The symptomatology of post-stroke depression: comparison of stroke and myocardial infarction patients

The Inclusion of the Other in the Self-Scale (IOSS) as a valid self-discrepancy measure after stroke

Self-discrepancy, i.e., negative changes in self-concept, is a common post-stroke phenomenon which is closely associated with depression and quality of life. In earlier research, self-discrepancy has been measured with the 18-item seven-stepped Head Injury Semantic Differential Scale (HISDS-III), by comparing pre- and post-morbid self-concepts. As completing this scale may be demanding especially for cognitively impaired stroke survivors, a straightforward instrument is desirable. Therefore, the validity of the Inclusion of the Other in the Self Scale (IOSS), which measures self-discrepancy with a single visualized item, was cross-sectionally examined in 123 individuals three years after stroke. Results revealed a substantial correlation between the IOSS and the established HISDS-III (r = .47, p < .001) and a Gini Index corresponding to an AUC of 0.74, both indicating convergent validity. Both measures showed similar correlations with relevant covariates. Prediction of depressive symptoms using established predictors was significantly improved by the inclusion of the IOSS (ΔR² = .07, p < .001). The findings indicate the high validity of the IOSS as an economic measure of global self-discrepancy after stroke. In addition, the results confirm self-discrepancy as a relevant determinant of post-stroke depression and thus as a potential target for psychological interventions in stroke patients.

Sex Differences in Post-Stroke Depression in the Elderly

OBJECTIVE

Post-stroke depression (PSD) occurs in approximately one-third of ischemic stroke patients. However, there is conflicting evidence on sex differences in PSD. We sought to assess sex differences in risk and time course of PSD in US ischemic stroke (IS) patients. We hypothesized that women are at greater risk of PSD than men, and that a greater proportion of women experience PSD in the acute post-stroke phase.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 100% de-identified data for US Medicare beneficiaries admitted for ischemic stroke from July 1, 2016 to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression, stratified by sex, up to 1.5 years following index admission. We performed Cox regression to report the hazard ratio (HR) for diagnosis of depression up to 1.5 years post-stroke in females vs. males, adjusting for patient demographics, comorbidities, length of stay, and acute stroke interventions.

RESULTS

In elderly stroke patients, females (n=90,474) were 20% more likely to develop PSD than males (n=84,427) in adjusted models. Cumulative risk of depression was consistently elevated for females throughout 1.5 years of follow-up (0.2055 [95% CI 0.2013-0.2097] vs. 0.1690 [95% CI 0.1639-0.1741] (log-rank p < 0.0001). HR for PSD in females vs. males remained significant in fully adjusted analysis at 1.20 (95% CI 1.17-1.23, p < 0.0001).

CONCLUSIONS

Over 1.5 years of follow-up, female stroke patients had significantly greater hazard of developing PSD, highlighting the need for long-term depression screening in this population and further investigation of underlying reasons for sex differences.

Risk and Predictors of Depression Following Acute Ischemic Stroke in the Elderly

OBJECTIVE

We sought to comprehensively evaluate predictors of poststroke depression (PSD) in the United States and to compare PSD to post-myocardial infarction (MI) depression to determine whether ischemic stroke uniquely elevates risk of depression.

METHODS

This is a retrospective cohort study of 100% deidentified inpatient, outpatient, and subacute nursing Medicare data from 2016 to 2017 for US patients ≥65 years of age from July 1, 2016, to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression up to 1.5 years after the index admission. We performed Cox regression to report the hazard ratio for diagnosis of depression up to 1.5 years after stroke vs MI and independent predictors of PSD, and we controlled for patient demographics, comorbid conditions, length of stay, and acute stroke interventions.

RESULTS

In fully adjusted models, patients with stroke (n = 174,901) were ≈50% more likely than patients with MI (n = 193,418) to develop depression during the 1.5-year follow-up period (Kaplan-Meier cumulative risk 0.1596 ± 0.001 in patients with stroke vs 0.0973 ± 0.000778 in patients with MI, log-rank p < 0.0001). History of anxiety was the strongest predictor of PSD, while discharge home was most protective. Female patients, White patients, and patients <75 years of age were more likely to be diagnosed with depression after stroke.

CONCLUSIONS

Despite the similarities between MI and stroke, patients with stroke were significantly more likely to develop depression. There were several predictors of PSD, most significantly history of anxiety. Our findings lend credibility to a stroke-specific process causing depression and highlight the need for consistent depression screening in all patients with stroke.

