Lesion Location and Poststroke Depression

Efficacy of hyperbaric oxygen treatment for depression in the convalescent stage following cerebral hemorrhage

The present study aimed to evaluate the clinical efficacy of hyperbaric oxygen (HBO) treatment for depression in the convalescent stage following cerebral hemorrhage. A total of 60 cases of patients with depression in the convalescent stage following cerebral hemorrhage (2–6 months) were randomly divided into the treatment group (treated with HBO, 30 cases) and the control group (treated with Deanxit, 30 cases). Prior to treatment and at 4 weeks post-treatment, efficacy was evaluated by the Hamilton Depression Scale (HAMD) and nerve function defect scores. There was a significant difference in the total efficacy between the two groups (P<0.05), and a significant difference in the HAMD scores (P<0.05). There were also significant differences between the pre- and post-treatment HAMD scores within the two groups (both P<0.05). HBO is able to significantly improve the degree of depression in the convalescent stage following cerebral hemorrhage and also promote nerve function recovery.

Neurobehavioral disorders

Neurobehavioral disorders are composed of a large group of behavioral impairments seen in association with brain disease (e.g., stroke, multiple sclerosis, dementia, and neuro-oncological conditions), transient as well as permanent brain impairments (e.g., metabolic and toxic encephalopathies), and/or injury (e.g., trauma, hypoxia, and/or ischemia). The neurorehabilitative assessment and management of such disorders is often poorly addressed in the context of overall neurological, psychiatric, and rehabilitative care. Too often, more basic, yet critical, aspects of behavioral assessment and treatment are not addressed or only superficially addressed by evaluating clinicians. Physicians often overly rely on pharmacological interventions as initial and/or sole treatment approaches rather than taking a pragmatic biopsychosocial approach that focuses on holistic disease state management. This chapter provides readers with an overview of the common behavioral impairments associated with brain dysfunction due to disease, injury, or toxicity. Details regarding the nature of impairments such as localization-related syndromes, affective disorders and personality disorders, among others are expounded. Principles of neurobehavioral assessment and treatment are examined including general guidelines for eliciting a history and physical, behavioral analysis, and functional behavioral assessment. General treatment caveats are provided including discussion of impairment and disability adaptation, and creation of positive behavioral supports. The topic of pharmacological management of neurobehavioral disorders is covered in numerous other references including Chapter 33 of this text.

Associations of cytokine gene polymorphisms with post-stroke depression

OBJECTIVES

Inflammatory cytokines are implicated in the pathophysiology of both stroke and depression, and their production is influenced by the transcriptional activity of particular gene polymorphisms. We hypothesised that alleles related to higher pro-inflammatory and/or lower anti-inflammatory cytokine production would be associated with post-stroke depression (PSD).

METHODS

In 276 stroke cases, depression was diagnosed using DSM-IV, and classified into major PSD (N = 29), all (major plus minor) PSD (N = 77), and control (N = 199) groups. Genotyping for six pro-inflammatory polymorphisms (TNF-α -850C/T and -308G/A, IL-1β -511C/T and + 3953C/T, IL-6 -174G/C, and IL-8 -251T/A) and two anti-inflammatory polymorphisms (IL-4 + 33T/C and IL-10 -1082G/A) was conducted. Individual associations with PSD were estimated using logistic regression models. Total numbers of potential risk alleles were calculated for pro-inflammatory and anti-inflammatory cytokine genes and analysed against depression using χ(2)-tests.

RESULTS

The IL-4 + 33C/C genotype was associated with major PSD, and the IL-10 -1082A/A genotype was associated with all PSD. Increasing numbers of risk alleles for these two anti-inflammatory cytokine genotypes were significantly associated with both PSD categories. No significant associations were found with any pro-inflammatory cytokine allele.

CONCLUSIONS

Alleles associated with reduced anti-inflammatory cytokine function were associated with PSD, supporting the cytokine hypothesis in its etiology.

Neuropathological substrates and structural changes in late-life depression: the impact of vascular burden

A first episode of depression after 65 years of age has long been associated with both severe macrovascular and small microvascular pathology. Among the three more frequent forms of depression in old age, post-stroke depression has been associated with an abrupt damage of cortical circuits involved in monoamine production and mood regulation. Late-onset depression (LOD) in the absence of stroke has been related to lacunes and white matter lesions that invade both the neocortex and subcortical nuclei. Recurrent late-life depression is thought to induce neuronal loss in the hippocampal formation and white matter lesions that affect limbic pathways. Despite an impressive number of magnetic resonance imaging (MRI) studies in this field, the presence of a causal relationship between structural changes in the human brain and LOD is still controversial. The present article provides a critical overview of the contribution of neuropathology in post-stroke, late-onset, and late-life recurrent depression. Recent autopsy findings challenge the role of stroke location in the occurrence of post-stroke depression by pointing to the deleterious effect of subcortical lacunes. Despite the lines of evidences supporting the association between MRI-assessed white matter changes and mood dysregulation, lacunes, periventricular and deep white matter demyelination are all unrelated to the occurrence of LOD. In the same line, neuropathological data show that early-onset depression is not associated with an acceleration of aging-related neurodegenerative changes in the human brain. However, they also provide data in favor of the neurotoxic theory of depression by showing that neuronal loss occurs in the hippocampus of chronically depressed patients. These three paradigms are discussed in the light of the complex relationships between psychosocial determinants and biological vulnerability in affective disorders.

Post-stroke depression: an update

INTRODUCTION

Post-stroke depression (PSD) is the most common mood disorder following a stroke, and also the main factor limiting recovery and rehabilitation in stroke patients. In addition, it may increase mortality by up to ten times.

