Ecosystem focused therapy in poststroke depression: a preliminary study

Anxiety and sleep quality in patients receiving maintenance hemodialysis: multiple mediating roles of hope and family function

The objective of this cross-sectional study was to examine the extent of sleep quality among individuals undergoing maintenance hemodialysis (MHD) and to scrutinize whether hope and family function serve as mediators in the association between anxiety and sleep quality in this cohort. A convenience sampling method was used to recruit 227 patients receiving maintenance hemodialysis from two tertiary hospitals in Wuhan. Participants completed several self-report questionnaires, including the Sociodemographic questionnaire, Hospital Anxiety and Depression Scale, Athens Insomnia Scale, Herth Hope Index, and Family APGAR Index. As per the findings of the chain mediation analysis, it was observed that the sleep quality scores were directly predicted by anxiety. Moreover, anxiety positively predicted sleep quality scores through hope and family function as mediators. The observed types of mediation were partial mediation. The total indirect effect value was 0.354, indicating the mediating effect of hope and family function, while the total effect value was 0.481, representing the overall effect of anxiety on sleep quality. The total effect size was 73.60% (0.354/0.481), indicating that the mediation accounted for a significant portion of the relationship. This study established the chain mediating effect of hope and family function between anxiety and sleep quality in patients receiving maintenance hemodialysis. The findings highlight the importance of addressing anxiety and promoting hope and family function to improve sleep quality in this population. The findings suggest that healthcare professionals should be attentive to the anxiety levels of these patients and implement targeted interventions to help alleviate anxiety, enhance hope, and improve family functioning, with the ultimate goal of improving sleep quality in this population.

A comprehensive overview of post-stroke depression treatment options

Nearly one-third of all stroke patients develop depression at any time after a stroke, and its presence is associated with unfavorable outcomes. This narrative review aims to provide a synopsis of possible pharmacological and non-pharmacological treatment modalities for post-stroke depression (PSD). Several studies have demonstrated the efficacy and safety of selective serotonin reuptake inhibitors in treating the symptoms of this clinical condition. The treatment of PSD has been recently enhanced by innovative approaches, such as cognitive-behavioral therapy, virtual reality, telehealth, repetitive transcranial magnetic stimulation, and non-conventional therapies, which might improve depression treatment in stroke survivors. Future high-quality randomized controlled trials are necessary to confirm this hypothesis.

Stroke rehabilitation adaptive approaches: A theory-focused scoping review

BACKGROUND

Stroke rehabilitation consists of restorative and adaptive approaches. Multiple adaptive approaches exist.

AIMS/OBJECTIVES

The objective of this study was to develop a framework for categorising adaptive stroke rehabilitation interventions, based on underlying theory.

MATERIAL AND METHODS

We searched multiple databases to April 2020 to identify studies of interventions designed to improve participation in valued activities. We extracted the name of the intervention, underlying explicit or implicit theory, intervention elements, and anticipated outcomes. Using this information, we proposed distinct groups of interventions based on theoretical drivers.

RESULTS

Twenty-nine adaptive interventions were examined in at least one of 77 studies. Underlying theories included Cognitive Learning Theory, Self-determination Theory, Social Cognitive Theory, adult learning theories, and Psychological Stress and Coping Theory. Three overarching theoretical drivers were identified: learning, motivation, and coping.

CONCLUSIONS

At least 29 adaptive approaches exist, but each appear to be based on one of three underlying theoretical drivers. Consideration of effectiveness of these approaches by theoretical driver could help indicate underlying mechanisms and essential elements of effective adaptive approaches.

SIGNIFICANCE

Our framework is an important advance in understanding and evaluating adaptive approaches to stroke rehabilitation.

Integrative-interpersonal dynamic therapy for poststroke depression (INID): study protocol of a randomised controlled pilot trial

INTRODUCTION

Depression is the most frequent psychiatric disorder following stroke, affecting about one-third of stroke survivors. Patients experience poorer recovery, lower quality of life and higher mortality compared with stroke survivors without depression. Despite these well-known malign consequences, poststroke depression (PSD) is regarded underdiagnosed and undertreated. Evidence of beneficial effects of psychotherapy to treat PSD remains scarce and inconclusive and is limited by heterogeneity in design, content and timing of the intervention. This pilot study aims to assess the feasibility of a newly developed integrative-interpersonal dynamic PSD intervention in an outpatient setting and provide a first estimation of the potential effect size as basis for the sample size estimation for a subsequent definite trial.

METHOD AND ANALYSIS

Patients will be recruited from two German stroke units. After discharge from inpatient rehabilitation, depressed stroke survivors will be randomised to short-term psychotherapy (12 weeks, ≤16 sessions) or enhanced treatment as usual. The manualised psychotherapy integrates key features of the Unified Psychodynamic and Cognitive-Behavioural Unified Protocol for emotional disorders and was adapted for PSD. Primary endpoints are recruitment feasibility and treatment acceptability, defined as a recruitment rate of ≥20% for eligible patients consenting to randomisation and ≥70% completion-rate of patients participating in the treatment condition. A preliminary estimation of the treatment effect based on the mean difference in Patient Health Questionnaire-9 (PHQ-9) scores between intervention and control group six months poststroke is calculated. Secondary endpoints include changes in depression (PHQ-9/Hamilton Depression Scale) and anxiety (Generalised Anxiety Disorder 7) of all participants across all follow-ups during the first year poststroke.

ETHICS AND DISSEMINATION

The INID pilot study received full ethical approval (S-321/2019; 2022-2286_1). Trial results will be published in a peer-reviewed journal in the first half of 2025. One-year follow-ups are planned to be carried out until summer 2025.

TRIAL REGISTRATION NUMBER

DRKS00030378.

Interventions targeting psychosocial adaptation in people with stroke: A scoping review

OBJECTIVE

This scoping review aimed to describe and map interventions targeting psychosocial adaptation in people with stroke.

METHODS

A scoping review was conducted using the Joanna Briggs Institute methodology and reported according to Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines. We included original studies with interventions targeting psychosocial adaptation (concept) on people with stroke (population) in any setting (context). We searched five online electronic databases (PubMed, Embase, CINAHL, PsycINFO, and Cochrane Central Registry of Controlled Trials). We described interventions in terms of design characteristics, theoretical basis, details of interventions, and quantitative outcomes indicated in psychosocial adaptation.

RESULTS

Forty-three studies were identified. Five intervention categories were identified to describe the interventions targeting psychosocial adaptation. Quantitative outcomes indicated psychosocial adaptation in our review were grouped into four domains: global adaptation, psychological adaptation, social adaptation, and others.

CONCLUSIONS

The mapping and description brought to light the large heterogeneity of interventions targeting psychosocial adaptation in people with stroke.