Readmissions for Depression and Suicide Attempt following Stroke and Myocardial Infarction

Background and Purpose

Rates of depression after ischemic stroke (IS) and myocardial infarction (MI) are significantly higher than in the general population and associated with morbidity and mortality. There is a lack of nationally representative data comparing depression and suicide attempt (SA) after these distinct ischemic vascular events.

Methods

The 2013 Nationwide Readmissions Database contains >14 million US admissions for all payers and the uninsured. Using International Classification of Disease, 9th Revision, Clinical Modification Codes, we identified index admission with IS (n = 434,495) or MI (n = 539,550) and readmission for depression or SA. We calculated weighted frequencies of readmission. We performed adjusted Cox regression to calculate hazard ratio (HR) for readmission for depression and SA up to 1 year following IS versus MI. Analyses were stratified by discharge home versus elsewhere.

Results

Weighted depression readmission rates were higher at 30, 60, and 90 days in patients with IS versus MI (0.04%, 0.09%, 0.12% vs. 0.03%, 0.05%, 0.07%, respectively). There was no significant difference in SA readmissions between groups. The adjusted HR for readmission due to depression was 1.49 for IS versus MI (95% CI 1.25–1.79, p < 0.0001). History of depression (HR 3.70 [3.07–4.46]), alcoholism (2.04 [1.34–3.09]), and smoking (1.38 [1.15–1.64]) were associated with increased risk of depression readmission. Age >70 years (0.46 [0.37–0.56]) and discharge home (0.69 [0.57–0.83]) were associated with reduced hazards of readmission due to depression.

Conclusions

IS was associated with greater hazard of readmission due to depression compared to MI. Patients with a history of depression, smoking, and alcoholism were more likely to be readmitted with depression, while advanced age and discharge home were protective. It is unclear to what extent differences in type of ischemic tissue damage and disability contribute, and further investigation is warranted.

Cerebrovascular burden and depressive symptomatology interrelate over 18 years: support for the vascular depression hypothesis

OBJECTIVE

Potentially incongruent research literatures suggest three divergent hypotheses about depressive symptomatology: (1) symptoms are recurrent; (2) later-life depression results from high cerebrovascular burden (CVB); and (3) depressive symptoms contribute to comorbidities causing vascular burden. Past vascular depression research assumes that later-life depressive symptoms relate uniquely to high CVB and not to prior, recurrent depression. This study examines these divergent hypotheses.

METHODS

Data include 5175 participants across 18 years from the Wisconsin Longitudinal Study (mean age at 1993 baseline was 53 years; follow-ups in 2004 and 2011). Depressive symptomatology was measured using the Center for Epidemiological Studies Depression. CVB was operationalized as hypertension, high blood sugar, diabetes, and other heart problems. Hypotheses were examined via a cross-lagged structural equation model and logistic regression.

RESULTS

Model fit was acceptable (root mean square error of approximation (RMSEA) = 0.047; comparative fit index = 0.963). Hypotheses 1 and 2 were supported. Depressive symptomatology at 2004 and 2011 follow-ups was predicted by earlier depressive symptomatology and prior CVB. Hypothesis 3 was partially supported; depressive symptomatology in 2004 predicted subsequent CVB. Logistic regression results were that CVB predicted clinically significant depressive symptoms based on the Center for Epidemiological Studies Depression clinical cutoff.

CONCLUSIONS

Cerebrovascular burden in midlife predicts depressive symptomatology in later-life, even after accounting for prior depressive symptomatology, supporting a fundamental assumption of the vascular depression hypothesis. Midlife depressive symptomatology also predicted escalation of CVB in later-life. Results suggest a process model of later-life depressive symptom development that interrelates CVB and depressive symptoms throughout the life span and have clinical implications for the interruption of this process through the integration of primary care and behavioral health specialists. Copyright © 2017 John Wiley & Sons, Ltd.

Clinical Manifestation of Depression after Stroke: Is It Different from Depression in Other Patient Populations?

BACKGROUND

Despite ample research on depression after stroke, the debate continues regarding whether symptoms such as sleep disturbances, loss of energy, changes in appetite and diminished concentration should be considered to be consequences of stroke or general symptoms of depression. By comparing symptoms in depressed and non-depressed stroke patients with patients in general practice and patients with symptomatic atherosclerotic diseases, we aim to further clarify similarities and distinctions of depression after stroke and depression in other patient populations. Based on this, it is possible to determine if somatic symptoms should be evaluated in stroke patients in diagnosing depression after stroke.

METHODS

An observational multicenter study is conducted in three hospitals and seven general practices including 382 stroke patients admitted to hospital with a clinical diagnosis of intracerebral hemorrhage or ischemic infarction, 1160 patients in general practice (PREDICT-NL), and 530 patients with symptomatic atherosclerotic diseases (SMART-Medea).