DEVELOPMENT

PSD occurs in 1 in 3 stroke patients and more than half of all cases are neither diagnosed nor treated. Several mechanisms, including biological, behavioral, and social factors, are involved in its pathogenesis. Symptoms usually occur within the first three months after stroke (early onset PSD), and less frequently at a later time (late onset PSD). Symptoms resemble those of other types of depression, although there are some differences: PSD patients experience more sleep disturbances, vegetative symptoms, and social withdrawal. For PSD diagnosis, we recommended vigilance and use of specific diagnostic tools such as the Patient Health Questionnaire-2 (PHQ-2). The treatments of choice are selective serotonin reuptake inhibitors (SSRI). However, there are still many unanswered questions in the treatment of PSD, such as the best time to start treatment or the effects of antidepressants on cognition and motor function, among others.

CONCLUSIONS

Neurologists play a pivotal role in the care and management of patients recovering from stroke. They must be familiar with methods for early detection and treatment of PSD, as this can facilitate a patient's functional recovery and social reintegration, and improve quality of life for patients and their families.

Exofocal dopaminergic degeneration as antidepressant target in mouse model of poststroke depression

BACKGROUND

Although poststroke depression (PSD) is a frequent chronic complication of stroke with high relevance for outcome and survival, underlying pathomechanisms remain inadequately understood. This may be because suitable animal models are largely lacking and existing models are poorly characterized.

METHODS

Male 129/SV mice were subjected to 30-min middle cerebral artery occlusion (MCAo)/reperfusion and serial magnetic resonance imaging scans. A subset of animals received selective serotonin reuptake inhibitor citalopram starting 7 days after MCAo. Behavioral assessment was performed at 14 weeks. To identify biological correlates of PSD, we quantified corticosterone levels in serum and brain-derived neurotrophic factor levels in brain. The integrity of the mesolimbic dopaminergic system was assessed using tyrosine hydroxylase and dynorphin in situ hybridizations as well as dopamine transporter autoradiography.

RESULTS

Left, but not right, MCAo, elicited anhedonia and increased anxiety and despair. This depression-like syndrome was associated with alterations in the mesolimbic reward system. MCAo resulted in delayed degeneration of dopaminergic neurons in ipsilateral midbrain, which was accompanied by reduced dopamine concentrations and decreased levels of dopamine transporter density along with increased brain-derived neurotrophic factor protein levels in ischemic striatum and increased dynorphin messenger RNA expression in nucleus accumbens. Chronic antidepressant treatment initiated as late as 7 days after stroke reversed the behavioral phenotype, prevented degeneration of dopaminergic midbrain neurons, and attenuated striatal atrophy at 4 months.

CONCLUSIONS

Our results highlight the importance of the dopaminergic system for the development of PSD. Prevention of secondary neurodegeneration by antidepressants may provide a novel target for subacute stroke therapy.

Adherence to Canadian best practice recommendations for stroke care: assessment and management of poststroke depression in an Ontario rehabilitation facility

BACKGROUND AND PURPOSE

Although Canadian best practice recommendations regarding assessment and management of poststroke depression (PSD) have been established, the degree to which these evidence-based guidelines have been translated into practice is not known. The objectives of the present study are to compare current and recommended best practice and examine possible reasons for identified care gaps.

METHODS

Practice audit by chart review was performed to identify recorded screening, assessment, and treatment for PSD in patients discharged from a specialized inpatient rehabilitation program over a 6-month period. A questionnaire was administered to all clinical staff addressing current screening practices as well as opinions regarding the importance and feasibility of identification and treatment of PSD.

RESULTS

Of 123 patients, 40 (32.5%) had been prescribed antidepressants at discharge. However, evidence of screening was found for 4.9% of patients; another 9.8% were referred for psychological consult. Treatment was associated with previous antidepressant use or history of depression, but not screening or assessment. Of the survey respondents, 56.2% were not aware of best practice recommendations. However, most felt screening and assessment to be important and treatment was regarded as both simple and effective.

CONCLUSIONS

Despite potential benefit associated with identification and treatment of PSD and the availability of evidence-based best practice recommendations, PSD may remain unrecognized and undertreated. Given the juxtaposition of perceived importance with the lack of documented best practice, education regarding standardized screening and the development of consistent clinical protocols including roles and responsibilities in the identification, diagnosis, and treatment of PSD are underway.

Serotonergic and BDNF genes and risk of depression after stroke

BACKGROUND

Polymorphisms of serotonin transporter (5-HTT) and brain-derived neurotrophic factor (BDNF) have been investigated as candidate genes for post-stroke depression (PSD). Serotonin 2a receptor (5-HTR2a) genes have not been yet investigated in PSD. This study aimed to investigate whether the 5-HTT, 5-HTR2a, and BDNF genes are associated with PSD independently and/or interactively in a Korean sample with high prevalence of risk alleles.

METHODS

In 276 stroke cases, depression was diagnosed using DSM-IV at 2 weeks after stroke, further classified to major PSD (N=29), all (major plus minor) PSD (N=77), and control (N=199) groups. Associations between PSD and 5-HTTLPR, STin2 VNTR, 5-HTR2a 1438A/G, 5-HTR2a 102T/C, and BDNF val66met genotypes were estimated using logistic regression models, and gene-gene interactions were investigated using the generalized multifactor dimensionality reduction method.

RESULTS

5-HTR2a 1438 A/A genotype was associated with major PSD, while 5-HTTLPR s/s and BDNF met/met genotypes were associated with all PSD. There was a significant interaction between 5-HTR2a 1438A/G and BDNF val66met polymorphisms for major PSD and a borderline significant interaction between 5-HTTLPR and BDNF val66met polymorphisms for all PSD.

CONCLUSIONS

In a large cohort, we found evidence for serotonin and BDNF polymorphisms as susceptibility factors and gene-gene interactions between these systems for depression at 2 weeks post-stroke.

