for treating depression, Shugan Jieyu capsule (SG) is one of the classic prescriptions. Additionally, clinical studies have increasingly confirmed that using SG alone or in combination with Western medicine can significantly improve the psychiatric symptoms of PSD patients. Here, we reviewed the mechanism of antidepressant action of SG and its targets in PSD pathologic systems. This review provides further insights into the pharmacological mechanism, drug interaction, and clinical application of TCM prescriptions, as well as a basis for the development of new drugs to treat PSD.

Anxiety faintly and depression remarkably correlate with recurrence in acute ischemic stroke patients: A study with 3-year longitude evaluation and follow-up

Clinical value of anxiety and depression in acute ischemic stroke (AIS) is rarely studied. Thus, the aim of this study was to explore longitudinal changes of anxiety and depression, as well as their correlation with recurrence in AIS.A total of 120 AIS patients and 120 controls were enrolled in the study. Furthermore, comparison of the hospital anxiety and depression scale (HADS) score or rate between AIS and controls was determined by Mann-Whitney U test or Chi-square test. In AIS patients, change of HADS scores or linear trend of anxiety and depression rate over time were determined by Friedman test or Mantel-Haenszel Chi-square test. Moreover, correlation of anxiety and depression with the recurrence rate was analyzed by log-rank test.HADS for anxiety score, anxiety rate, HADS for depression score and depression rate were all elevated in AIS patients compared with controls (all P < .001). In AIS patients, HADS for anxiety score was elevated from discharged from hospital (M0) to month (M) 36 (P = .027), while anxiety rate was not (P = .107). Besides, HADS-D score and rate were both increased from M0 to M36 (both P < .001). Moreover, accumulating recurrence rate was 6.7%, 11.7%, and 17.5% at 1 year, 2 years, and 3 years, respectively. Additionally, anxiety at M24 (P = .033), depression at M0, M12, M24, and M36 (all P < .05) were all correlated with increased accumulating recurrence rate.Continuous monitoring of anxiety and depression might be beneficial for the management of AIS prognosis.

Effect of the Early Administration of Selective Serotonin Reuptake Inhibitors on the Time Course of Poststroke Fatigue: A 2-Year Longitudinal Study

Background

Poststroke fatigue (PSF) is a dynamic process over time. Current evidence for interventions for PSF is limited. Our study investigated the effects of selective serotonin reuptake inhibitors (SSRIs) on the time course of PSF.

Methods

The patients with acute ischaemic stroke were enrolled in this study. All patients were scored with the Fatigue Severity Scale (FSS) at baseline and 6, 12, and 24 months after the index stroke. The time course of PSF was classified as non-PSF, incident PSF, recovered PSF and persistent PSF according to the PSF status at baseline and the 24-month follow-up. Multivariate logistic regression analysis and generalized mixed model were applied to explore the relationships between SSRIs and the time course of PSF.

Results

Eight hundred forty-seven patients were analyzed in this study. No significant association between SSRIs and the time course of PSF was observed in all patients (p = 0.076). The subgroup analyses indicated that SSRI antidepressants reduced the risk of incident PSF [Odds Ratio (OR) 0.23; 95% confidence interval (CI) 0.05–0.96, p = 0.044] and persistent PSF (OR 0.28; 95% CI 0.09–0.90, p = 0.033) in the PSD subgroup, but not in the non-PSD group. In the longitudinal analysis, generalized logistical mixed-effect models indicated that early administration of SSRIs reduced the risk (OR 0.955; 95% CI 0.928–0.984, p = 0.002) and severity (β = −0.018, p = 0.041) of PSF in the PSD subgroup.

Conclusion

No relationship was identified between the use of SSRIs and the time course of PSF in all patients. However, these drugs might be effective in PSF patients with depression.

Effectiveness and safety of auricular therapy for post-stroke depression: A protocol for systematic review and meta-analysis

BACKGROUND

Post-stroke depression is a common and serious complication after stroke. Its main clinical manifestations are depression or instability, loss of interest, loss of appetite, sleep disorders, pessimism, and unworthiness, and even suicidal tendencies. Auricular therapy (AT), as part of traditional Chinese acupuncture, has achieved good results in the treatment of depression, but different clinical studies have shown mixed results. Therefore, the aim of this systematic review is to assess the effectiveness and safety of AT for post-stroke depression.

METHODS

Two reviewers will electronically search the following databases: the Cochrane Central Register of Controlled Trials; Medline (via PubMed); Excerpt Medica Database; China National Knowledge Infrastructure; Chinese Biomedical Literature Database; Chinese Scientific Journal Database; and Wan-Fang Database from the inception to January 1, 2022. Study selection, data extraction, and assessment of study quality will be performed independently by 2 reviewers. If it is appropriate for a meta-analysis, Review Manager Version 5.3 statistical software will be used; otherwise, a descriptive analysis will be conducted. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. The results will be presented as risk ratio with 95% confidence intervals for dichotomous data and weight mean difference or standard mean difference 95% confidence intervals for continuous data.

RESULT

This study will provide a comprehensive review of the available evidence for the treatment of AT with post-stroke depression.

CONCLUSIONS

The conclusions of our study will provide an evidence to judge whether AT is an effective and safe intervention for patients with post-stroke depression.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42021289870.

Gender-based differences in neuroprotective effects of hydrogen gas against intracerebral hemorrhage-induced depression

BACKGROUND

Post-stroke depression (PSD) severely affects recovery in patients with intracerebral hemorrhage (ICH). Although hydrogen gas (H₂) exerts excellent neuroprotective effects in patients with ICH, there are sex-based differences in H₂ efficacy in several diseases. Herein, we determined whether estrogen increases susceptibility to the neuroprotective effects of H₂ in males with ICH-induced depression.

METHODS

A rodent model of ICH in the basal ganglia was established using autologous blood injection (30 μL). Mice were treated with 2.9% H₂ for 2 h daily for 3 days post-ICH. Estrogen (1 mg/kg) was administered by subcutaneous injection daily for 3 days to male mice post-ICH. Thirty days post-ICH, PSD was evaluated by sucrose preference, forced swimming, and 3-chamber social tests. Following the completion of behavioral tests, levels of superoxide dismutase (SOD) and reactive oxygen species (ROS), astrocytic activation, phosphorylated (p)-NF-κB-positive astrocytes, p-NF-κB, p-IKKβ, IL-1β, and IL-6 expression were determined.

