Screening for mood disorders after stroke: a systematic review of psychometric properties and clinical utility

Validity of evaluation scales for post-stroke depression: a systematic review and meta-analysis

BACKGROUND

Post-stroke depression (PSD) is closely associated with poor stroke prognosis. However, there are some challenges in identifying and assessing PSD. This study aimed to identify scales for PSD diagnosis, assessment, and follow-up that are straightforward, accurate, efficient, and reproducible.

METHODS

A systematic literature search was conducted in 7 electronic databases from January 1985 to December 2023.

RESULTS

Thirty-two studies were included, the Patient Health Questionnaire-9 (PHQ-9) and Hamilton Depression Scale (HDRS) had higher diagnostic accuracy for PSD. The sensitivity, specificity, and diagnostic odds ratio of PHQ-9 or diagnosing any depression were 0.82, 0.87, and 29 respectively. And for HDRS, used for diagnosing major depression, the scores were 0.92, 0.89, and 94. Furthermore, these two scales also had higher diagnostic accuracy in assessing depressive symptoms during both the acute and chronic phases of stroke. In patients with post-stroke aphasia and cognitive impairment, highly diagnostic scales have not been identified for assessing depressive symptoms yet.

CONCLUSIONS

The PHQ-9 and HDRS scales are recommended to assess PSD. HDRS, which demonstrates high diagnostic performance, can replace structured interviews based on diagnostic criteria.

Continuous remote monitoring of neurophysiologic Immersion accurately predicts mood

Mental health professionals have relied primarily on clinical evaluations to identify in vivo pathology. As a result, mental health is largely reactive rather than proactive. In an effort to proactively assess mood, we collected continuous neurophysiologic data for ambulatory individuals 8-10 h a day at 1 Hz for 3 weeks (N = 24). Data were obtained using a commercial neuroscience platform (Immersion Neuroscience) that quantifies the neural value of social-emotional experiences. These data were related to self-reported mood and energy to assess their predictive accuracy. Statistical analyses quantified neurophysiologic troughs by the length and depth of social-emotional events with low values and neurophysiologic peaks as the complement. Participants in the study had an average of 2.25 (SD = 3.70, Min = 0, Max = 25) neurophysiologic troughs per day and 3.28 (SD = 3.97, Min = 0, Max = 25) peaks. The number of troughs and peaks predicted daily mood with 90% accuracy using least squares regressions and machine learning models. The analysis also showed that women were more prone to low mood compared to men. Our approach demonstrates that a simple count variable derived from a commercially-available platform is a viable way to assess low mood and low energy in populations vulnerable to mood disorders. In addition, peak Immersion events, which are mood-enhancing, may be an effective measure of thriving in adults.

The reliability, validity and clinical utility of the Clinical Outcomes in Routine Evaluation - ten-item version (CORE-10) in post-acute patients with stroke

OBJECTIVE

To explore the validity, reliability, and clinical utility of the Clinical Outcomes in Routine Evaluation - ten-item version (CORE-10: a ten-item questionnaire designed to measure psychological distress) in a stroke inpatient sample and calculate reliable and clinically significant change scores.

SETTING

A post-acute stroke rehabilitation ward in the East of England.

PARTICIPANTS

A total of 53 patients with stroke, capable of completing the CORE-10 as part of their routine clinical assessment. Exclusion criteria included moderate to severe aphasia and/or alexia.

MAIN MEASURES

Alongside the CORE-10, the Patient Health Questionnaire - 9, the Hospital Anxiety and Depression Scale, the Centre for Epidemiological Studies-Depression Scale, and the Beck Depression Inventory Second Edition were used as concurrent measures.

RESULTS

To assess reliability, the internal consistency and test-retest reliability of the CORE-10 were calculated. The average number of days between CORE-10 test-retest administrations was 2.84 (SD = 3.12, Mdn = 1). Concurrent validity was assessed by examining correlations between the CORE-10 and comparable measures, and clinical utility was assessed using the criteria of Burton and Tyson (2015). The internal consistency (Cronbach's alpha) for the CORE-10 was .80, and test-retest reliability interclass correlation coefficient was .81. Total score correlations between the CORE-10 and concurrent measures ranged from r = .49 to r = .89. The CORE-10 achieved the maximum score (i.e. 6/6) on criteria for clinical utility. Calculations demonstrated a reliable change index of nine points and a clinically significant change cut point of 12 on the CORE-10. Percentiles for CORE-10 total scores are reported.

CONCLUSIONS

This study provides preliminary support for the CORE-10 as a valid and reliable measure that has clinical utility for screening distress in inpatients with stroke.

Access to inpatient mood management services after stroke in Australian acute and rehabilitation hospitals

OBJECTIVE

Post-stroke mental health impairments are common, but under-assessed and under-treated. We aim to describe trends in the provision of mood management to patients with stroke, and describe factors associated with adoption of national mood management recommendations for stroke within Australian hospitals.

DESIGN

Secondary analysis of cross-sectional data from the biennial Stroke Foundation Audit Program.

SETTING

Participating acute (2011-2021) and rehabilitation hospitals (2012-2020) in Australia.

PARTICIPANTS

In the acute audit, 22,937 stroke cases were included from 133 hospitals. In the rehabilitation audit, 15,891 stroke cases were included from 127 hospitals.

MAIN MEASURES

Hospital- and patient-level mood management processes.

RESULTS

Among 133 acute hospitals (22,937 stroke episodes), improvements were made between 2011 and 2021 in utilization of mood screening (17% [2011], 33% [2021]; p < 0.001) and access to psychologists during hospital stay (18% [2011], 45% [2021]; p < 0.001). There was no change in access to a psychologist among those with a mood impairment (p = 0.34). Among 127 rehabilitation hospitals (15,891 stroke episodes) improvements were observed for mood screening (35% [2012], 61% [2020]; p < 0.001), and access to a psychologist during hospital stay (38% [2012], 68% [2020]; p < 0.001) and among those with a mood-impairment (30% [2012], 50% [2020]; p < 0.001). Factors associated with receiving mood management processes included: younger age, not requiring an interpreter and longer length of stay.

CONCLUSIONS

Adherence to mood management recommendations has improved over 10 years within Australian hospitals. Those aged over 65, requiring an interpreter, or with shorter hospital stays are at risk of missing out on appropriate mood management.

Pre-stroke and early post-stroke apathy is associated with increased risk of dementia 3 months after stroke

OBJECTIVES

Apathy is a frequent neuropsychiatric syndrome after stroke. We determined whether pre-morbid and early post-stroke apathy predicts dementia 3 months after stroke.

METHODS

We included ischemic stroke patients without dementia who participated in the Prospective Observational Polish Study on post-stroke delirium. We used the Neuropsychiatric Inventory and clinician-reported version of Apathy Evaluation Scale to score apathy symptoms before stroke and on day 8 after stroke. Patients underwent neuropsychological examination 3 months after stroke.

RESULTS

Of 422 patients with ischemic stroke and without pre-stroke dementia, 194 patients (mean age: 67.5 ± 12.3; 45.9% female) underwent neuropsychological examination. Dementia was diagnosed in 21.6% of them. Patients with dementia had higher apathy scores before stroke (mean: 0.9 ± 1.7 vs. 0.2 ± 0.9, p < 0.01) and on day 8 (mean: 37.2 ± 9.3 vs. 29.0 ± 9.6, p < 0.01). Depressive symptoms did not differ between groups. In multivariate analysis adjusted for age, diabetes mellitus, stroke severity and in-hospital delirium, apathy symptoms before stroke and on day 8 after stroke predicted post-stroke dementia (adjusted OR: 1.59, 95%CI: 1.13-2.26, p = 0.01 and OR: 1.06, 95%CI: 1.01-1.11, p = 0.03, respectively).

