Age, subjective stress, and depression after ischemic stroke

Prevalence of depression and anxiety symptoms after stroke in young adults: A systematic review and meta-analysis

BACKGROUND

Young adults with stroke have distinct professional and social roles making them vulnerable to symptoms of post-stroke depression (PSD) and post-stroke anxiety (PSA). Prior reviews have examined the prevalence of anxiety and depression in stroke populations. However, there are a lack of studies that have focused on these conditions in young adults.

OBJECTIVE

We performed a systematic review and meta-analysis of observational studies that reported on symptoms of PSD, PSA and comorbid PSD/PSA in young adults aged 18 to 55 years of age.

METHODS

MEDLINE, EMBASE, SCOPUS and PsycINFO were searched for studies reporting the prevalence of symptoms of PSD and/or PSA in young adults with stroke from inception until June 23, 2023. We included studies that evaluated depression and/or anxiety symptoms with screening tools or interviews following ischemic or hemorrhagic stroke. Validated methods were employed to evaluate risk of bias.

RESULTS

4748 patients from twenty eligible studies were included. Among them, 2420 were also evaluated for symptoms of PSA while 847 participants were evaluated for both PSD and PSA symptoms. Sixteen studies were included in the random effects meta-analysis for PSD symptoms, with a pooled prevalence of 31 % (95 % CI 24-38 %). Pooled PSA symptom prevalence was 39 % (95 % CI 30-48 %) and comorbid PSD with PSA symptom prevalence was 25 % (95 % CI 12-39 %). Varying definitions of 'young adult', combinations of stroke subtypes, and methods to assess PSD and PSA contributed to high heterogeneity amongst studies.

CONCLUSIONS

We identified high heterogeneity in studies investigating the prevalence of symptoms of PSD and PSA in young adults, emphasizing the importance of standardized approaches in future research to gain insight into the outcomes and prognosis of PSD and PSA symptoms following stroke in young adults. Larger longitudinal epidemiological studies as well as studies on tailored interventions are required to address the mental health needs of this important population.

FUNDING

None.

A nationwide cohort study on the association between intensive care treatments and mental distress linked psychiatric disorders

Given the psychic strain patients experience in the intensive care unit (ICU), a potential risk of mental disorders has been suggested. However, the effects of intensive care treatment per se are unknown. We investigated whether the level of intensive care treatments is an independent risk factor for developing long-term mental disorders after intensive care. In a national cohort of adult ICU patients we combined data on diagnoses, treatment, and causes of death. We defined extensive ICU treatment as being treated with invasive ventilation for > 24 h, continuous renal replacement therapy, or both. The primary outcome was incident mental disorder 1 year after ICU admission. Extensive ICU treatment was found to be associated with a decreased risk of developing a mental disorder ≥ 1 year after ICU admission (HR 0.90, 95% CI 0.82-0.99, p = 0.04), and increasing severity of acute illness (HR 1.18, 95% CI 1.06-1.32, p < 0.001) were associated with an increased risk of mental disorders. Because death acted as a competing risk for mental illness, mortality might help explain the apparent protective effect of extensive ICU care.Trial registration Clinical Trials Registry (Identification number NCT05137977). Registered 16 November 2021. As a registry trial the patients were already included at the trial registration i.e. it was retrospectively registered.

Factors associated with the effectiveness of immersive virtual therapy in alleviating depressive symptoms during sub-acute post-stroke rehabilitation: a gender comparison

BACKGROUND

The large-scale digitalization of healthcare has induced shifts in patient preferences, prompting the introduction of therapies utilizing novel technologies. In this context, the targeted application of these interventions is deemed as crucial as assessing their overall effectiveness. The aim of this study was to characterize the patient profile who benefited most from immersive virtual reality (VR) therapy.

METHODS

Based on the results from the previous randomized controlled trial study, we employed an exploratory study design to determine the factors associated with the most significant mental health improvement. A secondary analysis was conducted on a sample of 83 participants, with further analysis of participants with elevated depression symptoms, as indicated by a score of > 10 on the 30-item Geriatric Depression Scale (GDS-30). Both groups participated in a similar post-stroke rehabilitation program; however, the experimental group also received additional VR therapy through an immersive VR garden intervention. The GDS-30 was used to assess mood and depressive symptoms, and sociodemographic, cognitive status as well as stroke-related variables were considered as potential factors.

RESULTS

In both the experimental (mean change 5.3) and control groups (mean change 2.8), interventions significantly reduced depressive symptoms, with a more pronounced difference in the experimental group (p < 0.05). When examining gender differences, women exhibited greater improvement in the GDS, with mean between-group differences of 5.0 for the total sample and 6.0 for those with elevated depressive symptoms. Sociodemographic factors, cognitive status, and time from stroke were not found to be factors that alter the effectiveness of VR therapy.