RESULTS

Compared with female mice, H₂ administration post-ICH exhibited fewer neuroprotective effects, including decreased sucrose consumption and time spent sniffing a novel mouse, increased immobility time, downregulated total SOD content, upregulated ROS content and p-NF-κB levels, and elevated astrocyte branches, whereas estrogen enhanced the neuroprotective effects of H₂ in male mice. A reduced number of p-NF-κB-positive astrocytes, downregulated expression of p-NF-κB, p-IKKβ, IL-1β, and IL-6 in the amygdala were demonstrated in ICH-males treated with estrogen plus H₂.

CONCLUSIONS

Estrogen was responsible for increased H₂ sensitivity in male mice with ICH. The underlying mechanism may be associated with the suppression of NF-κB signaling in astrocytes.

Alleviative effects of foraging exercise on depressive-like behaviors in chronic mild stress-induced ischemic rat model

BACKGROUND

Poststroke depression (PSD) is a common complication that seriously affects the functional recovery and prognosis of an individual. As some patients with PSD fail to respond to drug therapy, it is urgent to find a viable alternative treatment.

METHODS

An active exercise program known as foraging exercise (FE), using food as bait, was designed. First, focal ischemia and chronic unpredictable mild stress (CUMS) were used to establish a PSD model in rats. FE was then performed for 4 weeks. Body weight and behavioral assessments were conducted at the end of the 4th and 8th weeks.

RESULTS

After 8 weeks, the results revealed that, compared with the PSD group, the behavioral scores of the rats in the PSD/FE group were significantly improved, the expression of Iba-1 in the affected frontal lobe and striatum was decreased, and serum levels of IL-6 and the IL-6/IL-10 ratio were downregulated. However, the ratio of residual brain volume in rats that had experienced CUMS was significantly less than that in the stroke group.

CONCLUSION

FE can alleviate the behavioral scores of PSD rats, and its mechanism may be related to a modulation of the immune-inflammation response of microglia. Furthermore, chronic, persistent stress may increase the volume of cerebral infarction after stroke.

Ultrasound Stimulation of Prefrontal Cortex Improves Lipopolysaccharide-Induced Depressive-Like Behaviors in Mice

Increasing evidence indicates that inflammatory responses may influence brain neurochemical pathways, inducing depressive-like behaviors. Ultrasound stimulation (US) is a promising non-invasive treatment for neuropsychiatric diseases. We investigated whether US can suppress inflammation and improve depressive-like behaviors. Mice were intraperitoneally injected with lipopolysaccharide to induce depressive-like behaviors. Ultrasound wave was delivered into the prefrontal cortex (PFC) for 30 min. Depressive- and anxiety-like behaviors were evaluated through the forced swimming test (FST), tail suspension test (TST), and elevated plus maze (EPM). Biochemical analyses were performed to assess the expression of inflammatory cytokines in the PFC and serum. The results indicated that US of the PFC significantly improved depressive-like behaviors in the TST (p < 0.05) and FST (p < 0.05). Anxiety-like behaviors also improved in the EPM (p < 0.05). Furthermore, the lipopolysaccharide-mediated upregulation of IL-6, IL-1β, and TNF-α in the PFC was significantly reduced (p < 0.05) by US. In addition, no tissue damage was observed. Overall, US of PFC can effectively improve lipopolysaccharide-induced depressive-like behaviors, possibly through the downregulation of inflammatory cytokines in the PFC. US may be a safe and promising tool for improvement of depression.

Elevated Red Blood Cell Distribution Width Levels at Admission Predicts Depression After Acute Ischemic Stroke: A 3-Month Follow-Up Study

PURPOSE

Red blood cell distribution width (RDW) is closely related to inflammatory-related disease markers. The present study aimed to investigate the association between the red blood cell distribution width (RDW) and post-stroke depression (PSD).

PATIENTS AND METHODS

A total of 414 patients with acute ischemic stroke (AIS) admitted to our hospital from June 2018 to July 2021 were consecutively enrolled and received 3 months' follow-up. According to the 17-item Hamilton Depression Scale (HAMD) assessment, they were divided into PSD group and non-PSD group. Diagnosis of PSD was made in accordance with DSM-IV. RDW was recorded within 24 hours of admission.

RESULTS

Among the included 414 patients, 95 (22.95%) patients were diagnosed as having PSD at 3 months after stroke. The results showed significantly higher level of RDW in patients with depression (13.69 (IQR13.24-13.88) vs. 13.56 (IQR 12.67-13.77), P<0.001) at admission than patients without depression. After adjustment for potential confounding factors, the odds ratio of PSD was 5.707 (95% CI, 2.717-11.989) for the highest tertile of RDW compared with the lowest tertile. Moreover, based on the receiver operating characteristic (ROC) curve, the optimal cutoff of RDW levels as an indicator for the prediction of PSD was projected as 13.01, which yielded a sensitivity of 83% and a specificity of 41.0%, with an area under the curve (AUC) of 0.643 (95% CI, 0.585-0.701; P = 0.012).

CONCLUSION

Higher RDW levels at admission were found to be correlated with PSD 3 months after stroke.

Does urinary metabolite signature act as a biomarker of post-stroke depression?

BACKGROUND

It is difficult to conduct the precise diagnosis of post-stroke depression (PSD) in clinical practice due to the complex psychopathology of depressive disorder. Several studies showed that gas chromatography-mass spectrometry (GC-MS)-identified urinary metabolite biomarkers could significantly discriminate PSD from stroke survivors.

METHODS

A systematic review was performed for the keywords of "urinary metabolite" and "PSD" using Medline, Cochrane Library, Embase, Web of Science, PsycINFO, Wanfang, CNKI, CBM, and VIP database from inception to 31 March 2022.

RESULTS

Four related studies were included in the review. Differential urinary metabolites including lactic acid, palmitic acid, azelaic acid, and tyrosine were identified in all the included studies. As a significant deviation in the metabolite biomarker panel, glyceric acid, azelaic acid, phenylalanine, palmitic acid, pseudouridine, and tyrosine were found in at least 2 included studies, which indicated good potential for the differentiation of PSD.

