Depressive symptoms in stroke patients: a 13 month follow-up study of patients referred to a rehabilitation unit

CRHR1 antagonist alleviated depression-like behavior by downregulating p62 in a rat model of post-stroke depression

Post-stroke depression (PSD) is a complication of cerebrovascular disease, which can increase mortality after stroke. CRH is one of the main signaling peptides released after activation of the hypothalamic-pituitary-adrenal (HPA) axis in response to stress. It affects synaptic plasticity by regulating inflammation, oxidative stress and autophagy in the central nervous system. And the loss of spines exacerbates depression-like behavior. Therefore, synaptic deficits induced by CRH may be related to post-stroke depression. However, the underlying mechanism remains unclear. The Keap1-Nrf2 complex is one of the core components of the antioxidant response. As an autophagy associated protein, p62 participates in the Keap1-NrF2 pathway through its Keap1 interaction domain. Oxidative stress is involved in the feedback regulation between Keap1-Nrf2 pathway and p62.However, whether the relationship between CRH and the Keap1-Nrf2-p62 pathway is involved in PSD remains unknown. This study found that serum levels of CRH in 22 patients with PSD were higher than those in healthy subjects. We used MCAO combined with CUMS single-cage SD rats to establish an animal model of PSD. Animal experiments showed that CRHR1 antagonist prevented synaptic loss in the hippocampus of PSD rats and alleviated depression-like behavior. CRH induced p62 accumulation in the prefrontal cortex of PSD rats through CRHR1. CRHR1 antagonist inhibited Keap1-Nrf2-p62 pathway by attenuating oxidative stress. In addition, we found that abnormal accumulation of p62 induces PSD. It alleviates depression-like behavior by inhibiting the expression of p62 and promoting the clearance of p62 in PSD rats. These findings can help explore the pathogenesis of PSD and design targeted treatments for PSD.

[A Structural Equation Model on Social Re-Adjustment of Stroke Patients: Based on Roy's Adaptation Model]

PURPOSE

This study aimed to develop and test a structural equation model on social re-adjustment of individuals with stroke based on a literature review and Roy's adaptation model.

METHODS

This study involved 321 participants who had a stroke and visited the outpatient department after discharge. The hypothetical model was developed based on Roy's adaptation model and a comprehensive review of previous literature on the topic. The model comprised four exogenous variables (neurological damage, gender [man], age, and social support) and five endogenous variables (activities of daily living, acceptance of disability, depression, rehabilitation motivation, and social re-adjustment). The data were analyzed using SPSS Windows software version 22.0 and AMOS 23.0.

RESULTS

Out of 28 research hypotheses, 18 were supported, and they indicated approximately 64% probability of social re-adjustment. Social re-adjustment is directly and significantly affected by age, social support, activities of daily living, and depression. Social re-adjustment is indirectly affected by neurological impairment, gender (men), age, social support, and rehabilitation motivation.

CONCLUSION

Continuous assistance and care should be provided for individuals with disabilities caused by sudden neurological damage to facilitate gradual improvement in their social re-adjustment. To enhance social re-adjustment, especially among older adults, newly developed interventions should focus on improving their activities of daily living, preventing depression, and enhancing support from family and healthcare personnel.

Depressive symptoms occurring after stroke by age, sex and socioeconomic status in six population-based studies: Longitudinal analyses and meta-analyses

AIMS

Population-based cohort studies that examined the effects of stroke on depressive symptoms in elderly participants with and without stroke in different countries/regions had yielded scant evidence. The objectives of this multi-cohort study were to identify the relationships between stroke and depressive symptoms and to assess the pooled risks of depressive symptoms in total populations and in stratified samples by age, sex, education levels, and total household income in large-scale studies.

METHODS

The associations in the overall participants in the six cohorts were examined using univariate and multivariable Cox proportional hazards models. The relationships in the population subgroups of the cohorts were determined using multivariable Cox regression models. Crude hazard ratios (HRs) were estimated, and adjusted or time-varying HRs were calculated and then pooled by meta-analyses.

RESULTS

During a median follow-up time of 3.8 (interquartile range [IQR]: 2.2-4.5) -7.9 (IQR: 4.0-8.0) years, 18267 participants out of 62150 participants developed incident cases of depressive symptoms. In the univariate Cox regression analyses, stroke was consistently linked to depressive symptoms across all studies, with HRs ranging from 1.39 (95% confidence interval [CI]: 1.04-1.85) to 1.84 (95% CI: 1.38-2.46). Adjusted HRs varied between 1.19 (95% CI: 0.89-1.59) and 1.48 (95% CI: 1.00-1.98), and time-varying HRs remained largely unchanged. According to the meta-analysis of overall HRs, stroke survivors were more likely than non-survivors to develop depressive symptoms (pooled HR: 1.35 (95% CI: 1.26-1.44)).

CONCLUSIONS

In general, stroke significantly increased the risk of depressive symptoms in total and stratified participants in most cohorts. In the future, extensive research will be needed to assess the variations in associations between various population subgroups.

A Person-Centered Approach Understanding Stroke Survivor and Family Caregiver Emotional Health

ABSTRACT

BACKGROUND: The purpose of this study was to incorporate a person-centered approach to understand the emotional health needs and perspectives of stroke survivors (SSs) and their caregivers. METHODS: In collaboration with 4 SSs and caregivers as research partners, quantitative data were collected to assess poststroke emotional health needs, and qualitative data were collected to gain insight into SS and caregiver emotional health perspectives after stroke. RESULTS: Forty surveys (n = 26 SSs, n = 14 caregivers) were collected. The predominate emotional health needs were frustration (65%), anxiety (54%), and stress (50%) for SSs and stress (71%), worry (57%), and frustration (57%) for caregivers. Two group interviews (n = 7 SSs, n = 3 caregivers) were completed. Four emerging themes were identified: receiving support from those in similar situations, poststroke emotional responses, situations experienced in healthcare settings, and a hypervigilance for sudden and unexpected events. CONCLUSION: Emotional healthcare services for SSs and their caregivers may consider providing reoccurring mental health education and multifaceted treatment approaches, including provision of peer support, and addressing the unique emotional stressors SSs and caregivers may be experiencing. The small sample size precludes generalizing the results into the broader stroke population. However, by leveraging the lived experience of SSs and their caregivers, the results may help find ways to support SSs' and caregivers' emotional health.

Determinants of Disability at 6 Months After Stroke: the GRECogVASC Study

BACKGROUND

The present study aimed at determining the contributions of background disorders responsible for participation restriction as indexed by a structured interview for the modified Rankin scale (mRS-SI).

METHODS

A subset of 256 patients was assessed at 6 months after stroke using the National Institutes of Health Stroke Scale (NIHSS), gait score, comprehensive cognitive battery (yielding a global cognitive Z-score), behavioral dysexecutive disorders (DDs), anxiety and depressive symptoms, epilepsy, and headache. Following bivariate analyses, determinants of participation restriction were selected using ordinal regression analysis with partial odds.

RESULTS

Poststroke participation restriction (mRS-SI >1) was observed in 59% of the patients. In bivariate analyses mRS-SI was associated with prestroke mRS-SI, 6-month NIHSS score, gait score, global cognitive Z-score, behavioral DDs, and presence of anxiety and depression (p=0.0001, all) (epilepsy: p=0.3; headache: p=0.7). After logistic regression analysis, the NIHSS score was associated with increasing mRS-SI grades (p=0.00001). Prestroke mRS-SI (p=0.00001), behavioral DDs (p=0.0008) and global cognitive Z-score (p=0.01) were associated with both mRS-SI>1 and mRS-SI>2. In addition, the gait score was associated with mRS-SI >2 (p=0.00001). This model classified 85% of mRS-SI correctly (p=0.001). Structural equation modeling showed the contributions of gait limitation (standardized coefficient (SC): 0.68, p=0.01), prestroke mRS-SI (SC: 0.41, p=0.01), severity of neurological impairment (SC: 0.16, p=0.01), global cognitive Z-score (SC: -0.14, p=0.05), and behavioral DDs (SC: 0.13, p=0.01).

CONCLUSION

These results provide a statistical model of weights of determinants responsible for poststroke participation restriction and highlight a new independent determinant: behavioral DDs.

Elevated Red Blood Cell Distribution Width Levels at Admission Predicts Depression After Acute Ischemic Stroke: A 3-Month Follow-Up Study

PURPOSE

Red blood cell distribution width (RDW) is closely related to inflammatory-related disease markers. The present study aimed to investigate the association between the red blood cell distribution width (RDW) and post-stroke depression (PSD).

PATIENTS AND METHODS

A total of 414 patients with acute ischemic stroke (AIS) admitted to our hospital from June 2018 to July 2021 were consecutively enrolled and received 3 months' follow-up. According to the 17-item Hamilton Depression Scale (HAMD) assessment, they were divided into PSD group and non-PSD group. Diagnosis of PSD was made in accordance with DSM-IV. RDW was recorded within 24 hours of admission.