CONCLUSIONS

Pre-stroke and early post-stroke apathy independently from age, stroke severity and delirium predicted dementia 3 months after stroke. Apathy might be useful in identifying at-risk patients.

Relationship between fear of falling and fall risk among older patients with stroke: a structural equation modeling

BACKGROUND

With reduced balance and mobility, older patients with stroke are more susceptible to fear of falling (FOF). A maladaptive form of FOF can cause excessive activity restriction, poor balance, and recurrent falls, forming a self-reinforcing vicious cycle. This study applied and adapted the FOF model to investigate the interaction between FOF and fall risk in older stroke patients.

METHODS

A cross-sectional study was conducted among 302 older stroke patients aged 60 and over. All participants were invited to complete the FOF, fall risk, physical activity, and balance tests, which were measured by the Falls Efficacy Scale International (FES-I), Self-Rated Fall Risk Questionnaire (FRQ), the long-form International Physical Activity Questionnaire (IPAQ-LF) and the Four-Stage Balance Test (FSBT) respectively. Data were analyzed using structural equation modeling.

RESULTS

The mean age of the respondents was 68.62 ± 7.62 years; 8.94% reported a high level of FOF, and 18.21% reported a moderate level of FOF. The structural equation model showed that FOF was directly associated with fall risk (β=-0.38, p < 0.001), and was indirectly associated with fall risk via physical activity (β=-0.075, p < 0.05) and balance ability (β=-0.123, p < 0.05). Depression (β=-0.47, p < 0.001), fall history (β=-0.13, p < 0.05), and female sex (β=-0.16, p < 0.05) affected FOF, while anxiety was not associated with FOF.

CONCLUSIONS

The increased risk of falling in older stroke patients results from a maladaptive FOF affected by depression, fall history, poor balance ability, and limited physical activity. Our results suggest that greater attention should be paid to FOF during stroke recovery and fall prevention. A multifaced intervention program encompassing physiological and psychological factors should be designed to address FOF and prevent falls.

Explainable Risk Prediction of Post-Stroke Adverse Mental Outcomes Using Machine Learning Techniques in a Population of 1780 Patients

Post-stroke depression and anxiety, collectively known as post-stroke adverse mental outcome (PSAMO) are common sequelae of stroke. About 30% of stroke survivors develop depression and about 20% develop anxiety. Stroke survivors with PSAMO have poorer health outcomes with higher mortality and greater functional disability. In this study, we aimed to develop a machine learning (ML) model to predict the risk of PSAMO. We retrospectively studied 1780 patients with stroke who were divided into PSAMO vs. no PSAMO groups based on results of validated depression and anxiety questionnaires. The features collected included demographic and sociological data, quality of life scores, stroke-related information, medical and medication history, and comorbidities. Recursive feature elimination was used to select features to input in parallel to eight ML algorithms to train and test the model. Bayesian optimization was used for hyperparameter tuning. Shapley additive explanations (SHAP), an explainable AI (XAI) method, was applied to interpret the model. The best performing ML algorithm was gradient-boosted tree, which attained 74.7% binary classification accuracy. Feature importance calculated by SHAP produced a list of ranked important features that contributed to the prediction, which were consistent with findings of prior clinical studies. Some of these factors were modifiable, and potentially amenable to intervention at early stages of stroke to reduce the incidence of PSAMO.

Addressing mood and fatigue in return-to-work programmes after stroke: a systematic review

Introduction

Return-to-work is a key rehabilitation goal for many working aged stroke survivors, promoting an overall improvement of quality of life, social integration, and emotional wellbeing. Conversely, the failure to return-to-work contributes to a loss of identity, lowered self-esteem, social isolation, poorer quality of life and health outcomes. Return-to-work programmes have largely focused on physical and vocational rehabilitation, while neglecting to include mood and fatigue management. This is despite the knowledge that stroke results in changes in physical, cognitive, and emotional functioning, which all impact one's ability to return to work. The purpose of this systematic review is to conduct a comprehensive and up-to-date search of randomised controlled trials (RCTs) of return-to-work programmes after stroke. The focus is especially on examining components of mood and fatigue if they were included, and to also report on the screening tools used to measure mood and fatigue.

Method

Searches were performed using 7 electronic databases for RCTs published in English from inception to 4 January 2023. A narrative synthesis of intervention design and outcomes was provided.

Results

The search yielded 5 RCTs that satisfied the selection criteria (n = 626). Three studies included components of mood and fatigue management in the intervention, of which 2 studies found a higher percentage of subjects in the intervention group returning to work compared to those in the control group. The remaining 2 studies which did not include components of mood and fatigue management did not find any significant differences in return-to-work rates between the intervention and control groups. Screening tools to assess mood or fatigue were included in 3 studies.

Conclusion

Overall, the findings demonstrated that mood and fatigue are poorly addressed in rehabilitation programmes aimed at improving return-to-work after stroke, despite being a significant predictor of return-to-work. There is limited and inconsistent use of mood and fatigue screening tools. The findings were generally able to provide guidance and recommendations in the development of a stroke rehabilitation programme for return-to-work, highlighting the need to include components addressing and measuring psychological support and fatigue management.

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

INTRODUCTION

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

METHOD AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

DRKS00030378.

Gene expression profiling in whole blood stimulated ex vivo with lipopolysaccharide as a tool to predict post-stroke depressive symptoms: Proof-of-concept study

Prediction of post-stroke depressive symptoms (DSs) is challenging in patients without a history of depression. Gene expression profiling in blood cells may facilitate the search for biomarkers. The use of an ex vivo stimulus to the blood helps to reveal differences in gene profiles by reducing variation in gene expression. We conducted a proof-of-concept study to determine the usefulness of gene expression profiling in lipopolysaccharide (LPS)-stimulated blood for predicting post-stroke DS. Out of 262 enrolled patients with ischemic stroke, we included 96 patients without a pre-stroke history of depression and not taking any anti-depressive medication before or during the first 3 months after stroke. We assessed DS at 3 months after stroke using the Patient Health Questionnaire-9. We used RNA sequencing to determine the gene expression profile in LPS-stimulated blood samples taken on day 3 after stroke. We constructed a risk prediction model using a principal component analysis combined with logistic regression. We diagnosed post-stroke DS in 17.7% of patients. Expression of 510 genes differed between patients with and without DS. A model containing 6 genes (PKM, PRRC2C, NUP188, CHMP3, H2AC8, NOP10) displayed very good discriminatory properties (area under the curve: 0.95) with the sensitivity of 0.94 and specificity of 0.85. Our results suggest the potential utility of gene expression profiling in whole blood stimulated with LPS for predicting post-stroke DS. This method could be useful for searching biomarkers of post-stroke depression.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The efficacy of therapist-supported acceptance and commitment therapy-based bibliotherapy for psychological distress after stroke: a single-case multiple-baseline study

BACKGROUND

Psychological distress is common after stroke, and affects recovery. However, there are few evidence-based psychological treatments. This study evaluates a bibliotherapy-based approach to its amelioration.