A prospective cohort study of lesion location and its relation to post-stroke depression among Chinese patients

BACKGROUND

Post-stroke depression (PSD) is a common consequence of stroke that negatively interferes with the rehabilitation outcome in patients. It remains unclear what relationship exists between the site and size of brain infarcts and the development of PSD and the risk factors for PSD. We conducted a MRI-based cohort study to examine the radiological correlations for PSD in Chinese patients with ischemic stroke.

METHODS

Our study included 163 patients with acute ischemic stroke. The diagnosis of PSD was made with World Health Organization Composite International Diagnostic Interview (WHO-CIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) during a follow-up exam at 3-month post stroke. The demographic, clinical, and detailed radiological variables (e.g., lesion location, and degree of white matter lesions) were also examined.

RESULTS

The univariate analyses suggested that the frequency of multiple acute infarcts, the total number and volume of acute infarcts were higher in the PSD group than those in the non-PSD group. In particular, PSD patients showed higher rates of infarcts in cortical-subcortical area of the frontal and temporal lobe as well as in internal capsule (including genu, anterior and posterior limb). The multivariate analysis suggested that independent radiological risk factors for PSD may include the presence of multiple acute infarcts, the infarct affecting either side of posterior limb of internal capsule, genu of internal capsule, and cortical-subcortical areas in the temporal lobe.

CONCLUSION

Our study on ischemic stroke patients suggested that certain neuroanatomical factors (i.e., lesions at posterior limb and genu of internal capsule and cortical-subcortical area of the temporal lobe, as well as the presence of multiple acute infarcts) may correlate with the PSD development.

The lived experience of stroke survivors with early depressive symptoms: A longitudinal perspective

PURPOSE

The aim of the study was to describe the lived experience as it develops over time in stroke survivors suffering from early depressive symptoms.

METHOD

This paper presents a phenomenological hermeneutical interview-study of nine participants at 6, 12, and 18 months after stroke.

FINDINGS

The participants related the depressive symptoms to the consequences of the stroke, and the experience of loss was crucial. Depressive symptoms was not meaningful on its own, but formed the backdrop of the experience of stroke. Our findings revealed three patterns of experience: (1) finding a restored self; (2) trapped in a different life; and (3) fighting to regain self. TWO GROUPS OF STROKE SURVIVORS ARE PARTICULARLY VULNERABLE AND SHOULD RECEIVE SPECIAL ATTENTION: (a) old adults living alone; and (b) adults experiencing serious threats to their commitments such as to work, family, and children.

CONCLUSION

Depressive symptoms have a severe impact on life after stroke. Life circumstances, degree of residual impairment from a stroke, and social context were found to influence people to move along different paths. Older adults living alone and adults experiencing serious threat to their commitments should receive special attention, in terms of further research and in terms of follow-up in clinical practice. More studies investigating the experience of post-stroke depression (PSD) over time and the association between depressive symptoms and loss/grieving are needed. There is also a need for continued empirical research on the identification of effective interventions aimed at prevention or improved coping with PSD.

Are vascular risk factors associated with post-stroke depressive symptoms?

OBJECTIVE

Vascular risk factors (VRFs) have been associated with stroke and cognitive impairment, however, the role of VRFs in predicting post-stroke depression (PSD) has not been assessed. The objective of the current study was to determine whether VRFs are associated with the risk of PSD in an acute stroke population.

METHODS

In this observational study, patients meeting World Health Organization MONICA Project and National Institute of Neurological Disorders and Stroke criteria for stroke were eligible. Patients were assessed for depression, cognition, and stroke severity, and VRF and demographic information were obtained.

RESULTS

A total of 102 patients were recruited within 4 months post-stroke. Using a score of ≥16 on the Center for Epidemiological Studies Depression scale to determine depressive symptoms, 38 patients (age 72.1 ± 15.6, 44.7% male) screened positive for depressive symptoms and 64 (age 70.1 ± 13.6, 51.6% male) screened negative. Analysis of VRFs showed that only hypertension (P = .044) independently predicted the presence of depressive symptoms (χ(2) = 4.742, P = .029, Nagelkerke R (2) = .062).

CONCLUSIONS

Hypertension was associated with post-stroke depressive symptoms, while there was no relationship between PSD and other VRFs. Hypertension may have a greater impact than other VRFs on mood following stroke and may have a role in prevention and treatment of PSD.

Motor cortex excitability in vascular depression

The aim of this study was to evaluate excitatory/inhibitory intracortical circuit changes in patients with vascular depression, and whether there are any interhemispheric differences of motor cortical excitability. Fifteen vascular depressed elderly (VD), ten nondepressed subcortical vascular disease patients (SVD) and ten age-matched controls underwent bilateral motor threshold and paired-pulse studies. They were also assessed for their brain vascular burden at MRI and neuropsychological profile. Executive dysfunction and apathy were significantly higher in VD; we were unable to find significant differences in resting motor threshold, cortical silent period and paired-pulse curves between VD, SVD and controls, and between the two hemispheres in the VD group. Our findings might suggest that neurophysiological mechanisms underlying VD differ from those previously reported in Major Depression (reduced excitability in the left hemisphere) and seem to be similar to those of patients with SVD. Our findings also, support the "vascular depression" hypothesis, suggesting that in VD patients the depressive syndrome is not the primary disease but can be considered as one of the clinical manifestations in the wide symptom spectrum of the cerebral small vessel disease.

'Living a life in shades of grey': experiencing depressive symptoms in the acute phase after stroke

AIM

The aim of the present study was to describe the lived experience of stroke survivors suffering from depressive symptoms in the acute phase; addressing the following questions: (a) what is the nature of depression as experienced by post-stroke patients in the acute phase? (b) what is it like to live with depression within the first weeks following stroke?

BACKGROUND

Post-stroke depression occurs in at least one quarter of stroke survivors and is linked to poorer outcomes.