RESULTS

Among the included 414 patients, 95 (22.95%) patients were diagnosed as having PSD at 3 months after stroke. The results showed significantly higher level of RDW in patients with depression (13.69 (IQR13.24-13.88) vs. 13.56 (IQR 12.67-13.77), P<0.001) at admission than patients without depression. After adjustment for potential confounding factors, the odds ratio of PSD was 5.707 (95% CI, 2.717-11.989) for the highest tertile of RDW compared with the lowest tertile. Moreover, based on the receiver operating characteristic (ROC) curve, the optimal cutoff of RDW levels as an indicator for the prediction of PSD was projected as 13.01, which yielded a sensitivity of 83% and a specificity of 41.0%, with an area under the curve (AUC) of 0.643 (95% CI, 0.585-0.701; P = 0.012).

CONCLUSION

Higher RDW levels at admission were found to be correlated with PSD 3 months after stroke.

Elevated monocyte-to-HDL cholesterol ratio predicts post-stroke depression

OBJECTIVES

Inflammation plays an important role in the development of depression after stroke. Monocyte-to-HDL Cholesterol Ratio (MHR) recently emerged as a novel comprehensive inflammatory indicator in recent years. This study aimed to investigate whether there is a relationship between MHR levels and post-stroke depression (PSD).

METHODS

From February 2019 to September 2021, patients with acute ischemic stroke (AIS) were recruited within 7 days post-stroke from the two centers and blood samples were collected after admission. The 17-item Hamilton Depression Scale (HAMD-17) was used to measure depressive symptoms at 3 months after stroke. Patients were given the DSM-V criteria for diagnosis of PSD.

RESULTS

Of the 411 enrolled patients, 92 (22.38%) patients were diagnosed with PSD at 3-months follow-up. The results also showed significantly higher level of MHR in patients with depression [0.81 (IQR 0.67-0.87) vs. 0.61 (IQR 0.44-0.82), P < 0.001] at admission than patients without depression. Multivariate logistic regression revealed that MHR (OR 6.568, 95% CI: 2.123-14.565, P = 0.015) was an independent risk factor for the depression at 3 months after stroke. After adjustment for potential confounding factors, the odds ratio of PSD was 5.018 (95% CI: 1.694-14.867, P = 0.004) for the highest tertile of MHR compared with the lowest tertile. Based on the ROC curve, the optimal cut-off value of MHR as an indicator for prediction of PSD was projected to be 0.55, which yielded a sensitivity of 87% and a specificity of 68.3%, with the area under the curve at 0.660 (95% CI: 0.683-0.781; P = 0.003).

CONCLUSION

Elevated level of MHR was associated with PSD at 3 months, suggesting that MHR might be a useful Inflammatory markers to predict depression after stroke.

Association between depressive symptoms and diagnosis of diabetes and its complications: A network analysis in electronic health records

OBJECTIVES

Diabetes and its complications are commonly associated with depressive symptoms, and few studies have investigated the diagnosis effect of depressive symptoms in patients with diabetes. The present study used a network-based approach to explore the association between depressive symptoms, which are annotated from electronic health record (EHR) notes by a deep learning model, and the diagnosis of type 2 diabetes mellitus (T2DM) and its complications.

METHODS

In this study, we used anonymous admission notes of 52,139 inpatients diagnosed with T2DM at the first affiliated hospital of Nanjing Medical University from 2008 to 2016 as input for a symptom annotation model named T5-depression based on transformer architecture which helps to annotate depressive symptoms from present illness. We measured the performance of the model by using the F1 score and the area under the receiver operating characteristic curve (AUROC). We constructed networks of depressive symptoms to examine the connectivity of these networks in patients diagnosed with T2DM, including those with certain complications.

RESULTS

The T5-depression model achieved the best performance with an F1-score of 91.71 and an AUROC of 96.25 compared with the benchmark models. The connectivity of depressive symptoms in patients diagnosed with T2DM (p = 0.025) and hypertension (p = 0.013) showed a statistically significant increase 2 years after the diagnosis, which is consistent with the number of patients diagnosed with depression.

CONCLUSION

The T5-depression model proposed in this study can effectively annotate depressive symptoms in EHR notes. The connectivity of annotated depressive symptoms is associated with the diagnosis of T2DM and hypertension. The changes in the network of depressive symptoms generated by the T5-depression model could be used as an indicator for screening depression.

Post-Stroke Depression and Its Effect on Functional Outcomes during Inpatient Rehabilitation

Objective  The aim of the study is to observe the effect of post-stroke depression on functional outcomes during inpatient rehabilitation.

Materials and Methods  The design involved is prospective observational study. The location involved is Neurological Rehabilitation unit in a tertiary care university hospital. The study period ranges from October 2019 to April 2020. The participants involved are the patients with first ever stroke, male and female with age ≥18 years and duration less than 1 year. All participants were assessed at admission and after 14 sessions of inpatient rehabilitation by depression subscale of Hospital Anxiety and Depression Scale (HADS-D) and Hamilton Depression Rating Scale (HDRS). The stroke outcomes measures used were: Barthel Index (BI), Scandinavian Stroke Scale (SSS), and Modified Rankin Scale (MRS).

Results  There are a total of 30 participants (18 males) with median stroke duration of 90 days. The median age of the patients was 58 years. Sixteen patients had ischemic and 14 had hemorrhagic stroke. Out of these, 57% ( n = 17) had symptoms of depression (HADS-D >7). Participants in both groups (with and without depression) showed improvement in all the functional outcome measures (BI, SSS, MRS) at the time of discharge as compared with admission scores. The changes in the outcome measures were statistically significant within groups ( p < 0.05) but not significant between the groups ( p > 0.05).

Conclusion  The post-stroke depression is common among stroke survivors of less than 1 year duration. There was no significant difference in the functional outcomes between stroke patients with depression and those without depression with inpatient rehabilitation program.

Trazodone improves obstructive sleep apnea after ischemic stroke: a randomized, double-blind, placebo-controlled, crossover pilot study

BACKGROUND

Low arousal threshold plays a part in the pathogenesis of obstructive sleep apnea (OSA) and may be improved by sedatives. Sedative antidepressants are frequently prescribed for stroke patients due to their high prevalence of insomnia and depression. However, the effect of sedative antidepressants on the severity of OSA in stroke patients has not been studied well.

METHODS

In a double-blinded randomized crossover pilot study, 22 post-acute ischemic stroke patients (mean age, 61.7 ± 10.6 y) with OSA received 100 mg of trazodone or a placebo just before polysomnography, with approximately 1 week between measures. The study also measured baseline heart rate variability and 24-h ambulatory blood pressure.

RESULTS

Administration of trazodone significantly increased the percentage time of slow-wave sleep (31.5 ± 13.2 vs. 18.4 ± 8.7%; P < 0.001) and improved almost all the parameters of OSA severity, including the apnea-hypopnea index (AHI, 25.4 ± 15.4 vs. 39.1 ± 18.4 events/h; P < 0.001), the respiratory arousal index (9.8 (5.8-11.95) vs. 14.1 (11.3-18.7) events/h; P < 0.001), and the minimum oxygen saturation (80.2 ± 9.1 vs. 77.1 ± 9.6%; P = 0.016). Responders to therapy (AHI reduced by > 50%; n = 7/22) had predominant OSA during rapid-eye-movement sleep and decreased sympathetic tone, as reflected in significantly lower mean blood pressure, diastolic blood pressure, and normalized low-frequency power.

CONCLUSIONS

Obstructive sleep apnea with comorbid ischemic stroke may be a distinctive phenotype which responds quite well to trazodone, decreasing OSA severity without increasing nocturnal hypoxia.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04162743, 2019/11/10.

Sex differences in risk factors, treatment, and prognosis in acute stroke

Objectives:

Stroke is a major cause of long-term disability and death worldwide. Several studies have shown that women in general have more severe symptoms at arrival to hospital and are less likely to return home and independent living. Our aim with the present study was to update previous results concerning sex differences in baseline characteristics, stroke management, and outcome in a population study from Sahlgrenska University Hospital, Gothenburg, Sweden.

Methods:

This study included patients with acute ischemic and hemorrhagic stroke in 2014 at Sahlgrenska University Hospital. All data were collected from The Swedish National Stroke Registry (Riksstroke).

Results:

The study population consisted of 1453 patients, with 46.7% females. Women were 5 years older than men. There was no sex difference in acute stroke severity. Frequency of revascularization was equal between men and women. The stroke mortality rate was the same between the sexes. At 3-months follow-up, women had a worse functional outcome and a higher frequency of depression and post-stroke fatigue.

Conclusion:

Our results show that there are no sex differences in management of acute stroke. However, the cause of worse functional outcome in women at 3-months follow-up, independent of other risk factors, is not clear and warrants further investigations.

