Comprehensive Rehabilitation Training Decreases Cognitive Impairment, Anxiety, and Depression in Poststroke Patients: A Randomized, Controlled Study

Non-pharmacological interventions to treat mood disturbances post-stroke: a systematic review

BACKGROUND

Stroke survivors face high rates of depression, anxiety, and pseudobulbar affect. Clinicians report lack of clarity on effective non-pharmacological interventions due to uncertainty about treatment options as barriers to evidence-based treatment. No systematic review has investigated the effectiveness of non-pharmacological interventions on the conditions of depression, anxiety, and pseudo-bulbar affect.

OBJECTIVES

The aim of this study was to evaluate the effectiveness of non-pharmacological interventions on the outcomes of depression, anxiety, and pseudobulbar affect in post-stroke individuals.

METHODS

Following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched databases Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO for randomized controlled trials in English, within 2012-2023, evaluating the effect of a non-pharmacological intervention on depression, anxiety, and/or pseudobulbar affect. Two researchers screened titles, abstracts, and full texts. One researcher extracted data and assessed risk of bias. Data were synthesized narratively.

RESULTS

Forty-two studies were included. Intervention types included education (n = 9), psychological therapy (n = 8), and physical exercise (n = 8). Intervention types reporting positive outcomes for depression were psychological therapy (n = 6), physical exercise (n = 3) and robot-assisted therapy (n = 3). Intervention types effective in improving anxiety were physical exercise (n = 2), psychological therapy (n = 3) and multi-modal therapy approaches (n = 2). No studies explored the impact on pseudobulbar affect.

CONCLUSION

Non-pharmacological interventions may be effective in improving mood in stroke survivors. Robot-assisted therapy and physical exercise were seen to improve multiple outcome measures. Patient education should be delivered alongside rehabilitation and directed to both stroke-survivor and caregiver.

Linear and non-linear associations of depressive symptoms with oral health knowledge, attitudes, and practices among rural older adults in China: a cross-sectional study

BACKGROUND

Depression affects the oral health of older adults; however, little is known about its impact on oral health among rural older adults in developing countries, which warrants further research. Taking China as an example, there is a large population base of rural older adults suffering from depression, and many rural older people also have long-term oral health problems, which have seriously affected their quality of life in later life. Therefore, this study aimed to explore linear and non-linear associations of depressive symptoms with oral health knowledge, attitudes, and practices among rural older adults in China.

METHODS

From November 2020 to December 2020, 1,902 rural community-dwelling older people aged 60 years and older were investigated, via a cross-sectional survey. The general information, depressive status, oral health knowledge, attitudes, and practices of the participants were obtained through face-to-face structured questionnaires. Among them, the Zung Depression Self-Rating Scale was used to investigate the depressive symptoms of the participants in this survey. The generalized linear model and classification and regression tree model were used, separately.

RESULTS

Based on linear analysis results, we found that minimal to mild depressive symptoms [regression coefficient (β) = -0.345; 95% confidence interval (CI): -0.582 to -0.109, P = 0.004] and depressive symptoms (β = -1.064; 95% CI: -1.982 to -0.146, P = 0.023) were significantly correlated with oral health knowledge. A negative correlation was observed between minimal to mild depressive symptoms (β = -0.385; 95% CI: -0.600 to -0.170, P < 0.001) and oral health attitudes. In addition, while both minimal to mild depressive symptoms (β = 0.018; 95% CI: -0.312 to 0.347, P = 0.916) and depressive symptoms (β = 0.604; 95% CI: -0.675 to 1.883, P = 0.355) were associated with oral health practices. Furthermore, the non-linear analysis showed a combined effect of depressive symptoms on oral health attitudes, indicating that older people of a younger age, not living alone, and not suffering from depressive symptoms are more likely to report better oral health attitudes.

CONCLUSION

Both the linear and non-linear analyses in our study showed that depressive symptoms are significantly correlated with the poor oral health attitudes of older adults in rural communities. Furthermore, depressive symptoms were associated with oral health knowledge in the linear analysis. However, no statistically significant difference was found between depressive symptoms and oral health practices in either analysis. This research deepens our knowledge and understanding of relevant evidence in the mental and oral health of people in later life. In addition, analyzing the factors that affect the oral health of older people from the perspective of their depressive status provides new thinking directions and scientific references for improving the oral health of older adults in practical life.