CONCLUSIONS

While VR therapy as an adjunctive treatment for post-stroke rehabilitation seems especially effective for women with elevated depressive symptoms, the results should be interpreted with caution due to the study's small experimental group size. Traditional methods showed reduced effectiveness in women compared to men; thus, developing technologically advanced and gender-specific approaches can lead to more tailored therapy.

TRIAL REGISTRATION

NCT03830372 (February 5, 2019).

Incidence of post-stroke depression symptoms and potential risk factors in adults with aphasia in a comprehensive stroke center

INTRODUCTION

Depression may be a frequent sequela after stroke, however, its incidence has rarely been reported. The likelihood of post-stroke depression (PSD) may relate to individual factors including the presence of aphasia, which also complicates PSD diagnosis. The current study's purpose was to investigate the incidence of PSD symptoms in adults with aphasia, compare it to the incidence of PSD symptoms in adults without aphasia, and to identify potential risk factors for developing PSD in adults with aphasia.

METHOD

Incidence proportions and relative risk were calculated using data compiled from 970 patient records at an urban tertiary care academic institution and comprehensive stroke center throughout the year of 2019. Focusing exclusively on adults with aphasia, the selected variables of age, gender, race, and aphasia severity were used to conduct logistic regression analyses to explore potential risk factors contributing to the development of PSD.

RESULTS

Adults with aphasia were 7.408 times more likely to exhibit PSD symptoms than adults without aphasia. Logistic regression controlling for the presence of aphasia showed a significant relationship between aphasia severity and post-stroke depression symptoms. Adults with aphasia were 2.06 times more likely to experience post-stroke depression symptoms with every 1-point increase in aphasia severity.

CONCLUSIONS

These findings align with earlier evidence identifying aphasia as a risk factor for experiencing PSD symptoms and also suggest aphasia severity is proportionate to the risk. This highlights the need for early identification of PSD symptoms in persons with aphasia in order to provide timely interventions.

Education Level Modulates the Presence of Poststroke Depression and Anxiety, But It Depends on Age

ABSTRACT

Depression and anxiety are common complications after stroke and little is known about the modulatory roles of education and age. Our study aimed to evaluate the modulatory effects of education level on anxiety and depression after stroke and their effect on each age group. Adults with first stroke took part in this cross-sectional observational clinical study. We used the following instruments: Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Scale, Pittsburgh Sleep Quality Index, Barthel index, and Functional Independence Measure. There were 89 patients. The mean (SD) age was 58.01 (13) years, mean (SD) years of education was 9.91 (5.22), 55.1% presented depression symptoms and 47.2% anxiety symptoms, 56.2% were young adults and 43.8% were older adults. We identified a negative association between education and anxiety score (r = -0. 269, p = 0.011) and depression score (r = -0.252, p = 0.017). In the linear regression analysis, we found that education is negatively associated with HADS, but this influence was more consistent in young adults. In conclusion, a higher education level reduces the risk of depression and anxiety, but their effect is less consistent in older adults.

Effects of Immersive Virtual Therapy as a Method Supporting Recovery of Depressive Symptoms in Post-Stroke Rehabilitation: Randomized Controlled Trial

PURPOSE

Depressive symptoms constitute an important group of mental problems that alter the course of post-stroke rehabilitation by reducing quality of life, physical activity, social functioning, and interpersonal relationships. Although several studies have shown the efficacy of virtual reality (VR) in the motor treatment of poststroke patients, there is a lack of studies that would also evaluate the impact of VR on psychological aspects. Thus, we investigated the effectiveness of immersive VR therapy on both functional activity and depressive symptoms in stroke survivors.

PATIENTS AND METHODS

We conducted a single blind, randomized controlled trial comparing VR therapy with Schultz's Autogenic Training (SAT). Patients randomized to the VR group received treatment in an immersive VR therapeutic garden with elements of psychotherapy and physical activity of the upper extremities, whereas patients in the control group received SAT. Additionally, patients in both groups received standard neurological rehabilitation. The full research cycle lasted six weeks. We used Geriatric Depression Scale, Generalized Self-Efficacy Scale, Acceptance of Illness Scale, Visual Analogue Scale of pain, Hospital Anxiety and Depression Scale, Barthel Index, Lawton Instrumental Activities of Daily Living Scale and Rivermead Motor Assessment for outcome assessment. This trial was registered with ClinicalTrials.gov (NCT03830372).