CONCLUSION

The systematic review provided evidence that differential urinary metabolites analyzed by the GC-MS-based approach might be used as a biomarker for the diagnosis and prognosis of PSD.

The Relationship Between 5-Hydroxytryptamine and Its Metabolite Changes With Post-stroke Depression

Post-stroke depression (PSD) is the most common and serious sequelae of stroke. Approximately 33% of stroke survivors were affected by PSD. However, many issues (e.g., incidence, diagnostic marker, and risk factor) related to PSD remained unclear. The "monoamine hypothesis" is a significant hypothesis for depression, which suggests that three monoamines play a key role in depression. Therefore, most current antidepressants are developed to modulate the monoamines on PSD treatment, and these antidepressants have good effects on patients with PSD. However, the potential mechanisms of three monoamines in PSD are still unclear. Previously, we proposed "three primary emotions," which suggested a new model of basic emotions based on the three monoamines. It may provide a new way for PSD treatment. In addition, recent studies have found that monoamine-related emotional intervention also showed potential effects in the treatment and prevention of PSD. This study discusses these issues and attempts to provide a prospect for future research on PSD.

Effect of transcranial magnetic stimulation on treatment effect and immune function

To explore the effect of transcranial stimulation on the therapeutic effect and immune function of patients with post-stroke depression (PSD). Methods Selection in September 2020-April 2021 on the diagnosis of 70 patients with PSD as the research object, 35 patients were randomly divided into control group and intervention group and control group given conventional treatment, the intervention group in the control group on the basis of the application of transcranial magnetic stimulation treatment, compare the curative effect of two groups of patients after the treatment cycle and the effects on the immune function. Results After treatment, the levels of DA, NE, 5-HT in 2 groups were significantly increased, and those in the observation group were significantly higher than those in the control group (P < 0.05). After 8 weeks of treatment, serum Gly content in 2 groups was significantly increased and Glu content was significantly decreased compared with before treatment. Compared with the control group, serum Gly content in observation group was significantly increased and Glu content was significantly decreased after treatment (P < 0.05). After 8 weeks of treatment, the contents of IL-1β, IL-6 and TNF-α in serum of 2 groups were significantly decreased, compared with the control group, the contents of IL-1β, IL-6 and TNF-α in serum of observation group were significantly decreased (P < 0.05); Before treatment, there was no significant difference in PHQ-9 score and MBI score between the two groups (P > 0.05). After 8 weeks of treatment, PHQ-9 score and MBI score in the two groups were better than before treatment, and the observation group was better than the control group (P < 0.05). Conclusion Transcranial magnetic stimulation therapy can not only effectively promote the synthesis and release of monoamine neurotransmitters in patients with post-stroke depression, regulate the inhibitory/excitatory amino acid neurotransmitters, reduce inflammatory response, improve the clinical treatment effect and enhance the immune function of PSD patients, which has clinical application value.

Elevated monocyte-to-HDL cholesterol ratio predicts post-stroke depression

OBJECTIVES

Inflammation plays an important role in the development of depression after stroke. Monocyte-to-HDL Cholesterol Ratio (MHR) recently emerged as a novel comprehensive inflammatory indicator in recent years. This study aimed to investigate whether there is a relationship between MHR levels and post-stroke depression (PSD).

METHODS

From February 2019 to September 2021, patients with acute ischemic stroke (AIS) were recruited within 7 days post-stroke from the two centers and blood samples were collected after admission. The 17-item Hamilton Depression Scale (HAMD-17) was used to measure depressive symptoms at 3 months after stroke. Patients were given the DSM-V criteria for diagnosis of PSD.

RESULTS

Of the 411 enrolled patients, 92 (22.38%) patients were diagnosed with PSD at 3-months follow-up. The results also showed significantly higher level of MHR in patients with depression [0.81 (IQR 0.67-0.87) vs. 0.61 (IQR 0.44-0.82), P < 0.001] at admission than patients without depression. Multivariate logistic regression revealed that MHR (OR 6.568, 95% CI: 2.123-14.565, P = 0.015) was an independent risk factor for the depression at 3 months after stroke. After adjustment for potential confounding factors, the odds ratio of PSD was 5.018 (95% CI: 1.694-14.867, P = 0.004) for the highest tertile of MHR compared with the lowest tertile. Based on the ROC curve, the optimal cut-off value of MHR as an indicator for prediction of PSD was projected to be 0.55, which yielded a sensitivity of 87% and a specificity of 68.3%, with the area under the curve at 0.660 (95% CI: 0.683-0.781; P = 0.003).

CONCLUSION

Elevated level of MHR was associated with PSD at 3 months, suggesting that MHR might be a useful Inflammatory markers to predict depression after stroke.

Study on Biomarkers Related to the Treatment of Post-Stroke Depression and Alternative Medical Treatment Methods

PURPOSE

PSD is a syndrome that occurs after a stroke, which manifests as a series of depressive symptoms and corresponding physiological symptoms. Relevant studies have shown that the drug therapy is often accompanied by drug side effects and patient resistance. Acupuncture has attracted attention as a treatment method without adverse reactions of patients. The purpose of this study was to investigate the possible mechanism of action of acupuncture in PSD.

PATIENTS AND METHODS

Download depression and stroke datasets from public databases. Bioinformatics methods were used to analyze the key gene targets related to stroke and depression. Functional enrichment analysis assesses important pathways. Further screen PSD-related biological pathways and genes. After the experimental model was established, the expression differences of key genes and related pathways were compared between the model group and the control group through acupuncture treatment and qPCR verification.

RESULTS

Depression and stroke-related genes were obtained by bioinformatics methods, and then important biological processes and biological pathways related to depression and stroke were analyzed by GO and KEGG. And further screen out the disease targets closely related to PSD. In the follow-up animal experiments, we confirmed that acupuncture can intervene on these key pathways and targets, and then play a role in the targeted therapy of diseases.

CONCLUSION

The results of this study show that five genes ("NRBP1", "SIRT1", "BDNF", "MAPK3", "CREB1".) and key biological pathways such as NFkB, PI3K/AKT activation, and MAPK are the keys to the occurrence and development of PSD biomarkers, which can also be therapeutically intervened by acupuncture.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Monocyte-to-Lymphocyte Ratio in Depression: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Research on neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) in depression is still emerging and has increased 3-fold since the first meta-analysis. An updated meta-analysis with sufficient studies can provide more evidence for a potential relationship between NLR, PLR, MLR, and depression.