Amygdala structural and functional reorganization as an indicator of affective dysfunction in patients with tinnitus

The aim of this study was to systematically investigate structural and functional alterations in amygdala subregions using multimodal magnetic resonance imaging (MRI) in patients with tinnitus with or without affective dysfunction. Sixty patients with persistent tinnitus and 40 healthy controls (HCs) were recruited. Based on a questionnaire assessment, 26 and 34 patients were categorized into the tinnitus patients with affective dysfunction (TPAD) and tinnitus patients without affective dysfunction (TPWAD) groups, respectively. MRI-based measurements of gray matter volume, fractional anisotropy (FA), fractional amplitude of low-frequency fluctuations (fALFF), regional homogeneity (ReHo), degree centrality (DC), and functional connectivity (FC) were conducted within 14 amygdala subregions for intergroup comparisons. Associations between the MRI properties and clinical characteristics were estimated via partial correlation analyses. Compared with that of the HCs, the TPAD and TPWAD groups exhibited significant structural and functional changes, including white matter integrity (WMI), fALFF, ReHo, DC, and FC alterations, with more pronounced WMI changes in the TPAD group, predominantly within the left auxiliary basal or basomedial nucleus (AB/BM), right central nucleus, right lateral nuclei (dorsal portion), and left lateral nuclei (ventral portion containing basolateral portions). Moreover, the TPAD group exhibited decreased FC between the left AB/BM and left middle occipital gyrus and right superior frontal gyrus (SFG), left basal nucleus and right SFG, and right lateral nuclei (intermediate portion) and right SFG. In combination, these amygdalar alterations exhibited a sensitivity of 65.4% and specificity of 96.9% in predicting affective dysfunction in patients with tinnitus. Although similar structural and functional amygdala remodeling were observed in the TPAD and TPWAD groups, the changes were more pronounced in the TPAD group. These changes mainly involved alterations in functionality and white matter microstructure in various amygdala subregions; in combination, these changes could serve as an imaging-based predictor of emotional disorders in patients with tinnitus.

Elaboration and validation of a novelty nomogram for the prognostication of anxiety susceptibility in individuals suffering from low back pain

Low back pain (LBP) constitutes a distressing emotional ordeal and serves as a potent catalyst for adverse emotional states, notably anxiety. We dedicated to discerning methodologies for identifying patients who are predisposed to heightened levels of anxiety and pain. A self-assessment questionnaire was administered to patients afflicted with LBP. The pain scores were subjected to analysis in conjunction with anxiety scores, and a clustering procedure was executed using the scientific k-means methodology. Subsequently, six machine learning algorithms, including Logistics Regression (LR), K-Nearest Neighbor (KNN), Decision Tree (DT), Support Vector Machine (SVM), Random Forest (RF), and Extreme Gradient Boosting (XGB), were employed. Next, five pertinent variables were identified, namely Age, Course, Body Mass Index (BMI), Education, and Marital status. Furthermore, a LR model was utilized to construct a nomogram, which was subsequently subjected to assessment for discrimination, calibration, and evaluation of its clinical utility. As a result, 599 questionnaires were valid (effective rate: 99 %). The correlation analysis revealed a significant association between anxiety and pain scores (r = 0.31, P < 0.001). LBP patients could be divided into two clusters, Cluster1 had higher pain scores (P < 0.05) and SAS scores (P < 0.001). The proposed nomogram demonstrated an area under the receiver operating characteristics curve (ROC) of 0.841 (95 %CI: 0.804-0.878) and 0.800 (95 %CI: 0.733-0.867) in the training and test groups, respectively. Briefly, the established nomogram has demonstrated remarkable proficiency in discerning individuals afflicted with LBP who are at a heightened risk of experiencing anxiety.

[Prevention of Post-Stroke Depression]

Post-stroke depression (PSD) is a clinically relevant complication of ischemic and hemorrhagic cerebral infarction that affects about 30% of all stroke survivors. It is associated with reduced quality of life as well as delayed recovery from neurological deficits and functional impairment, frequently leading to impeded rehabilitation. Suitable screening methods allow early detection of PSD. Timely initiation of treatment in patients with manifest PSD as well as implantation of effective prevention strategies can help reduce medical and socioeconomic burden associated with the disease. We reviewed the current literature on pharmacological and non-pharmacological prevention of PSD.

Knowledge and coping style about depression in medical students: A cross-sectional study in China

OBJECTIVES

The current study aimed at ascertaining the depression levels of medical students and their knowledge levels of depression, and exploring the relationship between the level of knowledge and coping styles of the medical students on depression.

METHODS

An online-based survey was developed in Changzhi Medical College. The questionnaire included demographic and socioeconomic data, questions about depression knowledge and copying styles of depression, and the Zung Self-Rating Depression Scale (SDS). A total of 1931 questionnaires were returned by respondents.