METHOD

This qualitative study is methodologically grounded in hermeneutic phenomenology, influenced by van Manen and Ricoeur. A descriptive, qualitative design was used applying in-depth interviews as the method of data collection with nine participants. The data collection took place in 2008.

RESULTS

The material revealed two main themes that generate the feeling and description of 'living a life in shades of grey': (a) being trapped and (b) losing oneself. 'Shades of grey' could be understood as being confined in a new life-world and losing oneself as the person one knew.

CONCLUSION

The participants confirmed suffering from depressive symptoms, but depression was not seen as meaningful on its own. They related their experiences of post-stroke depression in the acute phase to the losses they experienced. Nurses ought to take into account the depth of the life changes that stroke survivors may experience. There is a need for continued empirical research on how nurses may help and support stroke survivors dealing with depressive symptoms in the acute phase after stroke and how depressive symptoms develop over time.

A study of suicidal thoughts in acute stroke patients

BACKGROUND

In previous studies, suicidal thoughts in stroke patients were related to depression and recurrent stroke. The aim of this study was to describe the presence and correlates of suicidal thoughts in acute stroke patients.

METHODS

We assessed the presence of suicidal thoughts in a sample of 177 consecutive acute stroke patients (≤ 4 days), using the item "suicidal thoughts" of the Montgomery and Asberg Depression Rating Scale.

RESULTS

Fifteen percent of acute stroke patients had suicidal thoughts, 22% of them with explicit plans to complete suicide. Suicidal thoughts were more frequent in patients with a lower educational level (Chi-square 4.69; P = .05), previous mood disorder (Chi-square 12.80; P = .001), diabetes (Chi-square 5.48; P = .04), and acute depression (Chi-square 16.59; P = .001). In logistic regression, a lower educational level (odds ratio [OR] 5.13; 95% confidence interval [CI] 0.80-33.29), diabetes (OR 3.15; 95% CI 0.81-12.28), a previous mood disorder (OR 4.22; 95% CI 1.12-15.86), and depression (OR 7.82; 95% CI 1.58-38.71) were independent factors predicting suicidal thoughts (R(2) = 0.39%). The 23 depressed acute stroke patients with suicidal thoughts were similar in demographic, clinical, and lesion variables, and were similar in profile of depression to the 63 patients with depression but without suicidal thoughts, except for a higher frequency of a previous mood disorder in the former group (Chi-square 7.87; P = .01).

CONCLUSIONS

Suicidal thoughts may develop shortly after the onset of acute stroke, especially in patients with a lower educational level, a previous mood disorder, and those who developed depressive symptoms in the acute phase of stroke. The high frequency of suicidal thoughts makes the assessment of suicidal behavior in patients with acute stroke an important clinical issue.

Stroke lesion in cortical neural circuits and post-stroke incidence of major depressive episode: a 4-month prospective study

OBJECTIVE

Little is known about the relevance of lesion in neural circuits reported to be associated with major depressive disorder. We investigated the association between lesion stroke size in the limbic-cortical-striatal-pallidal-thalamic (LCSPT) circuit and incidence of major depressive episode (MDE).

METHODS

We enrolled 68 patients with first-ever ischemic stroke and no history of major depressive disorder. Neurological and psychiatric examinations were performed at three time-points. We diagnosed major depressive episode, following DSM-IV criteria. Lesion location and volume were determined with magnetic resonance imaging, using a semi-automated method based on the Brodmann Cytoarchitectonic Atlas.

RESULTS

Twenty-one patients (31%) experienced major depressive episode. Larger lesions in the left cortical regions of the LCSPT circuit (3,760 vs. 660 mm3; P = 0.004) were associated with higher incidence of MDE. Secondary analyses revealed that major depressive episode was associated with larger lesions in areas of the medial prefrontal cortex including the ventral (BA24) and dorsal anterior cingulate cortex (BA32) and subgenual cortex (BA25); and also the subiculum (BA28/36) and amygdala (BA34).

CONCLUSIONS

Our findings indicate that depression due to stroke is aetiologically related to the disruption of the left LCSPT circuit and support the relevance of the medial prefrontal cortex dysfunction in the pathophysiology of depression.

Post-stroke depression and apathy: Interactions between functional recovery, lesion location, and emotional response

Depression and apathy are often observed after stroke and are often confused with one another. In the present review, we argue that the current concept of 'post-stroke depression' (PSD) in fact consists of two core symptoms or syndromes: (i) affective (depressive) PSD; and (ii) apathetic PSD. We argue that these two core symptoms are each associated with a different underlying neuroanatomical mechanism, a pattern that influences functional recovery. Post-stroke disabilities can provoke several distinct emotional responses, some of which are associated with severe depression. We examined one of these emotional responses previously, namely 'insistence on recovery', which was believed to be a negative indicator of functional improvement in disabled stroke patients. However, an appropriate level of insistence on recovery may, in fact, be associated with reduced depression and apathy, resulting in enhanced recovery from stroke-related disabilities. Improvements in physical disabilities (trunk stability or activities of daily living, such as walking) also reduce depression and apathy. Therefore, the experience of PSD/apathy may be intertwined with various initial emotional responses and improvements in physical functioning. Effective treatment of PSD/apathy requires a multidisciplinary approach, such that neuroanatomical/neurobiological, emotional, and physical (rehabilitation) domains are all addressed.