METHODS

We identified 18 studies from the PubMed, EMBASE, Cochrane library, and Web of Science databases. Meta-analyses were performed to generate pooled standardized mean differences (SMDs) and 95% confidence intervals (CIs) between patients with depression and controls. Sensitivity analysis, subgroup analysis, meta-regression, and publication bias were conducted.

RESULTS

A total of 18 studies including 2,264 depressed patients and 2,415 controls were included. Depressed patients had significantly higher NLR and PLR compared with controls (SMD = 0.33, 95% CI: 0.15-0.52, p < 0.001 and SMD = 0.24, 95% CI: 0.02-0.46, p < 0.05, respectively). MLR was slightly higher in depressed individuals compared to controls (SMD = 0.15, 95% CI: -0.26 to 0.55, p > 0.05), despite the absence of significance. Sensitivity analysis removing one study responsible for heterogeneity showed a higher and significant effect (SMD = 0.32, 95% CI: 0.20-0.44) of MLR. Three subgroup analyses of NLR, PLR, MLR, and depression revealed obvious differences in the inflammatory ratios between depressed patients and controls in China and the matched age and gender subgroup. Individuals with post-stroke depression (PSD) had higher NLR and MLR values as compared to non-PSD patients (SMD = 0.51, 95% CI: 0.36-0.67, p < 0.001 and SMD = 0.46, 95% CI: 0.12-0.79, p < 0.01, respectively). Meta-regression analyses showed that male proportion in the case group influenced the heterogeneity among studies that measured NLR values (p < 0.05).

CONCLUSIONS

Higher inflammatory ratios, especially NLR, were significantly associated with an increased risk of depression. In the subgroup of China and matched age and gender, NLR, PLR, and MLR were all elevated in depressed patients vs. controls. Individuals with PSD had higher NLR and MLR values as compared to non-PSD patients. Gender differences may have an effect on NLR values in patients with depression.

Chronic Administration of 13-cis-retinoic Acid Induces Depression-Like Behavior by Altering the Activity of Dentate Granule Cells

Depression is a common but serious mental disorder and can be caused by the side effects of medications. Evidence from abundant clinical case reports and experimental animal models has revealed the association between the classic anti-acne drug 13-cis-retinoic acid (13-cis-RA) and depressive symptoms. However, direct experimental evidence of this mechanism and information on appropriate therapeutic rescue strategies are lacking. Herein, our data revealed that chronic administration of 13-cis-RA to adolescent mice induced depression-like behavior but not anxiety-like behavior. We next demonstrated that chronic 13-cis-RA application increased neural activity in the dentate gyrus (DG) using c-Fos immunostaining, which may be critically involved in some aspects of depression-like behavior. Therefore, we assessed electrophysiological functions by obtaining whole-cell patch-clamp recordings of dentate granule cells (DGCs), which revealed that chronic 13-cis-RA treatment shifted the excitatory-inhibitory balance toward excitation and increased intrinsic excitability. Furthermore, a pharmacogenetic approach was performed to repeatedly silence DGCs, and this manipulation could rescue depression-like behavior in chronically 13-cis-RA-treated mice, suggesting DGCs as a potential cellular target for the direct alleviation of 13-cis-RA-induced depression.

Occupational Therapy Interventions to Address Depressive and Anxiety Symptoms in the Physical Disability Inpatient Rehabilitation Setting: A Systematic Review

IMPORTANCE

Depressive and anxiety symptoms across physical disability inpatient rehabilitation (IPR) patient groups are well documented and negatively affect functional recovery. The strategies within the occupational therapy scope of practice to address these symptoms in IPR are unclear.

OBJECTIVE

To determine what interventions within the occupational therapy scope of practice have been used to address depressive and anxiety symptoms in IPR and to determine intervention efficacy.

DATA SOURCES

Nine databases for all publication years were searched (PubMed, Scopus, Embase, Web of Science, PsycINFO, Cochrane Library, AgeLine, OTseeker, and CINAHL). Study Selection and Data Collection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for abstracting data and assessing quality. Included articles were peer reviewed, based in the United States, in English, controlled clinical trials or randomized controlled trials, in the IPR setting, and within the occupational therapy scope of practice. Two reviewers independently screened articles, with disagreements resolved by consensus.

FINDINGS

Five of 8,082 articles met inclusion criteria. Diagnoses included stroke (n = 1), traumatic brain injury (n = 1), spinal cord injury (n = 1), and musculoskeletal conditions (n = 2). Results are discussed among four categories: study design and outcome variables, intervention type, intervention intensity, and intervention efficacy.

CONCLUSIONS AND RELEVANCE

Limited, moderate-quality evidence exists within the occupational therapy scope of practice for addressing depressive and anxiety symptoms in the physical disability IPR setting. Interventions primarily included cognitive and behavioral strategies. Further research among diverse patient populations is needed to support occupational therapy practitioners in facilitating client participation and functioning. What This Article Adds: This systematic review provides an evaluation of the evidence within the occupational therapy scope of practice to address depressive and anxiety symptoms within the physical disability IPR setting. This research can support occupational therapy practitioners to comprehensively address physical and mental health for participation in IPR.

Lipocalin-2 Regulates Hippocampal Microglial Activation in Poststroke Depression

Background and Purpose: Microglia play important role in poststroke depression (PSD), however, the exact mechanism was still unclear. The purpose of the study was to study the mechanism of microglial activation in PSD.

Methods: 24 rats were randomly divided into three groups: the PSD group (n = 10), the poststroke (PS) group (n = 7), and the sham group (n = 7). Primary hippocampal microglia were isolated and cultured, and recombined LCN2 protein was used to stimulate the cultured microglia. The protein expression of Iba1, P38 MAPK and PP38 MAPK was analyzed by western blotting; the LCN2 expression was measured by RT-qPCR, the serum LCN2 level and the NO level were analyzed by ELISA.

