Stroke-related depression

B-vitamin supplementation on mitigating post-stroke cognition and neuropsychiatric sequelae: A randomized controlled trial

BACKGROUND AND PURPOSE

A third of stroke patients suffer from post-stroke cognitive decline, depressive symptoms, and anxiety symptoms. B-vitamin supplementation provides a possible safe and affordable treatment to mitigate post-stroke neuropsychiatric sequelae via reducing homocysteine levels. Our study aims to examine the effect of B-vitamin supplementation in the prevention of post-stroke cognitive decline, depressive symptoms, and anxiety symptoms. Our secondary aims were to investigate associations between baseline factors and the three outcomes.

METHODS

Patients were recruited as part of a Singaporean substudy of a randomized controlled trial that examined the effect of B-vitamin supplementation on recurrent cardiovascular events. Cognitive decline, depressive symptoms, and anxiety symptoms were assessed with neuropsychological assessments and Hospital Anxiety and Depression Scale 6 monthly. Cox regression analyses were performed to determine treatment efficacy. Logistic regression used to examine factors associated with cognitive decline, depressive symptoms, and anxiety symptoms.

RESULTS

A total of 707 were included in the analyses. Survival and hazards ratio analysis showed no treatment effect of B-vitamins on cognitive decline, depressive symptoms, and anxiety symptoms. Cognitive decline was only associated with age. Depressive symptoms were associated with large anterior cerebral infarcts and hyperlipidemia.

CONCLUSIONS

Our study showed no benefit of supplementation with B-vitamins for post-stroke cognitive decline, depressive symptoms, or anxiety symptoms. Depressive symptoms were associated with larger anterior cerebral infarcts, which may be reflective of the disability associated with larger infarcts.

A pilot controlled trial of a combination of electroacupuncture and psychological intervention for post-stroke depression

OBJECTIVE

This study was to investigate effects of a combination of electroacupuncture (EA) and psychological intervention (PI) for post-stroke depression (PSD) and provide treatment suggestions METHODS: In a single-blind, randomized controlled trial, 49 patients with PSD were randomly divided into two groups, PI group (n = 23) and PI+EA group (n = 26). PI group received PI 2 times a week by a professional psychologist. In addition to PI treatment, PI+EA group was treated with EA at GB13 and HT7, 30 min, 5 times a week, 4 weeks as a course of treatment, a total of 12 weeks. The 17-item Hamilton Rating Scale for Depression (HAMD-17) and Lo Knapp Ron J's sleep score table were measured before treatment, 4 weeks, 8 weeks and 12 weeks after treatment.

RESULTS

After 12 weeks of PI or PI+EA therapy, 42 of 49 patients were effective and 7 were ineffective, with an effective rate of 85.7 %. Among them, the effective rate of PI group alone was 78.3 %, and the effective rate of PI+EA group was 92.3 %. Compared with values of PI, HAMD-17 values at 8 weeks of PI+EA treatment were significantly decreased (P < 0.01). At the same time, Sleep Score table was significantly decreased after PI+EA treatment (P < 0.05). Incidence of adverse events was not different in the two groups CONCLUSION: A combination of EA and PI maybe an effective and safe treatment option for PSD, which is statistically more significant than PI treatment alone. Due to small samples involved in this pilot study, further research is needed to see whether a combination of EA and PI will match the results of this pilot study.

Depression was associated with younger age, female sex, obesity, smoking, and physical inactivity, in 1027 patients with newly diagnosed type 2 diabetes: a Swedish multicentre cross-sectional study

BACKGROUND

Depression is a risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). The aims were to explore the prevalence of depression, anxiety, antidepressant use, obesity, Hemoglobin A1c > 64 mmol/mol, life-style factors, pre-existing CVD, in patients with newly diagnosed T2D; to explore associations with depression; and to compare with Swedish general population data.

METHODS

Multicentre, cross-sectional study.

INCLUSION CRITERIA

adults with serologically verified newly diagnosed T2D. Included variables: age, sex, current depression and anxiety (Hospital Anxiety and Depression Scale), previous depression, antidepressant use, obesity (BMI ≥ 30 and ≥ 40 kg/m²), Hemoglobin A1c, pre-existing CVD. Logistic regression analyses were performed.