An Integrative Neuro-Psychotherapy Treatment to Foster the Adjustment in Acquired Brain Injury Patients-A Randomized Controlled Study

Adjustment disorders (AjD) with depressive symptoms following an acquired brain injury (ABI) is a common phenomenon. Although brain injuries are increasing more and more, research on psychological therapies is comparably scarce. The present study compared, by means of a randomized controlled trial (RCT), a newly developed integrative treatment (Standard PLUS) to a standard neuropsychological treatment (Standard). Primary outcomes were depressive symptoms assessed with the Beck Depression Inventory (BDI-II) at post-treatment and 6-month follow-up assessment. In total, 25 patients (80% after a stroke) were randomized to one of the two conditions. Intention-to-treat analyses showed that the two groups did not significantly differ either at post-treatment nor at follow-up assessment regarding depressive symptoms. Both treatments showed large within-group effect sizes on depressive symptoms. Regarding secondary outcomes, patients in the Standard PLUS condition reported more emotion regulation skills at post-assessment than in the control condition. However, this difference was not present anymore at follow-up assessment. Both treatments showed medium to large within-group effects sizes on most measures for patients suffering from an AjD after ABI. More research with larger samples is needed to investigate who profits from which intervention.

Systematic review and meta-analysis of the effect of cognitive impairment on the risk of admission to long-term care after stroke

Introduction: Admission to long-term care (LTC) post-stroke can be a significant source of costs. Studies evaluating the effect of cognitive impairment (CI) and dementia on risk of LTC admission post-stroke have not been systematically reviewed. The aim of this paper was to conduct a systematic review and meta-analysis of studies of the association between post-stroke CI/dementia and admission to LTC. Patients and methods: PubMed, PsycInfo and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for peer-review articles in English published January 2000-June 2018. Included studies were population-based or hospital-based studies assessing the relationship between CI or dementia, and admission to LTC post-stroke. Abstracts were screened, followed by full-text review of potentially relevant articles. Relevant data was extracted using a standard form and the Crowe Critical Appraisal Tool was used for quality appraisal. Results were pooled using random-effects meta-analysis and heterogeneity was assessed using the I² statistic. Results: 18 articles were included in the review and 12 in a meta-analysis. 14/18 studies adjusted for covariates including functional impairment. Increased odds of admission to LTC was associated with post-stroke CI [Odds Ratio (CI 95%): 2.36 (1.18, 4.71), I²=77%] and post-stroke dementia [Odds Ratio (CI 95%): 2.58 (1.38 to 4.82), I²=60%]. Discussion and conclusion: Post-stroke CI and dementia increase odds of admission to LTC post-stroke, independent of functional impairment. This indicates the potential for interventions that reduce post-stroke CI and dementia to also reduce risk of admission to LTC post-stroke, and ultimately costs.

Selective Serotonin Reuptake Inhibitors and Intracerebral Hemorrhage Risk and Outcome

Background and Purpose- Selective serotonin reuptake inhibitors (SSRIs) have a well-established association with bleeding complications and conflicting reports on outcome after stroke. We sought to evaluate whether pre-intracerebral hemorrhage (ICH) SSRI use increased ICH risk and post-ICH SSRI use improved ICH outcome. Methods- Through post hoc analysis of the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage), SSRI use was categorized into no use, pre-ICH only, pre- and post-ICH use (termed "continuous"), and post-ICH only (termed "new"). Using multivariable modeling, associations were sought between pre-ICH SSRI use and ICH risk in the case-control set, and associations between post-ICH SSRI use and 3-month outcome were analyzed in the ICH case set. Exploratory analyses sought to assess influence of race/ethnicity in models. Results- The final study cohort consisted of 2287 ICH cases and 2895 controls. Pre-ICH SSRI use was not associated with ICH risk (odds ratio, 0.824 [95% CI, 0.632-1.074]) nor potentiation of ICH risk with anticoagulant or antiplatelet use. New post-ICH SSRI use was associated with unfavorable modified Rankin Scale score at 3 months after ICH (odds ratio, 1.673 [95% CI, 1.162-2.408]; P=0.006) in multivariable analyses. Additional propensity score analysis indicated a similar trend but did not reach statistical significance (P=0.107). When stratified by race/ethnicity, multivariable modeling demonstrated reduced ICH risk with pre-ICH SSRI use in Hispanics (odds ratio, 0.513 [95% CI, 0.301-0.875]; P=0.014), but not non-Hispanic whites or blacks, and no associations between post-ICH SSRI use and 3-month outcome in any racial/ethnic group. Conclusions- In a large multiethnic cohort, pre-ICH SSRI use was not associated with increased ICH risk, but post-ICH SSRI use was associated with unfavorable 3-month neurological outcome after ICH. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01202864.

Experiences of Occupational Performance in Survivors of Stroke Attending Peer Support Groups

BACKGROUND.

Survivors of stroke often experience environmental isolation and decreased occupational performance after discharge from the hospital. Peer groups benefit psychological, social, and cognitive functioning, though few studies have examined their influence on occupational performance of survivors of stroke.

PURPOSE.

This study explores the experiences of occupational performance in survivors of stroke attending an outpatient peer support group.

METHOD.

An interpretive qualitative study using semi-structured interviews was conducted with seven survivors of stroke attending an outpatient peer support group. Data was thematically analyzed.

FINDINGS.

Four themes related to the experience of peer support on occupational performance emerged: finding hope to return to meaningful occupation, a place for belonging, problem-solving occupational concerns, and finding purpose beyond oneself.

IMPLICATIONS.

This research adds to the existing literature that peer support groups help survivors of stroke reengage in meaningful occupations, manage their stroke experience, and move positively through recovery.

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.

[Incidence of epilepsy after cerebrovascular accident in Parakou in 2014]

Introduction

Les accidents vasculaires cérébraux (AVC) constituent une des principales causes acquises de l'épilepsie de l'adulte mais peu de données sont disponibles sur l'incidence de l'épilepsie après un AVC en Afrique. L'objectif de cette étude était d'estimer l'incidence de l'épilepsie chez les patients victimes d'AVC à Parakou.

Méthodes

Il s'est agi d'une étude de type cohorte dynamique ayant inclus 203 patients victimes d'AVC et hospitalisés dans le service de neurologie du CHU de Parakou. Les patients aux antécédents d'épilepsie étaient exclus du suivi. Les patients étaient suivis sur une période de 21mois allant du 1^er Janvier 2013 au 30 Septembre 2014. L'épilepsie était définie selon les critères de la Ligue Internationale contre l'Epilepsie.

Résultats

Ils étaient âgés de 18 à 99 ans avec une moyenne de 58,4 ans ± 14,2 ans. Le délai moyen de consultation après l'installation des symptômes était de 54,3h (+/-112,9h). Les AVC ischémiques représentaient 45,8%, les hémorragiques 31% et 23,2% d'indéterminés. L'incidence cumulée de l'épilepsie était de 17. La densité d'incidence de l'épilepsie était de 9,8 pour 100 personnes-années. Les facteurs associés à la survenue de l'épilepsie étaient le niveau d'instruction, la durée d'hospitalisation et le score de BARTHEL.

Conclusion

L'incidence de l'épilepsie reste très élevée et la prise en compte des facteurs associés dans les stratégies de prise en charge pourrait permettre de réduire sa charge globale.

Late-Life Depressive and Anxiety Symptoms Following Rehabilitation Services in Medicare Beneficiaries

OBJECTIVE

The aim of this study was to determine whether patients who received rehabilitation services had an increased risk of having late-life depressive or anxiety symptoms within the year following termination of services.

METHODS

The National Health and Aging Trends Study (NHATS) is a population-based, longitudinal cohort survey of a nationally representative sample of Medicare beneficiaries aged 65years and older. This study involved 5,979 participants from the 2016 NHATS survey. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder 2-item assessed for clinically significant depressive and anxiety symptoms.

RESULTS

The prevalence of depressive and anxiety symptoms was higher in older adults who had received rehabilitation services in the year prior and varied by site: no rehabilitation (depressive and anxiety symptoms): 10.4% and 8.8%; nursing home or inpatient rehabilitation: 38.8% and 23.8%; outpatient rehabilitation: 8.6% and 5.5%; in-home rehabilitation: 35.3% and 20.5%; multiple rehabilitation sites: 20.3% and 14.4%; and any rehabilitation site: 18.4% and 11.8%. In multiple logistic regression analyses, nursing home and inpatient and in-home rehabilitation services, respectively, were associated with an increased risk of having subsequent depressive symptoms (odds ratio: 3.51; 95% confidence interval [CI]: 1.85-6.63; OR: 2.15; 95% CI: 1.08-4.30) but not anxiety symptoms.

CONCLUSION

Older adults who receive rehabilitation services are at risk of having depressive and anxiety symptoms after these services have terminated. As mental illness is associated with considerable morbidity and may affect rehabilitation outcomes, additional efforts to identify and treat depression and anxiety in these older adults may be warranted.