PRACTICE IMPLICATIONS

Deepening understanding of psychosocial adaptation can help health professionals further develop effective interventions aiming at promoting psychosocial adaptation and reducing negative health sequelae, such as risk of reduced psychosomatic recovery post stroke.

Pharmacological, non-invasive brain stimulation and psychological interventions, and their combination, for treating depression after stroke

BACKGROUND

Depression is an important morbidity associated with stroke that impacts on recovery, yet is often undetected or inadequately treated.

OBJECTIVES

To evaluate the benefits and harms of pharmacological intervention, non-invasive brain stimulation, psychological therapy, or combinations of these to treat depression after stroke.

SEARCH METHODS

This is a living systematic review. We search for new evidence every two months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. We searched the Specialised Registers of Cochrane Stroke, and Cochrane Depression Anxiety and Neurosis, CENTRAL, MEDLINE, Embase, five other databases, two clinical trials registers, reference lists and conference proceedings (February 2022). We contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing: 1) pharmacological interventions with placebo; 2) non-invasive brain stimulation with sham stimulation or usual care; 3) psychological therapy with usual care or attention control; 4) pharmacological intervention and psychological therapy with pharmacological intervention and usual care or attention control; 5) pharmacological intervention and non-invasive brain stimulation with pharmacological intervention and sham stimulation or usual care; 6) non-invasive brain stimulation and psychological therapy versus sham brain stimulation or usual care and psychological therapy; 7) pharmacological intervention and psychological therapy with placebo and psychological therapy; 8) pharmacological intervention and non-invasive brain stimulation with placebo and non-invasive brain stimulation; and 9) non-invasive brain stimulation and psychological therapy versus non-invasive brain stimulation and usual care or attention control, with the intention of treating depression after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data from included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data, and risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and certainty of the evidence according to GRADE.

MAIN RESULTS

We included 65 trials (72 comparisons) with 5831 participants. Data were available for: 1) 20 comparisons; 2) nine comparisons; 3) 25 comparisons; 4) three comparisons; 5) 14 comparisons; and 6) one comparison. We found no trials for comparisons 7 to 9. Comparison 1: Pharmacological interventions Very low-certainty evidence from eight trials suggests pharmacological interventions decreased the number of people meeting the study criteria for depression (RR 0.70, 95% CI 0.55 to 0.88; P = 0.002; 8 RCTs; 1025 participants) at end of treatment and very low-certainty evidence from six trials suggests that pharmacological interventions decreased the number of people with inadequate response to treatment (RR 0.47, 95% CI 0.32 to 0.70; P = 0.0002; 6 RCTs; 511 participants) compared to placebo. More adverse events related to the central nervous system (CNS) (RR 1.55, 95% CI 1.12 to 2.15; P = 0.008; 5 RCTs; 488 participants; very low-certainty evidence) and gastrointestinal system (RR 1.62, 95% CI 1.19 to 2.19; P = 0.002; 4 RCTs; 473 participants; very low-certainty evidence) were noted in the pharmacological intervention than in the placebo group. Comparison 2: Non-invasive brain stimulation Very low-certainty evidence from two trials show that non-invasive brain stimulation had little to no effect on the number of people meeting the study criteria for depression (RR 0.67, 95% CI 0.39 to 1.14; P = 0.14; 2 RCTs; 130 participants) and the number of people with inadequate response to treatment (RR 0.84, 95% CI 0.52, 1.37; P = 0.49; 2 RCTs; 130 participants) compared to sham stimulation. Non-invasive brain stimulation resulted in no deaths. Comparison 3: Psychological therapy Very low-certainty evidence from six trials suggests that psychological therapy decreased the number of people meeting the study criteria for depression at end of treatment (RR 0.77, 95% CI 0.62 to 0.95; P = 0.01; 521 participants) compared to usual care/attention control. No trials of psychological therapy reported on the outcome inadequate response to treatment. No differences in the number of deaths or adverse events were found in the psychological therapy group compared to the usual care/attention control group. Comparison 4: Pharmacological interventions with psychological therapy No trials of this combination reported on the primary outcomes. Combination therapy resulted in no deaths. Comparison 5: Pharmacological interventions with non-invasive brain stimulation Non-invasive brain stimulation with pharmacological intervention reduced the number of people meeting study criteria for depression at end of treatment (RR 0.77, 95% CI 0.64 to 0.91; P = 0.002; 3 RCTs; 392 participants; low-certainty evidence) but not the number of people with inadequate response to treatment (RR 0.95, 95% CI 0.69 to 1.30; P = 0.75; 3 RCTs; 392 participants; very low-certainty evidence) compared to pharmacological therapy alone. Very low-certainty evidence from five trials suggest no difference in deaths between this combination therapy (RR 1.06, 95% CI 0.27 to 4.16; P = 0.93; 487 participants) compared to pharmacological therapy intervention and sham stimulation or usual care. Comparison 6: Non-invasive brain stimulation with psychological therapy No trials of this combination reported on the primary outcomes.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that pharmacological, psychological and combination therapies can reduce the prevalence of depression while non-invasive brain stimulation had little to no effect on the prevalence of depression. Pharmacological intervention was associated with adverse events related to the CNS and the gastrointestinal tract. More research is required before recommendations can be made about the routine use of such treatments.

Rehabilitation of Neuropsychiatric Symptoms in Patients With Long COVID: Position Statement

Long COVID, a term used to describe ongoing symptoms after COVID-19 infection, parallels the course of other postviral syndromes. Neuropsychiatric symptoms of long COVID can be persistent and interfere with quality of life and functioning. Within the biopsychosocial framework of chronic illness, rehabilitation professionals can address the neuropsychiatric sequelae of long COVID. However, current practice models are not designed to address concurrent psychiatric and cognitive symptoms in adults living with long COVID. Thus, we present a biopsychosocial framework for long COVID and provide treatment strategies based on evidence from current literature of postviral chronic illness. These recommendations will guide rehabilitation professionals in identifying common neuropsychiatric symptoms in long COVID that can be targeted for intervention and addressing these symptoms via integrative interventions taking into account the biopsychosocial presentation of long COVID symptoms.

Predictors of post-stroke depression: Validation of established risk factors and introduction of a dynamic perspective in two longitudinal studies

INTRODUCTION

Cerebral insults lead in many cases not only to cognitive impairment but also to disturbed emotionality. After stroke, one in three survivors develops a depression which impacts quality of life and rehabilitation. Meta-analyses have identified five main predictors of post-stroke depression (PSD): history of mental disorder, stroke severity, physical disability, cognitive impairment, and social support. However, these five established variables have never been conjointly investigated in a sample of stroke survivors. Therefore, their independent predictive values remain unclear. Moreover, predictors are most often used as time-invariant factors (status scores), neglecting the intraindividual dynamics after stroke.