RESULTS

In 1027 T2D patients, aged 18-94 years, depression was associated with age (per year) (inversely) (odds ratio (OR) 0.97), anxiety (OR 12.2), previous depression (OR 7.1), antidepressant use (OR 4.2), BMI ≥ 30 kg/m² (OR 1.7), BMI ≥ 40 kg/m² (OR 2.3), smoking (OR 1.9), physical inactivity (OR 1.8), and women (OR 1.6) (all p ≤ 0.013). Younger women (n = 113), ≤ 59 years, compared to younger men (n = 217) had higher prevalence of current depression (31% vs 12%), previous depression (43 vs 19%), anxiety (42% vs 25%), antidepressant use (37% vs 12%), BMI ≥ 30 kg/m² (73% vs 60%) and BMI ≥ 40 kg/m²) (18% vs 9%), and smoking (26% vs 16%) (all p ≤ 0.029). Older women (n = 297), ≥ 60 years, compared to older men (n = 400) had higher prevalence of previous depression (45% vs 12%), anxiety (18% vs 10%), antidepressant use (20% vs 8%), BMI ≥ 30 kg/m² (55% vs 47%), BMI ≥ 40 kg/m² (7% vs 3%) (all p ≤ 0.048), but not of current depression (both 9%). Compared to the Swedish general population (depression (women 11.2%, men 12.3%) and antidepressant use (women 9.8%, men 5.3%)), the younger women had higher prevalence of current depression, and all patients had higher prevalence of antidepressant use.

CONCLUSIONS

In patients with newly diagnosed T2D, the younger women had the highest prevalence of depression, anxiety, and obesity. The prevalence of depression in young women and antidepressant use in all patients were higher than in the Swedish general population. Three risk factors for CVD, obesity, smoking, and physical inactivity, were associated with depression.

Olfactory Stimulation and the Diagnosis of Patients With Disorders of Consciousness: A Double-Blind, Randomized Clinical Trial

OBJECTIVES

The aim of this study was to determine whether behavioral responses elicited by olfactory stimulation are a predictor of conscious behavioral response and prognosis of patients with disorders of consciousness (DOC).

METHODS

Twenty-three DOC patients (8 unresponsive wakefulness syndrome [UWS]; 15 minimally conscious state [MCS]) were recruited for this study in which 1-Octen-3-ol (familiar neutral odor) and pyridine were used to test odor behavioral responses, and water was used as an odorless stimulus. One rater presented the three odors in front of each patient's nose randomly, and another one videotaped all behavioral responses (e.g., pouting, wrinkling nose, slightly shaking head, frowning, etc.). Two independent raters, blind to the stimuli and the patient's diagnosis, gave the behavioral results according to the recorded videos. One-, 3-, and 6-month follow-up evaluations were conducted to obtain a good prognostic value.

RESULTS

All MCS patients showed behavioral responses to the 1-Octen-3-ol stimulus; nine MCS and one UWS showed olfactory emotional responses to the pyridine, and two MCS showed olfactory emotional responses to the water stimulus. The incidence of behavioral response was significantly higher using 1-Octen-3-ol than it was for water by McNemar test (p < 0.001), significantly higher using pyridine than it was for water (p < 0.01). The χ2 test results indicated that there were significant differences between MCS and UWS to 1-Octen-3-ol (p < 0.001). For MCS patients, the incidence of behavioral response was no different between using 1-Octen-3-ol and pyridine (p > 0.05). There was no significant relationship between the olfactory behavioral response and the improvement of consciousness based on the χ2 test analysis (p > 0.05).

CONCLUSION

Olfactory stimuli, especially for the familiar neutral odor, might be effective for eliciting a conscious behavioral response and estimating the clinical diagnosis of DOC patients.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT03732092], [identifier NCT03732092].

Comorbidity between depressive symptoms and chronic conditions - findings from the Indonesia Family Life Survey

PURPOSE

To estimate the prevalence of symptoms of depression in the population, and to identify patient groups with a history of chronic conditions with the highest risks of comorbid depression.