RESULTS

The medical students produced a mean SDS score of 44.29 (SD = 11.67). The prevalence of depression was 29.7%. Sophomore, female, and poor family relationships were parameters associated with a higher SDS score. The total correct rate for knowledge of depression was 64.14%. There were statistical differences between with depression students and non-depression students on the rate of the correct answers in the following questions:"Female has more probability", "Depression can be adjusted by oneself", "Associated with one's character", "Know cure method of depression", "Know drug use of depression", "Know depression influence for health", and "Know prevention method of depression". Depression students were more likely to have a lower rate of correct answer for above questions. Asking for help from psychological consultation was the primary coping mechanism among the medical students. The logistic regression analysis results found that depressed students who chose the coping way of no ways of coping were more likely to be females OR = 1.470 (1.078, 2.005), residents in rural area OR = 1.496 (1.038, 2.156), in poor family relationships OR = 2.428 (1.790, 3.293), and have lower cognitive level of depression knowledge OR = 1.920 (1.426, 3.226).

CONCLUSIONS

It is necessary to focus on mental health of medical students, especially in female, residents in rural area, in poor family relationships, and having lower cognitive level of depression knowledge. Medical students were insufficient on depression knowledge and coping styles, and efforts that train students know risk of impaired mental health could also improve diagnosis and treatment.

Effect of a Hospital-To-Home Transitional Intervention Based on an Interaction Model of Client Health Behavior for Adult Patients with Stroke

To develop and identify the effectiveness of a hospital-to-home transitional intervention based on an interaction model of client health behavior in adult patients with stroke. A non-equivalent control group pretest-posttest. Thirty-eight patients participated (18=intervention, 20=control); the intervention group received 12 weeks of the intervention. The intervention influenced anxiety, disease severity, health behavior adherence, patient satisfaction, and quality of life in adult patients with stroke. Transitional programs have potential to improve the health behaviors of subjects, and community health nurses can assist in the implementation of these programs. Health behaviors and quality of life scores were significantly higher in the intervention group than in the control group; these findings support the need for continuity of nursing care during the transitional period for patients with stroke. Given the challenges faced by adult stroke patients after stroke, community nurses should pay attention to patients' transitional experiences.

The effect of HIIT on body composition, cardiovascular fitness, psychological well-being, and executive function of overweight/obese female young adults

Purpose

To evaluate the effect of a short-term HIIT program on the selected health-related parameters for overweight/obese young adult women in a university context.

Methods

A total of 48 participants were randomly divided into two groups. The exercise group (HIIT) received a HIIT intervention of aerobics for 4 weeks, while the control group (CON) received no training. Body composition including waist circumference (WC), body fat percentage (BF %), Cardiorespiratory fitness (VO2max), the score of Self-Rating Depression Scale (SDS), and Stroop word-color test (SCWT) results were assessed before and after the intervention along with within- and between-group comparisons.

Results

All the indices were significantly improved in HIIT group (p < 0.01) after 4 weeks of intervention. No significant changes were found in CON. There were significant differences between HIIT and CON in cardiovascular fitness (p < 0.01), SDS (p < 0.01) and SCWT (p < 0.05) before and after 4 weeks. In addition, weekly measurements of HIIT effects showed significant changes (p < 0.01) from the second week in the variables of body composition, VO2max, SDS and SCWT when compared with the baseline and maintained the tendency till the end of program.

Conclusion

The short-term HIIT aerobics of the campus program conducted in a non-lab setting induced significant improvements in body composition, cardiovascular fitness, psychological well-being and executive function in overweight young female adults.

Transcranial direct current stimulation for the treatment of post-stroke depression: A systematic review

Background

Post-stroke depression (PSD) is not only a frequent neuropsychiatric manifestation secondary to stroke but is also associated with disability, poor rehabilitation outcomes, sleep disorders, cognitive impairment, and increased mortality. Transcranial direct current stimulation (tDCS), a primary modality of non-invasive brain stimulation (NIBS), has shown promising clinical results in the rehabilitation of patients with PSD recently. The primary aim of this systematic review is to assess the effects of tDCS on PSD.

Methods

PubMed and Cochrane databases were used for paper identification up to May 2022. Only English language studies and published data were taken into consideration. The methodological quality of selected studies was assessed according to the modified Sackett Scale, based on Physiotherapy Evidence Database (PEDro) scores.

Results

Six experimental studies were included for the PSD treatment of tDCS and all of them reported that, following the intervention of tDCS, the experimental group shows a statistically significant decrease in the depression level in accordance with different assessment scales.