RESULTS

We assessed 60 patients and randomly assigned to the VR or control group. The VR group showed a significant reduction in depressive symptoms (ηp² = 0.13, p < 0.01) compared to SAT. The applied VR therapy significantly increased the sense of self-efficacy and the level of acceptance of the illness; however, this effect was similar to that obtained with the standard intervention. We did not observe statistically significant changes in the functional parameters of post-stroke patients.

CONCLUSION

The use of VR therapy combined with neurological rehabilitation had a positive effect on improving mood and reducing depressive symptoms in post-stroke patients.

Depression symptoms in neurological patients: A survey of a large cohort of patients with focal brain lesions

INTRODUCTION

Examining depression following neurological injury is useful for understanding post-lesion depression and depression more generally. The extant literature shows variability in the incidence and severity of depression post-lesion, likely due to heterogeneity in study methodology, patient samples, measures of depression, and time of assessment. Here, we aim to characterize depression symptoms and their demographic correlates in a large sample of individuals in the chronic epoch following a focal brain lesion.

METHOD

We sampled 492 individuals who had focal, stable brain lesions and were in the chronic epoch (≥3 months post-onset). Demographic (gender, years of education), temporal (age at lesion onset, time since lesion onset), and lesion (lesion laterality, lesion etiology, lesion volume) factors were used to predict depression symptoms measured by the Beck Depression Inventory (BDI).

RESULTS

We found that on average, neurological patients exhibited elevated levels of depression symptoms (although not clinically significant) relative to a community sample, and the neurological patients showed higher rates of mild and moderate depression symptoms than are typical in a community sample. Gender and lesion etiology were predictive of depression symptoms, whereby women and patients with ischemic stroke had higher levels of depression symptoms.

CONCLUSIONS

Our results suggest that depression symptom severity may be elevated following a focal brain lesion. Moreover, some individuals may be more likely to develop depression symptoms post-lesion than others. This may be mediated by individual factors such as gender and lesion etiology. The findings have important implications for the diagnosis, prognosis, and treatment of depression in neurological patients.

Predictors of Post-Stroke Depression: A Retrospective Cohort Study

Despite reports of a high incidence and various predictors of post-stroke depression (PSD), the underdiagnosis and undertreatment rates of PSD are still high. This study aimed to examine the incidence of depression in stroke patients and identify factors associated with PSD. This was a retrospective cohort study on ischemic stroke patients from the Geisinger Neuroscience Ischemic Stroke (GNSIS) registry. The following statistical analyses were performed to predict PSD in the studied population: a Kaplan−Meier estimator and a Cox proportional hazards model. A total of 5882 patients were included in the study. The median age at the time of an ischemic stroke was 72 years and 56% were males. A total of 294 patients were diagnosed with PSD within one year of a stroke. The cumulative incidence of depression was found to be 6.4% (95% CI 5.7−7.1%) at one year for the entire cohort. Women were found to have a higher risk of PSD than men (HR for women = 1.47, 95% CI 1.18−1.85, p = 0.001). A history of prior stroke (HR = 1.58, 95% CI 1.18−2.11, p = 0.002) and myocardial infarction (HR = 1.47, 95% CI 1.05−2.06, p = 0.025) were associated with PSD. Medicaid patients had a higher risk for PSD (HR = 2.16, 95% CI 1.5−3.12, p < 0.001) than those with commercial insurance or health maintenance organization plans. Our findings showed that women, patients with a history of prior stroke or myocardial infarction, and with Medicaid insurance were more likely to develop PSD. Through an observational study on the EHR data, we confirmed that chronic stress, including financial and health-related stress, irrespective of age, significantly increased the risk for PSD.

Contributing Factors and Induced Outcomes of Psychological Stress Response in Stroke Survivors: A Systematic Review

Background

Remarkable evidence indicates that psychological stress is significantly associated with stroke. However, a uniform recommendation to identify and alleviate poststroke psychological stress responses and improve postmorbid outcomes is not currently available. Thus, this systematic review aimed to summarize the types of poststroke psychological stress, measurement tools, contributing factors, and outcomes.

Methods

This systematic review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A literature search was conducted in PubMed, Web of Science, Embase, CNKI, WanFangData, and CQVIP from database inception to November 2021. Cross-sectional and longitudinal studies were included in this research. Quality assessment was performed based on the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

Results

Eighteen quantitative, peer-reviewed studies were included for analysis. Selected articles mainly investigated perceived stress and posttraumatic stress disorder after stroke. We classified the contributing factors into four categories: sociodemographic factors, clinical disease factors, psychological factors, and behavioral and lifestyle factors. The postmorbid outcomes were divided into three categories: clinical disease outcomes, psychological outcomes, and behavioral and quality of life outcomes.