AIMS

To investigate a stroke-specific self-management book, based on acceptance and commitment therapy (ACT), as a therapist-supported intervention for psychological distress after stroke.

METHOD

The design was a single case, randomised non-concurrent multiple-baseline design (MBD). Sixteen stroke survivors, eight males and eight females (mean age 60.6 years), participated in an MBD with three phases: A (randomised-duration baseline); B (intervention); and follow-up (at 3 weeks). During the baseline, participants received therapist contact only. In the bibliotherapy intervention, participants received bi-weekly therapist support. The primary measures of psychological distress (General Health Questionaire-12; GHQ-12) and quality of life (Satisfaction with Life Scale; SWLS) were completed weekly. Secondary measures of mood, wellbeing and illness impact were completed pre- and post-intervention.

RESULTS

Omnibus whole-group TAU-U analysis was statistically significant for each primary measure with a moderate effect size on both (0.6 and 0.3 for GHQ-12 and SWLS, respectively). Individual TAU-U analyses demonstrated that the majority of individuals exhibited positive change. All the secondary measures showed significant pre-post improvements. Eighty-one per cent of participants reported the book was helpful and 81% also found the ACT-based sections helpful. Relative risk calculations showed finding the book helpful was associated with improvement in GHQ-12 and SWLS scores.

CONCLUSIONS

ACT-based bibliotherapy, with therapist support, is a promising intervention for psychological difficulties after stroke.

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

Long-term Changes in Depressive Symptoms Before and After Stroke

BACKGROUND AND OBJECTIVES

To determine the trajectory of depressive symptoms several years before and after incident stroke.

METHODS

We analyzed data from 10,797 participants from the English Longitudinal Study of Ageing without a history of stroke at baseline (wave 1). We matched participants with first-ever stroke during the 12-year follow-up (waves 2-7) to stroke-free individuals using propensity scores accounting for age, sex, education, ethnicity, and vascular risk factors. Trajectories of depressive symptoms before and after stroke were analyzed using multilevel models.

RESULTS

Among the 10,797 participants (mean age 64.6 ± 9.9 years, 54.8% women), we identified 425 individuals with incident stroke. At the assessment before stroke, these individuals demonstrated an increase in depressive symptoms when compared with matched controls. There was a further increase in depressive symptoms in stroke survivors after the acute event, which persisted for several years. Symptom-level analyses revealed that differences in depressive symptoms between stroke survivors and stroke-free controls before and after stroke were most pronounced for mood-related and fatigue-related symptoms.

DISCUSSION

Incident stroke is associated with long-term increases in depressive symptoms. A small part of this increase occurs in the years before stroke, perhaps indicating the incipient pathologic process. Particular attention should be paid to depressive symptoms in the long-term care of patients, and especially to fatigue-related symptoms.

General and comparative self-rated health in chronic stroke: an important outcome measure for health professionals

BACKGROUND

After a stroke, several aspects of health and function may influence how individuals perceive their own health. However, self-rated health (SRH), as well as its relationship with functioning, has been little explored in individuals with stroke. The aims of this study were to determine how individuals with chronic post-stroke disabilities evaluate their health, considering general, time- and age-comparative SRH questions and to investigate whether SRH measures would be influenced by the following health and functioning domains: mental/physical functions and personal factors.

METHODS

Sixty-nine individuals with chronic post-stroke disabilities answered the three types of SRH questions and were assessed regarding depressive symptoms (emotional function domain), physical activity levels (physical function domain), and engagement in physical activity practice (personal factor domain). Subjects were divided into the following groups: good/poor for the general SRH question; better, similar, and "worse" for both time- and age-comparative questions. Between-group differences in the three domains for each SRH question were investigated (α = 5%).

RESULTS

General SRH was rated as good by 73% of the participants. Time- and age-comparative SRH was rated as better by 36% and 47% and as similar by 31% and 28% of the subjects, respectively. Significant between-group differences in emotional function were found for both the general and age-comparative questions. For the time-comparative question, significant differences were only observed for physical function.

CONCLUSION

SRH evaluation differed in individuals with chronic post-stroke disabilities according to the types of questions and health/functioning domains.

Evaluating the GAD-2 to screen for post-stroke anxiety on an acute stroke unit

Post stroke anxiety is associated with reduced quality of life, worse rehabilitation outcomes and poor social functioning in stroke survivors. Despite its clinical relevance, there are a lack of screening tools to identify post-stroke anxiety. The Hospital Anxiety and Depression Scale (HADS-A) and Geriatric Anxiety Inventory (GAI) are the only self-report screening test for anxiety validated in stroke patients. However, both of these measures have limitations associated with their clinical utility, length of time to administer and cost to purchase. This study aimed to assess the classiciation accuracy of a freely available and shorter alternative, the Generalized Anxiety Disorder 2-item (GAD-2) for use in the acute stroke setting. This study used retrospective analysis of a sequential sample in a clinical database of mood and cognitive scores. Patients' scores on the GAD-2 and HADS-A were compared. The GAD-2 demonstrated strong convergent validity with the HADS-A and good specificity and sensitivity for clinical anxiety. In conclusion, the GAD-2 may be a useful screening assessment of post-stroke anxiety in the acute setting; however, it should be used with due consideration of the methodological limitations of this study.

Longitudinal assessment of depression during the first year after stroke: Dimensionality and measurement invariance

OBJECTIVE

Repeated measurement of depression using summative scores of commonly used depression scales assumes that the construct is unidimensional and invariant across time, but little is known about the validity of these assumptions in stroke patients. The study examined the assumptions during the first year after mild to moderate stroke using the 8-item Patient Health Questionnaire (PHQ-8).

METHODS

Data were obtained from the 2014-2016 Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study with longitudinal follow-up in Texas, United States. Depressive symptoms were assessed with the PHQ-8 at 3, 6, and 12 months post-stroke (n = 648, 542, 533, respectively). Dimensionality of the PHQ-8 was examined using exploratory bifactor analysis and confirmatory factor analysis (CFA). Based on a one-factor CFA model, longitudinal measurement invariance was examined by fitting configural, weak, strong and strict invariance models sequentially.

RESULTS

Mean age was 65.6 (SD = 11.2), half were women, and 56.7% were Mexican American. Reliability measures suggested a generally unidimensional construct (Omega Hierarchical: 0.79-0.86), good internal consistency (Cronbach's alpha: 0.84-0.88) and good temporal stability (intraclass correlation coefficient: 0.838). Configural invariance for equality of item-factor structure (RMSEA = 0.038, CFI = 0.982, WRMR = 0.970) was supported. Partial weak invariance for equality of factor loadings (p = 0.11) was supported by chi-square difference tests, whereas full longitudinal invariance was supported by changes in comparative fit index and root mean square error of approximation.

CONCLUSIONS

The findings suggest the PHQ-8 may be a reasonable tool for repeated measurement of depression in stroke patients, and more research on its longitudinal psychometric properties is needed.