Predictors of Remission of Early-Onset Poststroke Depression and the Interaction Between Depression and Cognition During Follow-Up

Objectives: This study aimed to examine the rate of remission in individuals experiencing early-onset poststroke depression (PSD) in China and to identify predictors of remission during a 3-month follow-up. This study also explored the interaction between cognitive impairment and depression. Methods: A total of 820 patients with PSD from a massive multicenter prospective cohort project in China (PRIOD) were included in the present study. Depressive symptoms were measured with the Hamilton Depression Rating Scale (17 Items, HDRS-17) at 2 weeks and the endpoint of the 3-month follow-up. The cut-off score of HDRS-17 (< 8) was used to define remission of depression at the endpoint. The Mini-Mental State Exam (MMSE) was used to evaluate the cognitive impairment of the patients (at the 2-week follow-up and 3-month endpoint). The National Institutes of Health Stroke Scale (NIHSS) was used to measure the severity of stroke. Results: (1) Six hundred and forty-two patients completed the 3-month follow-up, and 332 (51.7%) patients remitted by the end of the study. Univariate analyses indicated that there was a higher proportion of patients who had hypertension, frontal lobe lesion, basal ganglia lesion, poor outcome at 2 weeks, high scores on the NIHSS at 2 weeks, major life events within 3 months, and major medical diseases within 3 months in the nonremission group. In stepwise multiple logistic regression analyses, remission was significantly predicted by lower NIHSS scores at 2 weeks (p = 0.001, OR = 1.086, 95% CI 1.035-1.139), fewer major life events (p = 0.036, OR = 5.195, 95% CI 1.111-27.283), fewer major medical comorbidities (p = 0.015, OR = 2.434, 95% CI 1.190-4.979), and fewer frontal lobe lesions (p = 0.042, OR = 1.717, 95% CI 1.019-2.891). (2) After controlling for confounding variables, repeated measures analysis of variance revealed a significant interaction between time (2 weeks vs. 3 months) and group (remitters vs. nonremitters) on MMSE scores [F (1, 532) = 20.2, p < 0.001]. Conclusions: Early-onset PSD patients with milder neurological impairment, fewer major life events, fewer major medical comorbidities and no frontal lobe lesion at baseline were more likely to achieve remission 3 months after stroke. Only remitters of PSD improved significantly in cognitive impairment after stroke. The PRIOD trial is registered at http://www.isrctn.com/, number ISRCTN62169508.

Prevalence and Potential Associated Factors of Depression among Chinese Older Inpatients

INTRODUCTION

Little is known about the current representative depression situation among Chinese older inpatients. The aim of this study is to examine prevalence of depression and associated risk factors among Chinese older inpatients by a large-scale cross-sectional national survey.

METHODS

This study is based on baseline survey data from a large-scale cohort study in a representative sample of Chinese older inpatients. The procedure of this study involves physical examination and face-to-face questionnaire interviews. Depression was assessed based on the Geriatric Depression Scale 15. Mixed-effect Poisson regression model was used to examine the relationship between depression and covariates by controlling the cluster effect of hospital wards.

RESULTS

Of all 9727 respondents, the mean age of all respondents was 72.4±5.7 years, from 65 to 97. The average GDS score was 2 (1, 4). The prevalence rate of depression was 16.7% (95%CI: 15.8-17.4%) among older inpatients. The prevalence rates were 14.6% for males and 19.5% for females respectively. After controlling the cluster effect of hospital wards, age, gender, ADL score, educational level, BMI, frail, marriage, falls, alcohol drinking, cognitive function, living conditions, vision, hearing, sleep and defecation function were associated with depression. Emaciation (OR=1.176, 95%CI: 1.107-1.249), frail (OR=1.562, 95%CI: 1.489-1.639), divorced or widowed (OR=1.083 95%CI: 1.017-1.153), living in the bungalow (OR=1.075, 95%CI: 1.023-1.130), falls (OR=1.078, 95%CI: 1.030-1.128), cognitive function (OR=1.142, 95%CI: 1.091-1.195), vision dysfunction (OR=1.125, 95%CI: 1.076-1.177), hearing dysfunction (OR=1.061, 95%CI: 1.011-1.113), sleep dysfunction (OR=1.237, 95%CI: 1.194-1.282), defecation dysfunction (OR=1.160, 95%CI: 1.103-1.221) could increase prevalence risk of depression.

CONCLUSIONS

There was a high prevalence of depression among Chinese older inpatients. Demographic characteristics, physical and mental conditions indicators have strong effect on prevalence and strength of depression. Therefore, it is essential to assess depression and perform comprehensive measures to improve physical and mental conditions in order to manage depressive symptoms in older inpatients.

Serotonin Selective Reuptake Inhibitors (SSRIs) and Stroke

PURPOSE OF REVIEW

The interest in SSRIs after stroke has increased in the past few years, with better knowledge of post-stroke depression and with the demonstrated capacity of some SSRIs to act on the functional recovery of non-depressed subjects.

RECENT FINDINGS

Arguments for the action of SSRIs in favour of post-stroke neurological function recovery have improved through new elements: basic science and preclinical data, positive clinical trials and repeated series of stroke patient meta-analysis, and confirmation of favourable safety conditions in post-stroke patients. Global coherence is appearing, showing that SSRIs improve stroke recovery in non-depressed patients when given for 3 months after the stroke, with highly favourable safety conditions and a favourable benefit/risk ratio. Large series are still needed.

Burden of Depressive Symptoms Over 2 Decades and Risk of Nursing Home Placement in Older Women

OBJECTIVES

To determine the association between cumulative burden of depressive symptoms and risk of nursing home (NH) placement over 2 decades.

DESIGN

Prospective cohort study with data linked to Medicare claims files.

SETTING

Clinic sites in Baltimore, Maryland; Minneapolis, Minnesota; and the Monongahela Valley near Pittsburgh, Pennsylvania.

PARTICIPANTS

Initially community-dwelling women aged 65 and older (N=3,646).

MEASUREMENTS

Depressive symptom burden was determined using the Geriatric Depression Scale measured over 18 years to calculate accumulation of burden. NH placement was determined using Medicare claims data.

RESULTS

In Fine-Gray proportional hazards analyses including demographic characteristics, medical comorbidities, functional impairment, and recent depression exposure and accounting for competing risk of death, women with low depressive symptom burden were twice as likely to experience NH placement as those with minimal burden (hazard ratio (HR) = 1.92, 95% confidence interval (CI) = 1.16-3.20), women with moderate burden were more than twice as likely (HR = 2.62, 95% CI = 1.59-4.31), and women with high burden (HR = 3.08, 95% CI = 1.87-5.08) were three times as likely. The addition of antidepressant use to this model attenuated the risk only slightly.

CONCLUSION

In older women, cumulative burden of depressive symptoms over nearly 2 decades is associated with greater risk of transitioning from community-living to a NH irrespective of recent depression exposure, medical comorbidities, functional impairment, and the competing risk of death. This work supports the need for improving recognition, monitoring, and treatment of depressive symptoms early, which may reduce or delay NH placement.

Differences in Therapeutic Responses and Factors Affecting Post-Stroke Depression at a Later Stage According to Baseline Depression

Background and Purpose

The pathophysiology of post-stroke depression (PSD) is complex and may differ according to an individual’s mood immediately after stroke. Here, we compared the therapeutic response and clinical characteristics of PSD at a later stage between patients with and without depression immediately after stroke.

Methods

This study involved a post hoc analysis of data from EMOTION (ClinicalTrials.gov NCT01278498), a placebo-controlled, double-blind trial that examined the efficacy of escitalopram (10 mg/day) on PSD and other emotional disturbances among 478 patients with acute stroke. Participants were classified into the Baseline-Blue (patients with baseline depression at the time of randomization, defined per the Montgomery-Asberg Depression Rating Scale [MADRS] ≥8) or the Baseline-Pink groups (patients without baseline depression). We compared the efficacy of escitalopram and predictors of 3-month PSD (MADRS ≥8) between these groups.

Results

There were 203 Baseline-Pink and 275 Baseline-Blue patients. The efficacy of escitalopram in reducing PSD risk was more pronounced in the Baseline-Pink than in the Baseline-Blue group (p for interaction=0.058). Several risk factors differentially affected PSD development based on the presence of baseline depression (p for interaction <0.10). Cognitive dysfunction was an independent predictor of PSD in the Baseline-Blue, but not in the Baseline-Pink group, whereas the non-use of escitalopram and being female were more strongly associated with PSD in the Baseline-Pink group.

Conclusions

Responses to escitalopram and predictors of PSD 3 months following stroke differed based on the presence of baseline depression. Our data suggest that PSD pathophysiology is heterogeneous; therefore, different therapeutic strategies may be needed to prevent PSD emergence following stroke.