METHODS

Our study analyses the data of two prospective longitudinal studies, investigating stroke survivors from two rehabilitation hospitals (N ₁ = 273) and one acute care hospital (N ₂ = 226). Baseline assessments included the five established predictors and depressive symptoms. After 6 months, depressive symptoms were reassessed in both studies (n ₁ = 176, n ₂ = 183), and physical disability and social support were reassessed in study 2. The predictivity of the five predictors and the additional predictivity of intraindividual dynamics for PSD were examined in multiple linear regression analyses.

RESULTS

History of mental disorder was a risk factor for depressive symptoms after stroke at all measurement times (B = 3.32 to 3.97; p < 0.01). Physical disability was a risk factor at all measurement times (B = -0.09 to -0.03; p < 0.05) except 6 months after rehabilitation. Social support was a protective factor (B = -2.69 to -1.91; p < 0.01) outside the acute phase (R ² = 0.15-0.39). Intraindividual changes in physical disability and perceived social support were independent predictors of PSD 6 months after the acute phase (B = -0.08/-0.14; p < 0.01), in addition to status scores on established variables (ΔR ² = 0.08, p < 0.001).

DISCUSSION

History of mental disorder, physical disability, and social support are independent predictors of depressive symptoms in the first year post-stroke, also when considered conjointly. Future studies should control for these variables when investigating new predictors of PSD. In addition, intraindividual changes in known predictors after stroke play a relevant role in the pathogenesis of PSD and should be considered in clinical practice and future research.

Interventions to Improve Social Participation, Work, and Leisure Among Adults Poststroke: A Systematic Review

IMPORTANCE

Sustaining a stroke frequently leads to difficulties in returning to work, leisure, and social participation. These outcomes are important for occupational therapy practitioners to address.

OBJECTIVE

To determine the current evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve social participation, work, and leisure among adults poststroke.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases.

STUDY SELECTION AND DATA COLLECTION

Primary inclusion criteria were peer-reviewed journal articles published between January 1, 2009, and December 31, 2019, within the scope of occupational therapy that evaluated an intervention to address work, leisure, or social participation poststroke (levels of evidence ranged from Level 1b to Level 2b). Reviewers assessed records for inclusion, quality, and validity following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Forty-seven articles met the inclusion criteria. Forty-four articles related to social participation were categorized as follows: occupation-based approaches, metacognitive strategy training, education and training approaches, impairment-based approaches, and enriched environment approaches. Three articles related to work and 3 articles related to leisure were not further categorized (2 articles were each included in two categories). Seventeen Level 1b and 30 Level 2b articles were included. The strength of evidence to support occupational therapy interventions for social participation, work, and leisure outcomes is predominantly low.

CONCLUSIONS AND RELEVANCE

Occupational therapy interventions may improve work, leisure, and social participation outcomes poststroke, with the strongest evidence existing for client education, upper extremity training, and cognitive training for improving social participation. What This Article Adds: Occupational therapy practitioners may use the available literature along with clinical reasoning to improve work, leisure, and social participation outcomes among clients poststroke. Additional research is required to build stronger evidence to support clinical decision making in stroke rehabilitation in these areas.

Occupation-Based Interventions for Social Participation Outcomes for Adults Poststroke (January 1, 2009-December 31, 2019)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on occupation-based interventions for social participation outcomes for adults poststroke.

The Structural and Functional Neuroanatomy of Post-Stroke Depression and Executive Dysfunction: A Review of Neuroimaging Findings and Implications for Treatment

Post-stroke depression and executive dysfunction co-occur and are highly debilitating. Few treatments alleviate both depression and executive dysfunction after stroke. Understanding the brain network changes underlying post-stroke depression with executive dysfunction can inform the development of targeted and efficacious treatment. In this review, we synthesize neuroimaging findings in post-stroke depression and post-stroke executive dysfunction and highlight the network commonalities that may underlie this comorbidity. Structural and functional alterations in the cognitive control network, salience network, and default mode network are associated with depression and executive dysfunction after stroke. Specifically, post-stroke depression and executive dysfunction are both linked to changes in intrinsic functional connectivity within resting state networks, functional over-connectivity between the default mode and salience/cognitive control networks, and reduced cross-hemispheric frontoparietal functional connectivity. Cognitive training and noninvasive brain stimulation targeted at these brain network abnormalities and specific clinical phenotypes may help advance treatment for post-stroke depression with executive dysfunction.

Depression and executive functioning bidirectionally impair one another across 9 years: Evidence from within-person latent change and cross-lagged models

BACKGROUND

Scar and vulnerability models assert that increased psychopathology may predict subsequent executive functioning (EF) deficits (and vice versa) over protracted timescales, yet most prior work on this topic has been cross-sectional. Thus, we tested the within- and between-person relations between EF, depression, and anxiety.

METHODS

Older adult participants (n = 856) were assessed across four waves, approximately 2 years apart. Performance-based EF and caregiver-rated symptom measures were administered. Bivariate latent change score and random-intercept cross-lagged panel models were conducted.

RESULTS

Within persons, random-intercept cross-lagged panel models revealed that prior greater depression forecasted lower subsequent EF, and vice versa (d = -0.292 vs. -0.292). Bivariate dual latent change score models showed that within-person rise in depression predicted EF decreases, and vice versa (d = -0.245 vs. -0.245). No within-person, cross-lagged, EF-anxiety relations emerged. Further, significant negative between-person EF-symptom relations were observed (d = -0.264 to -0.395).

CONCLUSION

Prospective, within-person findings offer some evidence for developmental scar and vulnerability models.

Effectiveness of dyadic psychoeducational intervention for stroke survivors and family caregivers on functional and psychosocial health: A systematic review and meta-analysis

OBJECTIVES

Stroke is the third leading cause of disability worldwide, influencing the whole family's health and well-being. Dyadic (i.e., stroke survivor and family caregiver) psychoeducational intervention is a potential alternative to disease management and support, targeting at the dyads of stroke survivors and their caregivers as active participants in partnership. This review aimed to evaluate the current evidence on supporting the dyadic psychoeducational intervention for the functional and psychosocial health of stroke survivors' and their family caregivers.

DESIGN

Systematic review and meta-analysis DATA SOURCES: Nine English databases (Cochrane Library, Medline, CINAHL, PsycINFO, EMBASE, British Nursing Index, PubMed, Web of Science and Digital Dissertation Consortium) and two Chinese databases (CNKI and Wanfang) were searched to identify eligible studies published from their inception to April 2020. Additional relevant studies were identified from the reference lists and bibliographies of the identified articles and a manual search of relevant journals.