RESULTS

The prevalence of major depressive disorder according to DSM-IV criteria was 14.1% (95% CI 11.0%-18.0%) in the stroke cohort, 5.4% (95% CI 3.8%-7.9%) in the symptomatic atherosclerotic diseases cohort and 12.9% (95% CI 11.1%-15.0%) in the general practice cohorts. Comparing depressed patients of the three cohorts demonstrated broadly similar symptom profiles, as well as comparable levels of individual symptom prevalence. However, the stroke patients suffered more severely from these symptoms than patients in the other populations.

CONCLUSIONS

The findings suggest that depression after stroke is not a different type of depression. This finding indicates that all depressive symptoms should be evaluated in stroke patients, including somatic symptoms.

Factors of Hamilton Depression Rating Scale (17 items) at 2 weeks correlated with poor outcome at 1 year in patients with ischemic stroke

There was fewer paper about the relation between the Hamilton Depression Rating Scale (17 Items, HDRS-17) factors and stroke outcomes. Our aim was to investigate the influence of total score and factors of HDRS-17 on outcome of ischemic stroke at 1 year. A total of 1,953 patients with acute ischemic stroke were enrolled into a multicentered and prospective cohort study. The HDRS-17 was used to assess symptoms at 2 weeks after ischemic stroke. The Modified Ranking Scale (mRS) scores of 3-6 points and 0-2 points were regarded as poor outcome and benign outcome, respectively. At 1 year, 1,753 (89.8 %) patients had mRS score data. After adjusting for the confounders, patients with a total HDRS-17 score of ≥ 8 had a worse outcome at 1 year (OR = 1.62, 95 % CI 1.18-2.23). Symptoms of suicide (OR = 1.89, 95 % CI 1.27-2.83), decreased or loss of interest of work (OR = 1.89, 95 % CI 1.38-2.58), retardation (OR = 1.74, 95 % CI 1.27-2.38), psychic anxiety (OR = 1.72, 95 % CI 1.26-2.34), and agitation (OR = 1.61, 95 % CI 1.08-2.40) increased the risks for poor outcome by >60 %, respectively. Depressed mood, somatic anxiety, somatic symptoms-gastrointestinal, and early insomnia also increased the risk for poor outcome by nearly 50 %, respectively. A total HDRS-17 score of ≥ 8, and suicide, decreased or loss of interest of work, anxiety, agitation, retardation, depressed mood, somatic anxiety, somatic symptoms-gastrointestinal, and early insomnia of the HDRS-17 factors at 2 weeks after ischemic stroke increase the risk for poor outcome at 1 year.

Does brain reserve protect older women from vascular depression?

OBJECTIVES

Brain reserve theory, typically discussed in relation to dementia, was examined with regard to late-life depression symptomatology and cerebrovascular burden (CVB) in older-old women.

METHOD

It was predicted that in a 6-year longitudinal sample (Health and Retirement Study) of 1,355 stroke-free women aged 80 years and older, higher levels of depressive symptomatology (8-item Center for Epidemiologic Studies-Depression score) would be predicted by high CVB, less educational attainment, and the education × CVB interaction after controlling for age and cognitive functioning (Telephone Interview for Cognitive Status). A latent growth curve model was used to identify differences in depression symptomatology at baseline and over time. Logistic regression analyses were used to predict clinically significant depressive symptomatology at each wave based on CVB, education, and the education × CVB interaction.

RESULTS

Results indicate that among older women, greater educational attainment predicted fewer depression symptoms at baseline, but this advantage was partially eroded over time. The education × CVB interaction predicted clinically significant depressive symptoms at baseline when the benefits of education were most robust.

DISCUSSION

Brain reserve, characterized by educational attainment, may counterbalance the effect of high CVB with respect to depressive symptoms, thereby preserving mood in late life. These findings support the application of brain reserve theory to late-life depression.

Incorporating the treatment of medical and psychiatric disorders in the critical care area

Critical care areas are fast moving, often chaotic, and therefore confusing, even frightening, to patients attempting to understand what has happened to them. The nurse acts to mitigate these reactions by understanding the range of possibilities that can occur with patients, including potential psychiatric issues, and serving as patient advocate to ensure that appropriate treatment is initiated. Certainly there may be other psychiatric problems not described in the preceding text. The main possibilities are covered in this article. Assessing and acting early are tools the critical care nurse uses to meet patient needs and prevent behavioral problems that can interfere with life-preserving care.