METHODS

Data were drawn from a population-representative sample of 31,447 participants in The Fifth Wave of the Indonesia Family Life Survey (IFLS5) conducted in 2014-15. Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale-Revised (CES-D-R 10) that measures symptoms defined by the Diagnostic and Statistical Manual (DSM). Socio-demographic variables controlled for in the adjusted analysis included age, sex, education, and ethnicity.

RESULTS

Weighted prevalence of depressive symptoms, above the CES-D-R 10 cut-off, was 22.6% (females=23.0%, males=22.2%). Among those with a chronic condition, the highest risk of comorbid symptoms of depression was observed in those with a memory-related disease (OR=2.64 [1.49-4.68]) or stroke (OR=2.39 [1.75-3.27]). Depressive symptoms were also more commonly reported among people with hypertension, tuberculosis, asthma, other lung conditions, heart problems, liver diseases, arthritis or rheumatism, kidney diseases, stomach or digestive diseases.

CONCLUSIONS

Symptoms of depression are common in the general Indonesian population, and comorbidities are high in those with a history of chronic conditions, supporting the need for mental health care in patients presenting for physical diseases. Future research of clinical and patient samples will provide data in those who may be at increased risks.

Ecological Momentary Assessment of Social Interactions: Associations With Depression, Anxiety, Pain, and Fatigue in Individuals With Mild Stroke

OBJECTIVES

To examine real-time relationships between social interactions and poststroke mood and somatic symptoms in participants' daily environments.

DESIGN

Prospective observational study using smartphone-based ecological momentary assessment (EMA) surveys 5 times a day for 2 weeks. Multilevel models were used to analyze data for concurrent and lagged associations.

SETTING

Community.

PARTICIPANTS

Adults (N=48) with mild stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

EMA measures of self-appraisal of social interactions (confidence, satisfaction, and success), as well as mood (depression and anxiety) and somatic (pain and fatigue) symptoms.

RESULTS

In concurrent associations, increased depressed mood was associated with reduced ratings of all aspects of social interactions. Fatigue was associated with reduced ratings of social satisfaction and success. In lagged associations, increased anxious mood preceded increased subsequent social confidence. Higher average social satisfaction, confidence, and success were related to lower momentary fatigue, anxious mood, and depressed mood at the next time point. Regarding clinicodemographic factors, being employed was concurrently related to increased social interactions. An increased number of comorbidities predicted higher somatic, but not mood, symptoms at the next time point.

CONCLUSIONS

This study provides preliminary evidence of dynamic relationships between social interactions and somatic and mood symptoms in individuals with mild stroke. Interventions to not only address the sequelae of symptoms, but also to promote participation in social activities in poststroke life should be explored.

Distress in neurocognitive disorders due to Alzheimer's disease and stroke

Patients with neurocognitive disorders experience subjectively the concept of quality of life; this is the reason why researchers avoid approaching this concept and prefer to focus attention on the emotional profile of the caregivers. Many studies highlight the efforts both emotional and financial made by caregivers in case of patients diagnosed with neurocognitive disorders. The present study shows the differences between the patients diagnosed with neurocognitive disorder due to Alzheimer's disease and patients diagnosed with stroke, as well as the Romanian norms for the short form of Geriatric Depression Scale. The study group consisted of the clinical population (N=45), selected according to the inclusion/exclusion criteria, following the principles of Helsinki Declaration for Ethical Medical Research. The study was conducted at the Neuropsychiatry section of the Municipal Clinical Hospital, Dr Gavril Curteanu, Oradea, Romania. The results showed significant differences between the two types of patients in terms of quality of life, t(43)=-7.99, P=0.001, affective distress, t(43)=5.10, P=0.001 and perceived stress, t(43)=3.81, P=0.001. The internal consistency of the scale is high, the coefficient KR-20 being 0.86.

Functional connectivity between salience, default mode and frontoparietal networks in post-stroke depression

BACKGROUND

Previous studies have demonstrated altered resting state functional connectivity (rsFC) in patients with post-stroke depression (PSD). It remains unclear whether rsFC is changed at the network level as was shown for major depressive disorder (MDD). To address this question, we investigated rsFC of resting sate networks (RSNs) in PSD.