Association of frontal subcortical circuits infarcts in poststroke depression: a magnetic resonance imaging study of 591 Chinese patients with ischemic stroke

Despite extensive research into poststroke depression (PSD), the role played by lesion location in the pathogenesis of PSD remains uncertain. The aim of this study was to estimate the magnetic resonance imaging (MRI) correlates of PSD in Chinese patients with first or recurrent stroke. A total of 591 patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong were recruited. A psychiatrist assessed all the patients 3 months after the stroke. The psychiatrist used the Structured Clinical Interview for Diagnostic and Statistical Manual, fourth edition (DSM-IV) to confirm whether the patients met the criteria of a depressive disorder. In addition, a host of demographic, clinical, and radiological variables were examined. A tota; of 475 and 116 patients had first and recurrent strokes, respectively. In all, 75 (12.7%) patients received a diagnosis of PSD. In univariate analysis of the MRI findings, the presence of infarcts in the frontal subcortical circuits ([FSC], 66.7% vs 53.3%) was significantly associated with PSD (P = .03) compared to the patients without PSD. The FSC infarct-PSD association remained significant (odds ratio = 2.6) in subsequent logistic regression analysis after adjusting for gender, history of depression, neurological impairment, level of social support, and major life events. In conclusion, FSC infarcts are independent predictors of PSD. Further work is needed to clarify whether these infarcts have an impact on the clinical presentation, treatment responses, and prognosis of PSD.

A prospective cohort study of the incidence and determinants of post-stroke depression among the mainland Chinese patients

BACKGROUND

Post-stroke depression is a common consequence of stroke and can negatively affect the rehabilitation process in patients. This work was undertaken to examine the incidence, demographic factors and clinical determinants of post-stroke depression in 3 months after ischemic stroke in mainland Chinese patients.

METHODS

One hundred and sixty-five patients with acute ischemic stroke were included in the present work. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of post-stroke depression was evaluated by the World Health Organization Composite International Diagnostic Interview during the follow-up exam at 3 months after the stroke. The demographic factors and clinical variables at the time of stroke onset and 14 days after stroke were also examined.

RESULTS

The 3 month cumulative incidence of post-stroke depression was 27.3% in this patient population. The univariate analysis suggests that the female gender, past history of depression, marital status and level of handicap at 14 days after stroke were factors associated with the development of post-stroke depression. In the multivariate model, female gender [p=0.0040; odds ratio (OR)=3.550; 95% confidence interval (CI): 1.499-8.408], past history of depression (p=0.0010; OR=5.225; 95% CI: 1.959-13.940) and level of handicap at 14 days after stroke (p=0.0066; OR=1.607; 95% CI: 1.141-2.262) were further confirmed as demographic and clinical factors that correlate with the development of post-stroke depression.

CONCLUSION

The present work suggests that female gender, history of depression and level of handicap at 14 days after stroke are three independent determinants of post-stroke depression occurrence during the first 3 months after ischemic stroke in mainland Chinese patients.

Poststroke depression: a review

OBJECTIVE

To review the world's (English-language) publications related to depression following stroke.

METHOD

The databases from MEDLINE and PubMed were reviewed for articles related to poststroke depression (PSD), depression and cerebral vascular accident, depression and cerebral vascular disease, and depression and cerebral infarction.

RESULTS

Most studies examined prevalence rates of depression and the clinical correlates of depression. Based on pooled data, the overall prevalence of major depression was 21.7% and minor depression was 19.5%. The strongest single correlate of depression was severity of impairment in activities of daily living. However, the existence of depression at baseline was found to be associated with greater impairment at follow-up, ranging from 6 weeks to 2 years in 83% of studies. Further, depression following acute stroke was also associated with greater cognitive impairment and increased mortality. PSD has been shown in 6 double-blind controlled studies to be effectively treated with antidepressants, and 1 study has recently shown that PSD can be effectively prevented.

CONCLUSIONS

During the past 20 years, significant progress has been made in the identification and treatment of depression following stroke. In the future, antidepressant treatment will likely play an increasing role in the management of patients with acute stroke. Further research is needed to identify the mechanisms of depression and why antidepressants lead to improved physical and cognitive recovery and decreased mortality.

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

BACKGROUND

Depression is a frequent problem in stroke patients but, all too often, the problem goes unrecognized. How depression-like symptoms in post-stroke depression (PSD) should be interpreted is still subject to debate. If PSD has a distinct symptom profile of depression accompanying other chronic vascular somatic conditions then this could imply that PSD is a specific disease entity.

OBJECTIVE

To study whether depressed stroke patients exhibit other signs and symptoms than patients suffering from depression after myocardial infarction (MI).

METHODS

Depressive signs and symptoms were measured using the Hospital Anxiety and Depression Scale and the 17-item Hamilton Depression Rating Scale. The results of 190 stroke patients were compared with the results of 198 MI patients every 3 months during the first year after the event.

RESULTS

Depressed stroke patients exhibited more loss of interest, psychomotor retardation, and gastro-intestinal complaints as compared to depressed MI patients. However, in multivariate analyses including both depressed and non-depressed stroke and MI patients, no specific symptom profile was found to differentiate between the two depressive syndromes by looking at the modifying effect of stroke vs MI on the occurrence of specific symptoms in depression.

CONCLUSION

Although in their clinical presentation, depressed stroke patients exhibit a symptom profile different from depressed MI patients, this is not due to differences in the depressive syndrome in these two patient groups but it reflects differences between stroke and MI patients in general.

[Correlation of depression with stroke. Pathophysiological mechanisms]

Stroke is the third leading cause of death, just after heart disease and cancer. Its incidence will probably increase dramatically in the coming decades. For prevention it is urgently necessary to gain fundamental knowledge about the risk factors and pathophysiological mechanisms. It is now widely accepted that depression and stroke are correlated with each other. There is little knowledge, however, about the links that might connect both diseases. This review discusses different mechanisms that lead to an increased stroke risk and can be influenced by depression as well thus possibly linking depression and stroke.