Conclusion

This article simply aims at providing a comprehensive overview of the raw data reported in this field to date. Based on the current evidence, tDCS presents promising results for the treatment of PSD. Moreover, tDCS is also effective in PSD patients with aphasia or CPSP. However, an optimal stimulation protocol is needed to formulate. Thus, the development of robustly controlled, randomized, and high-quality clinical trials to further assess the utility of tDCS as a therapeutic tool for the treatment of PSD survivors is encouraged.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023322076, identifier: CRD42023322076.

Factors Associated with Medication Adherence among Community-Dwelling Older People with Frailty and Pre-Frailty in China

BACKGROUND

Frail and pre-frail older people often need to take medications. However, factors related to medication adherence among this population remain unclear, warranting further research. This study aims to identify correlates of medication adherence among frail and pre-frail older adults.

METHODS

From November 2020 to December 2020; a total of 4218 community-dwelling residents aged ≥ 60 years were interviewed by a cross-sectional survey in China. Data on subjects' general information; medication adherence; and frailty status was obtained via the face-to-face structured questionnaire. Logistic regression models were fitted; separately; to examine these factors linked to medication adherence.

RESULTS

We found that 36.2% (n = 1527) and 18.8% (n = 792) of respondents were classified as pre-frail and frail. According to the Morisky scale scores, 66.74% (n = 2815) were found to have adequate medication adherence, and 33.26% (n = 1403) were found to have inadequate medication adherence. Among the pre-frail respondents, age (adjusted odds ratio (AOR) = 1.64; 95% confidence interval (CI): 1.18-2.29, P = 0.003), marital status (AOR = 1.52; 95% CI: 1.04-2.21, P = 0.030), smoking status (AOR = 0.61; 95% CI: 0.37-0.99, P = 0.044), and functional ability (AOR = 0.72; 95% CI: 0.58-0.91, P = 0.006) were significantly related to medication adherence. Among them, advanced age and single were risk factors, which were positively related to the medication adherence of subjects in pre-frailty, while quitting smoking and limited functional ability contributed to improving their medication adherence. In contrast, only age (AOR = 1.77; 95% CI: 1.16-2.69, P = 0.008) was significantly associated with medication adherence among frail subjects.

CONCLUSION

Influencing factors to medication adherence of old people in pre-frailty and frailty have been enriched, which provides a certain reference for promoting medication adherence in this population. Future adherence intervention methods should be designed based on these factors.

Rehabilitation interventions for cognitive deficits in stroke survivors: A systematic review of randomized controlled trials

Cognitive deficits are one of the most common impairments after stroke. It negatively affects physical and social functioning. Rehabilitation interventions for cognitive deficits post-stroke have taken less consideration. The present study aimed to provide an overview of the effects of various rehabilitation interventions on cognitive functions in patients with stroke. PUBMED, SCOPUS, PEDro, EMBASE, MEDLINE, and REHABDATA were searched for randomized controlled trials (RCTs) investigating the effects of rehabilitation interventions on cognitive domains poststroke until August 2021. The methodological quality of the selected studies was evaluated using the Cochrane Collaboration tool, and the effect sizes were calculated. Forty-four studies met the inclusion criteria. A total of 3561 individuals with stroke, 57.60% of whom were males. The mean age for all participants was 65.48 years. Eighteen RCTs were high, moderate (n = 17), and low methodological quality (n = 9). The results showed evidence for the beneficial effects of many rehabilitation interventions on cognition in individuals with stroke. Rehabilitation plays a crucial role in improving cognitive functions in stroke patients with mild cognitive deficits. Virtual reality (VR), computer-based cognitive rehabilitation (CBCR), and non-aerobic exercises may promote cognitive functions in patients with stroke.

The impacts of COVID-19 outbreak on mental health in general population in different areas in China

BACKGROUND

This study aimed to explore the impacts of COVID-19 outbreak on mental health status in general population in different affected areas in China.

METHODS

This was a comparative study including two groups of participants: (1) general population in an online survey in Ya'an and Jingzhou cities during the COVID-19 outbreak from 10-20 February 2020; and (2) matching general population selected from the mental health survey in Ya'an in 2019 (from January to May 2019). General Health Questionnaire (GHQ-12), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS) were used.

RESULTS

There were 1775 participants (Ya'an in 2019 and 2020: 537 respectively; Jingzhou in 2020: 701). Participants in Ya'an had a significantly higher rate of general health problems (GHQ scores ⩾3) in 2020 (14.7%) than in 2019 (5.2%) (p < 0.001). Compared with Ya'an (8.0%), participants in Jingzhou in 2020 had a significantly higher rate of anxiety (SAS scores ⩾50, 24.1%) (p < 0.001). Participants in Ya'an in 2020 had a significantly higher rate of depression (SDS scores ⩾53, 55.3%) than in Jingzhou (16.3%) (p < 0.001). The risk factors of anxiety symptoms included female, number of family members (⩾6 persons), and frequent outdoor activities. The risk factors of depression symptoms included participants in Ya'an and uptake self-protective measures.