METHODS

Eleven subjects with PSD underwent fMRI scanning at rest before and after treatment. The severity of depression was assessed using the aphasic depression rating scale (ADRS). We performed functional network connectivity (FNC) analysis for RSNs, region of interest - FC analysis (ROI-FC) and calculation of brain matter volumes in ROIs overlapping with RSNs and in other brain regions associated with mood maintenance.

RESULTS

We found positive correlation of FNC between anterior default mode network (aDMN) and salience network (SAL) with depression severity before treatment, the latter accompanied by the increase of white matter in the middle frontal and left angular gyri. FNC of aDMN and left frontoparietal network (LFP) decreased after treatment. ROI-FC and the brain matter volumes of several regions of DMN, LFP and SAL also showed a correlation with ADRS or significant change after treatment.

LIMITATIONS

Limitations include small sample size and methodological issues concerning altered hemodynamics in stroke. However, we took complex preprocessing steps to overcome these issues.

CONCLUSION

Present results of altered rsFC in PSD are consistent with previous findings in MDD. The convergence of results obtained in PSD and MDD supports the validity of rsFC approach for investigation of brain network dysfunctions underling these psychiatric symptoms.

Use of Newly Covered Versus Established Preventive Care Screening: Comparison of Depression and Smoking Screening

Pay-for-value initiatives include both depression and smoking screening. Evaluating how patterns of care differ for an established screening (smoking) versus newer screening (depression) can help programs better implement these measures. Our objective is to evaluate (1) patterns of smoking and depression screening and (2) how patient factors affect screening patterns. We analyzed retrospectively collected electronic health record data from 4,763 Medicare-patients in 34 primary care practices between 2010 and 2012. The relationship between multimorbidity, history of stroke, and having depression on receipt of screening was evaluated. The outcome variables were no screening, smoking screening only, or concurrent smoking and depression screening. Fifty percent of patients were screened for smoking at every visit and never screened for depression (n = 2,378). Twelve percent of patients with ≥five visits received both depression and smoking-status screens on each of their first five visits. Screening patterns varied significantly across sites. For example, one site screened approximately 87% of patients for both depression and smoking-status at every visit. Another site screened 93% of patients for smoking during the first visit but did not conduct depression screening. Programs considering initiating new screenings should evaluate the clinic-specific workflow of successful screenings and integrate new screenings using the same strategy.

Depressive symptoms influence use of feedback for motor learning and recovery in chronic stroke

PURPOSE

Sensorimotor impairments and depressive symptoms (PSD) influence arm motor recovery post-stroke. Feedback provision improves upper limb motor learning in patients with chronic stroke but factors including PSD may affect ability to use feedback. We evaluated the influence of PSD on the ability to use auditory feedback for upper limb recovery and motor learning in patients with chronic stroke.

METHODS

Participants (n = 24) practiced 72 pointing movements/session (6 targets, 12 sessions, randomized) with auditory feedback on movement speed and trunk displacement. The presence of PSD (Beck's Depression Inventory; BDI-II) was assessed at pre-intervention (PRE). Arm motor impairment (Fugl-Meyer Assessment, shoulder horizontal adduction, shoulder flexion, elbow extension ranges, trunk displacement) and arm use (Motor Activity Log) were assessed at PRE, immediately after (POST) and retention (3 mos; RET). Participants were divided into two groups based on BDI-II scores: ≥ 14/63 (DEP group; n = 8; score: 20.5 ± 7.5) and ≤ 13/63 (no PSD (ND) group; n = 16; score: 5.0 ± 3.8). Changes in impairment and arm use levels were assessed (mixed-model ANOVAs).

RESULTS

All participants improved arm use. DEP had lower Fugl-Meyer scores, used more compensatory trunk displacement and had lower shoulder horizontal adduction range compared to ND.

CONCLUSION

The presence of PSD diminished the ability to use auditory feedback for arm motor recovery and motor learning.