Prevalence, Severity, and Predictors of Poststroke Depression in a Prospective Cohort of Jordanian Patients

Poststroke depression (PSD) is common and remains a significant risk factor for poor outcomes. This prospective study is aimed at assessing the prevalence, severity, and predictors of PSD among Jordanian stroke survivors. A total of 151 patients who were consequently admitted to a tertiary teaching hospital with ischemic or hemorrhagic strokes were enrolled. Participants were screened on admission for premorbid depression using the PHQ-9 questionnaire; then, screening for PSD was repeated one and three months after stroke using the same tool. Depression prevalence at each screening was reported, and logistic regression analysis was conducted to evaluate for significant predictors. PHQ-9 scores suggestive of depression were reported by 15%, 24.83%, and 17.39% of respondents on admission and after one and three months, respectively. Scores suggesting severe depression were reported by 0.71%, 2.13%, and 6.52% of respondents, respectively. Significant predictors of PSD were having chronic kidney disease, current smoking status, moderate or severe disability (mRS score) at stroke onset, and severe dependence (BI) after one month (p values 0.007, 0,002, 0.014, and 0.031, respectively). Patients with secondary and high school education levels were less likely to get depression compared with illiterate patients (p 0.042). This study showed that nearly one in four Jordanian stroke survivors experienced PSD after one month. In contrast, while the overall PSD prevalence declined towards the end of follow-up period, patients who remained depressed showed a tendency towards higher PSD severity.

Depression in Stroke Survivors: Ten-Year Follow-Up. Determinants of the Natural Course of Depressive Symptoms in Stroke Survivors in the Netherlands: The SMART-Medea Study

OBJECTIVES

Stroke is the second most common cause of death and a major cause of disability. Besides the physical consequences, depressive symptoms are frequent in the aftermath after stroke. Every year, approximately 15 million stroke survivors worldwide are at risk of developing post-stroke depression. In this study we describe the natural course of depressive symptoms in stroke patients over a long-period of time post stroke and identify associated determinants.

MATERIALS AND METHODS

From the Second Manifestations of ARTerial disease-Memory, depression and aging (SMART-Medea) study, an observational prospective cohort study, we selected patients with cerebrovascular disease, and used the biannually collected data of the Patient Health Questionnaire-9 for depressive symptoms. A score of ≥10 indicated the presence of depressive symptoms. A multinomial logistic regression analysis was used to identify prognostic determinants for courses of depressive symptoms after stroke.

RESULTS

During a mean follow-up time of 7.9 years, 62% of the 172 participants was never depressed, 19% had a single episode and 19% had recurrent depressive symptoms. Physical function was associated with increased risk for single episode and recurrent depressive symptoms (OR=1.06 [1.01-1.11]). OR's for social, mental and (vascular) comorbidities variables were not significant. Participants' physical function was only measured at baseline. Several relevant variables were not present in this dataset, including information about clinical events during follow-up.

CONCLUSION

Nearly 40% of the participants are confronted with depressive symptoms on the long-term. Physical function plays a substantial part for stroke survivors in the development of these symptoms.

Assessments of a novel digital follow-up tool Rehabkompassen® to identify rehabilitation needs among stroke patients in an outpatient setting

Introduction

It remains a huge challenge to identify individual rehabilitation needs in a time-efficient manner for providing patient-tailored rehabilitation during the continuum of stroke care. We have recently demonstrated the usefulness of a paper-version Rehab-Compass as a follow-up tool. The aim of the current study was to develop a digital version of the Rehab-Compass and evaluate its usability and feasibility.

Methods

The novel digital tool Rehabkompassen® was developed by an iterative and participatory design process. Patients' rehabilitation needs were visualized by the tool and used before, during, and after the consultation. The usability and feasibility of the tool was assessed by task completion rate, the System Usability Scale, and satisfaction questionnaires among 2 physicians and 24 adult stroke patients in an outpatient clinical setting.

Results

Rehabkompassen® identified and graphically visualized a panoramic view of the stroke patients' multidimensional needs in individual- and group levels. The instrument appeared to be feasible and time efficient in clinical use with a 100% overall task completion rate for both patients and physicians. A majority of the patients reported that it was very easy or fairly easy to answer the digital questionnaires and to understand their own digital Rehab-Compass graph. Two physicians reported a high mean score on the System Usability Scale (95/100) and were positive about using the tool in the future.

Conclusions

The current results indicated that Rehabkompassen® was a feasible, useful, and time-saving follow-up tool for the identification of rehabilitation needs among stroke survivors in the post-acute continuum of care after stroke. Further research is needed to evaluate the efficacy of the digital instrument among stroke patients.

The Post-Stroke Depression Risk Scale (PoStDeRiS): Development of an Acute-Phase Prediction Model for Depression 6 Months After Stroke

BACKGROUND

Depression after stroke is common but often undertreated as increasing depression prevalence and decreasing health care contacts diverge after the event.

OBJECTIVE

To develop an acute-phase prediction scale for prognosis of depression 6 months after stroke.

METHODS

Participants (N = 226) were consecutively recruited and assessed within the first week after ischemic stroke for history of depression, stroke severity (National Institutes of Health Stroke Scale), and functional independence (Barthel Index). Early depressive symptoms were self-reported via the Patient Health Questionnaire-2 and external-rated by nurses via the Signs of Depression Scale. Six months later, 183 participants were assessed for Diagnostic and Statistical Manual of Mental Disorders, 5th edition diagnosis of depression. Significant predictors of depression were identified in multivariate logistic regression analysis and their coefficients transformed into a risk scale. Measurement precision was identified using receiver operating characteristic curve analysis.

RESULTS

Depression was diagnosed in 32 (17.5%) participants 6 months after stroke. History of depression, the Barthel Index, and the Patient Health Questionnaire-2 were significant predictors of depression. Transformation of the coefficients yielded the Post-Stroke Depression Risk Scale that demonstrated good discrimination (area under the receiver operating characteristic curve = 0.84; 95% confidence interval = 0.78/0.90). The optimum cutoff showed a sensitivity of 0.81, a specificity of 0.72, a positive predictive value of 0.38, and a negative predictive value of 0.95.

CONCLUSIONS

The Post-Stroke Depression Risk Scale accurately identifies people in the acute phase with low risk of depression 6 months later, which saves expendable psychiatric interviews in stroke patients. While the sensitivity indicates that recognition of people with later depression is adequate, positive results in the acute phase show low predictivity. Clinical and methodological reasons for these results as well as implications for future research to increase case-finding ability are discussed.

Exploring the Impact of Illness Perceptions, Self-efficacy, Coping Strategies, and Psychological Distress on Quality of Life in a Post-stroke Cohort

This study evaluated the mediating role of self-efficacy, coping, depression and anxiety on the relationship between illness perceptions and quality of life in stroke survivors (n = 72; 32 females; mean [SD] age 65.09 [14.14] years; male mean [SD] age 69.83 [11.81]). Illness perceptions (Brief Illness Perceptions Questionnaire; BIPQ), coping styles (Carver Brief-COPE scale; B-COPE), depression/anxiety (Hospital Anxiety and Depression Scale; HADS), self-efficacy (General Self-Efficacy Scale; GSE) and quality of life (Assessment of quality of life; AQOL-6D) were analysed. Correlation analyses showed illness perception, maladaptive coping, self-efficacy, depression and anxiety to have a significant negative relationship with quality of life. Mediation analyses showed that while maladaptive coping and self-efficacy did not mediate the relationship between illness perception and quality of life, depression and anxiety did. The final model explained 76.74% of the variance in quality of life. Although based on a relatively small sample size, these results provide evidence for the important role of psychosocial factors in quality of life in post-stroke cohorts.