Conclusions

Compared to common patients, stroke survivors with the following characteristics suffered an increased psychological stress response: younger age, the presence of caregivers, depression, unsuitable coping strategies, etc. Meanwhile, lower quality of life, worse drug compliance, worse functional independence, and more severe mental disorders were significantly associated with increased psychological stress symptoms. Further studies are required to provide more trustworthy and meaningful references for mitigating the damage caused by psychological stress after stroke.

Magnetic Resonance Imaging to Evaluate the Recovery Effects of Cerebral Nerve Function in Comprehensive Treatment of Poststroke Depression by Intelligent Algorithm-Based Hyperbaric Oxygen Therapy

This research was aimed to discuss magnetic resonance imaging (MRI) evaluation of recovery effects of cerebral nerve function in comprehensive treatment of poststroke depression (PSD) by intelligence-based hyperbaric oxygen therapy. Low-rank matrix algorithm was adopted to denoise MRI images of patients with PSD, and mean square error (MSE) and peak signal-to-noise ratio (PSNR) were the evaluation indicators of the results of image denoising. 118 patients were randomly divided into the control group (administered escitalopram oxalate) and the research group (hyperbaric oxygen therapy was implemented based on the treatment in control group). National Institutes of Health Stroke Scale (NIHSS), Hamilton Depression Scale (HAMD), Pittsburgh Sleep Quality Index (PSQI), glial fibrillary acidic protein (GFAP), and changes of norepinephrine (NE) level of patients in two groups were compared before and after treatment. The value of MSE of MRI images processed by low-rank matrix algorithm was 92.39, which was higher than that calculated by nonlocal mean (NLM) algorithm (80.54). The PSNR value calculated by low-rank matrix algorithm was 25.35, which was lower than that calculated by NLM algorithm (29.07). In contrast, NIHSS score and HAMD score of the research group after treatment were lower than those of the control group, while PSQI score of the research group was higher than that of the control group. The level of GFAP of the research group was at 852.46 ± 94.47, which was significantly lower than that of the control group, reaching 948.53 ± 98.42. However, the level of NE of the research group was 1478.59 ± 99.85, which was higher than that of the control group (1061.80 ± 98.02). All the comparisons of above indicators had statistical meaning (P < 0.05). The low-rank matrix algorithm can help in clinical diagnosis and treatment to provide more accurate MRI images. In addition, hyperbaric oxygen comprehensive therapy can promote the recovery of neurological function in patients with poststroke depression and significantly improve the depressive state and sleep quality of patients.

Psychometric properties of the Cognitive Emotion Regulation Questionnaire (CERQ) in Spanish older adults

The Cognitive Emotion Regulation Questionnaire (CERQ) assesses nine cognitive strategies used to cope with negative events. The aim of this study was to generate validity evidences of this instrument in an older Spanish population. The Spanish version of the CERQ (CERQ-S) and self-report scales, measuring psychological well-being, depression and resilience, were administered to 305 older adults aged 65-90 (70.0 ± 4.7) residents in the Autonomous Community of Madrid, Spain. 150 participants completed the 6-month follow-up in April 2020 (during the COVID-19 pandemic). Confirmatory factor analyses supported 9-strategy structure, with an improved fit 27-item version (CERQ-S-27). Generally adequate composite reliability (CR between 0.63 and 0.84) and temporal stability (ICC between 0.38 and 0.71; p < 0.001) were found. Subscales correlated coherently with measures of depression, well-being and resilience, and T-tests indicated different use between older adults who did or did not have depressive symptoms. Multiple linear regression analysis indicated that subscales predicted depressive symptoms (R² = 0.17; p < 0.001) and psychological well-being after six months (R² = 0.21; p < 0.001). Results provided evidences of concurrent, predictive and criterion validity, suggesting that the CERQ-S-27 could be useful for studying use of cognitive emotion regulation strategies among older adults and understanding their influence in ageing and mental health.

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

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

Post-Stroke Depression in Patients with Large Spontaneous Intracerebral Hemorrhage

OBJECTIVES

To determine factors associated with post-stroke depression (PSD) and relationship between PSD and functional outcomes in spontaneous intracerebral hemorrhage (ICH) using prospective data from a large clinical trial.

MATERIALS AND METHODS

MISTIE III, a randomized, multicenter, placebo-controlled trial, was conducted to determine if minimally invasive surgery with thrombolysis improves outcome compared to standard medical care. Our primary outcome was post-stroke depression at 180 days. Secondary outcomes were change in blinded assessment of modified Rankin Scale (mRS) from 30 to 180 days, and from 180 to 365 days. Logistic regression models were used to assess the relationship between PSD and outcomes.