REVIEW METHODS

Studies were searched using keywords based on the 'PICOS' framework. The eligibility of individual full-text articles was independently assessed by two reviewers in accordance with the selection criteria. The risk of bias of the included studies was assessed using Cochrane RoB 2.0. The main outcomes were subjected to meta-analysis whenever possible; otherwise, narrative syntheses were conducted.

RESULTS

Eleven studies with 1769 stroke survivors and 1578 family caregivers were identified. The meta-analysis of pooled data suggested that the dyadic psychoeducational intervention had a significant immediate (<1 month) effect on family caregivers' burden (SMD = -0.25, 95% CI: -0.50 to -0.01, p = 0.04) and a long-term (≥6 months) effect on survivors' quality of life (SMD = -0.30, 95% CI: -0.53 to -0.07, p = 0.01). Subgroup pooled analyses indicated that the interventions initiated in hospitals could significantly improve the survivors' functional independence immediately after intervention (SMD = 0.40, 95% CI: 0.08 to 0.72, p = 0.01). Conversely, the interventions initiated at home did not significantly affect this functional outcome.

CONCLUSIONS

This review supports the notion that the dyadic psychoeducational intervention can be effective in improving the stroke survivors' functional independence and their family caregivers' burden for a short period and the survivors' quality of life in the long run. However, its effectiveness is not conclusive because other psychosocial health outcomes for the stroke survivors and their family caregivers have not yet been found to significantly improve after intervention. Therefore, further large-scale randomised controlled trials with a high-quality design are warranted to evaluate their effectiveness in diverse functional and psychosocial health outcomes for stroke survivors and their family caregivers.

Family Functioning Mediates the Relationship Between Activities of Daily Living and Poststroke Depression

BACKGROUND

Poststroke depression is common and includes depressive and somatic symptoms. However, few studies have confirmed the influence of family functioning on poststroke depression or explored the association among daily activities, family functioning, and poststroke depression.

OBJECTIVES

We examined the independent risk factors of daily activities and family functioning for poststroke depression and identified the mediating effect of family functioning on the association between daily activities and poststroke depression.

METHODS

This cross-sectional study design used convenience sampling to recruit 422 stroke survivors from the neurology department of a hospital in Harbin, China, from February to July 2018. We assessed participants' demographic and clinical variables, including depression, daily activities, and family functioning. Pearson's correlations and multiple linear regression analyses were conducted, and a path analysis with bootstrapping was utilized to define direct/indirect effects.

RESULTS

Daily activities and family functioning had a significant and direct negative effect on participants' depression. The indirect effect of 1,000 bootstrap samples after bias correction with a 95% confidence interval was below zero, indicating that family function had a significant mediating effect on the association between depression and daily activities.

DISCUSSION

This study revealed the importance of family functioning in the association between depression and daily activities in stroke survivors. To the best of our knowledge, this study was the first to explore the mediating role of family functioning in poststroke depression, emphasizing the importance of family for the mental health of stroke patients. To reduce the incidence of poststroke depression, interventions that enhance daily activities and family functioning may include nurses, family therapists, rehabilitation physicians, and community workers.

What can virtual reality offer to stroke patients? A narrative review of the literature

BACKGROUND

Studies demonstrated the efficacy of virtual reality (VR) as a method supporting the post-stroke neuro-rehabilitation process by activating motor learning processes. Nevertheless, stroke is frequently accompanied by serious psychological problems including depression, which is associated with an increased risk of mortality, lower post-stroke physical activity, and higher disability in stroke patients.

OBJECTIVES

To explore the current use of VR as a method supporting the neuro-rehabilitation process, both in physical and psychological dimensions.

METHODS

An exploratory review was conducted with a narrative synthesis. PubMed was used for literature search. Search includes the use of VR in physical rehabilitation, and as support therapy in psychiatric disorders. Both primary research and systematic reviews were included.

RESULTS

In neurological disorders rehabilitation, out of 22 studies, 16 concerned stroke survivors. In psychiatric disorders, 44 literature reviews were included.

CONCLUSION

The studies confirmed the effectiveness of various forms of VR treatment in the alleviation of psychological and behavioral problems and psychiatric disorders. There is a shortage of VR-based technological solutions that would, besides physical rehabilitation, offer stroke patients therapeutic tools to alleviate psychological disturbance and improve the patient's mood and motivation. Such solutions will most likely become a field of intensive research in the coming years.

Post-stroke depression: Chaos to exposition

Cerebral ischemia contributes to significant disabilities worldwide, impairing cognitive function and motor coordination in affected individuals. Stroke has severe neuropsychological outcomes, the major one being a stroke. Stroke survivors begin to show symptoms of depression within a few months of the incidence that overtime progresses to become a long-term ailment. As the pathophysiology for the progression of the disease is multifactorial and complex, it limits the understanding of the disease mechanism completely. Meta-analyses and randomized clinical trials have shown that intervening early with tricyclic antidepressants and selective serotonin receptor inhibitors can be effective. However, these pharmacotherapies possess several limitations that have given rise to newer approaches such as brain stimulation, psychotherapy and rehabilitation therapy, which in today's time are gaining attention for their beneficial results in post-stroke depression (PSD). The present review highlights numerous factors like lesion location, inflammatory mediators and genetic abnormalities that play a crucial role in the development of depression in stroke patients. Further, we have also discussed various mechanisms involved in post-stroke depression (PSD) and strategies for early detection and diagnosis using biomarkers that may revolutionize treatment for the affected population. Towards the end, along with the preclinical scenario, we have also discussed the various treatment approaches like pharmacotherapy, traditional medicines, psychotherapy, electrical stimulation and microRNAs being utilized for effectively managing PSD.

Complementary and alternative therapies for poststroke depression: A protocol for systematic review and network meta-analysis

BACKGROUND

Poststroke depression (PSD) is an important complication of stroke, resulting in increased disability and mortality, which is a great threat to stroke survivors and public health. Complementary and alternative medicine (CAM) therapies is widely used in the treatment of PSD, However, the selection strategies of different CAM approaches in clinical practice is still not clear, and the purpose of this protocol is to compare the efficacy and acceptability of different CAM therapies using systematic review and network meta-analysis.

METHODS

According to the strategy, the authors will retrieve a total of seven electronic databases by August 2020, including PubMed, the Cochrane Library, EMbase, China National Knowledge Infrastructure, China Biological Medicine, Chinese Scientific Journals Database, and Wan-fang databases. The network meta-analysis will be performed using Aggregate Data Drug Information System 1.16.8 and Stata 13.0 software. In addition, the Cochrane Collaboration's tool is employed for the methodological quality, and the quality of evidence will be evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

This study will provide a reliable evidence for the selection strategy of CAM therapies for PSD.

CONCLUSION

The results of this study will provide references for evaluating the effects of different CAM therapies on PSD, and provide decision-making references for clinical practitioners, patients, and health policy makers.