Prevalence and Course of Depression During the First Year After Mild to Moderate Stroke

Background This study examined the prevalence and longitudinal course of depression during the first year after mild to moderate stroke. Methods and Results We identified patients with mild to moderate ischemic stroke or intracerebral hemorrhage (National Institutes of Health Stroke Scale score <16) and at least 1 depression assessment at 3, 6, or 12 months after stroke (n=648, 542, and 533, respectively) from the Brain Attack Surveillance in Corpus Christi project (2014-2016). Latent transition analysis was used to examine temporal profiles of depressive symptoms assessed by the 8-item Patient Health Questionnaire between 3 and 12 months after stroke. Mean age was 65.6 years, 49.4% were women, and 56.7% were Mexican Americans. The prevalence of depression after stroke was 35.3% at 3 months, decreased to 24.9% at 6 months, and remained stable at 25.7% at 12 months. Approximately half of the participants classified as having depression at 3 or 6 months showed clinical improvement at the next assessment. Subgroups with distinct patterns of depressive symptoms were identified, including mild/no symptoms, predominant sleep disturbance and fatigue symptoms, affective symptoms, and severe/all symptoms. A majority of participants with mild/no symptoms retained this symptom pattern over time. The probability of transitioning to mild/no symptoms was higher before 6 months compared with the later period, and severe symptoms were more likely to persist after 6 months compared with the earlier period. Conclusions The observed dynamics of depressive symptoms suggest that depression after stroke tends to persist after 6 months among patients with mild to moderate stroke and should be continually monitored and appropriately managed.

Association between neurological outcome and poststroke comorbid mood and anxiety disorders: A real-life experience

INTRODUCTION

Poststroke depression (PSD) and anxiety (PSA) are prevalent and have a strong impact on functional outcome. Beside stroke severity, little is known on their clinical determinants. This study investigated the association between stroke mechanism, neurological poststroke complications and remaining vascular risk factors and the presence of comorbid PSD and PSA, termed poststroke emotional distress (PSED).

METHODS

This was a retrospective analysis of a prospectively compiled medical records database of consecutive patients evaluated during a follow-up visit 3- to 4-month poststroke. HAD scale was used to define PSED category (PSD+PSA vs. NoPSD+NoPSA). Stroke mechanism and poststroke complications were identified clinically or using appropriate scales. Their association with PSED was tested using a multivariate logistic regression model.

RESULTS

The sample included 2,300 patients (male: 64.8%); 19% had a PSED and 56.39% were free of any depression or anxiety. The most frequent poststroke complications were fatigue/fatigability (58.4%), sleep problems (26.7%), and pain (20.4%). While no association was observed between PSED and stroke mechanism, higher functional disability (OR:1.572), lower cognitive abilities (OR:0.953), sleep problems (OR:2.334), pain (OR:1.478), fatigue/fatigability (OR:2.331), and abnormal movements (OR:2.380) were all independent risk factors. Persisting tobacco consumption (OR:1.360) was the only vascular significant risk factor.

CONCLUSIONS

The frequency of comorbid PSED remains high (1/5 patient) despite improved awareness of these conditions. The association between poststroke complications and the presence of PSED emphasizes the need for standardized neurological and psychological evaluations at follow-up. These results foster the need to improve the management of addictive behaviors to reduce the burden of PSED.

Toll-like receptor 4-mediated cytokine synthesis and post-stroke depressive symptoms

Altered cytokine synthesis thought to contribute to the pathophysiology of post-stroke depression (PSD). Toll-like receptor 4 (TLR4) is a master regulator of innate immunity. The aim of this study was to explore the putative association between TLR4-mediated cytokine synthesis and subsequent symptoms of PSD. In total, 262 patients with ischemic stroke and without a history of PSD were included. Depressive symptoms were assessed using the Patient Health Questionnaire-9 in 170 patients on Day 8 and in 146 at 3 months after stroke. Blood samples taken on Day 3 after stroke were stimulated ex vivo with lipopolysaccharide (LPS). Ex vivo synthesized cytokines (TNFα, IP-10, IL-1β, IL-6, IL-8, IL-10, and IL-12p70) and circulating cytokines (TNFα, IL-6, sIL-6R, and IL-1ra) were measured using the enzyme-linked immunoassay or cytometric method. RNA sequencing was used to determine the gene expression profile of LPS-induced cytokines and chemokines. LPS-induced cytokine synthesis and the gene expression of TLR4-dependent cytokines and chemokines did not differ between patients with and without greater depressive symptoms. The plasma level of IL-6, but not TNFα, sIL-6R, and IL-1ra, was higher in patients who developed depressive symptoms at 3 months after stroke (median: 4.7 vs 3.4 pg/mL, P = 0.06). Plasma IL-6 predicted the severity of depressive symptoms at 3 months after stroke (β = 0.42, P = 0.03). In conclusion, TLR4-dependent cytokine synthesis was not associated with greater post-stroke depressive symptoms in this study. Circulating IL-6 might be associated with depressive symptoms occurring at 3 months after stroke.

Association of early and later depressive symptoms with functional outcome after ischemic stroke

Background

Post-stroke depressive symptoms (DS) can be chronic or transient, occurring shortly or long after stroke and lasting only few months. It remains unclear if the prognosis differs between patients with DS in the acute phase of stroke and those who develop DS several months later. We aimed to determine whether outcomes vary among patients with different trajectories of post-stroke depressive symptoms.

Methods

Of 698 enrolled patients with ischemic stroke, we included 335 participants (median age: 68, 48% female) who were assessed for DS both 8 days and 3 months post-stroke. We divided patients into 4 groups: without greater DS (Group 1), only earlier DS (Group 2), only later DS (Group 3), and persistent DS (Group 4). Logistic regression was used to determine the association between DS and 3- and 12-month functional outcome.

Results

Group 2 was predominantly female and had the highest rate of previous stroke or transient ischemic attack. Group 3 was more likely to suffer from delirium and more severe stroke. Group 4 had the highest frequency of vascular risk factors, pre-morbid psychiatric symptoms, and cognitive decline. In multivariate analysis, Group 3, but not Groups 2 and 4, had an increased risk of poor 3- and 12-month functional outcome (adjusted OR 2.59, 95% CI 1.64–4.07, P < 0.01 and OR 3.97, 95% CI 2.32–6.76, P < 0.01, respectively) compared with Group 1.

Conclusions

Different trajectories of post-stroke DS are related to different outcomes. Patients who only have later DS also have the worst prognosis.

Early apathetic, but not depressive, symptoms are associated with poor outcome after stroke

BACKGROUND AND PURPOSE

Depression and apathy are frequent neuropsychiatric disturbances after stroke and may appear together. Despite the overlap in symptoms between poststroke depression and apathy, these two syndromes might be associated with different prognoses and benefit from different treatments. We aimed to disentangle the relationship between early depressive and apathetic symptoms and outcome after stroke.

METHODS

Of 698 enrolled patients with ischemic stroke, we included 443 participants (median age = 69 years, 51% female) who underwent depressive and apathetic symptom assessment on Day 8 after stroke. We divided patients into four groups: without greater depressive and apathetic symptoms (Group 1), with only apathetic symptoms (Group 2), with only depressive symptoms (Group 3), and with both depressive and apathetic symptoms (Group 4).