RESULTS

Among 379 survivors at day 180, 308 completed Center for Epidemiologic Studies Depression Scale, of which 111 (36%) were depressed. In the multivariable analysis, female sex (Adjusted Odds Ratio [AOR], 95% Confidence Interval [CI]: 1.93 [1.07-3.48]), Hispanic ethnicity (3.05 [1.19-7.85]), intraventricular hemorrhage (1.88 [1.02-3.45]), right-sided lesions (3.00 [1.43-6.29]), impaired mini mental state examination at day 30 (2.50 [1.13-5.54]), and not being at home at day 30 (3.17 [1.05-9.57]) were significantly associated with higher odds of PSD. Patients with PSD were significantly more likely to have unchanged or worsening mRS from day 30 to 180 (42.3% vs. 25.9%; p=0.004), but not from day 180 to 365.

CONCLUSIONS

We report high burden of PSD in patients with large volume ICH. Impaired cognition and not living at home may be more important than physical limitations in predicting PSD. Increased screening of high-risk post-stroke patients for depression, especially females and Hispanics may be warranted.

Depression after stroke

Stroke treatment has dramatically improved in recent decades. However, although new treatments have reduced its mortality and the severity of its physical and cognitive sequelae, many people still have incapacitating disabilities following a stroke. Depression is the most common psychiatric disorder following stroke; it is important to recognise and treat as it limits motor and cognitive rehabilitation. Antidepressant medication is an effective treatment and can improve adherence to clinically recommended physical and cognitive tasks, thereby enhancing functional remodelling of neuronal pathways and improving rehabilitation outcomes.

Neuropsychiatric symptoms among young stroke survivors-frequency, patterns, and associated factors

BACKGROUND

Although neuropsychiatric symptoms are reported in stroke survivors, details of its prevalence and patterns among young stroke subjects are sparse.

METHODS

In a hospital-based cross-sectional study in India, we recruited 150 young stroke subjects (aged < 45 years) and their caregivers > 3 months from ictus. Neuropsychiatric symptoms were evaluated using the Neuropsychiatric Inventory-12 (NPI-12) and self-reported depression with the Centre for Epidemiological Studies - Depression (CES-D) scale. Descriptive statistics were used. Multivariate analysis was performed to identify associated factors. All statistical analyses were carried out using STATA ver. 14.2, StataCorp, TX, USA.

RESULTS

Eighty-four (56%; 95% CI: 47.7-64.1%) had ≥ 1 symptoms on the NPI-12 over median time from stroke of 2 years (IQR 2). Self-reported depression was seen in 71 (47.3%). Post-stroke epilepsy was associated with presence of at least one neuropsychiatric symptom. Dementia was associated with increased odds; and having spouse as principal caregiver with reduced odds, of self-reported depression. Multiple infarcts on imaging were associated with self-reported depression (OR: 3.29; 95%CI: 1.31-8.27) and presence of any neuropsychiatric symptom (OR: 3.55; 95% CI: 1.42-8.88).

CONCLUSION

Young stroke survivors frequently have neuropsychiatric symptoms with depression being most common. Presence of multiple infarcts on imaging was associated with self-reported depression and presence of any neuropsychiatric symptom.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

Association between Poststroke Depression and Psychological Crisis: A Retrospective Cross-Sectional Study

Objective

To investigate the association between poststroke depression (PSD) and psychological crisis in patients who have experienced a stroke within 6 months.

Methods

This was a retrospective cross-sectional study that enrolled patients within 6 months after stroke onset. The investigators reviewed medical charts to obtain patients' baseline characteristics, and a psychologist evaluated each patient for depression using the Taiwanese Depression Questionnaire (TDQ) and for psychological crisis using the Triage Assessment System (TAS). A generalized linear model (GLM) was used to analyze the association between the results of the TDQ and TAS.

Results

Ninety-seven patients with stroke were included. Age (p = 0.003), time since onset of stroke (p = 0.041), diabetes mellitus (p = 0.004), hypertension (p = 0.016), heart disease (p = 0.005), and TDQ score were significantly different between the hemorrhagic stroke group and the ischemic stroke group. The TDQ score was significantly lower in the hemorrhagic stroke group (p = 0.012). The TDQ score was associated with the TAS total score and each domain score, and the presence of heart disease was associated with poorer TAS score in the behavioral domain (p = 0.016).