Factors predicting community participation in patients living with stroke, in the Western Cape, South Africa

Purpose: An important focus of poststroke rehabilitation is the attainment of community participation. However, several factors may influence participation some of which vary from setting to setting. The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa. Materials and methods: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Social Support Questionnaire 6 (SSQ6) were the instruments used to collect data. Participant demographics, clinical features and domain-specific scores of the WHODAS 2.0 were used as potential predictors. Correlation analysis and multiple regression models were used to examine determinants of community participation. All assessments were conducted using face-to-face interviews. Results: One hundred and six stroke survivors enrolled in this cross-sectional study. Risk factors, cognition, mobility, self-care, getting along with people, household activities and total WHODAS 2.0 score were associated with participation. Four predictors of community participation were identified from multiple regression, namely mobility (38%), cognition (11%), life activities (4%) and stroke risk factors (1%). Determinants varied by gender and age group. Mobility predominated in males and younger adults, while cognition was more pronounced in females and the elderly. Lastly, the influence of social support on community participation was largely defined by the gender and age of stroke survivors. Conclusion: The findings suggest focusing stroke rehabilitation on important factors such as mobility, cognition, life activities and risk factors to advance patients' participation. It also emphasizes giving specific consideration to key factors specific for gender and age of stroke survivors. Implications for Rehabilitation Community participation in the general population of stroke survivors' is largely determined by their mobility function. Determinants of community participation among stroke survivors essentially vary according to age and gender. Clinically, this study suggests that focusing on specific determinants of improved community participation according to stroke patients' demographic categories (gender and age) may be an important impetus to enhance rehabilitation outcome.

Risk Factors for Post-stroke Depression: A Meta-analysis

Background: Stroke not only impacts patients physically but also economically. Post-stroke depression (PSD), as a common complication of stroke, always obstructs the process of stroke rehabilitation. Accordingly, defining the risk factors associated with PSD has extraordinary importance. Although there have been many studies investigating the risk factors for PSD, the results are inconsistent.

Objectives: The objectives of this study were to identify the risk factors for PSD by evidence-based medicine.

Data sources: A systematic and comprehensive database search was performed of PubMed, Medline, CENTRAL, EMBASE.com, the Cochrane library and Web of Science for Literature, covering publications from January 1, 1998 to November 19, 2016.

Study Selection: Studies on risk factors for PSD were identified, according to inclusion and exclusion criteria. The risk of bias tool, described in the Cochrane Handbook version 5.1.0, was used to assess the quality of each study. Meta-analysis was performed using RevMan 5.3 software.

Results: Thirty-six studies were included for review. A history of mental illness was the highest ranking modifiable risk factor; other risk factors for PSD were female gender, age (<70 years), neuroticism, family history, severity of stroke, and level of handicap. Social support was a protective factor for PSD.

Conclusion: There are many factors that have effects on PSD. The severity of stroke is an important factor in the occurrence of PSD. Mental history is a possible predictor of PSD. Prevention of PSD requires social and family participation.

The Association between Post-Stroke Depression and the Activities of Daily Living/Gait Balance in Patients with First-Onset Stroke Patients

This study evaluated the association between post-stroke depression (PSD) and clinical outcomes, including activities of daily living (ADL) and gait balance, in patients with first-onset stroke. One hundred and eighty inpatients were recruited and followed-up for a 6-month. The depressive, cognitive, and stroke symptoms were assessed using the Beck Depression Inventory (BDI), the Global Deterioration Scale (GDS), the modified Rankin Scale (MRS), and the Berg Balance Scale (BBS). All patients were assessed at baseline and at the end of the observation (6-month). Among 180 patients, 127 (70.6%) were diagnosed with minimal-to-mild depression (MMD) while 53 (29.4%) were diagnosed with moderate-to-severe depression (MSD). The odd ratio (OR) for poor outcome in the MSD group was approximately 3.7 relative to the MMD group. The proportion of patients with better balance classified by the BBS score at 6-month was significantly higher in the MMD group than in the MSD group (OR=1.375). Our findings demonstrate the potential relationship between PSD and rehabilitation outcomes measured by different rating scales in Korean stroke patients. Our study suggests that clinicians should carefully evaluate depressive symptoms in patients with stroke during routine clinical practice. Adequately-powered and well-controlled further studies are necessary to confirm and fully characterize this relationship.

Alterations in anxiety and social behaviour in Npas4 deficient mice following photochemically-induced focal cortical stroke

In addition to causing widespread cell death and loss of brain function, cerebral ischaemia also induces extensive neuroplasticity. In humans, stroke is often accompanied by severe cognitive and psychiatric changes that are thought to arise as a consequence of this infarct-induced remodelling. A candidate for producing these post-stroke neuropsychiatric changes is Npas4, an activity-dependent transcription factor involved in synaptic plasticity whose expression is aberrantly up-regulated following ischaemic injury. In this study we investigated the role of Npas4 in modulating these stroke-induced neuropsychiatric responses by comparing the performance of wildtype and Npas4^-/- mice in various cognitive and behavioural tasks in a photochemical model of focal cortical stroke. We show that this stroke model results in impaired spatial recognition memory and a reduction in despair-like behaviour that affect both genotypes to a similar degree. Moreover, mice lacking Npas4 also show differences in some aspects of post-stroke sociability and anxiety. Specifically, we show that while stroke had no effect on anxiety levels in wildtype mice, Npas4^-/- mice became significantly more anxious following stroke. In addition, Npas4^-/- mice retained a greater level of sociability in the acute post-stroke period in comparison to their wildtype littermates. Thus, our findings suggest that Npas4 may be involved in post-stroke psychiatric changes related to anxiety and sociability.

Predictors of Depressive Mood in Patients With Isolated Cerebellar Stroke: A Retrospective Study

Objective

To identify predictive factors of depressive mood in patients with isolated cerebellar stroke.

Methods

A retrospective chart review was performed in patients who had experienced their first isolated cerebellar stroke during 2002–2014. The patients were classified into two groups by the Geriatric Depression Scale (GDS) (non-depressive group, 0≤GDS≤16; depressive group, 17≤GDS≤30). Data on demographic and socioeconomic factors, comorbidities, functional level, cognitive and linguistic function, and stroke characteristics were collected. Significant variables in univariate analysis were analyzed using logistic regression.

Results

Fifty-two patients were enrolled, of whom 55.8% had depressive mood, were older (p=0.021), and had higher hypertension rates (p=0.014). Cognitive and linguistic functions did not differ between the two groups. The depressive group had higher ischemic stroke rates (p=0.035) and showed a dominant right posterior cerebellar hemisphere lesion (p=0.028), which was independently associated with depressive mood in the multiple logistic regression analysis (odds ratio, 5.081; 95% confidence interval, 1.261–20.479).

Conclusion

The risk of depressive mood after cerebellar stroke was increased in patients at old age, with a history of hypertension, ischemic stroke, and lesion of the right posterior cerebellar hemisphere. The most significant determining factor was stroke lesion of the right posterior cerebellar hemisphere. Early detection of risk factors is important to prevent and manage depressive mood after cerebellar stroke.

The natural history of depression and trajectories of symptoms long term after stroke: The prospective south London stroke register

BACKGROUND

The natural history of depression in stroke patients is complex and the mechanism of change in symptoms over time is not fully understood. We hypothesise that there are different trajectories of symptoms after stroke.

METHODS

The primary analysis comprised 761 patients who completed 5 years follow up, obtained from the prospective South London Stroke Register (1998-2013). The Hospital Anxiety and Depression scale (HADs) was used to screen patients for depression symptoms at 3 months after stroke, then annually. Trajectories of depression symptoms were detected using group based trajectory modelling (GBTM).

RESULTS

Four patterns of symptoms (Groups I-IV) were identified: 6.31% of patients had severe symptoms, improved slightly in early years then worsen (predicted mean HADs score, 15.74 (se=1.06)); 28.65% had moderate symptoms, a tendency to get worse over time, predicted mean score 7.36 (se=0.35); 49.54% had mild symptoms and a tendency of getting worse, predicted mean 3.89 (se=0.30), and 15.51% of the cohort, had no symptoms and remained so over time. The lowest rate of Selective serotonin reuptake inhibitors (SSRI) use, over 5 years after stroke was 1.1% for group (I) and highest was 35% for group (IV). Sensitivity analyses were used to assess the robustness of the findings using several inclusion criteria and findings agreed with the primary results.

LIMITATIONS

There is loss to follow up of around 20%.

CONCLUSIONS

The study identified 4 trajectories of depression symptoms, providing useful information for the long term management of stroke patients and for the implementation of cost effective personalized interventions.

Depression after minor stroke: the association with disability and quality of life--a 1-year follow-up study

OBJECTIVE

Minor stroke is characterized by mild neurological functional impairment and relatively good outcome. Little is known about the association between post-stroke depression (PSD) and outcomes of minor stroke. The aim of this study was to investigate the association between PSD and disability and quality of life (QoL) at 1 year after minor ischemic stroke.

METHODS

Patients with first-ever minor ischemic stroke (n = 747) were followed up at 14 ± 2 days, 3 months, 6 months, and 1 year after stroke. Depressive symptoms were assessed at each follow-up. Patients diagnosed with depression at 14 ± 2 days formed the early-onset PSD group; those who were diagnosed with depression at any subsequent follow-ups for the first time constituted the late-onset PSD group. The outcomes of minor stroke including disability (modified Rankin score ≥ 2) and QoL (Short Form-36 Health Survey) were assessed at the 1-year follow-up.