RESULTS

After adjusting for age and stroke severity, Group 2 and Group 4 had an increased risk of poor 3-month outcome (odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.16-3.38, p = 0.01 and OR = 1.58, 95% CI = 1.24-2.01, p < 0.01, respectively). Group 2 and Group 4 also had an increased risk of poor 12-month outcome (OR = 3.85, 95% CI = 2.19-6.78, p < 0.01 and OR = 1.54, 95% CI = 1.22-1.96, p < 0.01, respectively) and mortality (hazard ratio [HR] = 2.76, 95% CI = 1.19-6.41, p = 0.02 and HR = 1.77, 95% CI = 1.32-2.38, p < 0.01, respectively). Compared with Group 1, Group 3 did not have an increased risk of unfavorable outcomes.

CONCLUSIONS

Early apathetic, but not depressive, symptoms are related to worse outcomes after stroke. Our study underscores the importance of recognizing apathetic symptoms independently from depressive symptoms.

Predictors and short-term outcomes of post-stroke fatigue in initial phase of transition from hospital to home: A prospective observational study

AIM

To analyse the interactions of associated factors with post stroke fatigue (PSF) after discharge home and determine the predictors of PSF and their impact on stroke survivors.

DESIGN

A prospective observational study.

METHODS

A total of 94 patients with acute stroke were recruited between May 2019 -July 2020. The main outcomes were fatigue, depression, insomnia, sarcopenia, and health-related quality of life (HRQOL) and were assessed at admission and 1 month after discharge. Fatigue was measured using the Fatigue Assessment Scale. Depression and Insomnia were assessed using the Hospital Anxiety and Depression Scale-Depression and Insomnia Severity Index, respectively. Sarcopenia was measured using the SARC-F questionnaire, and HRQOL was assessed using the Short Form-8.

RESULTS

Acute phase PSF was an independent predictor of PSF after discharge home. Moreover the path analysis revealed that this effect is mediated through both the direct effect of acute-phase PSF on PSF after discharge home and through the indirect effect of interaction with pre-stroke SARC-F, acute phase depression, and acute phase insomnia, which remains a separate predictor of acute-phase PSF. In total, 17% of the survivors had persistent PSF. Persistent PSF was significantly associated with depression, insomnia, sarcopenia, and a lower quality of life scores.

CONCLUSIONS

Post-stroke fatigue may occur in the acute phase and persists after discharge, it will not only affect later depression, insomnia, and quality of life, but also sarcopenia.

IMPACT

Acute phase PSF was found to be an independent predictor of PSF after discharge home. In addition, the interaction with pre-stroke SARC-F, acute phase depression and insomnia had an indirect connection with PSF after discharge home, which remains a separate predictor of acute-phase PSF. Thus, early assessment and management of mental status, sleep problems, and sarcopenia during hospitalization might be an important step in post-stroke rehabilitation and home transition.

Development and Internal Validation of a Nomogram to Predict Post-Stroke Fatigue After Discharge

OBJECTIVES

We aimed to develop and validate a nomogram for the individualized prediction of the risk of post-stroke fatigue (PSF) after discharge.

MATERIALS AND METHODS

Fatigue was measured using the Fatigue Assessment Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the predictive model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was conducted using bootstrapping validation. Finally, a web application was developed to facilitate the use of the nomogram.

RESULTS

We developed a nomogram based on 95 stroke patients. The predictors included in the nomogram were sex, pre-stroke sarcopenia, acute phase fatigue, dysphagia, and depression. The model displayed good discrimination, with a C-index of 0.801 (95% confidence interval: 0.700-0.902) and good calibration. A high C-index value of 0.762 could still be reached in the interval validation. Decision curve analysis showed that the risk of PSF after discharge was clinically useful when the intervention was decided at the PSF risk possibility threshold of 10% to 90%.

CONCLUSION

This nomogram could be conveniently used to provide an individual, visual, and precise prediction of the risk probability of PSF after being discharged home. Thus, as an aid in decision-making, physicians and other healthcare professionals can use this predictive method to provide early intervention or a discharge plan for stroke patients during the hospitalization period.

Depression impedes neuroplasticity and quality of life after stroke

Background and Purpose:

Depression following a stroke/poststroke depression (PSD) has been newly recognized as one of the most common complications after stroke. PSD may affect neuroplasticity and quality of life. The purpose of present study was to find out effects of depression on functional recovery, quality of life and neuroplasticity in patients with acute stroke.

Methods:

A total of 76 cases were recruited for the study and out of which 44 were available for the analysis after six months. Patients were divided into three groups according to severity of depression: Group A (without depression), Group B (mild-to-moderate depression), and Group C (severe depression) on the basis of Patient Health Questionnaire-9 (PHQ-9) scale scores. All patients were assessed for depression by PHQ-9, and for quality of life by Stroke Specific Quality of Life (SSQOL) scale. Neuroplasticity was assessed by measuring levels of serum brain-derived neurotrophic factor.

Results:

Quality of life was observed to be significantly affected by depression (P ≤ 0.05). The most commonly affected characteristics were energy, family roles, mobility, self-care, social roles, upper extremity function, and work productivity. Serum BDNF levels were also affected significantly by depression (P ≤ 0.05).

Conclusion:

PSD is a serious complication, affecting quality of life and neuroplasticity (BDNF) in patients. Decreased neuroplasticity further may affect functional improvement.

A psychosocial intervention for stroke survivors and carers: 12-month outcomes of a randomized controlled trial

Background and Purpose: Stroke can have a devastating impact on the mental and physical health of stroke survivors and their carers. We aimed to evaluate the effectiveness of a novel psychosocial intervention designed to improve health outcomes in both groups.Methods: We conducted a randomized controlled trial of a personalized psychosocial intervention (eight 1-hour weekly sessions plus one booster) compared to usual care for adult stroke survivors and carers. Participants recruited from hospital services and community referrals completed questionnaires at baseline, 3, 6, and 12 months. Primary outcomes were quality of life and self-efficacy; secondary outcomes were depressive and anxiety symptoms, coping, illness perception, work and social adjustment, carer strain, and carer satisfaction. Mixed-effect model repeated measures analysis between groups and across time was conducted.Results: Of the 173 participants recruited (89 stroke survivors; 84 carers), a total of 137 participants - 73 stroke survivors (intervention n = 42; usual care n = 31) and 64 carers (intervention n = 35; usual care n = 29) - underwent analysis up to 12 months. No statistically significant differences were found in the primary outcomes between groups over time, though a significant improvement in carer satisfaction was found at 6 months in the intervention group compared to the usual care group.Conclusion: A personalized psychosocial intervention resulted in a significant improvement in carer satisfaction at 6 months but in no other outcomes. A lack of available services and barriers to social engagement may have impeded the effectiveness of this intervention.

C-reactive protein and post-stroke depressive symptoms

Our study aimed to explore the association between serum C-reactive protein (CRP) and post-stroke depressive symptoms. We prospectively recruited 572 patients with ischemic stroke or transient ischemic attack in whom serum CRP level was measured within 48 h after stroke onset. Depressive symptoms were assessed at day 8 and 3 months after stroke in 405 and 306 patients, respectively. Patients with greater depressive symptoms at day 8 and patients with greater depressive symptoms 3 months after stroke had higher CRP level (median: 7.9 vs 4.3 mg/L, P < 0.01 and 6.7 vs 3.4 mg/L, P = 0.01, respectively). In the univariate analysis, CRP > 9.2 mg/L was associated with depressive symptoms at day 8 (OR: 2.06, 95%CI: 1.30-3.28, P < 0.01) and CRP > 4.3 mg/L was associated with depressive symptoms 3 months after stroke (OR: 1.79, 95%CI: 1.06-3.02, P = 0.03). In the multivariate analysis, higher CRP level was related to depressive symptoms at day 8 (OR: 2.23, 95%CI: 1.28-3.90, P < 0.01), but not depressive symptoms 3 months after stroke (OR: 1.13, 95%CI: 0.59-2.17, P = 0.71). In conclusion, higher levels of CRP are associated with greater depressive symptoms at day 8 after stroke, but their effects on depressive symptoms 3 months after stroke are less significant.