CONCLUSIONS

The prevalence of psychological symptoms has increased sharply in general population during the COVID-19 outbreak. People in COVID-19 severely affected areas may have higher scores of GHQ and anxiety symptoms. Culture-specific and individual-based psychosocial interventions should be developed for those in need during the COVID-19 outbreak.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

Rehabilitation of Cognitive Deficits Poststroke: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Despite the prevalence of cognitive impairment poststroke, there is uncertainty regarding interventions to improve cognitive function poststroke. This systematic review and meta-analysis evaluate the effectiveness of rehabilitation interventions across multiple domains of cognitive function.

METHODS

Five databases were searched from inception to August 2019. Eligible studies included randomized controlled trials of rehabilitation interventions for people with stroke when compared with other active interventions or standard care where cognitive function was an outcome.

RESULTS

Sixty-four randomized controlled trials (n=4005 participants) were included. Multiple component interventions improved general cognitive functioning (MD, 1.56 [95% CI, 0.69-2.43]) and memory (standardized MD, 0.49 [95% CI, 0.27-0.72]) compared with standard care. Physical activity interventions improved neglect (MD, 13.99 [95% CI, 12.67-15.32]) and balance (MD, 2.97 [95% CI, 0.71-5.23]) compared with active controls. Noninvasive brain stimulation impacted neglect (MD, 20.79 [95% CI, 14.53-27.04) and functional status (MD, 14.02 [95% CI, 8.41-19.62]) compared with active controls. Neither cognitive rehabilitation (MD, 0.37 [95% CI, -0.94 to 1.69]) nor occupational-based interventions (MD, 0.45 [95% CI, -1.33 to 2.23]) had a significant effect on cognitive function compared with standard care.

CONCLUSIONS

There is some evidence to support multiple component interventions, physical activity interventions, and noninvasive brain stimulation improving cognitive function poststroke. Findings must be interpreted with caution given the overall moderate to high risk of bias, heterogeneity of interventions, and outcome measures across studies.

Anxiety, depression, psychological stress and coping style in medical postgraduates in southeastern China when restricted to commuting between the campus and hospital during the COVID-19 pandemic

BACKGROUND

As the COVID-19 epidemic was gradually brought under control, a new autumn semester began in 2020. How was the mental health of postgraduates as they experienced quarantine at home, only commuting between the school and hospital?

METHODS

The research was conducted in a cross-sectional online survey in October 2020. The data were collected from 1,645 medical postgraduates (master's and doctoral students) by using the demographic information questionnaire, the Self-rating Depression Scale (SDS), the Self-rating Anxiety Scale (SAS), the Questionnaire on Psychological Stressors of Postgraduates (QPSP), the Simplified Coping Style Questionnaire (SCSQ) and the Social Support Rate Scale (SSRS). One-way ANOVA and Pearson correlation were used to explore the relationships among anxiety, depression, psychological stressors, social support and coping style. Structural equation modeling (SEM) was conducted to assess the mediation model.

RESULTS

Among the total of 1,645 medical postgraduates, 21.6% (n = 356) had self-rated depression symptoms, and 9.4% (n = 155) had self-rated anxiety symptoms. The main disturbances they experienced were employment, academic and interpersonal pressure. The master of third grade students had the highest employment pressure, and the master of second grade students had the highest academic and interpersonal pressure. Negative coping played a negative mediating role and social support played a positive mediating role in the relationships between perceived stress and anxiety (β = 0.027, P < 0.01; β = 0.124, P < 0.01) and depression (β = 0.016, P < 0.01; β = 0.193, P < 0.01).

CONCLUSION

Medical postgraduates in China restricted to studies on campus and in the hospital experienced psychological distress. Our results suggest that providing employment and learning guidance, while strengthening social support and guiding positive coping may be effective at improving the mental health of the medical graduate students, mediating their perceived stress and negative emotions.

Impact of Academic Support on Anxiety and Depression of Chinese Graduate Students During the COVID-19 Pandemic: Mediating Role of Academic Performance

INTRODUCTION

The COVID-19 pandemic broke out and has spread globally since 2019. It became a public health concern. This pandemic has brought tremendous changes in students' lives and modes of learning. Graduate students are likely to be more affected as they are a part of a special training program. According to the main-effect model, social support has a positive effect on mental health. The pandemic has exerted a negative impact on the social support of individuals, and as a result, the behavior of a person is more likely to be at risk and has resulted in psychological crisis in people/individuals.