Conclusion

PSD is likely an important component of psychological crisis in stroke patients. For clinicians, a comprehensive psychologic evaluation is necessary to optimize treatment.

Edaravone reduces depression severity in patients with symptomatic intracranial stenosis and is associated with the serum expression of sex hormones

OBJECTIVE

To investigate the effect of edaravone on depression relief in symptomatic patients with intracranial stenosis and its relationship with the expression of sex hormones.

METHODS

We recruited 112 patients with symptomatic intracranial arterial stenosis from Renmin Hospital, Wuhan University, between October 2014 and October 2017. All patients were divided into the traditional or experimental (traditional treatment + intravenous infusion of edaravone 30 mg twice a day for 14 days) treatment groups. The general clinical data were collected, and neurological functional recovery using the Modified Rankin Scale (mRS) and National Institute of Health stroke scale (NIHSS) scores were recorded. Symptom Checklist 90 (SCL-90) was used to assess the general psychological changes of the patient, followed by the 24 Hamilton Depression Scale (HAMD) to examine the incidence of post-stroke depression (PSD). This divided the patients into the mild, moderate, and severe depression groups. Next, we measured the serum protein expression of the sex hormones estradiol (E2), testosterone (T), follicle stimulating hormone (FSH), prolactin (PRL), and luteinizing hormone (LH).

RESULTS

The mRS and NIHSS scores were significantly lower in the experimental group than in the control group (P < .05). There was no significant difference in SCL90 score before intervention (P > .05); the scores were significantly lower in the experimental group after intervention (P < .05). There was a significant difference in SCL-90 and HAMD scores between groups before treatment (P < .05), with significantly lower scores in the experimental group post-treatment (P < .05). The incidence of depression was significantly reduced in the experimental group post-treatment. Furthermore, the expression of E2 and FSH was significantly higher (P < .01) and lower (P < .001), respectively, in women than in men in the experimental group post-treatment. Interestingly, the expression of T was significantly lower in men in the experimental group post-treatment (P < .001).

CONCLUSION

Edaravone significantly improved the clinical efficacy of stent implantation in intracranial artery stenosis treatment by alleviating depression and reducing the incidence of PSD.

Emotion regulation processes as mediators of the impact of past life events on older adults' psychological distress

OBJECTIVE

Although it is known that certain emotion regulation processes produce a buffering effect on the relationship between life events and well-being, this issue has been poorly studied in the elderly population. Thus, the aim of the present study is to test and confirm a comprehensive model of the impact that past life events have on older adults' psychological distress, exploring the possible mediating roles of emotion regulation processes. These include rumination, experiential avoidance, and personal growth.

METHODS

In this cross-sectional study, 387 people over 60 years old residing in the community were assessed on life events, physical functioning, emotion regulation variables, psychological well-being, as well as symptoms of anxiety and depression.

RESULTS

The structural model tested achieved a satisfactory fit to the data, explaining 73% of the variance of older adults' psychological distress. In addition, the main results suggest possible mediation effects of both the physical functioning and the emotional variables: rumination, experiential avoidance, and personal growth in the face of hardship.

CONCLUSIONS

These findings confirm the importance of emotion regulation processes in the final stages of life. They reveal the various adaptive and maladaptive mechanisms that underlie the relationship between life events and psychological distress. The findings suggest - both in the explanatory models of psychological well-being and in psychotherapeutic interventions - the importance of emotion regulation in the elderly population's health.

Assessment of the Progression of Poststroke Depression in Ischemic Stroke Patients Using the Patient Health Questionnaire-9

BACKGROUND

Poststroke depression (PSD) affects one-third of stroke patients and is linked with higher stroke morbidity, mortality, and recurrence. Current guidelines do not direct when to screen for PSD, and predictors of PSD are not well understood. We sought to understand progression of PSD symptoms early after ischemic stroke, identify predictors of PSD, and describe the use of antidepressants in PSD.

METHODS

We collected demographic, clinical, and PSD (Patient Health Questionnaire-9; PHQ-9) data from ischemic stroke patients hospitalized at our Comprehensive Stroke Center and followed up in our clinic. PHQ-9 was obtained during hospitalization and again in clinic within 180 days of discharge. We performed univariate analysis and logistic regression to detect variables associated with PSD.

RESULTS

Among 201 patients, PSD symptoms (PHQ-9 > 4) were identified in 30% of patients during hospitalization and 46% during follow-up (54% of which had no symptoms during hospitalization). At follow-up, 36% were worse by PHQ-9 category. In univariate analysis, follow-up modified Rankin Scale (mRS) greater than or equal to 2 (P = .03) and antidepressant prescription (P < .001) were associated with worsening PHQ-9 category. In logistic regression analysis, follow-up mRS greater than or equal to 2 (P = .02), posterior circulation stroke (P = .03), and antidepressant prescription (P < .01) were associated with worsening PHQ-9 category.