The removal of the bereavement exclusion in the DSM-5: exploring the evidence

Since 1980, the DSM-III and its various iterations through the DSM-IV-TR have systematically excluded individuals from the diagnosis of major depressive disorder if symptoms began within months after the death of a loved one (2 months in DSM-IV), unless the depressive syndrome was 'severely' impairing and/or accompanied by specific features. This criterion became known as the 'bereavement exclusion'. No other adverse life events were noted to negate the diagnosis of major depressive disorder if all other symptomatic, duration, severity and distress/impairment criteria were met. However, studies since the inception of the bereavement exclusion have shown that depressive syndromes occurring after bereavement share many of the same features as other, non-bereavement related depressions, tend to be chronic and/or recurrent if left untreated, interfere with the resolution of grief, and respond to treatment. Furthermore, the bereavement exclusion has had the unintended consequence of suggesting that grief should end in only 2 months, or that grief and major depressive disorder cannot co-occur. To prevent the denial of diagnosis and the consideration of sometimes much needed care, even after bereavement or other significant losses, the DSM-5 no longer contains the bereavement exclusion. Instead, the DSM-5 now permits the diagnosis of major depressive disorder after and during bereavement and includes a note and a comprehensive footnote in the major depressive episode criteria set to guide clinicians in making the diagnosis in this context. The decision to make this change was widely and publically debated and remains controversial. This article reports on the rationale for this decision and the way the DSM-5 now addresses the challenges of diagnosing major depressive disorder in the context of someone grieving the loss of a loved one.

Stroke survivor and informal caregiver perceptions of poststroke depressive symptoms

Poststroke depression is common but remains underdiagnosed and undertreated. One explanation for this is that depressive symptoms go unrecognized by stroke survivors and their family caregivers and thus go unreported to the stroke survivor's healthcare provider. Forty-four stroke survivor-informal caregiver dyads were interviewed using a depression knowledge scale, the Center for Epidemiologic Studies Depression Scale, and an adapted version of the Revised Illness Perception Questionnaire to determine their lay knowledge of depressive symptoms, recognition of poststroke depressive symptoms, and perception of the recognized symptoms. Caregivers and stroke survivors had moderate knowledge of depressive symptoms but had some misconceptions. The most commonly recognized poststroke depressive symptoms by stroke survivors were "feeling like everything was an effort," "restless sleep," "difficulty concentrating," and "talking less than usual." Caregivers identified that the stroke survivor was "feeling like everything was an effort," had "restless sleep," "felt sad," and "felt depressed." Three quarters of stroke survivors with high levels of depressive symptoms identified the cluster of symptoms as potentially being depression. Neuroscience nurses are in the unique position to educate stroke survivors and their caregivers about poststroke depressive symptoms, treatment options, and the importance of discussing depressive symptoms with their healthcare provider.

The association between depression, suicidal ideation, and stroke in a population-based sample

BACKGROUND

Stroke survivors often experience poststroke depression and suicidal ideation.

PURPOSE

to determine the frequency and odds ratio of depression and suicidal ideation among stroke survivors, in comparison to those without stroke, and to identify demographic factors associated with elevated odds of depression and suicidal ideation among stroke survivors.

METHODS

Secondary analysis of the Canadian Community Health Survey, a population-based sample. Logistic regressions of depression and suicidal ideation were conducted.

RESULTS

Among those with stroke, 7·4% were depressed, in comparison to 5·2% of those without stroke (P = 0·01). The cumulative lifetime frequency of suicidal ideation was 15·2% among stroke survivors in comparison to 9·4% of those without stroke (P < 0·001). After adjusting for sociodemographic factors, stroke survivors had twice the odds of depression and suicidal ideation in comparison to those without stroke (odds ratio = 2·21; 95% confidence interval = 1·61, 3·04 and odds ratio = 2·07; 95% confidence interval = 1·68, 2·55, respectively). When functional limitations and activities of daily living limitations were added to the analyses, there was a substantial decrease in the associations between stroke and depression (odds ratio = 1·29; confidence interval = 0·93, 1·80) and between stroke and suicidal ideation (odds ratio = 1·37; 95% confidence interval = 1·10, 1·69). Caucasians and younger individuals had higher odds of poststroke depression and suicidal ideation. Stroke survivors with functional limitations had much higher odds of suicidal ideation than those without such limitations.