METHODS

A sample of 3137 graduate students responded to the instrument developed to assess the impact of the pandemic on the academic activities and performance, Self-rating Anxiety Scale and Self-rating Depression Scale.

RESULTS

The results showed that: 1) the pandemic impacted the academic support and performance of graduate students in varying degrees, 21% of graduate students experienced anxiety, and 33.9% of graduate students experienced depressive symptoms in varying degrees; 2) academic support variables (ie, academic exchange with mentors and peers) and academic performance variables (ie, data collection and thesis writing) were significantly associated with anxiety and depressive symptoms; 3) the model fitted the data well (RMSEA = 0.029; SRMR = 0.014; TLI = 0.99; CFI = 0.996). The direct effects of academic support on anxiety and depressive symptoms were significant. The impact on academic performance played a mediating role between the impact on academic support, anxiety, and depressive symptoms.

DISCUSSION

Academic support significantly affected academic performance, which in turn affected anxiety and depressive symptoms. So, it implies that, due to the pandemic, the academic support for graduate students had decreased, resulting in deterioration in academic performance, causing anxiety and depressive symptoms.

Depression and Anxiety after Stroke in Young Adult Filipinos

BACKGROUND AND OBJECTIVES

Young adult patients may suffer from poststroke depression (PSD) and anxiety. Few studies have evaluated these important psychiatric conditions that may lead to adverse outcomes in young adults. We aimed to determine the prevalence of PSD and anxiety as well as to identify their predictors in a population of young Filipino adults (18-49 years old).

METHODS

We performed a cross-sectional epidemiologic study in the largest tertiary hospital in the Philippines. The study involved the administration of a structured survey tool and review of medical records. The Hospital Anxiety and Depression Score - Pilipino version (HADS-P) was used to screen for anxiety and depression. Multivariable logistic regression analysis was performed to determine significant socio-economic and clinical risk factors of PSD and anxiety.

RESULTS

114 young adult stroke patients were included. The prevalence of depression was 20.2% while that of anxiety was 34.2%. Significant predictors of PSD were the presence of anxiety (OR 1.84; CI 1.05-3.22), lower mRS scores (mRS 3-5 OR 5.52; 95% CI 1.09-8.03) and diabetes (OR 2.09; 95% CI 1.67-6.26). Meanwhile, significant predictors of poststroke anxiety included depression (OR 7.5; 95% CI 5.02-21.94) and dependency (Barthel Index scores 95-100; OR 0.94; 95% CI 0.89-0.99). Relationship status, educational attainment, stroke subtype and location were not found to be significant predictors of PSD and anxiety.

CONCLUSION

A significant proportion of young adults suffered from depression and anxiety after stroke. Clinicians should be aware of these psychiatric conditions that influence outcomes and quality of life of young adults with stroke.

Multimodal brain imaging effect of "Adjust Zang-fu and Arouse Spirit" electroacupuncture on diabetic cognitive impairment: study protocol of a randomized, sham-controlled pilot trial

BACKGROUND

Diabetic cognitive impairment (DCI) is a serious chronic complication caused by diabetes. The pathogenesis of DCI is complex, but brain nerve injury and brain nerve cell apoptosis are important pathological changes. Multimodal brain imaging is one of the most important techniques to study the neural mechanism of the brain. For the clinical treatment of DCI, there is no effective targeted Western medicine and a lack of clear drug intervention methods. Therefore, there is an urgent need to find effective complementary and alternative methods and clarify their mechanism. This research seeks to explore the multimodal brain imaging effect of "Adjust Zang-fu and Arouse Spirit" electroacupuncture for DCI.

METHODS

This clinical research will be a randomized, sham-controlled pilot trial. Eligible participants will be randomly assigned to the intervention group (n = 60) and the control group (n = 30). The intervention group will be divided into the "Adjust Zang-fu and Arouse Spirit" electroacupuncture group (n = 30) and sham electroacupuncture group (n = 30). All participants will continue to receive routine hypoglycemic therapy. The treatment period is the same in both groups. The primary outcomes include functional magnetic resonance imaging (fMRI), magnetic resonance spectroscopy (MRS), Montreal Cognitive Assessment Scale (MoCA), and Clinical Dementia Rating (CDR). The secondary outcomes include blood glucose and blood lipid tests, Instrumental Activities of Daily Living Scale (IADL), Hachinski Ischemic Scale (HIS), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS). Outcomes will be assessed at baseline and before and after treatment, and adverse events will be examined. Inter- and intragroup analyses will be performed.