CONCLUSIONS

Almost half of ischemic stroke patients develop PSD symptoms and more than one-third worsen between hospitalization and follow-up. Poststroke disability (mRS ≥ 2) and posterior circulation stroke were associated with worsening PSD. Worsening PSD symptoms prompted treatment change in 29% of patients. Screening for PSD during hospitalization should be repeated during early follow-up.

Mild to Severe Depressive Symptoms in Elderly Stroke Survivors and Its Associated Factors: Evidence From a Cross-Sectional Study in Zhejiang Province, China

Objective: The objective of the study is to explore the prevalence of mild to severe depressive symptoms in elderly stroke survivors and its associated factors. Methods: We did data analyses of 335 elders with stroke history. Data were collected in a survey conducted between 2014 and 2015, among permanent residents aged 60 and older in Zhejiang Province, China. Prevalence of mild to severe depressive symptoms among stroke survivors were calculated, and univariate analyses and multilevel logistic regression were used to explore its associated factors. Results: Prevalence of mild to severe depressive symptoms was 22.09% (95% CI: 17.65-26.53%) in elders with stroke history, more than twice compared to their counterparts not suffering stroke (9.77%, P < 0.001). In multilevel logistic regression, we found that elderly stroke survivors who were illiterate (OR = 2.33, p = 0.008), or had limitation in activities of daily living (OR = 3.04, p = 0.001) were more likely to be present with mild to severe depressive symptoms, respectively, while those with more fresh vegetable consumption were at lower odds (OR = 0.82, p = 0.047). Conclusions: Prevalence of mild to severe depressive symptoms was high in elderly stroke survivors. Targeted screening might be needed for those being illiterate, disabled in activities of daily living, and having little consumption of fresh vegetable. The association between fresh vegetable consumption and depressive symptom in stroke patients calls for further research.

Mental illness after admission to an intensive care unit

PURPOSE

Survivors of critical illness may be at higher risk of developing subsequent mental illness. We sought to determine the risk of new mental illness diagnoses across a large population of intensive care unit (ICU) survivors compared with hospitalized patients.

METHODS

Population-based study (2005-2015) conducted in adults hospitalized in Ontario, Canada. The primary exposure was ICU admission for ≥ 48 h; secondary exposures were ICU procedures including mechanical ventilation and duration of ICU. The primary outcome was mental illness diagnosed during the year after hospital discharge. To account for case mix differences between ICU and other hospitalized patients, sensitivity analyses were conducted restricting to six pre-specified diagnoses that can lead to hospitalization with or without ICU.

RESULTS

1,847,462 patients survived hospitalization, of whom 121,101 were admitted to ICU for ≥ 48 h. ICU patients had a higher rate of new mental illness diagnoses in the year after discharge compared to hospitalized patients (17 vs. 15%, adjusted hazard ratio (aHR) 1.08, 95% CI 1.07-1.10). In analyses restricted to pre-specified most responsible diagnoses, the increased risk associated with ICU was only significant for patients with pneumonia. Among ICU survivors, exposure to mechanical ventilation (aHR: 1.08; 95% CI 1.05-1.12) or longer ICU stays (aHR: 1.004 per day; 95% CI 1.003-1.005) increased the risk of new mental illness diagnosis.

CONCLUSIONS

ICU was associated with a marginally increased risk of mental illness diagnosis after hospitalization that was often no longer apparent when reason for admission was considered. Patients exposed to mechanical ventilation or longer ICU stays may be at higher risk of subsequent mental illnesses.

Prevalence of pre-stroke depression and its association with post-stroke depression: a systematic review and meta-analysis

BACKGROUND

Depression is a common post-stroke complication. Pre-stroke depression may be an important contributor, however the epidemiology of pre-stroke depression is poorly understood. Using systematic review and meta-analysis, we described the prevalence of pre-stroke depression and its association with post-stroke depression.

METHODS

We searched multiple cross-disciplinary databases from inception to July 2017 and extracted data on the prevalence of pre-stroke depression and its association with post-stroke depression. We assessed the risk of bias (RoB) using validated tools. We described summary estimates of prevalence and summary odds ratio (OR) for association with post-stroke depression, using random-effects models. We performed subgroup analysis describing the effect of depression assessment method. We used a funnel plot to describe potential publication bias. The strength of evidence presented in this review was summarised via 'GRADE'.