RESULTS

A total of 198 (26.5%) patients were diagnosed with PSD over the 1-year follow-up; 136 and 62 patients were allocated to the early-onset PSD group and late-onset PSD group, respectively. Both early-onset and late-onset PSD were independently associated with disability and poor physical and mental health at 1 year after stroke. Recovery from depression (n = 112) within 1 year decreased the adverse impacts of PSD on functional outcome and QoL.

CONCLUSIONS

Post-stroke depression was independently associated with disability and poor QoL at 1 year after first-ever minor ischemic stroke. Recovery from PSD decreased but did not eliminate the adverse impacts of PSD on outcomes of minor stroke.

The association between serum ferritin levels and post-stroke depression

BACKGROUND

Post-stroke depression (PSD) is a common neuropsychiatric affective disorder occurring after stroke. Elevated serum ferritin levels have been reported to contribute to depression. Our aim was to determine whether there is a relationship between serum ferritin levels and PSD.

METHODS

196 ischemic stroke patients were consecutively recruited within the first 24h of stroke onset and were followed up for 2 months. Serum ferritin levels were assayed by electrochemiluminescence immunoassay at hospital admission. Clinical depression was diagnosed according to DSM-IV criteria and a HAMD -17 score of ≥ 7. Meanwhile, 100 normal control subjects were also recruited.

RESULTS

We found that 56 stroke patients (28.6%) were diagnosed with PSD at two months. There was a significant intergroup difference in serum ferritin levels within 24h after admission (F=25.044, P<0.001). Serum ferritin levels were significantly higher at admission in PSD patients than in non-PSD patients and normal controls. There was a positive correlation between serum ferritin levels and hs-CRP at admission in PSD patients (r=0.129, P=0.042). In multivariate analyses, serum levels of ferritin ≥ 130.15 µg/L were independently associated with PSD at two months [odds ratio OR=5.388, 95%CI:1.725-16.829; P=0.004] after adjusting for all possible variables.

LIMITATIONS

We excluded patients with severe aphasia and with serious conditions.In addition, the information for dietary intake was not recorded, which may influence body iron stores.

CONCLUSION

Our findings show that elevated serum ferritin levels at admission are associated with PSD and may predict its development at 2 months post-stroke.

Understanding stroke survivors' and informal carers' experiences of and need for primary care and community health services--a systematic review of the qualitative literature: protocol

INTRODUCTION

Despite the rising prevalence of stroke, no comprehensive model of postacute stroke care exists. Research on stroke has focused on acute care and early supported discharge, with less attention dedicated to longer term support in the community. Likewise, relatively little research has focused on long-term support for informal carers. This review aims to synthesise and appraise extant qualitative evidence on: (1) long-term healthcare needs of stroke survivors and informal carers, and (2) their experiences of primary care and community health services. The review will inform the development of a primary care model for stroke survivors and informal carers.

METHODS AND ANALYSIS

We will systematically search 4 databases: MEDLINE, EMBASE, PsycINFO and CINAHL for published qualitative evidence on the needs and experiences of stroke survivors and informal carers of postacute care delivered by primary care and community health services. Additional searches of reference lists and citation indices will be conducted. The quality of articles will be assessed by 2 independent reviewers using a Critical Appraisal Skills Programme (CASP) checklist. Disagreements will be resolved through discussion or third party adjudication. Meta-ethnography will be used to synthesise the literature based on first-order, second-order and third-order constructs. We will construct a theoretical model of stroke survivors' and informal carers' experiences of primary care and community health services.

ETHICS AND DISSEMINATION

The results of the systematic review will be disseminated via publication in a peer-reviewed journal and presented at a relevant conference. The study does not require ethical approval as no patient identifiable data will be used.

Improving Quality of Life and Depression After Stroke Through Telerehabilitation

OBJECTIVE

The aim of this study was to determine the effects of home-based robot-assisted rehabilitation coupled with a home exercise program compared with a home exercise program alone on depression and quality of life in people after stroke.

METHOD

A multisite randomized controlled clinical trial was completed with 99 people<6 mo after stroke who had limited access to formal therapy. Participants were randomized into one of two groups, (1) a home exercise program or (2) a robot-assisted therapy+home exercise program, and participated in an 8-wk home intervention.

RESULTS

We observed statistically significant changes in all but one domain on the Stroke Impact Scale and the Center for Epidemiologic Studies Depression Scale for both groups.

CONCLUSION

A robot-assisted intervention coupled with a home exercise program and a home exercise program alone administered using a telerehabilitation model may be valuable approaches to improving quality of life and depression in people after stroke.

Depression, anxiety, and cognitive functioning after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Post-stroke depression (PSD) is an important complication of stroke. We studied long-term PSD after intracerebral hemorrhage (ICH) at young age, as well as anxiety, and cognitive functioning of the survivors.

METHODS

We gathered clinical and imaging data of 336 young ICH patients between age 16 and 49 treated in the Helsinki University Central Hospital. After a median follow-up of 9.7 (7.0-12.0) years, we interviewed 130 survivors with structural questionnaires including Beck Depression Inventory II (BDI-II), Hospital Anxiety and Depression Scale (HADS), Pain Anxiety Symptoms Scale (PASS), Brief Pain Inventory (BPI), and Montreal Cognitive Assessment (MoCA). Univariate and multivariate analysis was performed to identify factors associated with PSD (BDI-II score >13). Degree of disability was measured by modified Rankin Scale score (mRS).

RESULTS

PSD was present among 30 (23.1%) and anxiety among 52 (40.0%) patients (HADS score >6). Higher degree of disability was associated with symptoms of depression (higher BDI-II scores, P = 0.001), emotional distress (higher HADS scores, P = 0.004), and pain (higher PASS scores, P = 0.008, and higher BPI scores, P = 0.003). The only baseline factor identified to associate with PSD was hydrocephalus (P = 0.014). Median PASS score was 9 (IQR 0-25), median BPI score was 5 (0-23), and median MoCA score was 26 (22-28) hinting to normal or mild cognitive dysfunction. Antidepressants were used by 9.2%.

CONCLUSIONS

One of four survivors of ICH at young age suffers long-term PSD. Higher degree of disability predicted occurrence of PSD. Treatment of depression appears as an unmet need in young ICH survivors.

Serum Levels of High-sensitivity C-Reactive Protein at Admission Are More Strongly Associated with Poststroke Depression in Acute Ischemic Stroke than Homocysteine Levels

Inflammatory processes have fundamental roles in depression. The primary purpose of this study was to assess the serum levels of high-sensitivity C-reactive protein (Hs-CRP) and homocysteine (HCY) at admission to the presence of poststroke depression (PSD). From December 2012 to December 2013, first-ever acute ischemic stroke patients who were admitted to the hospital within the first 24 h after stroke onset were consecutively recruited and followed up for 6 months. Serum levels of Hs-CRP and HCY were tested at admission. Based on the symptoms, diagnoses of depression were made in accordance with DSM-IV criteria for depression at 6 months after stroke. Ninety-five patients (42.0%) showed depression (major + minor) at 6 months after admission, and in 69 patients (30.5%), this depression was classified as major. In the 69 patients with major depression, our results showed significantly higher Hs-CRP and HCY levels at admission than patients without major depression. After adjusting all other possible covariates, Hs-CRP and HCY still were independent predicators of PSD with adjusted OR of 1.332 (95% CI, 1.230-1.452; P < 0.001) and 1.138 (95% CI, 1.072-1.274; P < 0.001), respectively. The area under the receiver operating characteristic curve values of Hs-CRP and HCY were 0.765 (95% CI, 0.701-0.9825) and 0.684 (95% CI, 0.610-0.757) for PSD, respectively. The prognostic accuracy of combined model (HCY and Hs-CRP) was higher compared to those biomarkers alone and other markers. Elevated serum levels of Hs-CRP and HCY at admission were found to be associated with depression 6 months after stroke, suggesting that these alterations might participate in the pathophysiology of depression symptoms in stroke patients.

The association between the severity of poststroke depression and clinical outcomes after first-onset stroke in Korean patients

OBJECTIVE

The purpose of the present study is to evaluate the association between poststroke depression (PSD) and clinical outcomes in first-onset stroke patients who are undergoing a rehabilitation program.

METHODS

The present study included 180 inpatients that were recruited consecutively and followed up over a 6-month observational period. Poststroke depression was diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Symptoms of depression and clinical outcomes were assessed using the Beck Depression Inventory, the modified Barthel Index (MBI) and the Mini Mental State Examination (MMSE). All patients were assessed at baseline and at the end of the 6-month observational period.

RESULTS

Of the 180 patients, 127 (70.6%) were diagnosed with minimal-to-mild depression (MMD), and 53 (29.4%) were diagnosed with moderate-to-severe depression (MSD). The mean change in MBI scores from baseline to 6 months was significantly higher (P=.029) in the MMD group (23.8) than in the MSD group (8.6). The odds ratio for an unfavorable outcome (MBI score <60) in patients with MSD was approximately 3.5 in relation to patients with MMD. The mean change in MMSE score (4.4 versus 7.4) was not significantly different between the MMD and MSD groups.