DISCUSSION

This randomized controlled study, combined with multimodal brain imaging techniques and a clinical evaluation scale, was designed to explore the mechanism of "Adjust Zang-fu and Arouse Spirit" electroacupuncture in improving the central nervous system in DCI.

TRIAL REGISTRATION

Chinese Clinical Trial Registration ChiCTR2000040268 . Registered on 26 November 2020.

The novel effectiveness of Tai Chi on cardiopulmonary fitness among stroke patients in the recovery phase: a study protocol for a randomized controlled trial

BACKGROUND

Stroke is the leading cause of death worldwide. China faces a similar risk of stroke as developed countries because of considerable changes in lifestyle, such as overeating and smoking. Tai Chi is a traditional form of mind-body exercise that has been widely practiced in China for thousands of years. However, there are few studies on the effect of Tai Chi on the cardiopulmonary function of stroke patients in the recovery phase. Therefore, it is necessary to observe the effect of Tai Chi on the cardiorespiratory fitness of patients after stroke.

METHODS

This is a parallel-design, two-arm, analyst assessor-blinded, randomized controlled trial. A total of 226 stroke patients in the recovery phase will be recruited and assigned randomly to a control group or Tai Chi group at a 1:1 ratio. The patients in the Tai Chi group will perform the Tai Chi exercise. The patients in the control group will perform walking exercises. Patients in both groups will receive conventional treatments and healthy education. The primary outcomes will be VO2peak and scores on the MOS item short form health survey (SF-36) scale. Secondary outcomes will include vital capacity (VC), ejection fractions (EF), and cardiac output (CO). The assessments of the tests will be performed at three time points (before exercise, at the end of exercise, and 6 weeks after exercise). Adverse events will be recorded faithfully during the study.

DISCUSSION

If the results are positive, this study will contribute to the establishment of further guided Tai Chi rehabilitation programs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000034719 . Registered on 16 July 2020.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment

BACKGROUND AND PURPOSE

The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis.

METHODS

Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations.

RESULTS

There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes.

CONCLUSIONS

These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Preventive Approaches for Post-Stroke Depression: Where Do We Stand? A Systematic Review

PURPOSE

Post-stroke depression (PSD) occurs in one-third of stroke survivors, leading to a substantial decrease in quality of life as well as delayed functional and neurological recovery. Early detection of patients at risk and initiation of tailored preventive measures may reduce the medical and socioeconomic burden associated with PSD. We sought to review the current evidence on pharmacological and non-pharmacological prevention of PSD.

MATERIALS AND METHODS

We conducted a systematic review using PubMed/MEDLINE and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including randomized controlled studies. Eligible studies were included when performed within 1 year after the index cerebrovascular event. Animal and basic research studies, studies lacking a control group, review papers, and case reports were excluded.

RESULTS

Out of 150 studies screened, 37 met our criteria. Among the strategies identified, administration of antidepressants displayed the most robust evidence for preventing PSD, whereas non-pharmacological interventions such as psychotherapy appear to be the most frequently used approaches to prevent depression after stroke. Research suggests that the efficacy of PSD prevention increases with the duration of preventive treatment. Seven out of 11 studies (63%) that used pharmacological and eight out of 16 (50%) that used non-pharmacological interventions reported a positive preventive effect on PSD.

CONCLUSION

Overall, the current literature on PSD prevention shows heterogeneity, substantiating a need for well-designed randomized controlled trials to test the safety and efficacy of pharmacological as well as non-pharmacological and composite prevention regimens to minimize the risk of PSD in stroke survivors. Integrative strategies combining personalized non-pharmacological interventions such as educational, mental, and physical health support, and pharmacological strategies such as SSRIs may be the most promising approach to prevent PSD.

Post-stroke depression: Chaos to exposition

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

Cerebral Functional Manipulation of Repetitive Transcranial Magnetic Stimulation in Cognitive Impairment Patients After Stroke: An fMRI Study

Objective: Recently, the area of repetitive transcranial magnetic stimulation (rTMS) targeting neurological rehabilitation has been advanced as a potential treatment for post-stroke cognitive impairment (PSCI). However, the underlying mechanisms remains to be elusived. This study aims to figure out cerebral functional manipulation of rTMS in patients with PSCI through using the resting-state functional magnetic resonance imaging (rs-fMRI).

Methods: Thirty patients with PSCI were recruited and randomly allocated into two groups: the rTMS intervention group and control group. The rTMS intervention group was given 20 min of 5 Hz rTMS (or control) over left dorsolateral prefrontal cortex (DLPFC) besides routine cognitive intervention training for 3 consecutive weeks, five times per week, on weekdays. Cognition performance was assessed by the Minimum Mental State Examination (MMSE) and Montreal cognitive assessment (MoCA). Neural activity and functional connectivity (FC) changes were acquired by rs-fMRI with fractional amplitude of low-frequency fluctuation (fALFF) and seed-based correlation analysis.