Results: Open field test scores (horizontal score, vertical score, and self-grooming score) and the serum LCN2 level were significantly decreased in the PSD group compared with the other two groups (P < 0.05). The serum LCN2 level was positively correlated with the horizontal score and negatively correlated with the self-grooming score in the open field test (P < 0.05). The relative protein level of Iba1 and the LCN2 mRNA level were significantly increased in the hippocampal region compared with other brain regions (P < 0.05), while the relative protein level of Iba1 and the LCN2 mRNA level were significantly increased in the PSD group compared with the other two groups (P < 0.05). The length, supernatant NO level, phagocytic ability and migration ability of LCN2-treated microglia were significantly increased compared with those of untreated microglia (P < 0.05). The relative protein levels of P38 MAPK and the PP38 MAPK significantly increased in hippocampal region in the PSD group and LCN2-treated hippocampal microglia (P < 0.05).

Conclusion: Hippocampal microglia are activated during PSD; LCN2 may regulate hippocampal microglial activation by the P38 MAPK pathway in the process of PSD.

Effectiveness of non-pharmacological interventions for treating post-stroke depression: Study protocol of an umbrella review of systematic reviews and meta-analyses

BACKGROUND

Many systematic reviews and meta-analyses have evaluated the effectiveness of non-pharmacological therapies to improve symptoms of post-stroke depression (PSD) and reduce disability and mortality in patients with PSD. However, no research has appraised the credibility of the evidence. This study aims to summarize and evaluate the current evidence for non-pharmacological treatment of PSD and to seek effective treatment with reference to reliable evidence.

METHODS

We searched the electronic databases EMBASE, MEDLINE, Cochrane Central, PubMed, PROSPERO, Web of Science, and CINAHL. We will search articles from the above database for all published meta-analyses to December 2021 to evaluate the effect of non-pharmacological treatment of PSD. Two reviewers will extract the general characteristics of the included articles, as well as participants, interventions, outcome measures, and conclusions. The quality evaluation of each systematic review will be conducted with reference to the AMSTAR 2 tool. The effect size of each review will be recalculated using either a fixed-effects or a random-effects model. Cochrane's Q test and I2 statistics will be used to evaluate the heterogeneity between studies. To determine whether a systematic review had small study effects, we will use the Egger test. We expect to extract valid evidence and classify it from strong to weak.

RESULTS

The findings of this umbrella review will provide effective evidence for the non-pharmacological treatment of PSD.

CONCLUSION

Our research conclusion will provide clinical staff and PSD patients with appropriate treatment recommendations.

ETHICS AND DISSEMINATION

As the data were obtained from published materials, there is no need for ethical approval for this umbrella review. The findings of this umbrella review will be published in a peer-reviewed journal.

INPLASY REGISTRATION NUMBER

INPLASY2021100083.

Effectiveness and safety of manual acupuncture therapy in patients with post-stroke depression: a protocol for a systematic review and meta-analysis

INTRODUCTION

Acupuncture is widely used on the rehabilitation of stroke survivors, including hemiplegia, constipation, emotional disorders and so on. Although the effectiveness of manual acupuncture therapy on post-stroke depression (PSD) has been confirmed by multiple randomised controlled trials, there were few meta-analyses focused on the connection between different techniques, durations or other detailed operations of manual acupuncture and their effectiveness of improving the depression severity and quality of life for patients with PSD.

METHODS AND ANALYSIS

A systematic search will be performed on English databases (PubMed, the Cochrane Library, Medline and Embase), Chinese databases (China National Knowledge Infrastructure, WanFang Data, VIP and Chinese biomedical databases) and Japanese databases (Japan Science and Technology Agency and CiNii). The retrieval time limit will be from the establishment of the database to November 2020. Two researchers will independently screen the literature works, extract data and evaluate the quality of the included studies. Meta-analysis will be conducted by using STATA V.14.0 and Review Manager V.5.3.

ETHICS AND DISSEMINATION

The results of this meta-analysis will be disseminated through publication in peer-reviewed journals or conference presentations. The data used in this meta-analysis will not contain individual patient data; therefore, ethical approval is not required.

PROSPERO REGISTRATION NUMBER

CRD42020222825.

Neuroinflammation as a Key Driver of Secondary Neurodegeneration Following Stroke?

Ischaemic stroke involves the rapid onset of focal neurological dysfunction, most commonly due to an arterial blockage in a specific region of the brain. Stroke is a leading cause of death and common cause of disability, with over 17 million people worldwide suffering from a stroke each year. It is now well-documented that neuroinflammation and immune mediators play a key role in acute and long-term neuronal tissue damage and healing, not only in the infarct core but also in distal regions. Importantly, in these distal regions, termed sites of secondary neurodegeneration (SND), spikes in neuroinflammation may be seen sometime after the initial stroke onset, but prior to the presence of the neuronal tissue damage within these regions. However, it is key to acknowledge that, despite the mounting information describing neuroinflammation following ischaemic stroke, the exact mechanisms whereby inflammatory cells and their mediators drive stroke-induced neuroinflammation are still not fully understood. As a result, current anti-inflammatory treatments have failed to show efficacy in clinical trials. In this review we discuss the complexities of post-stroke neuroinflammation, specifically how it affects neuronal tissue and post-stroke outcome acutely, chronically, and in sites of SND. We then discuss current and previously assessed anti-inflammatory therapies, with a particular focus on how failed anti-inflammatories may be repurposed to target SND-associated neuroinflammation.

Nrf2-BDNF-TrkB pathway contributes to cortical hemorrhage-induced depression, but not sex differences

Post-stroke depression, observed in 30-50% of stroke patients, negatively affects quality of life and mortality. The pathogenesis of post-stroke depression is complex, but heightened reactive oxygen species production and inflammation might be two key factors. We have reported that intracerebral hemorrhage (ICH) in cerebral cortex produces depression-like behavior in young male mice. Here, we found that mice lacking nuclear factor erythroid-derived 2-related factor 2 (Nrf2), a transcription factor that upregulates antioxidant proteins and trophic factors such as brain-derived neurotrophic factor (BDNF), had more severe depression-like behavior than wild-type mice at days 21 to 28 after cortical ICH (c-ICH). Moreover, the expression of Nrf2, heme oxygenase-1, BDNF, and TrkB were significantly decreased in wild-type mice after c-ICH. Interestingly, TP-500 (2 mg/kg), a potent Nrf2 inducer, decreased the inflammatory response and reactive oxygen species production on day 28 after c-ICH and improved depression-like behaviors. TrkB receptor antagonist ANA-12 abolished this anti-depression effect. Depression was more severe in female than in male wild-type mice after ICH, but TP-500 improved depression-like behavior in females. These results suggest that downregulation of Nrf2-BDNF-TrkB signaling contributes to development of post-stroke depression, and that Nrf2 inducer TP-500 might improve depression after c-ICH.