CONCLUSIONS

Regular screening for depression and suicidal ideation is important for stroke survivors, particularly those with substantial physical limitations.

Psychometric Evaluation of the Appraisal of Health Scale in Stroke Survivors

Background/Purpose: Little is known about the cognitive appraisal process influencing poststroke depressive symptoms. Based on a framework derived from Lazarus and Folkman (1984), psychometric properties of the Appraisal of Health Scale (AHS) were tested. Methods: Secondary analysis of data from 394 stroke survivors tested internal consistency reliability and construct validity of the AHS, consisting of 3 subscales (threat, benign, benefit). Results: Cronbach’s alphas were satisfactory (threat .92, benign .85, benefit .73). After principal axis factoring, two factors emerged (threat, benefit). Sequential multiple regression accounted for 43% of the variance in depressive symptoms (p < .001), partly explained by the threat and benefit subscales after controlling for depression history, disability, age, social support, self-esteem, and optimism. Conclusion: Threat and benefit AHS subscales demonstrated satisfactory evidence of internal consistency reliability and construct validity in stroke survivors.

Pneumonia and in-hospital mortality in the context of neurogenic oropharyngeal dysphagia (NOD) in stroke and a new NOD step-wise concept

The aim of our work was to develop a step-wise concept for investigating neurogenic oropharyngeal dysphagia (NOD) that could be used by both trained nursing staff as well as swallowing therapists and physicians to identify patients with NOD at an early stage and so enable an appropriate therapy to be started. To achieve this objective, we assessed uniform terminology and standard operating procedures (SOP) in a new NOD step-wise concept. In-house stroke mortality rates and rates of pneumonia were measured over time (2003–2009) in order to show improvements in quality of care. In addition, outcome measures in a stroke-unit monitoring system were studied after neurorehabilitation (day 90) assessing quality of life (QL) and patient feedback. An investigation that was carried out in the context of internal and external quality assurance stroke projects revealed a significant correlation between the NOD step-wise concept and low rates of pneumonia and in-house mortality. The quality of life measures show a delta value that can contribute to “post-stroke” depression. The NOD step-wise concept (NSC) should, on the one hand, be capable of being routinely used in clinical care and, on the other, being able to fulfil the requirements of being scientifically based for investigating different stages of swallowing disorders. The value of our NSC relates to the effective management of clinical resources and the provision of adequate diagnostic and therapeutic options for different grades of dysphagia. We anticipate that our concept will provide substantial support to physicians, as well as swallowing therapists, in clinical settings and rehabilitation facilities, thereby promoting better guidance and understanding of neurogenic dysphagia as a concept in acute and rehabilitation care, especially stroke-unit settings.

Usefulness of the Japan Stroke Scale-Depression Scale-(JSS-D) for the diagnosis of post-stroke depression

BACKGROUND

Post-stroke depression (PSD) has a great impact on the quality of life of patients with stroke. The Mini International Neuropsychiatric Interview (MINI) and the Hamilton Depression Scale (HAM-D(17)) are considered the most reliable diagnostic tests for depression. However, both are difficult to conduct in a clinical setting since they require completion of a questionnaire in a limited time period. The Japan Stroke Scale -Depression Scale- (JSS-D) was established by the Japan Stroke Society to evaluate mood disorders following stroke, including PSD. Here, we correlated the results of HAM-D(17), MINI and JSS-D scores.

METHODS

We studied 100 stroke patients (mean age: 64.6+/-11.6 [+/-SD], range: 32-85 years) in the subacute phase (2-5 weeks after onset). We determined the correlations between HAM-D(17) and JSS-D scores. We used MINI to diagnose PSD, which represented major and minor depression, and compared the results with those of JSS-D.

RESULTS

JSS-D scores correlated with those of HAM-D(17) (r=0.847, p <0.0001). The cutoff value of JSS-D score for PSD was 2.40. The sensitivity and specificity were 0.950 and 0.988, respectively.

CONCLUSION

JSS-D is the most valuable diagnostic test for PSD based on its ease of use and reliability for estimating PSD in Japan.