RESULTS

Of 11 884 studies identified, 29 were included (total participants n = 164 993). Pre-stroke depression pooled prevalence was 11.6% [95% confidence interval (CI) 9.2-14.7]; range: 0.4-24% (I2 95.8). Prevalence of pre-stroke depression varied by assessment method (p = 0.02) with clinical interview suggesting greater pre-stroke depression prevalence (~17%) than case-note review (9%) or self-report (11%). Pre-stroke depression was associated with increased odds of post-stroke depression; summary OR 3.0 (95% CI 2.3-4.0). All studies were judged to be at RoB: 59% of included studies had an uncertain RoB in stroke assessment; 83% had high or uncertain RoB for pre-stroke depression assessment. Funnel plot indicated no risk of publication bias. The strength of evidence based on GRADE was 'very low'.

CONCLUSIONS

One in six stroke patients have had pre-stroke depression. Reported rates may be routinely underestimated due to limitations around assessment. Pre-stroke depression significantly increases odds of post-stroke depression.Protocol identifierPROSPERO identifier: CRD42017065544.

Prevalence, patterns and predictors of depression treatment among community-dwelling older adults with stroke in the United States: a cross sectional study

BACKGROUND

Depression is one of the most common psychiatric conditions among stroke survivors and is associated with several negative health outcomes. However, little is known about the depression treatment patterns among stroke survivors. The objective of this study was to examine national-level prevalence, patterns and predictors of depression treatment among community-dwelling stroke survivors.

METHODS

This study adopted a retrospective, cross-sectional study design using multiple years of Medical Expenditure Panel Survey (MEPS) (2002-2012) data. The study population consisted of older adults (age ≥ 50 years) who (i) were stroke survivors (ICD-9-CM codes of 430-438), (ii) did not die during the calendar year, and (iii) had co-occurring depression (ICD-9-CM code of 296.xx, or 311.xx). Depression treatment, identified by antidepressant medication and/or psychotherapy use, was the dependent variable of this study. Multinomial logistic regression analysis was conducted to examine the association of individual level factors with depression treatment among stroke survivors with co-occurring depression.

RESULTS

The final study sample consisted 370 (unweighted) community-dwelling older adults with self-reported stroke and depression. The prevalence of co-occurring depression among stroke survivors was 22.03% [95% Confidence Interval (CI) 19.7-24.4%]. An overwhelming majority (87.6%) of stroke survivors with co-occurring depression reported some form of depression treatment. Antidepressants only and combination therapy was reported by 74.8% (95% CI, 71.6-78.0%] and 12.8% (95% CI, 10.5-15.1%) by stroke survivors with co-occurring depression respectively. Approximately, 61% of stroke survivors with co-occurring depression reported using SSRIs, followed by SNRIs (15.2%), miscellaneous antidepressants (12.1%), TCAs (9.8%), phenylpiperazine antidepressants (5.2%), and tetracyclic antidepressants (4%). Sertraline (15.8, 95% CI, 12.7-19.0%) had the highest reported use among individual antidepressants.

CONCLUSIONS

Vast majority (nearly 90%) of the study sample received some form of depression treatment and several individual level factors (such as age, education) were associated with the report of depression treatment use. Future longitudinal studies are warranted to assess the comparative treatment benefits of antidepressants, psychotherapy and their combination. Healthcare providers should carefully assess the risks and benefits of antidepressant (such as SSRIs or TCAs) use in this vulnerable population prior to their use.

An analysis of depressive symptoms in stroke survivors: verification of a moderating effect of demographic characteristics

BACKGROUND

The rehabilitation of depressed stroke patients is more difficult because poststroke depression is associated with disruption of daily activities, functioning, and quality of life. However, research on depression in stroke patients is limited. The aim of our study was to evaluate the interaction of demographic characteristics including gender, age, education level, the presence of a spouse, and income status on depressive symptoms in stroke patients and to identify groups that may need more attention with respect to depressive symptoms.

METHODS

We completed a secondary data analysis using data from a completed cross-sectional study of people with stroke. Depression was measured using the Center for Epidemiologic Studies Depression Scale.

RESULTS

In this study, depressive symptoms in women living with a spouse were less severe than among those without a spouse. For those with insufficient income, depressive symptom scores were higher in the above high school group than in the below high school group, but were lower in patients who were living with a spouse than in those living without a spouse.

CONCLUSION

Assessing depressive symptoms after stroke should consider the interaction of gender, economic status, education level, and the presence/absence of a spouse. These results would help in comprehensive understanding of the importance of screening for and treating depressive symptoms during rehabilitation after stroke.