ETHICS AND DISSEMINATION

This study does not require ethical approval. the results will be disseminated through a peer-reviewed publication.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/TNGH6.

Pharmacological, psychological, and non-invasive brain stimulation interventions for treating depression after stroke

BACKGROUND

Depression is an important morbidity associated with stroke that impacts on recovery yet often undetected or inadequately treated. This is an update and expansion of a Cochrane Review first published in 2004 and updated in 2008.

OBJECTIVES

Primary objective • To determine whether pharmacological therapy, non-invasive brain stimulation, psychological therapy, or combinations of these interventions reduce the prevalence of diagnosable depression after stroke Secondary objectives • To determine whether pharmacological therapy, non-invasive brain stimulation, psychological therapy, or combinations of these interventions reduce levels of depressive symptoms, improve physical and neurological function and health-related quality of life, and reduce dependency after stroke • To assess the safety of and adherence to such treatments SEARCH METHODS: We searched the Specialised Registers of Cochrane Stroke and Cochrane Depression Anxiety and Neurosis (last searched August 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), in the Cochrane Library, MEDLINE (1966 to August 2018), Embase (1980 to August 2018), the Cumulative Index to Nursing and Alllied Health Literature (CINAHL) (1982 to August 2018), PsycINFO (1967 to August 2018), and Web of Science (2002 to August 2018). We also searched reference lists, clinical trial registers (World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) to August 2018; ClinicalTrials.gov to August 2018), and conference proceedings, and we contacted study authors.

SELECTION CRITERIA

Randomised controlled trials comparing (1) pharmacological interventions with placebo; (2) one of various forms of non-invasive brain stimulation with sham stimulation or usual care; (3) one of various forms of psychological therapy with usual care and/or attention control; (4) pharmacological intervention and various forms of psychological therapy with pharmacological intervention and usual care and/or attention control; (5) non-invasive brain stimulation and pharmacological intervention with pharmacological intervention and sham stimulation or usual care; (6) pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy; (7) pharmacological intervention and non-invasive brain stimulation with placebo plus non-invasive brain stimulation; (8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and (9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy, with the intention of treating depression after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data, and risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and certainty of the evidence according to GRADE.

MAIN RESULTS

We included 49 trials (56 comparisons) with 3342 participants. Data were available for: (1) pharmacological interventions with placebo (with 20 pharmacological comparisons); (2) one of various forms of non-invasive brain stimulation with sham stimulation or usual care (with eight non-invasive brain stimulation comparisons); (3) one of various forms of psychological therapy with usual care and/or attention control (with 16 psychological therapy comparisons); (4) pharmacological intervention and various forms of psychological therapy with pharmacological intervention and usual care and/or attention control (with two comparisons); and (5) non-invasive brain stimulation and pharmacological intervention with pharmacological intervention and sham stimulation or usual care (with 10 comparisons). We found no trials for the following comparisons: (6) pharmacological intervention and various forms of psychological therapy interventions versus placebo and psychological therapy; (7) pharmacological intervention and non-invasive brain stimulation versus placebo plus non-invasive brain stimulation; (8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and (9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy. Treatment effects observed: very low-certainty evidence from eight trials suggests that pharmacological interventions decreased the number of people meeting study criteria for depression (RR 0.70, 95% CI 0.55 to 0.88; 1025 participants) at end of treatment, and very low-certainty evidence from six trials suggests that pharmacological interventions decreased the number of people with less than 50% reduction in depression scale scores at end of treatment (RR 0.47, 95% CI 0.32 to 0.69; 511 participants) compared to placebo. No trials of non-invasive brain stimulation reported on meeting study criteria for depression at end of treatment. Only one trial of non-invasive brain stimulation reported on the outcome <50% reduction in depression scale scores; thus, we were unable to perform a meta-analysis for this outcome. Very low-certainty evidence from six trials suggests that psychological therapy decreased the number of people meeting the study criteria for depression at end of treatment (RR 0.77, 95% CI 0.62 to 0.95; 521 participants) compared to usual care/attention control. No trials of combination therapies reported on the number of people meeting the study criteria for depression at end of treatment. Only one trial of combination (non-invasive brain stimulation and pharmacological intervention) therapy reported <50% reduction in depression scale scores at end of treatment. Thus, we were unable to perform a meta-analysis for this outcome. Five trials reported adverse events related to the central nervous system (CNS) and noted significant harm in the pharmacological interventions group (RR 1.55, 95% CI 1.12 to 2.15; 488 participants; very low-certainty evidence). Four trials found significant gastrointestinal adverse events in the pharmacological interventions group (RR 1.62, 95% CI 1.19 to 2.19; 473 participants; very low-certainty evidence) compared to the placebo group. No significant deaths or adverse events were found in the psychological therapy group compared to the usual care/attention control group. Non-invasive brain stimulation interventions and combination therapies resulted in no deaths.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that pharmacological or psychological therapies can reduce the prevalence of depression. This very low-certainty evidence suggests that pharmacological therapy, psychological therapy, non-invasive brain stimulation, and combined interventions can reduce depressive symptoms. Pharmacological intervention was associated with adverse events related to the CNS and the gastrointestinal tract. More research is required before recommendations can be made about the routine use of such treatments.

Cognitive rehabilitation for attention deficits following stroke

BACKGROUND

Many survivors of stroke report attentional impairments, such as diminished concentration and distractibility. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.This is an update of the Cochrane Review first published in 2000 and previously updated in 2013.

OBJECTIVES

To determine whether people receiving cognitive rehabilitation for attention problems 1. show better outcomes in their attentional functions than those given no treatment or treatment as usual, and 2. have a better functional recovery, in terms of independence in activities of daily living, mood, and quality of life, than those given no treatment or treatment as usual.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PsycBITE, REHABDATA and ongoing trials registers up to February 2019. We screened reference lists and tracked citations using Scopus.

SELECTION CRITERIA

We included controlled clinical trials (CCTs) and randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. We did not consider listening to music, meditation, yoga, or mindfulness to be a form of cognitive rehabilitation. We only considered trials that selected people with demonstrable or self-reported attentional deficits. The primary outcomes were measures of global attentional functions, and secondary outcomes were measures of attentional domains (i.e. alertness, selective attention, sustained attention, divided attention), functional abilities, mood, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed the risk of bias. We used the GRADE approach to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included no new trials in this update. The results are unchanged from the previous review and are based on the data of six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no convincing effect of cognitive rehabilitation on subjective measures of attention either immediately after treatment (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) -0.03 to 1.08; P = 0.06; 2 studies, 53 participants; very low-quality evidence) or at follow-up (SMD 0.16, 95% CI -0.23 to 0.56; P = 0.41; 2 studies, 99 participants; very low-quality evidence). People receiving cognitive rehabilitation (when compared with control) showed that measures of divided attention recorded immediately after treatment may improve (SMD 0.67, 95% CI 0.35 to 0.98; P < 0.0001; 4 studies, 165 participants; low-quality evidence), but it is uncertain that these effects persisted (SMD 0.36, 95% CI -0.04 to 0.76; P = 0.08; 2 studies, 99 participants; very low-quality evidence). There was no evidence for immediate or persistent effects of cognitive rehabilitation on alertness, selective attention, and sustained attention. There was no convincing evidence for immediate or long-term effects of cognitive rehabilitation for attentional problems on functional abilities, mood, and quality of life after stroke.