Association Between Behavioral Dysexecutive Syndrome and the Health-Related Quality of Life Among Stroke Survivors

AIM

Behavioral dysexecutive syndrome (BDES) is one common neuropsychiatric comorbidity after stroke. Despite evidences suggesting the adverse effect of BDES on the survivors' outcome, little is known about the association between BDES and the health-related quality of life (HRQoL) among stroke survivors and how BDES impacts the HRQoL. This study aimed to address these questions.

METHODS

This study included 219 patients with acute ischemic stroke consecutively admitted to a regional hospital in Hong Kong. BDES was defined as a Chinese version of the Dysexecutive Questionnaire (DEX) score of ≥20 assessed at three months after stroke. The HRQoL was assessed with the Chinese version of the Stroke-Specific Quality of Life (SSQoL) questionnaire encompassing 12 domains. Multivariate linear regression models were employed to examine the association between BDES symptoms and the SSQoL total and domain scores. Structural equation model (SEM) was further constructed to delineate the linking pathways linking BDES and the HRQoL.

RESULTS

The study sample compromised mainly older patients with mild to moderate ischemic stroke. Compared with patients without BDES, those with BDES exhibited poorer performances regarding with the summarized SSQoL (226.2 ± 18.8 vs. 200.3 ± 29.8, p < 0.001) and almost all domains. The BDES symptoms were independently contributed to the whole HRQoL (SSQoL total score) (β = -0.20, p = 0.002), specifically to the domains in personality (β = -0.34, p < 0.001), language (β = -0.22, p = 0.01), and work/productivity (β = -0.32, p < 0.001), after adjusting demographic and clinical characteristics in linear models. The impacts of the BDES symptoms on the HRQoL were mainly explained by the indirect path mediated by depression and anxiety (path coefficient = -0.27, p < 0.05) rather than physical disability, while the resting was elucidated by the path directly linking BDES to the HRQoL (path coefficient = -0.17, p < 0.05).

CONCLUSION

The present study preliminarily demonstrated a potential association between BDES and a lower level of the HRQoL, predominantly in domains of personality, language, and work/productivityafter acute ischemic stroke. This study also offered insights into the underlying mechanisms linking BDES and the HRQoL, implicating that integrative psychological therapies were urged to achieve better HRQoL after stroke.

An exploratory investigation of the effect of naturalistic light on depression, anxiety, and cognitive outcomes in stroke patients during admission for rehabilitation: A randomized controlled trial

BACKGROUND

Patients admitted for rehabilitation often lack sufficient natural light to entrain their circadian rhythm.

OBJECTIVE

Installed diurnal naturalistic light may positively influence the outcome of depressive mood, anxiety, and cognition in such patients.

METHODS

A quasi-randomized controlled trial. Ninety stroke patients in need of rehabilitation were randomized between May 1, 2014, and June 1, 2015 to either a rehabilitation unit equipped entirely with always on naturalistic lighting (IU), or to a rehabilitation unit with standard indoor lighting (CU).Examinations were performed at inclusion and discharge. The following changes were investigated: depressive mood based on the Hamilton Depression scale (HAM-D6) and Major Depression Inventory scale (MDI), anxiety based on the Hospital Anxiety and Depression Scale (HADS), cognition based on the Montreal Cognitive Assessment (MoCA) and well-being based on the Well-being Index (WHO-5).

RESULTS

Depressive mood (MDI p = 0.0005, HAM-D6 p = 0.011) and anxiety (HADS anxiety p = 0.045) was reduced, and well-being (WHO-5 p = 0.046) was increased, in the IU at discharge compared to the CU. No difference was found in cognition (MoCA p = 0.969).

CONCLUSIONS

This study is the first to demonstrate that exposure to naturalistic light during admission may significantly improve mental health in rehabilitation patients. Further studies are needed to confirm these findings.

Healthcare utilization after stroke in Canada- a population based study

BACKGROUND

More people are surviving stroke but are living with functional limitations that pose increasing demands on their families and the healthcare system. The aim of this study was to determine the extent to which stroke survivors use healthcare services on a population level compared to people without a stroke.

METHODS

This was a cross-sectional population-based survey that collected information related to health status, healthcare utilization and health determinants using the 2014 Canadian Community Health Survey. Healthcare utilization was assessed by a computer-assisted personal interview asking about visits to healthcare professionals in the last 12 months. Negative binomial regression was used to estimate the incidence rate ratios (IRR) and 95% confidence intervals (CI) for the number of health professional visits between stroke survivors and people without a stroke. The regression models were adjusted for demographics, as well as for mobility, mood/anxiety disorder and cardiometabolic comorbid conditions.

RESULTS

The study sample included 35,759 respondents (948 stroke, 34,811 non-stroke) and equate to 12,396,641 (286,783 stroke; 12,109,858 non-stroke) when sampling weights were applied. Stroke survivors visited their family doctor the most, and stroke was significantly associated with more visits to most healthcare professionals [e.g., family doctor IRR 1.6 (CI 1.4-1.8); nurse IRR 3.0 (CI 1.8-4.8); physiotherapist IRR 1.8 (CI 1.1-1.9); psychologist IRR 4.0 (CI 1.1-5.7)] except the dental practitioner, which was less [IRR 0.7 (CI 0.6-0.9)]. Mood/anxiety condition, but not cardiometabolic comorbid condition increased the probability of visiting a family doctor or social worker/ counsellor among people with stroke.

CONCLUSION

Stroke survivors visited healthcare professionals more often than people without stroke, and were approximately twice as likely to visit with those who manage problems that may arise after a stroke (e.g., family doctor, nurse, psychologist, physiotherapist). The effects of a stroke include mobility impairment and mood/ anxiety disorders. Therefore, adequate access to stroke-related healthcare services should be provided for stroke survivors, as this may improve functional outcome and reduce future healthcare costs.

RecoverNow: A mobile tablet-based therapy platform for early stroke rehabilitation

Introduction

Stroke survivors frequently experience a range of post-stroke deficits. Specialized stroke rehabilitation improves recovery, especially if it is started early post-stroke. However, resource limitations often preclude early rehabilitation. Mobile technologies may provide a platform for stroke survivors to begin recovery when they might not be able to otherwise. The study objective was to demonstrate the feasibility of RecoverNow, a tablet-based stroke recovery platform aimed at delivering speech and cognitive therapy.

Methods

We recruited a convenience sample of 30 acute stroke patients to use RecoverNow for up to 3 months. Allied health professionals assigned specific applications based on standard of care assessments. Participants were encouraged to take home the RecoverNow tablets upon discharge from acute care. The study team contacted participants to return for a follow-up interview 3 months after enrollment. The primary outcome of interest was feasibility, defined using 5 facets: recruitment rate, adherence rate, retention rate, the proportion of successful follow-up interventions, and protocol deviations. We tracked barriers to tablet-based care as a secondary outcome.