Results: Cognition improvements were observed both in rTMS intervention group and control group (P < 0.01), while the rTMS group got more significant improvent than control group (P < 0.05). To be specified, compared with the control group, the rTMS group got higher fALFF values in these brain regions including superior temporal gyrus, inferior frontal gyrus and parahippocampal gyrus, while lower fALFF values in middle temporal gyrus, middle frontal gyrus and fusiform gyrus. In addition, the rTMS group showed increased FC between LDPFC and toprecuneus, inferior temporal gyrus, middle and inferior frontal gyrus and marginal gyrus, while decreased FC between LDPFC and middle temporal gyrus and thalamus.

Conclusion: The increase and decrease of neural activity and FC in cognition-related regions detected by rs-fMRI are good indicators to clarify the underlining mechanisms of rTMS on PSCI.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Prevalence of depression and anxiety and correlations between depression, anxiety, family functioning, social support and coping styles among Chinese medical students

Background

Medical students experience depression and anxiety at a higher rate than the general population or students from other specialties. While there is a growing literature on the high prevalence of depression and anxiety symptoms and about potential risk factors to the prevalence of depression and anxiety symptoms among medical students, there is a paucity of evidence focused on the prevalence of depression and anxiety symptoms and associations with family function, social support and coping styles in Chinese vocational medicine students. This study aims to investigate the prevalence of depression and anxiety symptoms among Chinese medical students and assess the correlation between depression/anxiety symptoms and family function, social support and coping styles.

Methods

A sample of 2057 medical students from Chongqing Medical and Pharmaceutical College in China was investigated with a self-report questionnaire, which included demographic information, Zung self-rating depression scale, Zung Self-Rating Anxiety Scale, Family APGAR Index, Social Support Rating Scale and Trait Coping Style Questionnaire.

Results

The prevalence of depression and anxiety symptoms among the medical students was 57.5 and 30.8%, respectively. Older students(≥20 years) experienced higher levels of depression and anxiety. More depression and anxiety symptoms were exhibited among students with big financial burden, big study-induced stress and poor sleep quality. Students with large employment pressure showed more anxiety symptoms. Students who live alone or had bad relationship with their lovers or classmates or friends showed higher depression and anxiety scores. Depression and anxiety symptoms had highly significant correlations with family functioning, social support and coping style.

Conclusions

Academic staffs should take measures to reduce depression and anxiety among medical students and to provide educational counseling and psychological support for students to cope with these problems.

A systematic review and meta-analysis of the effects of cardiac rehabilitation interventions on cognitive impairment following stroke

PURPOSE

The cardiac rehabilitation model has potential as an approach to providing rehabilitation following stroke. This review aims to identify evidence for the participation of stroke patients in cardiac/cardiovascular rehabilitation programs internationally, whether or not such programs offer a cognitive intervention as part of treatment, and the impact of rehabilitation on post-stroke cognitive function.

METHOD

Five electronic databases were searched from inception to 1 May 2019, namely: MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and the Web of Science. Eligible studies included both randomized and non-randomized studies of cardiac rehabilitation-type interventions which measured cognitive function in patients with transient ischemic attack (TIA) or stroke.

RESULTS

Of 14,153 records reviewed, nine studies which delivered cardiac rehabilitation-type interventions to stroke patients were finally included. Only three of these studies delivered cognitive rehabilitation as part of the intervention. Cardiac rehabilitation had no statistically significant effect on cognitive function in five randomized controlled trials (standardized mean difference= 0.28, 95% CI= -0.16 to 0.73) or in three one group pre-post studies (standardized mean difference= 0.15, 95% CI= -0.03 to 0.33).

CONCLUSIONS

This review highlights that there are very few studies of delivery of cardiac rehabilitation to stroke patients and that the inclusion of cognitive interventions is even less common, despite the high prevalence of post-stroke cognitive impairment.IMPLICATIONS FOR REHABILITATIONThe cardiac rehabilitation model has the potential to be expanded to include patients post-stroke given the commonality of secondary prevention needs, thereby becoming a cardiovascular rehabilitation model.Up to half of patients experience cognitive impairment after stroke; suggesting that a post-stroke cardiovascular rehabilitation model should incorporate specific cognitive strategies for patients.This systematic review identified three cardiovascular rehabilitation programmes which delivered cognitive rehabilitation as part of treatment; however, evidence for efficacy is weak.

Treatment of Post-Stroke Depression

PURPOSE OF REVIEW

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

RECENT FINDINGS

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