AUTHORS' CONCLUSIONS

The effectiveness of cognitive rehabilitation for attention deficits following stroke remains unconfirmed. The results suggest there may be an immediate effect after treatment on attentional abilities, but future studies need to assess what helps this effect persist and generalise to attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

Depression and the Use of Selective Serotonin Reuptake Inhibitors in Patients with Acute Intracerebral Hemorrhage

Introduction

Depression is a common psychiatric complication associated with stroke. However, while most studies focus on post-stroke depression (PSD) subsequent to ischemic strokes, fewer studies have specifically explored depressive symptoms and the use of selective serotonin reuptake inhibitors (SSRIs) in patients with acute intracerebral hemorrhage (ICH). The aim of our study was to identify the incidence and factors associated with depression in ICH patients and the use of SSRIs as therapy by physicians at a tertiary care hospital in Karachi, Pakistan.

Materials and methods

A retrospective chart review was conducted to identify patients with ICH through the International Classification of Diseases, Ninth Revision (ICD-9) coding system electronic medical records of Aga Khan University Hospital, Karachi, Pakistan. Patient records spanning a period of five years at the hospital were identified and analyzed by neurology residents. Patients' clinical, laboratory, radiological, and pharmacological data were recorded and analyzed using a structured proforma. Patients with a past history of depression or those who were taking SSRIs at the time of admission were excluded from the analysis. Depression was defined as the presence of five or more symptoms according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Results

Out of the 458 patients we analyzed, 258 (56%) were men and 200 (44%) were women. The mean age was 59 years. Median National Institutes of Health Stroke Scale (NIHSS) score on admission was 13 (range: 0-42), and the median modified Rankin Scale (mRS) score was 4 (range: 0-6). On neuroimaging, sites of hemorrhage in patients were found to include the basal ganglia/thalamus in 279 (61%) patients, cerebral cortex in 105 (23%), cerebellum in 25 (5%), brain stem in 17 (4%), ventricles in 17 (4%), and multiple sites in eight (2%). We found that 48 (10%) patients had a ventricular extension, and 130 (28%) had midline shift, hydrocephalus, or both. Overall, 103 (22%) patients met the DSM-IV diagnostic criteria for depression. The most common depressive symptoms included tearfulness (67%), sadness (55%), and loss of interest or pleasure in life activities (53%). None of the patients reported suicidal ideation. Only seven patients (2%) were seen by a psychiatrist. The presence of depression was not significantly associated with hemorrhage sites [prabability value (p): 0.55] or the extent of disability (p: 0.09). Among the 103 depressed patients, only 25 (24%) received SSRIs during the hospital stay. A total of 57 (12%) received SSRIs during the hospital stay, of which only 25 had met the DSM-IV diagnostic criteria for depression. The mean duration between the diagnosis of ICH and the start of SSRIs was five days (range 3-25 days). None of the patients received any psychotherapeutic help for depression. At the time of discharge, only 13 (13%) of the 103 patients diagnosed with depression were discharged on SSRIs, while 23 that had not met the DSM-IV diagnostic criteria were discharged on SSRIs.

Conclusion

The present study demonstrates that depression is not uncommon in acute ICH patients, and it is both underdiagnosed and inadequately treated. Physicians should be trained to accurately identify and effectively treat depressive symptoms in ICH patients. Clear guidelines should be developed to aid the diagnosis and treatment of post-ICH depression in hospital settings.

Psychosocial interventions for stroke survivors, carers and survivor-carer dyads: a systematic review and meta-analysis

Objective: To evaluate the effectiveness of psychosocial interventions on depressive symptoms, anxiety symptoms, quality of life, self-efficacy, coping, carer strain and carer satisfaction among stroke survivors, carers and survivor-carer dyads. Data sources: MEDLINE, CINAHL, PsycINFO, SocINDEX, Cochrane Library, Web of Science and Scopus databases and the grey literature were searched up to September 2018. Methods: A systematic review and meta-analysis of randomized controlled trials of psychosocial interventions for stroke survivors, carers and survivor-carer dyads, compared to usual care. Outcomes measured were depressive symptoms, anxiety symptoms, quality of life, coping, self-efficacy, carer strain, and carer satisfaction. Results: Thirty-one randomized controlled trials (n = 5715) were included in the systematic review which found improvements in depressive symptoms, anxiety symptoms, quality of life and coping, though the number of trials assessing each outcome varied. A meta-analysis (11 trials; n = 1280) on depressive symptoms found that in seven trials psychosocial interventions reduced depressive symptoms in stroke survivors (SMD: -0.36, 95% CI -0.73 to 0.00; p = .05) and in six trials reduced depressive symptoms in carers (SMD: -0.20, 95% CI -.40 to 0.00; p = .05). Conclusion: Psychosocial interventions reduced depressive symptoms in stroke survivors and their carers. There was limited evidence that such interventions reduced anxiety symptoms, or improved quality of life and coping for stroke survivors and carers and no evidence that they improved self-efficacy, carer strain or carer satisfaction.

Treatment of Post-Stroke Depression

PURPOSE OF REVIEW

This review presents a critical appraisal of current therapeutic strategies for patients with post-stroke depression (PSD). We present the reader with the most recent evidence to support pharmacological, psychosocial, and neuromodulation interventions in PSD. We also discuss the relevance of using antidepressants and psychotherapy to prevent PSD and discuss evidence that antidepressant treatment may reduce mortality after stroke.

RECENT FINDINGS

Neuroinflammation and decrease neurogenesis and plasticity may play an important role in the mechanism of PSD. The strongest predictors of PSD are stroke severity, early physical disability, and severity of loss of functioning. Nevertheless, populations at risk for PSD are yet to be identified. Recent meta-analysis examined the efficacy of pharmacotherapy and psychotherapy. There is consensus that antidepressants such as escitalopram and paroxetine produce a significantly greater response and remission rate of PSD than placebo. Randomised controlled trials (RCTs) using psychotherapy are fewer, but recent meta-analysis tend to suggest efficacy for this treatment modality. Neuromodulation using repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS), as well as novel psychosocial interventions are potentially useful treatments in need of further research. Pharmacological therapy with antidepressants and psychotherapy should be considered as first line of treatment for PSD. The most effective antidepressants are the selective serotonin reuptake inhibitors escitalopram and paroxetine, whereas cognitive behavioural therapy is the most effective psychotherapeutic intervention.