The impact of vascular burden on late-life depression

Small vessel pathology and microvascular lesions are no longer considered as minor players in the fields of cognitive impairment and mood regulation. Although frequently found in cognitively intact elders, both neuroimaging and neuropathological data revealed the negative impact on cognitive performances of their presence within neocortical association areas, thalamus and basal ganglia. Unlike cognition, the relationship between these lesions and mood dysregulation is still a matter of intense debate. Early studies focusing on the role of macroinfarct location in the occurrence of post-stroke depression (PSD) led to conflicting data. Later on, the concept of vascular depression proposed a deleterious effect of subcortical lacunes and deep white matter demyelination on mood regulation in elders who experienced the first depressive episode. More recently, the chronic accumulation of lacunes in thalamus, basal ganglia and deep white matter has been considered as a strong correlate of PSD. We provide here a critical overview of neuroimaging and neuropathological sets of evidence regarding the affective repercussions of vascular burden in the aging brain and discuss their conceptual and methodological limitations. Based on these observations, we propose that the accumulation of small vascular and microvascular lesions constitutes a common neuropathological platform for both cognitive decline and depressive episodes in old age.

Post-stroke depression: can we predict its development from the acute stroke phase?

OBJECTIVES

To identify possible predictive factors for post-stroke depression (PSD) in the acute phase of stroke.

METHODS

The study design was prospective, observational cohort study of patients with acute cerebral infarction (CI). Neurological and neuropsychological evaluations were conducted within the first 10 days from the onset of stroke and repeated at the 3-month follow-up. DSM-IV criteria were used to define PSD.

RESULTS

From a total of 85 patients with CI, 59 patients completed the 3-month follow-up and 17 of them (28.8 %) fulfilled PSD criteria at the 3-month follow-up. Melancholy index of the Hamilton Depression Rankin Scale (HDRS) was associated with a risk three times greater than that of PSD at the 3-month follow-up in the univariate analysis (OR 3.07; 95% CI 1.53-6.16; P = 0.002) with no significant influence of stroke severity or the location of brain infarction (right or left side). The receiver operating characteristic curves pointed to a melancholy index > or =1.5 as the optimal cut-off level associated with the development of PSD at the 3-month follow-up.

CONCLUSIONS

Melancholy index of the HDRS > or =1.5 could be a useful clinical tool to detect patients with acute stroke at high risk of developing PSD.

Differential impact of lacunes and microvascular lesions on poststroke depression

BACKGROUND AND PURPOSE

Previous studies have postulated that poststroke depression (PSD) might be related to cumulative vascular brain pathology rather than to the location and severity of a single macroinfarct. We performed a detailed analysis of all types of microvascular lesions and lacunes in 41 prospectively documented and consecutively autopsied stroke cases.

METHODS

Only cases with first-onset depression <2 years after stroke were considered as PSD in the present series. Diagnosis of depression was established prospectively using DSM-IV criteria for major depression. Neuropathological evaluation included bilateral semiquantitative assessment of microvascular ischemic pathology and lacunes; statistical analysis included Fisher exact test, Mann-Whitney U test, and regression models.

RESULTS

Macroinfarct site was not related to the occurrence of PSD for any of the locations studied. Thalamic and basal ganglia lacunes occurred significantly more often in PSD cases. Higher lacune scores in basal ganglia, thalamus, and deep white matter were associated with an increased PSD risk. In contrast, microinfarct and diffuse or periventricular demyelination scores were not increased in PSD. The combined lacune score (thalamic plus basal ganglia plus deep white matter) explained 25% of the variability of PSD occurrence.

CONCLUSIONS

The cumulative vascular burden resulting from chronic accumulation of lacunar infarcts within the thalamus, basal ganglia, and deep white matter may be more important than single infarcts in the prediction of PSD.

Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence

OBJECTIVE

To review the evidence for an association between depression and anxiety and the National Health Priority Area conditions -- heart disease, stroke, diabetes mellitus, asthma, cancer, arthritis and osteoporosis -- and for the effectiveness of treatments for depression and anxiety in these settings.

DATA SOURCES

Systematic literature search of systematic reviews, meta-analyses and evidence-based clinical practice guidelines published between 1995 and 2007, inclusive.

DATA EXTRACTION

Each review was examined and summarised by two people before compilation.

DATA SYNTHESIS

Depression is more common in all disease groups than in the general population; anxiety is more common in people with heart disease, stroke and cancer than in the general population. Heterogeneity of studies makes determination of risk and the direction of causal relationships difficult to determine, but there is consistent evidence that depression is a risk factor for heart disease, stroke and diabetes mellitus. Antidepressants appear to be effective for treating depression and/or anxiety in patients with heart disease, stroke, cancer and arthritis, although the number of studies in this area is small. A range of psychological and behavioural treatments are also effective in improving mood in patients with cancer and arthritis but, again, the number of studies is small.

CONCLUSION

The evidence for the association of physical illness and depression and anxiety, and their effects on outcome, is very strong. Further research to establish the effectiveness of interventions is required. Despite the limits of current research, policy and practice still lags significantly behind best evidence-based practice. Models of integrated care need to be developed and trialled.

Prefrontal asymmetry in depression? The long-term effect of unilateral brain lesions

The proposal that a functional asymmetry in prefrontal cortex (PFC) may play a role in the pathophysiology of depression has sparked vigorous debate and investigation. One particularly contentious issue of clinical and theoretical importance is whether left PFC lesions are associated with the development of depression, and whether any such lesion-depression association is stable over time. To address this issue, we assessed the long-term depressive symptomotology of Vietnam veterans who had acquired left PFC lesions (n=21), right PFC lesions (n=18), non-PFC lesions (n=38), or no brain lesions (n=31) during the Vietnam War. Depressive symptoms were assessed at two different timepoints, approximately 15 and 35 years after lesion onset, respectively. There was no significant effect of PFC lesion laterality on overall depression severity at either timepoint. These data converge with previous stroke studies to suggest that PFC lesion laterality has no long-term systematic effect on vulnerability to depression.