Increased high-mobility group box 1 levels are associated with depression after acute ischemic stroke

BACKGROUND AND PURPOSE

Increased high-mobility group box 1 (HMGB1) levels were found in patients after acute ischemic stroke. The aim of this study was to examine whether the circulating HMGB1 levels could predict the 3-month post-stroke depression (PSD).

METHODS

The subjects were first-ever ischemic stroke patients who were hospitalized during the period from July 2020 to December 2020. HMGB1 concentrations were measured by enzyme-linked immunosorbent assay after admission. A 24-item Hamilton Depression Rating Scale was performed to evaluate PSD at 3 months after stroke.

RESULTS

The analyses included 324 participants (mean age, 63.7 years; 171 male). Ninety-four patients (29.0%) were diagnosed as having PSD at 3 months. The median serum HMGB1 levels at admission was 7.5 ng/mL (IQR, 4.4-11.3 ng/mL). The PSD distribution across the HMGB1 quartiles ranged between 17.5% (first quartile) and 57.5% (fourth quartile). After covariate adjustments, the fourth quartile of HMGB1 was found to be associated with a higher risk of PSD (as compared with first HMGB1 quartile, odd ratio, 1.26; 95% confidence interval [CI], 1.17-1.35; P < 0.001). The area under the receiver operating characteristic curve of HMGB1 was 0.726 (95% CI 0.660-0.792) for PSD. Similar results were found when HMGB1 was analyzed as continuous variable. Furthermore, the optimal cutoff point of circulating HMGB1 levels was 8.6 ng/mL, with a sensitivity of 69.2% and a specificity of 73.9%.

CONCLUSIONS

This study demonstrated that higher HMGB1 levels in the acute phase of ischemic stroke were associated with increased risk of PSD.

The role of rehabilitation and vitamin D supplementation on motor and psychological outcomes in poststroke patients

Post-Stroke depression affects between 12% and 72% of patients who have suffered a stroke. The association between low serum levels of 25-hydroxyvitamin D (25(OH) D) and increased risk of depression is reported in both stroke and non-stroke patients. Similarly, high 25(OH) D levels might be associated with greater functional improvement during rehabilitation program.We wanted to investigate the effects of an intensive rehabilitation on poststroke outcomes. We wondered if the daily rehabilitation of motor and cognitive functions could also have an effect on mood and functional abilities in addition to or as an alternative to vitamin D supplementation.We conducted a 12-week, randomized trial, double blind, parallel, monocentric clinical trial of 40 patients undergoing intensive neuro-rehabilitation treatment at a specialized care facility for ischemic or hemorrhagic brain stroke. Participants were randomly assigned, in a 1:1 ratio, to 1 of 2 parallel groups: in the experimental group, 2000 IU/day of oral cholecalciferol was administered; in the control group patients were not taking vitamin D supplementation. Patients underwent a text evaluation to investigate psychological and motor outcomes.Significant intra-group difference in outcomes measures was found but not between control group and experimental group. In the vitamin D group, we highlighted significant differences between T0 and T1 in calcium (P < .001), vitamin D (P < .001), in Montgomery Aasberg Depression Rating Scale (P = .001), and in Functional Independent Measures (P < .001). In the health control group, we found a significant difference in calcium (P = .003), vitamin D (P < .001), Montgomery Aasberg Depression Rating Scale (P = 0.006), in general self-efficacy (P = .009), and in Functional Independent Measures (P < .001).Our results show that the beneficial effect on mood and functional recovery is mainly due to neurorehabilitation rather than vitamin D supplementation.

Xingnao Jieyu Decoction Reduces Neuroinflammation through the NF-κB Pathway to Improve Poststroke Depression

The neuroinflammatory pathway regulated by nuclear factor kappa-B (NF-κB) plays an important role in the occurrence, development, and prognosis of poststroke depression (PSD). The regulatory effect of the traditional Chinese medicine compound Xingnao Jieyu decoction (XNJY) on the NF-κB pathway of PSD is still unclear. This study aimed to observe the effect of XNJY on PSD and explore the molecular mechanism of its intervention in the NF-κB pathway. Middle cerebral artery occlusion (MCAO) and chronic unpredictable mild stress were used to establish a PSD rat model. Body mass measurement, behavioral testing, Nissl staining, ELISA, and Western blot were also performed. XNJY and fluoxetine hydrochloride (Flu) treatment of PSD model rats showed significant antidepressant effects. XNJY and Flu treatment could reduce cortical and hippocampal neuronal damage. XNJY reduced inflammation and restored the levels of IL-4, IL-10, and BDNF. In addition, XNJY showed a significant regulatory effect on the NF-κB pathway and the expression of synapse-related proteins PSD-95 and SYN. These results showed that XNJY could significantly reduce the depressive symptoms of PSD rats, and this reduction may be related to the regulation of the NF-κB signaling pathway to improve neuroinflammation and synaptic function.

Efficacy of frequently-used acupuncture methods for specific parts and conventional pharmaceutical interventions in treating post-stroke depression patients: A network meta-analysis

BACKGROUND

Acupuncture is considered as an effective alternative treatment for post-stroke depression because of its low side effects and easy availability. However, it usually depends on the skills and experience of doctors to choose which acupuncture methods for specific parts. This study compared the effectiveness of different frequently-used acupuncture methods for specific parts in treating post-stroke depression patients by using network meta-analysis.

METHODS

We searched eight databases including China National Knowledge Infrastructure (CNKI) database, Wanfang database, Chinese Biomedical Database (CBM), VIP Chinese Science, the Cochrane Library, Embase, PubMed and Web of Science from the date of database inception to November 29, 2020 to identify eligible RCTs. The trial registers in ClinicalTrials.gov, World Health Organization, and Cochrane trials were searched as a supplement. The effective rate was extracted from the included RCTs as primary outcomes after screening. The network meta-analysis was performed by Review Manager 5.3, Stata14.0, and R 3.6.3.