CONCLUSION

The present findings suggest that the severity of PSD may be associated with clinical outcomes in Korean patients 6 months after a first-onset stroke. Our data agree with previous findings, which indicate that clinicians should carefully evaluate symptoms of depression in stroke patients during routine clinical practice. The methodological shortcomings of the present study may require further studies with adequate power and improved design to clarify the association between PSD and clinical outcomes following stroke.

The effect of post-stroke depression on rehabilitation outcome and the impact of caregiver type as a factor of post-stroke depression

OBJECTIVE

To evaluate the effect of post-stroke depression (PSD) on rehabilitation outcome and to investigate the risk factors of PSD, especially, the role of caregivers type (family or professional) in subacute stroke patients.

METHODS

Two hundred twenty-six stroke patients were enrolled retrospectively. All the subjects' basic characteristics, Korean version of the Beck Depression Inventory (K-BDI), Korean version of the Modified Barthel Index (K-MBI), and the modified Rankin Scale (mRS) were recorded when the patient was transferred into the Department of Rehabilitation Medicine and at the time of discharge. The results were statistically analyzed by using SPSS ver. 20.0.

RESULTS

The patients' K-BDI score showed a significantly negative association with K-MBI at discharge (β=-0.473, p<0.001) and a significantly positive association with the mRS score at discharge (β=0.316, p<0.001). Patients with lesions on the left hemisphere (odds ratio [OR], 3.882; 95% confidence interval [CI], 1.726-8.733) and professional caregiver support (OR, 0.028; 95% CI, 0.012-0.065) had a higher rate of depression.

CONCLUSION

Depression was prevalent in stroke patients, and it had a negative effect on patients' functional outcome. Patients who had a lesion on the right hemisphere had less depression. The type of caregiver was related to the incidence of subacute PSD, and family caregivers were found to lower the frequency of stroke patients' depression.

Risk factors for poststroke depression: identification of inconsistencies based on a systematic review

OBJECTIVE

Depression after stroke or poststroke depression (PSD) has a negative impact on the rehabilitation process and the associated rehabilitation outcome. Consequently, defining risk factors for development of PSD is important. The relationship between stroke and depression is described extensively in the available literature, but the results are inconsistent. The aim of this systematic review is to outline conflicting evidence on risk factors for PSD.

METHODS

PubMed, Medline, and Web of Knowledge were searched using the keywords "stroke," "depression," and "risk factor" for articles published between January 01, 1995, and September 30, 2012. Additional articles were identified and obtained from a hand search in related articles and reference lists.

RESULTS

A total of 66 article abstracts were identified by the search strategy and 24 articles were eligible for inclusion based on predefined quality criteria. The methodology varies greatly between the various studies, which is probably responsible for major differences in risk factors for PSD reported in the literature. The most frequently cited risk factors for PSD in the literature are sex (female), history of depression, stroke severity, functional impairments or level of handicap, level of independence, and family and social support.

CONCLUSIONS

Many risk factors are investigated over the last 2 decades and large controversy exists concerning risk factors for development of PSD. These contradictions may largely be reduced to major differences in clinical data, study population, and methodology, which underline the need for more synchronized studies.

Plasma levels of glutamate during stroke is associated with development of post-stroke depression

BACKGROUND

Depression is a frequent mood disorder that affects around 33% of stroke patient. Our aim was to test the possible association between plasma glutamate and the development of post-stroke depression (PSD) in Chinese patients.

METHODS

The subjects were first-ever acute ischemic stroke (AIS) patients who were hospitalized during the period from November 2011 to September 2013. Clinical information and stroke severity was collected at admission. Neurological and neuropsychological evaluations were conducted at the 3-month follow-up. Plasma glutamate levels were analyzed at baseline using liquid chromatography followed by tandem mass spectrometry. Glutamate oxaloacetate transaminase (GOT), glutamate-pyruvate transaminase (GPT) and blood markers were also tested. Multivariate analyses were performed using logistic regression models.

RESULTS

During the study period, 209 patients were included in the analysis. Seventy patients (33.5%) were diagnosed as having major depression at 3 month. Patients with major depression showed higher levels of plasma glutamate [299 (235-353) vs. 157 (108-206) μM, P<0.0001] and lower GOT [14 (11-20) vs. 21 (15-32)U/L, P<0.0001] at admission. In multivariate analyses, plasma glutamate and GOT were independent predictors of PSD at 3 months [odds ratio (OR): 1.03 (1.02-1.04), P<0.0001; 0.84 (0.75-0.97), P=0.003]. Plasma levels of glutamate >205 μM were independently associated with PSD (OR, 21.3; 95% CI, 8.28-67.36, P<0.0001), after adjustment for possible variables.

CONCLUSION

The present study demonstrates a strong relationship between plasma glutamate and GOT levels at admission and the development of PSD within 3 months. Further studies are necessary to confirm this association, which may open the way to the proposal of new therapeutic options.

Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial

OBJECTIVES

Depression and anxiety related to stroke are caused by vascular lesions and psychological reactions. Treatment of vascular and modifiable behavioral risk factors reduces the risk of stroke and may also reduce the risk of emotional changes after stroke. We aimed to investigate whether a multifactorial risk factor intervention program in patients with first-ever stroke or transient ischemic attack (TIA) can influence post-stroke anxiety and depressive symptoms in patients one year post-stroke.

METHOD

The study population consisted of first-ever stroke and TIA patients allocated in a randomized, evaluator-blinded, controlled trial to care as usual or a structured and multidisciplinary follow-up including intensive treatment of vascular risk. The primary endpoint (cognition) has previously been reported. The secondary endpoint, reported here, was changes in the Hospital Anxiety and Depression Scale (HADS) from baseline to 12-month follow-up.

RESULTS

One hundred and ninety-five patients were randomized. The estimated difference between treatment groups, in changes in HADS, from baseline to 12 months was -1.32 (95% confidence interval: -2.61, -0.04; P = 0.044) in favor of the intervention group. One year post-stroke, 4/85 (4.7%) patients in the intervention group and 12/89 (13.5%) in the control group suffered from depression (P = 0.045), while 7/85 (8.2%) patients in the intervention group and 13/89 (14.6%) patients in the control group suffered from anxiety (P = 0.19).

CONCLUSION

A structured, multidisciplinary, multifactorial risk factor program including vascular risk factor management may be associated with reduced HADS scores and a lower prevalence of depressive symptoms one year after stroke.

Natural history, predictors and associated outcomes of anxiety up to 10 years after stroke: the South London Stroke Register

BACKGROUND

evidence on the long-term natural history, predictors and outcomes of anxiety after stroke is insufficient to inform effective interventions. This study estimates within 10 years of stroke: (i) the incidence, cumulative incidence, prevalence, and time of onset of anxiety. (ii) Predictors of anxiety and its association with depression. (iii) The association between anxiety 3 months after stroke and mortality, stroke recurrence, disability, cognitive impairment and quality of life (QoL) at follow-up.

METHODS

data from the South London Stroke Register (1995-2010). Patients were assessed at the time of the stroke, at 3 months, 1 year and then annually for up to 10 years. Baseline data included socio-demographics and stroke severity. Follow-up data included assessments for anxiety and depression (hospital anxiety and depression scale), disability, cognition and QoL. Multivariate regression was used to investigate predictors and associated outcomes of anxiety.

RESULTS

incidence of anxiety up to 10 years ranged from 17 to 24%. Cumulative incidence: 57%. Prevalence range: 32-38%. Amongst patients with anxiety, 58% were anxious at 3 months. 57-73% of patients with anxiety had co-morbid depression. Predictors of anxiety included age under 65, female gender, inability to work, depression treatment, smoking and stroke severity. Anxiety at 3 months was associated with lower QoL at follow-up.

CONCLUSIONS

anxiety is a frequent problem affecting stroke survivors in the long term. Clinicians should pay attention to patients at risk of anxiety since it is associated with lower QoL and depression.

The long-term outcomes of depression up to 10 years after stroke; the South London Stroke Register

BACKGROUND

Post-stroke depression is a frequent chronic and recurrent problem that starts shortly after stroke and affects patients in the long term. The health outcomes of depression after stroke are unclear.

AIMS

(1) To investigate the associations between depression at 3 months and mortality, stroke recurrence, disability, cognitive impairment, anxiety and quality of life (QoL), up to 5 years post-stroke. (2) To investigate these associations in patients recovering from depression by year 1. (3) To investigate associations between depression at 5 years and these outcomes up to 10 years.

METHODS

Data from the South London Stroke Register (1997-2010) were used. Patients (n at registration=3240) were assessed at stroke onset, 3 months after stroke and annually thereafter. Baseline data included sociodemographics and stroke severity measures. Follow-up assessments included anxiety and depression (Hospital Anxiety and Depression scale), disability, QoL and stroke recurrence. Multivariable regression models adjusted for age, gender, ethnicity, stroke severity and disability were used to investigate the association between depression and outcomes at follow-up.