Outcomes after stroke: risk of recurrent ischemic stroke and other events

Stroke is a common and debilitating disease, and much is known about the incidence and risk factors for first stroke. Much less is known, however, about outcomes after stroke. The epidemiology of outcomes after stroke has been relatively less studied for several reasons, including the traditional study of populations in which rates of cardiac disease are higher than those of stroke, the heterogeneity of stroke, and the absence until recently of effective therapies. The importance of recurrent stroke, cardiac events, dementia, depression, and other vascular and nonvascular events will increase as the population ages and as more patients survive a first stroke. This article discusses the relative importance of recurrent stroke and other events after initial ischemic stroke or transient ischemic attack, and proven and potential risk factors for recurrent stroke. Based on growing evidence regarding the high rates of cardiovascular events after stroke, and the efficacy of statin therapy in reducing the risk of stroke as well as cardiac disease, it may be time to consider expanding the "coronary risk equivalent" category to include patients with stroke. Patients who have had a stroke are likely at high enough risk for subsequent events to warrant the same aggressive treatment, including statins and antihypertensive drugs, as would be given to patients with other forms of cardiovascular disease. Future clinical trials will better define the optimal management of patients after stroke.

The neuroanatomical model of post-stroke depression: towards a change of focus?

One third of all stroke survivors develop post-stroke depression (PSD). Depressive symptoms adversely affect rehabilitation and significantly increase risk of death in the post-stroke period. One of the theoretical views on the determinants of PSD focuses on psychosocial factors like disability and social support. Others emphasize biologic mechanisms such as disruption of biogenic amine neurotransmission and release of proinflammatory cytokines. The "lesion location" perspective attempts to establish a relationship between localization of stroke and occurrence of depression, but empirical results remain contradictory. These divergences are partly related to the fact that neuroimaging methods, unlike neuropathology, are not able to assess precisely the full extent of stroke-affected areas and do not specify the different types of vascular lesions. We provide here an overview of the known phenomenological profile and current pathogenic hypotheses of PSD and present neuropathological data challenging the classic "single-stroke"-based neuroanatomical model of PSD. We suggest that vascular burden due to the chronic accumulation of small macrovascular and microvascular lesions may be a crucial determinant of the development and evolution of PSD.

A brief history of poststroke depression neuroimaging

The past 25 years have witnessed a dramatic rise and fall in clinical research investigating lesion localization in poststroke depression patients. Early studies focused on basic lesion characteristics, such as left versus right hemisphere and anterior versus posterior location, that would dominate studies in this field for the next 15 years. While results were inconsistent, some studies suggested that the left hemisphere and more anterior lesions were associated with increased prevalence and severity of depression. Recent studies have suggested lesion preference in components of the basal ganglia and frontal–subcortical circuitry and have proposed a combined effect of large stroke lesions and other lesions, such as white matter hyperintensities and lacunar infarcts. The effect of lesion location on poststroke depression requires further clarification.

Theory of mind disability in major depression with or without psychotic symptoms: a componential view

Previous reports have conceptualized theory of mind (ToM) as comprising two components and questioned whether ToM deficits are associated with psychotic symptoms. We investigated 33 nonpsychotic depressed inpatients, 23 psychotic depressed inpatients, and 53 normal controls with the following measures: Eyes Task, Faux pas Task, Verbal Fluency Test (VFT), Digit Span Test (DST) and WAIS-IQ. The depressed patients were also evaluated with the Beck Depression Inventory-II (BDI-II) and the Brief Psychiatric Rating Scale (BPRS). The nonpsychotic depressed patients and the psychotic depressed individuals were significantly impaired on tasks involving ToM social-perceptual and social-cognitive components, as well as the VFT. The psychotic depressed patients performed significantly worse than nonpsychotic depressed patients on ToM tasks. An association was found between ToM performances and both BPRS total and hostile-suspiciousness scores in the depressed group. Both of the ToM components were impaired in depressed patients. Similar mechanisms and neurobiological substrate may contribute to schizophrenia and major depression.

Diagnosis and treatment of depression comorbid with neurologic disorders

Depression is common in patients with neurologic disorders such as Alzheimer disease, stroke, Parkinson disease, and multiple sclerosis. Diagnosing depression in the context of neurologic disease is challenging, given the overlap between many signs and symptoms of depression with those of the neurologic disorders. Cognitive impairment further complicates diagnostic evaluation. The etiology of depression in these patients is not well understood and variously has been attributed to emotional reaction to the diagnosis or disability associated with the neurologic condition, the anatomical and/or neurochemical outcomes of neurodegeneration, and the influence of other disease factors. Beyond the inherent burden depression places on patients and caregivers, it increases cognitive and functional disability and, depending on the neurologic disorder, poorer treatment adherence and recovery, earlier institutionalization, and increased suicide risk. Few controlled antidepressant trials are available to guide treatment. In the absence of validated diagnostic guidelines for depression in each neurologic condition, clinicians are urged to remain vigilant for this treatable comorbidity. Although more controlled trials clearly are needed, existing studies suggest that depression in patients with neurologic disorders responds to antidepressant medication and, in some disorders, to psychotherapeutic approaches. Investigating the neuroanatomical and neurochemical correlates of depression comorbid with neurologic conditions also may clarify depression etiology and treatment in the general population.