RESULTS

51 studies were included, which contained 3966 participants among 12 interventions. Based on the ranking probability, scalp acupuncture plus conventional acupuncture was considered to be the most effective method, followed by auricular acupuncture, eye acupuncture, eye acupuncture plus drug, auricular acupuncture plus drug, auricular acupuncture plus conventional acupuncture, scalp acupuncture, scalp acupuncture plus drug, abdominal acupuncture, conventional acupuncture plus drug, drug, conventional acupuncture.

CONCLUSIONS

12 acupuncture methods may be effective and safe in improving the condition of patients with PSD. Higher quality randomized controlled trials need sufficient evidence because the overall quality of included trials can only be classified as low quality. This study is registered with PROSPERO (CRD42020177099).

Effects of acute and chronic depression on 12-year long-term outcomes after stroke

OBJECTIVES

This study aimed to investigate whether acute and chronic poststroke depression (PSD) were associated with cardio-cerebrovascular events (CVEs).

METHODS

A total of 423 patients with recent stroke were recruited from 2006 to 2009. They were diagnosed with major or minor depressive disorder during the acute phase (within 2 weeks) after stroke. Of these, 284 completed the same diagnostic evaluation during the chronic phase (1 year) after stroke. An average 12-year (range 8.7-14.1 years) follow-up was conducted to assess composite CVEs including recurrent stroke, myocardial infarction, and vascular death after the index stroke. During the follow-up, Kaplan-Meier event rates for outcomes were calculated, and hazard ratios were estimated using Cox regression models after adjusting for a range of covariates.

RESULTS

The composite CVE incidence was higher in patients with acute or chronic PSD than in those without. Composite event incidence was highest in patients with PSD during both the acute and chronic phases.

CONCLUSIONS

The presence of depression at acute and chronic phase of stroke predicted worse long-term cardio-cerebrovascular outcomes. Evaluation of PSD during both the acute and chronic phases is recommended.

Effect of the Interaction between Depression and Sleep Disorders on the Stroke Occurrence: An Analysis Based on National Health and Nutritional Examination Survey

OBJECTIVE

To investigate the effect of the interaction between depression and sleep disorders on the stroke occurrence based on the data from the National Health and Nutritional Examination Survey (NHANES).

METHODS

Seven cycles of 2-year NHANES data (2005-2018) were analyzed in this study. Univariate analysis was first performed between the stroke and nonstroke patients, and then, multivariate logistic regression models were conducted to analyze the association of depression, sleep disorders, and their interactions with stroke occurrence.

RESULTS

A total of 30473 eligible participants were included in this study, including 1138 (3.73%) with stroke and 29335 (96.27%) with nonstroke. Except sex, the differences were all significant between the stroke and nonstroke patients in baseline information (all P < 0.001). Depression (odds ratio (OR): 2.494, 95% confidence interval (CI): 2.098-2.964), depression severity (moderate, OR: 2.013, 95% CI: 1.612-2.514; moderately severe, OR: 2.598, 95% CI: 1.930-3.496; severe, OR: 5.588, 95% CI: 3.883-8.043), and sleep disorders (OR: 1.677, 95% CI: 1.472-1.910) were presented to be associated with an increased risk of stroke after correcting all the confounders. The logistic regression analysis showed that there was a synergic, additive interaction between depression and sleep disorders on the stroke occurrence, and the proportion of stroke patients caused by this interaction accounted for 27.1% of all the stroke patients.

CONCLUSION

Depression, depression severity, and sleep disorders are all independently associated with a high risk of stroke. The interaction between depression and sleep disorders can synergistically increase the stroke occurrence.

Cognitive Testing During Mild Acute Ischemic Stroke Predicts Long-Term Return to Work

OBJECTIVES

Many survivors of a mild ischemic stroke do not return to work or driving. Cognitive testing is commonly done to assess long-term cognitive impairment after stroke. Inpatient cognitive testing during the acute period of ischemic stroke may also be a predictor for workforce reengagement and functional outcome.

MATERIALS AND METHODS

At our comprehensive stroke center, we prospectively enrolled previously working adults < 65 years old who were diagnosed with first-ever ischemic stroke, had a prestroke modified Rankin Scale (mRS) ≤ 1 and NIHSS ≤ 3. Testing performed within 1 week of stroke included the Montreal Cognitive Assessment (MOCA), Clock Drawing Test (CDT), Trail Making Tests A and B, Backward Digit Span Test, and Hospital Anxiety and Depression Scale (HADS). Other data obtained included age, gender, years of education, occupation, stroke location, stroke laterality, and presence of white matter disease on imaging. Outcome measures assessed at 3 months, 6 months, and 12 months post-stroke included return to work, return to driving, and mRS. In a logistic regression analysis, we performed both univariate and multivariate analyses. Multivariate analysis was completed on variables with p-value ≤ 0.05 in the univariate analysis.

RESULTS

Of 39 total stroke patients enrolled and tested (median [IQR] age 55 [46-60] years; 77.5% male; 22.5% female), 36 completed 3-month follow up, of which 58% returned to work, 78% returned to driving, and 72% had mRS of 0-1. In multivariate analysis, a single point increase in the clock drawing task score increased the odds of return to work by 3.79 (95% CI, 1.10-14.14) and return to driving by 6.74 (95% CI, 1.22-37.23) at 3 months. MOCA and HADS were both associated with mRS ≤ 1. MOCA was associated with return to work at 6 months and CDT was associated with return to work at 12 months.

CONCLUSION

Cognitive testing with CDT and MOCA in the acute period after ischemic stroke may predict common patient goals post stroke, including return to work, driving, and independence. These tools can potentially be used for prognosis and identifying those who may benefit from further interventions.

Interleukin-10 level is associated with post-stroke depression in acute ischaemic stroke patients

BACKGROUND

Interleukin-10 (IL-10) is a pathophysiological factor in acute ischaemic stroke (AIS) and is relevant to mood disorders after stroke. We evaluated the predictive value of IL-10 in patients with post-stroke depression (PSD).