Effectiveness of paroxetine in the treatment of poststroke depression

This study retrospectively investigated the effectiveness of paroxetine for the treatment of poststroke depression (PSD).Seventy patient cases with PSD were included in this study, and were assigned to an intervention group and a control group equally. All patients received routine treatment in both groups. Additionally, patients in the intervention group underwent paroxetine, while patients in the control group received psychotherapy for a total of 8 weeks intervention. The primary outcomes included depression, measured by Hamilton depression rating scale (HAMD); and anxiety, measured by Hamilton Anxiety Rating Scale (HAMA). The secondary outcomes consisted of neurological impairment, measured by Scandinavian Stroke Scale (SSS), and activities of daily living, measured by Barthel index (BI), as well as the adverse events. All outcomes were assessed before and after 8-week treatment.After 8-week treatments, patients in the intervention group did not show greater effectiveness in depression, measured by HAMD (P = .11), and anxiety, assessed by HAMA (P = .13), as well as the neurological impairment, evaluated by SSS (P = .24), and activities of daily, performed by BI (P = .19), compared with patients in the control group. In addition, no significant differences regarding adverse events were found between the 2 groups.The results of this study indicated that paroxetine may not bring promising effectiveness for patients with PSD. Future studies are still needed to warrant the results of this study.

Randomized trial of telephone versus in-person delivery of a brief psychosocial intervention in post-stroke depression

Background

A psychosocial behavioral intervention delivered in-person by advanced practice nurses has been shown effective in substantially reducing post-stroke depression (PSD). This follow-up trial compared the effectiveness of a shortened intervention delivered by either telephone or in-person to usual care. To our knowledge, this is the first of current behavioral therapy trials to expand the protocol in a new clinical sample. 100 people with Geriatric Depression Scores ≥ 11 were randomized within 4 months of stroke to usual care (N = 28), telephone intervention (N = 37), or in-person intervention (N = 35). Primary outcome was response [percent reduction in the Hamilton Depression Rating Scale (HDRS)] and remission (HDRS score < 10) at 8 weeks and 12 months post treatment.

Results

Intervention groups were combined for the primary analysis (pre-planned). The mean response in HDRS scores was 39% reduction for the combined intervention group (40% in-person; 38% telephone groups) versus 33% for the usual care group at 8 weeks (p = 0.3). Remission occurred in 37% in the combined intervention groups at 8 weeks versus 27% in the control group (p = 0.3) and 44% intervention versus 36% control at 12 months (p = 0.5). While favouring the intervention, these differences were not statistically significant.

Conclusions

A brief psychosocial intervention for PSD delivered by telephone or in-person did not reduce depression significantly more than usual care. However, the comparable effectiveness of telephone and in-person follow-up for treatment of depression found is important given greater accessibility by telephone and mandated post-hospital follow-up for comprehensive stroke centers.

Clinical Trial Registration URL: https://register.clinicaltrials.gov, unique identifier: NCT01133106, Registered 5/26/2010

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2819-y) contains supplementary material, which is available to authorized users.

Advances in Psychotherapy for Depressed Older Adults

PURPOSE OF REVIEW

We review recent advances in psychotherapies for depressed older adults, in particular those developed for special populations characterized by chronic medical illness, acute medical illness, cognitive impairment, and suicide risk factors. We review adaptations for psychotherapy to overcome barriers to its accessibility in non-specialty settings such as primary care, homebound or hard-to-reach older adults, and social service settings.

RECENT FINDINGS

Recent evidence supports the effectiveness of psychotherapies that target late-life depression in the context of specific comorbid conditions including COPD, heart failure, Parkinson's disease, stroke and other acute conditions, cognitive impairment, and suicide risk. Growing evidence supports the feasibility, acceptability, and effectiveness of psychotherapy modified for a variety of health care and social service settings. Research supports the benefits of selecting the type of psychotherapy based on a comprehensive assessment of the older adult's psychiatric, medical, functional, and cognitive status, and tailoring psychotherapy to the settings in which older depressed adults are most likely to present.

Application of Solution-Focused Brief Therapy (SFBT) in individuals after stroke

OBJECTIVE

To examine the effects of Solution Focused Brief Therapy (SFBT) in individuals after stroke on self-efficacy, symptoms of depression and anxiety.

DESIGN

Randomized controlled trial.

SETTING

Clinic of Adult Neurology of Medical University of Gdańsk and M. Copernicus Pomeranian Traumatology Centre in Gdańsk.

SUBJECTS

A total of 62 patients, aged 54.0 ± 9.6 years.

INTERVENTIONS

They were randomly assigned to one of the two groups: SFBT participating in 10 therapy sessions and control - not participating in any psychotherapy.

MAIN MEASURES

Symptoms of depression and anxiety according to Hospital Anxiety and Depression Scale, Mini-Mental Adjustment to Cancer (scale originally designed for cancer patients) and Self-efficacy Scale were examined at baseline of the study and later in the same time intervals in both groups.

RESULTS

The intensity of depression and anxiety complaints drops in the SFBT group (from 5.0 to 2.0 and 8.0 to 4.0 respectively; both p < .001 Friedman's ANOVA (analysis of variance)) whilst in the control group remains unchanged. In addition to the gradual reduction of destructive attitudes (from 34.5 to 17.0), the increase in the number of constructive attitudes (from 42.0 to 50.5) and increased self-efficacy (from 79.0 to 96.0) was observed after therapy but not in the control group.

CONCLUSIONS

The authors suggest SFBT as a simple, beneficial and inexpensive method to manage patients after stroke.

Reducing depressive or anxiety symptoms in post-stroke patients: Pilot trial of a constructive integrative psychosocial intervention

BACKGROUND

About 30% of stroke survivors clinically have depressive symptoms at some point following stroke and anxiety prevalence is around 20-25%.

OBJECTIVE

The purpose of this brief report is to evaluate a pilot trial of a constructive integrative psychosocial intervention (CIPI) over standard care in post-stroke depression or anxiety.

METHODS

Patients were randomly assigned to either CIPI (n = 23) or standard care (n = 19). Patients were assessed using the Hospital Anxiety and Depression Scale at the 1^st, 3^rd, and 6^th months to monitor changes of mood.

RESULTS

A Wilcoxon signed-rank test indicated that compared to admission baseline, patients with the intervention had significantly normal post-stroke depression symptom levels at the 1^st, 3^rd, and 6^th months (P < 0.005).