Poststroke depression

Neuropsychological symptoms are probably among the most commonly ignored complications in stroke patients. Depression is a common yet often unrecognized neuropsychological consequence of stroke, having biological, psycho-behavioral, and social dimensions. The reported prevalence of depression following a stroke varies from 20% to 50% within the first year, with an apparent peak within the first 6 months of onset event. The disparity of reported prevalence rates significantly depends on study methodology, diagnostic assessment tools, and time elapsed after stroke onset. The etiology of depression after a stroke is complex; it is likely determined by multiple factors, including lesion location, social handicap, and family support. Depression impedes rehabilitation progress following stroke and is associated with impaired functional outcome, cognitive decline, and increased mortality. Similarly, depression has been linked to increased risk of stroke occurrence. Despite high prevalence and serious sequels, poststroke depression (PSD) remains undetected and untreated. Early diagnosis and successful intervention may improve clinical outcome and should be considered a key for better stroke care. In this article, we review the clinical presentation, epidemiology, pathogenesis, and consequences of PSD and summarize current recommendations for therapeutic intervention.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

Depression or apathy and functional recovery after stroke

OBJECTIVES

While depression and apathy are common after stroke, past studies have done little to examine the influence of these two symptoms on functional outcome respectively. This study was designed to examine the effect of depression or apathy on functional recovery after stroke in 237 Japanese stroke patients.

METHODS

We assessed the psychological status using self-rating scales [the Zung Self-Rating Depression Scale (SDS) for depression and the Apathy Scale (AS) for apathy] and an observer-rating scale [the Neuropsychiatric Inventory (NPI)]. We assessed physical disability using the Functional Independence Measurement (FIM). Post-hoc test and multiple regression analysis were used to determine the independent effects of post-stroke depression and apathy on functional outcome.

RESULTS

Depression was observed in 75 (31.6%) using SDS and 88 (40.2%) using NPI, and apathy in 95 (40.1%) using AS and 42 (19.2%) using NPI, respectively. Post-hoc test and multiple regression analysis indicated that the cognitive variable (Mini-Mental State Examination: MMSE score) and AS score, but not SDS score, correlated negatively with improvement in FIM.

CONCLUSIONS

Apathy might be more frequently associated with functional abilities and likely interact with the recovery process as compared with depression after stroke.

Sitting balance as an early predictor of functional improvement in association with depressive symptoms in stroke patients

The aim of the present study was to assess the relationship between sitting balance at an early stage and activities of daily living (ADL) function in 452 stroke patients. The effect of sitting balance on the two core elements of depression (apathy and depressive mood) was also examined. The ability to maintain a sitting position for 10 min (10-min sitting balance) was assessed, along with ADL using the Functional Independence Measurement, and psychological status using the Zung Self-rating Depression Scale (depressive mood), Apathy Scale (apathy) and Neuropsychiatric Inventory. Proportional-hazards analysis was used to determine the independent effect of post-stroke depression on functional outcome. Comparisons between sitting balance and psychological status were performed using logistic multiple regression analysis. Cox multiple regression analysis showed that significant differences were obtained for the sitting balance (P < 0.0002) and Mini-Mental State Examination scores (P < 0.02) in all six ADL subscales, and for age in four of the six ADL subscales (Dressing-Upper Body and Dressing-Lower Body, Toileting, Walking). Kaplan-Meier survival curves for reaching independence in ADL subscales showed highly significantly differences in achievement rate and time to reach goal for each subgroup on 10-min sitting balance (with or without assistance) and on age (young, <65; elderly, >/=65 years). Ten-minute sitting balance correlated with depressive mood and apathy. A rapid and simple screening method, 10-min sitting balance was related to scores for two core depressive symptoms, lowered mood and apathy, and was predictive of post-stroke ADL outcomes in the rehabilitation unit along with age.

Exclusion and inclusion criteria for people with aphasia in studies of depression after stroke: a systematic review and future recommendations

BACKGROUND/AIMS

A third of individuals are depressed following stroke. A similar proportion have aphasia. The extent of their inclusion in depression following stroke studies affects the generalizability of findings.

METHODS

We systematically reviewed published studies (to December 2005) that diagnosed depression following stroke. We identified aphasia screening methods, aphasia exclusion and inclusion criteria and respective numbers of individuals with aphasia.

RESULTS

Of 129 studies (n = 19,183), aphasia screening methods were only reported by 57 (31 described a published aphasia-specific tool). No mention of aphasia was made in 13 studies. Most studies (92, 71%) reported some exclusion of people with aphasia (49 reported how many: n = 3,082, range = 2-554). Almost half of the studies (60, 47%) actually reported participants with aphasia (37 specified numbers: n = 829, range = 5-60). Aphasia exclusion or inclusion was not associated with sample source (community, acute hospital, other) or study purpose (observation, intervention, screening). Studies that reported screening for aphasia were more likely to describe aphasia exclusion and inclusion criteria and include participants with aphasia.

CONCLUSION

Aphasia screening, exclusion and inclusion criteria reporting across studies of depression following stroke has been highly inconsistent. This impairs the interpretation of generalizability. Improved aphasia screening and reporting of exclusion and inclusion criteria are urgently recommended.

Lesions of dopaminergic neurons in the substantia nigra pars compacta and in the ventral tegmental area enhance depressive-like behavior in rats

Depression is the most common psychiatric complication in Parkinson's disease (PD). The pathophysiological events leading to PD-associated depression, however, remain largely unknown. The present study tested the differential implication of dopaminergic systems in depressive-like behavior in rats and its response to l-Dopa and the selective serotonin reuptake inhibitor citalopram. The learned helplessness model was used as a behavioral paradigm. Rats were lesioned in the substantia nigra pars compacta (SNc) and the ventral tegmental area (VTA) and assigned to subgroups with respect to the stereologically verified extent of the nigral and/or VTA degeneration. Both lesions increased depressive-like behavior in rats, which was reduced by both citalopram and l-Dopa treatment. We conclude that dopaminergic lesions of either the SNc or the VTA contribute to the manifestation of depressive-like behavior in rats. The effects of citalopram administration on depressive behavior induced by lesions of dopaminergic brain regions furthermore suggest an involvement of serotonergic pathways in dopaminergic cell loss-induced depression.