METHODS

A total of 350 stroke patients were recruited at baseline, and 151 AIS patients were screened and completed a 1-month follow-up. Serum IL-10 levels were measured within 24 h of admission. We used the 17-item Hamilton Depression Scale (HAMD-17) to evaluate depression symptoms; PSD was defined as an HAMD score ≥ 7.

RESULTS

Fifty-one (33.8%) patients showed a more serious stroke degree, larger infarction volume, and poorer daily life activities and prognosis (P < 0.05) and were diagnosed with PSD at the 1-month follow-up. Their IL-10 level decreased significantly compared to the non-PSD group (P < 0.001). After adjusting for confounders, IL-10 could be used as an independent predictor for PSD with an adjusted odds ratio (OR) of 0.615 (95% CI 0.410-0.923, P = 0.019). In addition, the optimal cut-off value of IL-10 was 0.615 pg/mL based on an area under the receiver operating characteristic curve of 0.692 (95% CI 0.604-0.781, P < 0.001), demonstrating that IL-10 could predict the occurrence of PSD. Moreover, IL-10 was an indicator of stroke severity, living ability, and functional outcomes (P < 0.05).

LIMITATIONS

IL-10 was only measured upon admission; dynamic changes need to be further monitored. This was also a single-centre study with a relatively small sample.

CONCLUSIONS

Lower IL-10 levels may be used to predict PSD.

Morinda officinalis oligosaccharides alleviate depressive-like behaviors in post-stroke rats via suppressing NLRP3 inflammasome to inhibit hippocampal inflammation

Aims

Morinda officinalis oligosaccharides (MOOs), a traditional Chinese medicine, have been used to treat mild and moderate depressive episodes. In this study, we investigated whether MOOs can ameliorate depressive‐like behaviors in post‐stroke depression (PSD) rats and further explored its mechanism by suppressing microglial NLRP3 inflammasome activation to inhibit hippocampal inflammation.

Methods

Behavioral tests were performed to evaluate the effect of MOOs on depressive‐like behaviors in PSD rats. The effects of MOOs on the expression of IL‐18, IL‐1β, and nucleotide‐binding domain leucine‐rich repeat (NLR) family pyrin domain containing 3 (NLRP3) inflammasome were measured in both PSD rats and lipopolysaccharide (LPS) and adenosine triphosphate (ATP) stimulated primary rat microglia by reverse transcription polymerase chain reaction (RT‐PCR), immunofluorescence and Western blot analysis. Adeno‐associated virus (AAV) was injected into the hippocampus to regulate NLRP3 inflammasome expression. The detailed molecular mechanism underlying the effects of MOOs was analyzed by Western blot and immunofluorescence.

Results

MOOs can alleviate depressive‐like behaviors in PSD rats. PSD rats showed increased expression of IL‐18, IL‐1β, and NLRP3 inflammasome in the ischemic hippocampus, while MOOs reversed the elevation. NLRP3 downregulation ameliorated depressive‐like behaviors and hippocampal inflammation response in PSD rats, while NLRP3 upregulation inhibited the effect of MOOs on depressive‐like behaviors and hippocampal inflammation response in PSD rats. Moreover, we found that NLRP3 was mainly expressed on microglia. In vitro, MOOs effectively inhibited the expression of IL‐18, IL‐1β, and NLRP3 inflammasome in LPS + ATP treated primary rat microglia. We also showed that modulation of NLRP3 inflammasome by MOOs was associated with the IκB/NF‐κB p65 signaling pathway.

Conclusion

Overall, our study reveals the antidepressive effect of MOOs on PSD rats through modulation of microglial NLRP3 inflammasome. We also provide a novel insight into hippocampal inflammation response in PSD pathology and put forward NLRP3 inflammasome as a potential therapeutic target for PSD.

Effect of repetitive transcranial magnetic stimulation on the kynurenine pathway in stroke patients

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) improves depressive symptoms and motor function in stroke patients. While metabolic derangement of the kynurenine pathway has been reported in stroke patients, the effect of rTMS on this pathway remains unknown. This study was performed to investigate the effect of rTMS on serum levels of kynurenine and tryptophan in stroke patients.

METHODS

Sixty-two stroke patients received rTMS in addition to intensive rehabilitation and 33 stroke patients received intensive rehabilitation alone for 14 days. The rTMS involved low-frequency stimulation (at 1 Hz) of the primary motor cortex on the unaffected side of the cerebrum. The depressive state of the patients was evaluated with the Beck Depression Inventory (BDI) before and after treatment. Motor function of the patients was evaluated with Fugl-Meyer Assessment (FMA). Serum levels of kynurenine and tryptophan levels were also measured before and after treatment.

RESULTS

The serum tryptophan level decreased in the group receiving rTMS to the right brain and increased in the group receiving rTMS to the left brain. The serum kynurenine/tryptophan ratio was elevated in the group receiving rTMS to the right brain. The BDI indicated improvement of depressive symptoms in the rehabilitation alone group and the group receiving rTMS to the right brain plus rehabilitation. The FMA improved in all groups.

CONCLUSIONS

The effect of low-frequency rTMS on the kynurenine pathway may differ depending on whether it is applied to the right or left cerebral hemisphere.

Higher levels of C-reactive protein in the acute phase of stroke indicate an increased risk for post-stroke depression: A systematic review and meta-analysis

BACKGROUND

Investigations have revealed the association between inflammation and post-stroke depression (PSD). However, whether the C-reactive protein (CRP) level, a biomarker of inflammation, would affect the development of PSD is still controversial.

METHODS

A systematic search of databases was performed for eligible studies. Standardized Mean Difference (SMD) with 95 % Confidence Interval (CI) was used to assess the association between the CRP level in the acute phase of stroke and the risk of PSD.

RESULTS

13 cohort studies that involved 3536 participants were included. Combined results showed that compared with non-PSD patients, the CRP level of PSD patients was significantly higher on admission (SMD = 0.19, 95 % CI: 0.12-0.27). A subgroup analysis by classifying the assessment time of depression showed obvious differences of the CRP levels between the PSD patients who were diagnosed more than 1 month after stroke and the non-PSD (1-3 months: SMD = 0.16, 95 % CI: 0.06-0.25; >3months: SMD = 0.34, 95 % CI: 0.18-0.51).

CONCLUSION

A higher level of CRP in the acute phase of stroke suggests an increased risk for PSD.