CONCLUSION

CIPI appears to be of incremental value in treating depression as well as anxiety in subacute care.

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.

Systematic review of dyadic and family-oriented interventions for late-life depression

OBJECTIVE

Supportive behaviors (both instrumental and emotional) from spouses and close family members can impact the trajectory of older adults' depressive symptoms. Interventions that target both the patient and support person may be more effective than interventions that target the patient only, in terms of alleviating mood symptoms in the identified patient. The purpose of this paper was to review the characteristics and findings of dyadic and family-oriented interventions for late-life mood disorders to determine if they are effective and beneficial.

METHODS

Following PRISMA guidelines, we conducted a systematic review of reports in the literature on dyadic or family-oriented interventions for late-life mood disorders. We searched PubMed, OVID PsycINFO, and EMBASE for peer-reviewed journal articles in English through October 2014.

RESULTS

We identified 13 articles, representing a total of 10 independent investigations. Identified studies focused on spouses and close family members as support persons. Effect sizes for dyadic interventions that treated major depressive disorder were, on average, moderately strong, while effect sizes for dyadic interventions that reduced depressive symptoms were generally small. We did not identify any dyadic studies that treated bipolar disorder.

CONCLUSIONS

This review showed that dyadic interventions are feasible and that these interventions can decrease symptomatology in individuals who have major depressive disorder. Research is needed to understand the relative efficacy of a dyadic approach over a single-target approach in treating depression. Copyright © 2016 John Wiley & Sons, Ltd.

Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke Practice Guidelines, Update 2015

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals, and the evidence suggests one-third or more will experience vascular-cognitive impairment, and/or intractable fatigue, either alone or in combination. The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. The three consequences of stroke that are the focus of the this guideline (poststroke depression, vascular cognitive impairment, and fatigue) have high incidence rates and significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes. Significant practice variations and gaps in the research evidence have been reported for initial screening and in-depth assessment of stroke patients for these conditions. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact patient recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community. Additionally, building system capacity to ensure access to appropriate specialists for treatment and ongoing management of stroke survivors with these conditions is another great challenge.

Models of care for late-life depression of the medically ill: examples from chronic obstructive pulmonary disease and stroke

Depression worsens most treatment outcomes in medically ill older adults. Chronic medical illnesses weaken and demoralize patients and compromise their ability to adhere to treatments requiring consistency and effort. Acute medical illnesses create a psychosocial storm that finds patients and their ecosystem unprepared. We describe two intervention models that can be used to target and personalize treatment in depressed, chronically, or acutely medically ill older adults. The Personalized Adherence Intervention for Depression and COPD (PID-C) is a model intervention for depressed patients with chronic medical illnesses. It targets patient-specific barriers to treatment engagement and aims to shift the balance in favor of treatment participation. PID-C led to higher remission rates of depression, reduction in depressive symptoms, and reduction in dyspnea-related disability. The addition of problem-solving training enables patients to use resources available to them and hopefully improve their outcomes. Ecosystem-focused therapy (EFT) is a model intervention for depression developing in the context of an acute medical event. It was developed for patients with poststroke depression (PSD) and targets five areas, part of the "psychosocial storm" originating from the patient's sudden disability and the resulting change in the patient's needs and family's life. A preliminary study suggests that EFT is feasible and efficacious in reducing depressive symptoms and signs and disability in PSD.

Do family-oriented interventions reduce poststroke depression? A systematic review and recommendations for practice

INTRODUCTION

Up to half of all stroke survivors become depressed. Poststroke depression (PSD) negatively impacts on quality of life and rehabilitation outcomes and increases risk of mortality. Depression is also common in carers, leading to poorer outcomes in survivors. Few stroke patients receive adequate care to support prevention and management of PSD. We aimed to systematically review the evidence regarding the effectiveness of family-oriented interventions to prevent and manage depression after stroke and identify components of effective interventions.

METHODS

A systematic review was conducted, adhering to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Eight databases were searched, and relevant journals and reference lists were hand searched. Abstracts were screened for relevance and two authors independently assessed selected full texts against inclusion criteria. Studies were included if they (1) engaged stroke patients and their informal/family caregivers; (2) measured changes in depression due to an intervention; and (3) were available in English.

RESULTS

Twenty-five of 2741 identified citations met the inclusion criteria. Five studies demonstrated significant reductions in depression. Commonalities across effective studies included the delivery of interventions that were structured and multicomponent, actively engaged patients and families, coordinated care, and were initiated soon after a stroke.

CONCLUSION

Family-oriented stroke rehabilitation may reduce depression in stroke survivors and their family caregivers. More research is required to clarify the effectiveness, feasibility, and acceptability of working with families and patients living with or who may be at risk of PSD.

Diagnosis and treatment of depression and cognitive impairment in late life

Cognitive impairment in late-life depression is prevalent, disabling, and heterogeneous. Although mild cognitive impairment in depression does not usually progress to dementia, accurate assessment of cognition is vital to prognosis and treatment planning. For example, executive dysfunction often accompanies late-life depression, influences performance across cognitive domains, and is associated with poor antidepressant treatment outcomes. Here, we review how assessment can capture dysfunction across cognitive domains and discuss cognitive trajectories frequently observed in late-life depression in the context of the neurobiology of this disorder. We also review the efficacy of a sample of interventions tailored to specific cognitive profiles.

[Coexistent depressive and anxiety disorders in neurological diseases: from a perspective of multimorbidity]

The high rate of coexistent emotional disorders in neurological diseases is challenging. As a rule this coexistence comprises a more dramatic subjective suffering, reduced psychological coping, possible negative interferences with somatic treatments and rehabilitation, an impaired quality of life and higher grades of psychosocial disability. It may also lead to an overall increased risk of somatic morbidity and even mortality in the further course of illness. The complex interrelations may be favorably integrated within a biopsychosocial model. Psychological and psychosocial stressors can be appreciated on their own discrete levels but have to be reflected in their neurobiological correlates. Both neurological and emotional disorders frequently share decisive pathogenetic mechanisms, i.e. the underlying process of neurological disease may contribute to major affective problems also in a somatopsychic direction. From a perspective of multimorbidity the prevalence and clinical relevance of coexistent depressive and anxiety disorders, common pathogenetic mechanisms and implications for treatment will be described for stroke and Parkinson's disease, as selected neurological disorders.

Psychotherapies for Late-Life Depression

Late-life depression often occurs in the context of cognitive impairment, medical burden, and disability. For this reason, the assessment of depressed older adults consists of detailed psychiatric history and mental status examination and focuses on their broader clinical context and their ecosystem. This article outlines assessment procedures and the principles of therapies developed to utilize their assets and address limitations imposed by their clinical problems and their behavioral consequences.