RESULTS

Depression at 3 months was associated with: increased mortality (HR: 1.27 (1.04 to 1.55)), disability (RRs up to 4.71 (2.96 to 7.48)), anxiety (ORs up to 3.49 (1.71 to 7.12)) and lower QoL (coefficients up to -8.16 (-10.23-6.15)) up to year 5. Recovery from depression by 1 year did not alter these risks to 5 years. Depression in year 5 was associated with anxiety (ORs up to 4.06 (1.92 to 8.58)) and QoL (coefficients up to -11.36 (-14.86 to -7.85)) up to year 10.

CONCLUSIONS

Depression is independently associated with poor health outcomes.

Decreased expression of neuronal Per-Arnt-Sim domain protein 4 gene in the hippocampus of a post-stroke depression rat model

Neuronal Per-Arnt-Sim domain protein 4 (NPAS4) is important in regulating transcription and function in the limbic system and in brain development. Post-stroke depression (PSD) is a common complication following a stroke. Furthermore, organic damage as a result of a stroke affects the restoration of nerve function and indicates that hippocampal neural activity may be associated with PSD. A PSD rat model was established via a middle cerebral artery occlusion procedure, which was combined with isolation and chronic unexpected mild stress, and was used to investigate the expression of the NPAS4 gene in the hippocampus. The neurological deficit and behavior were evaluated and NPAS4 mRNA expression was measured by semi-quantitative reverse transcription-polymerase chain reaction; furthermore, the association with cognitive impairment was analyzed. The PSD rats displayed neuropsychopathic disorders and the NPAS4 mRNA expression levels in the hippocampus were significantly lower in the depression and PSD groups compared with the control group. Therefore, the present study identified that NPAS4 expression was decreased in the hippocampus of PSD rats.

Cognitive decline one year after hospitalization in older adults without dementia

BACKGROUND/AIMS

We studied cognitive functioning 1 year after hospitalization (T2) in patients at least 65 years old without cognitive impairment at baseline (T1).

METHODS

Cognition was assessed using the Mini-Mental State Examination (MMSE) at both time points. We included 211 (114 women) patients with a mean age of 78.3 (SD 7.0) years and an MMSE score of 24 and above.

RESULTS

At T2, 69 (32.7%) patients had an MMSE score below 24. In participants with MMSE 24-26 at T1, cognitive decline was related to impaired physical self-maintenance, a decline in the performance of the instrumental activities of daily living, impaired hearing and less reading ability. In participants with MMSE 27-30, cognitive decline was associated with higher comorbidity (Charlson Index) and impaired physical self-maintenance and hearing.

CONCLUSION

A reduced functioning level and increased comorbidity predicted a decline in cognitive functioning.

Use of antidepressant medications to improve outcomes after stroke

Interest in the use of antidepressants after stroke has been renewed by better knowledge of poststroke depression, but mainly by the capacity of some of them to promote functional recovery of nondepressed subjects. Recombinant tissue plasminogen activator thrombolysis within the first few hours after the stroke is currently the only validated treatment able to improve the spontaneous--and most of the time incomplete--recovery of neurological functions after stroke. However, we have learned from research over the last decade, in part based on the considerable improvement of neuroimaging techniques, that spontaneous recovery of neurological functions is associated with a large intracerebral reorganization of the damaged human brain. The question of whether lesioned-brain plasticity can be modulated by external factors such as pharmacological antidepressant agents is now being addressed with the aim of improving recovery and reducing the final disability of patients. Poststroke depression is known to be frequent and deleterious for patient outcome. We review the interest in the use of antidepressants after stroke in classic but often neglected poststroke depression and we strongly underline the action of some antidepressants in promoting functional recovery of nondepressed patients after stroke.

Association between cerebral lesions and emotional changes in acute ischemic stroke patients

Controversies and interest are present in the associations between specific brain locations and depression or anxiety. This study investigated the association between stroke location and emotional changes in stroke patients. This prospective observational study analyzed the neuroimages and neuropsychiatric conditions of 26 patients with acute middle cerebral artery infarction. Each patient's neurological and psychiatric condition was evaluated 1 week as well as 1 month after the stroke. We found that the right superior and middle temporal gyrus was associated with anxiety at 1 month after stroke. Moreover, better mentality is associated with deterioration of anxiety within 1 month after stroke, and larger lesion volume is associated with deterioration of depression within 1 month after stroke.

Depression increases stroke hospitalization cost: an analysis of 17,010 stroke patients in 2008 by race and gender

Objective. This analysis focuses on the effect of depression on the cost of hospitalization of stroke patients. Methods. Data on 17,010 stroke patients (primary diagnosis) were extracted from 2008 Tennessee Hospital Discharge Data System. Three groups of patients were compared: (1) stroke only (S^O, n = 7,850), (2) stroke + depression (S^+D, n = 3,965), and (3) stroke + other mental health diagnoses (S^+M, n = 5,195). Results. Of all adult patients, 4.3% were diagnosed with stroke. Stroke was more prevalent among blacks than whites (4.5% versus 4.2%, P < 0.001) and among males than females (5.1% versus 3.7%, P < 0.001). Nearly one-quarter of stroke patients (23.3%) were diagnosed with depression/anxiety. Hospital stroke cost was higher among depressed stroke patients (S^+D) compared to stroke only (S^O) patients ($77,864 versus $47,790, P < 0.001), and among S^+D, cost was higher for black males compared to white depressed males ($97,196 versus $88,115, P < 0.001). Similar racial trends in cost emerged among S^+D females. Conclusion. Depression in stroke patients is associated with increased hospitalization costs. Higher stroke cost among blacks may reflect the impact of comorbidities and the delay in care of serious health conditions. Attention to early detection of depression in stroke patients might reduce inpatient healthcare costs.

The natural history of depression up to 15 years after stroke: the South London Stroke Register

BACKGROUND AND PURPOSE

Evidence on the natural history of depression after stroke is still insufficient to inform prognosis and treatment strategies. This study estimates the incidence, cumulative incidence, prevalence, time of onset, duration, and recurrence rate of depression up to 15 years after stroke.

METHODS

Data from patients registered in the South London Stroke Register between 1995 and 2009 were used (N=4022 at registration. Maximum number of participants for these analyses n=1233). Depression was assessed in all patients with the Hospital Anxiety and Depression Scale (scores >7=depression) 3 months after stroke, 1 year after stroke, and annually thereafter up to 15 years after stroke. Inverse probability weighting was used to calculate the estimates accounting for missing data.

RESULTS

The poststroke incidence of depression ranged from 7% to 21% in the 15 years after a stroke, with cumulative incidence of 55% and prevalence ranging from 29% to 39%. Most episodes of depression started within a year of stroke, with 33% of the cases starting in the 3 months after a stroke, and none from year 10 onward. Fifty percent of the patients with depression at 3 months had recovered 1 year after stroke. The proportion of recurrent episodes of depression after stroke increased gradually from 38% in year 2 to 100% in years 14 and 15.

CONCLUSIONS

The natural history of depression after stroke is dynamic. Depression affects most of the stroke patients with episodes that have a short duration but a high risk of recurrence in the long term.

Depressive symptoms among the medically hospitalized older individuals -- a 1-year follow-up study

AIM

The present follow-up study of older medically hospitalized patients from a rural area in Norway assessed the prevalence of depressive symptoms at 1-year follow-up and furthermore explored whether depressive symptoms at follow-up was associated with change in the medical, functional or emotional situation between baseline and follow-up.

METHODS

A 1-year follow-up study included 363 (175 men) older medical inpatients with age range 65-98 (mean = 80.2; standard deviation (SD) = 7.5) years. Information was collected at baseline and follow-up using the Hospital Anxiety and Depression scale (HAD), the Mini-Mental State Examination, Lawton and Brody's scales for physical self-maintenance and performance of the instrumental activities of daily living.

RESULTS

The prevalence of depressive symptoms, as defined by a score ≥ 8 at HAD-D, was 10% at baseline and 7% at follow-up. Of those with depressive symptoms at baseline, 78% had experienced remission. The incidence of depressive symptoms at follow-up was 5%. In logistic regression analyses adjusted for age, gender, and depressive symptoms at baseline, becoming or being in need of assistance from nursing or social services (odds ratio (OR) = 8.1, 95% CI: 1.9-34.2 and OR = 4.4, 95% CI: 1.1-17.4, respectively), having a cognitive decline (OR = 1.1, 95% CI: 1.0-1.3), and exhibiting poorer physical self-maintenance (OR = 1.2, 95% CI: 1.0-1.3), becoming vision impaired (OR = 8.3, 95% CI: 2.8-25.0), and with increased anxiety (OR = 1.2, 95% CI: 1.0-1.3) during follow-up was associated with depressive symptoms at follow-up.

CONCLUSION

The 1-year follow-up study of older medical inpatients contributes to the research body regarding risk factors of depression in older people.