The Impact of Poststroke Depression on Healthcare Use by Veterans With Acute Stroke

BACKGROUND AND PURPOSE

Poststroke depression (PSD) is common among stroke survivors, and it is associated with worse functional outcomes and increased poststroke mortality. Limited information is available about its impact on healthcare use. This study assessed the impact of PSD on healthcare use by veterans with acute stroke.

METHODS

In this retrospective, observational national study, 5825 veterans with acute stroke were identified from Veterans Affairs' (VA) inpatient databases. To determine the patients' comprehensive PSD and use status, VA and Medicare fee-for-service inpatient and outpatient as well as VA pharmacy data were used. PSD was established if a patient had an inpatient or outpatient depression diagnosis or if a patient received one of the antidepressants within the VA 12 months postindex stroke. Healthcare use referred to the number of hospital stays, outpatient visits, and cumulative length of inpatient stays under both VA and Medicare fee-for-service programs. Poisson regression was fitted to estimate the impact of PSD on use controlling for sociodemographic, clinical, and disease severity factors.

RESULTS

Forty-one percent of the sample had PSD. After adjusting for patient demographic and clinical factors, we found that the patients with stroke with PSD had significantly (P<0.0001) more hospitalizations, outpatient visits, and longer length of stays 12 months poststroke compared with these patients with stroke without PSD.

CONCLUSIONS

Patients with PSD had greater 12-month poststroke healthcare use even when controlling for other demographic and clinical variables. Early detection and appropriate management of PSD for veterans with acute stroke may help reduce their poststroke healthcare use.

Characteristics of post-stroke depression in Japanese patients

Post-stroke depression (PSD) has an important impact on the quality of life of patients with stroke. We studied 100 stroke patients (mean age+/-SD: 64.6+/-11.6, range: 32-85 years) in the subacute phase (2-5 weeks after onset) and investigated the prevalence and clinical correlates of PSD in the subacute phase. The prevalences of PSD and major depression in the subacute phase evaluated by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were 20.0 and 5.0%, respectively. These values were lower than those reported in Caucasian studies. The Zung Self-Rating Depression Scale (SDS) did not underestimate the presence of PSD and was thus considered valuable for the initial screening of PSD. However, SDS may overestimate PSD especially in patients with anxiety disorders or somatoform disorders and vice versa. Apathy was observed in 40.2% of patients; however, it was widely distributed and observed even in patients without serious depression.

Stroke: epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management

Cerebrovascular accident, or stroke, refers to an acute onset of neurologic deficits lasting more than 24 hours or culminating in death caused by a sudden impairment of cerebral circulation. Stroke is the third leading cause of death and a major cause of long-term disability in the United States. This article provides the dental community with an up-to-date understanding of the epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management issues pertaining to stroke.

A pilot study to describe antidepressant prescriptions dispensed to veterans after stroke

BACKGROUND

Stroke is the third leading cause of death in the United States, following only heart disease and cancer. Approximately 500,000 strokes occur each year in the United States. Patients suffering from poststroke depression have higher rates of morbidity and mortality, slower physical recovery, and lower functional status than stroke patients without depression. Depressed stroke patients may benefit from early treatment with an antidepressant.

OBJECTIVES

The objectives of this study were to (1) describe antidepressant-dispensing patterns to veteran patients during the 6-month period before their stroke and 1-year time afterward and (2) examine the association of poststroke antidepressant treatment with mortality.

METHODS

Veteran patients (n=543) with one or more hospital discharges during FY2001 with a primary diagnosis of stroke were identified. The discharge date minus the length of stay indicated the index hospitalization date. Antidepressant prescription dispensing records were obtained from the Veterans Integrated System Network 8 Veteran's Affairs (VA) Pharmacy Benefits Management database.

RESULTS

One-third of eligible veteran patients were dispensed one or more antidepressant prescriptions (n=181) either before or after the index hospitalization. Of these veterans, 146 received an antidepressant after the index hospitalization. More than 80% of veteran patients survived the stroke for 1 year or longer (n=448). Among the veteran patients who were discharged from the index hospitalization alive, those with no antidepressant or an antidepressant dispensed only before the stroke had a higher 1 year all cause mortality rate (8.0%) compared with those who were dispensed a prescription for one or more antidepressants afterward (4.8%).

CONCLUSIONS

Veterans dispensed an antidepressant after their stroke appeared to have benefited. Opportunities to reduce poststroke sequelae and improve recovery may be lost.

An Exploration of Central Nervous System Medication Use and Outcomes in Stroke Rehabilitation

Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An exploration of central nervous system medication use and outcomes in stroke rehabilitation.

OBJECTIVE

To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables.

DESIGN

Observational cohort study of post-stroke rehabilitation.

SETTING

Six inpatient rehabilitation hospitals in the United States.

PARTICIPANTS

Patients with moderate or severe strokes (N=919).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge disposition, FIM score change, and rehabilitation length of stay (LOS).

RESULTS

Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neuro-stimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counter-intuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation.

CONCLUSIONS

There are many opportunities to enhance a stroke survivor's ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups.

Impact of pain severity and location on health-related quality of life

Despite evidence that persistent pain affects well-being, little is known about the relationship of the location of pain to psychological and functional well-being. To determine whether patients with musculoskeletal disorders (MSD) are more likely to be depressed and functionally disabled compared to patients with pain at other sites, we conducted a secondary data analysis of the Medical Outcome Study--an observational study of adult outpatients with chronic medical conditions. Of the 3,360 patients who completed the baseline assessment, 1,237 (36.8%) had MSD and 2,123 (63.2%) had no MSD. Among patients in the MSD group, 84.5% reported > or = mild pain as compared to 70% in the no MSD. In multivariate analyses, MSD patients were more likely than non-MSD patients to be depressed (beta coefficient=-1.9, p=0.008) and functionally disabled (beta coefficient=-4.4, p<0.0001). However, the impact of MSD was eliminated after controlling for pain severity. Regardless of the location of pain, pain severity appears to be an important correlate of functional status, both mental and physical.

Does rat global transient cerebral ischemia serve as an appropriate model to study emotional disturbances?

We used two validated psychopharmacological methods, the forced swimming test (FST 20 min and 5 min) and the elevated plus-maze (EPM), to quantify depression-like and anxiety-like behavior induced by transient global cerebral ischemia in the rat. We also validated use of these methods for the study of antidepressant (imipramine) and anti-anxiety drugs (diazepam). Twelve days after surgery to provoke transient global ischemia, spontaneous motor activity was 40% higher in ischemic rats than in sham-operated controls. Duration of immobility during the FST 20 min and 5 min was 28 and 30% shorter, respectively, than in controls. Treatment with imipramine (3 x 30 mg/kg i.p.) induced a significantly shorter duration of immobility during the FST 5 min, but with no difference between ischemia and control rats. The EPM demonstrated that ischemia did not induce any change in the six behavior parameters measured. Diazepam (1.5 mg/kg i.p.) induced significant anxiolytic effects which were similar in ischemic and sham-operated animals. Both tests failed to demonstrate perturbed performance but conversely, these findings did disclose the sensitivity of ischemia-exposed rats to the action of imipramine and diazepam, demonstrating the usefulness of these tests as psychopharmocological tools for evaluating the effect of psychotropics in the ischemic rat.

Secondary prevention strategies in ischemic stroke: identification and optimal management of modifiable risk factors

The identification and treatment of modifiable Ischemic stroke risk factors, in addition to appropriate antithrombotic therapy, can reduce the likelihood of first or recurrent stroke, prevent long-term morbidity and mortality after first stroke or transient Ischemic attack, and lower health care costs. Long-term morbidity and mortality in patients with ischemic stroke includes patients with coronary artery disease. Therefore, in patients with ischemic stroke (especially those with carotid artery disease and lacunar disease), the goal is to prevent not only recurrent stroke but also coronary artery disease. Neurologists and general practitioners must be aware of the specific risk factors and recommendations for patients with ischemic stroke and apply the information systematically. We review known risk factors for ischemic stroke and current recommendations for treatment, focusing primarily on atherosclerotic risk factors as they apply to patients with stroke. In particular, recent data on hypertension and hyperlipidemia are described. In addition, we discuss the challenges in managing these risk factors and the potential strategies for overcoming them.