Results

We successfully recruited 30 of 62 eligible patients in 15 weeks (48% recruitment rate). Participants were non-adherent to tablet-based therapy inside and outside of acute care, using RecoverNow for a median of 12 minutes a day. Retention was high with 23 of 30 patients participating in follow-up interviews (77% retention rate) and all but 3 of the 23 interviews (87%) were successfully completed. Only 2 major protocol deviations occurred: one enrollment failure and one therapy protocol violation. Barriers to tablet-based care were frequently encountered by study participants with many expressing the assigned applications were either too easy or too difficult.

Conclusions

Acute stroke patients are interested in attempting tablet-based stroke rehabilitation and are easily recruited early post-stroke. However, tablet-based therapy may be challenging due to patient, device and system-related barriers. Reducing the frequency of common barriers will be essential to keeping patients engaged in tablet-based therapy.

Validating the Geriatric Depression Scale with proxy-based data: A case-control psychological autopsy study in rural China

BACKGROUND

The Geriatric Depression Scale (GDS) has been widely used for late-life depression, but it lacks validation in psychological autopsy research. This study aimed to assess the validity and establish the optimal cut-off values of the GDS-30 and the GDS-15 with proxy-based data in rural China.

METHODS

We applied psychological autopsy to collect data from 242 consecutive suicide cases and 242 paired living community controls.

RESULTS

Subject-proxy concordance for the GDS-30 (ICC = 0.590) and the GDS-15 (ICC = 0.539) were fair in the living controls. Based on proxy-data, we found that the suicide cases had higher scores of depression than the living controls did; the values of Cronbach's alpha demonstrated good internal consistency of the GDS-30 and the GDS-15; the Spearman correlation analysis indicated that the GDS scores were correlated with hopelessness, loneliness, and quality of life. For suicide cases, the GDS-30 showed the highest Youden's index as 34.86% with a cut-off value at 22, when its sensitivity and specificity was 0.78 and 0.56, respectively; the score of 12 on the GDS-15 showed the highest Youden's index of 31.39%, and its sensitivity and specificity was 0.74 and 0.58, respectively.

LIMITATIONS

This study is limited to its generalizability to Chinese urban elderly with psychological autopsy method.

CONCLUSIONS

The GDS-30 and the GDS-15 were both valid tools for measuring the severity of depressive symptoms rather than screening for major depression in psychological autopsy research in rural China. The GDS-15 can be considered as a good substitute for the GDS-30.

Identifying Unmet Rehabilitation Needs in Patients After Stroke With a Graphic Rehab-CompassTM

BACKGROUND

Unmet rehabilitation needs are common among stroke survivors. We aimed to evaluate whether a comprehensive graphic "Rehab-Compass," a novel combination of structured patient-reported outcome measures, was feasible and useful in facilitating a capture of patients' rehabilitation needs in clinical practice.

METHODS

A new graphic overview of broad unmet rehabilitation needs covers deficits in functioning, daily activity, participation, and quality of life. It was constructed by using 5 patient-oriented, well-validated, and reliable existing instruments with converted data into a 0 (worst outcome) to 100 (best outcome) scale but unchanged in terms of variable properties. Satisfaction of the Rehab-Compass^TM was studied by a qualitative interview of 9 patients with stroke and 3 clinicians. Practical feasibility and capacity of the instrument were evaluated in a cross-sectionalstudy with 48 patients at 5-month follow-ups after subarachnoid hemorrhage.

RESULTS

The Rehab-Compass^TM identified and graphically visualized a panoramic view of the multidimensional needs over time which was completed before clinical consultation. The Rehab-Compass^TM appeared to be feasible and time-efficientin clinical use. The interviews of both patients and clinicians showed high satisfaction when using the Rehab-Compass^TM graph. In the studied stroke patients, the Rehab-Compass^TM identified memory and processing information, fatigue, mood, and pain after subarachnoid hemorrhage as the most common problems.

CONCLUSIONS

The graphic Rehab-Compass^TM seems to be a feasible, useful, and time-saving tool for identification of unmet rehabilitation needs among stroke survivors in clinical practice. Further research is needed to make the Rehab-Compass^TM more concise and evaluate the instrument among different stroke subgroups.

Enlarged perivascular spaces in the centrum semiovale are associated with poststroke depression: A 3-month prospective study

BACKGROUND

Enlarged perivascular spaces (EPVS), markers of cerebral small vessel disease, are associated with unfavorable prognosis of stroke. This study explored the relationship between EPVS and poststroke depression (PSD).

METHODS

A total of 725 patients with acute ischemic stroke were recruited from the Stroke Unit of a university-affiliated hospital in Hong Kong. PSD was defined as a Geriatric Depression Scale score of ≥ 7 assessed at three months after stroke. The extent of EPVS in the basal ganglia (BG) and the centrum semiovale (CS) was assessed on axial T2 weighted magnetic resonance imaging using a validated scale. Patients' EPVS status was categorized as either mild or moderate to severe degree. The association between EPVS and PSD was examined with logistic regression.

RESULTS

One hundred and fifty-three (21.1%) of the study sample had PSD three month after stroke. 55.6% of the study sample were classified as having a minor stroke. The median scores of CS- and BG-EPVS were 1 (1-2) and 1 (0-2), respectively. After adjusting for demographic, clinical and imaging characteristics in multivariate logistic regression analyses, the CS-EPVS continuous score remained an independent predictor of PSD [odds ratio (OR) = 1.27; 95% confidence interval (CI) = 1.03-1.57]. After dichotomized, moderate to severe CS-EPVS was independently associated with PSD with an OR of 1.68 (95%CI = 1.10-2.57).

LIMITATIONS

The diagnosis of PSD was based on GDS score rather than a standardized clinical examination. The study favored the patients with milder stroke.

CONCLUSION

CS-EPVS were associated with PSD identified at three months after mild to moderate acute ischemic stroke.

Cerebral Small Vessel Disease Burden Is Associated With Poststroke Depressive Symptoms: A 15-Month Prospective Study

Objective: All types of cerebral small vessel disease (SVD) markers including lacune, white matter hyperintensities (WMH), cerebral microbleeds, and perivascular spaces were found to be associated with poststroke depressive symptoms (PDS). This study explored whether the combination of the four markers constituting an overall SVD burden was associated with PDS. Methods: A cohort of 563 patients with acute ischemic stroke were followed over a 15-month period after the index stroke. A score of ≥7 on the 15-item Geriatric Depression Scale was defined as clinically significant PDS. Scores of the four SVD markers ascertained on magnetic resonance imaging were summed up to represent total SVD burden. The association between SVD burden and PDS was assessed with generalized estimating equation models. Results: The study sample had a mean age of 67.0 ± 10.2 years and mild-moderate stroke [National Institutes of Health Stroke Scale score: 3, interquartile, 1-5]. PDS were found in 18.3%, 11.6%, and 12.3% of the sample at 3, 9, and 15 months after stroke, respectively. After adjusting for demographic characteristics, vascular risk factors, social support, stroke severity, physical and cognitive functions, and size and locations of stroke, the SVD burden was associated with an increased risk of PDS [odds ratio = 1.30; 95% confidence interval = 1.07-1.58; p = 0.010]. Other significant predictors of PDS were time of assessment, female sex, smoking, number of acute infarcts, functional independence, and social support. Conclusion: SVD burden was associated with PDS examined over a 15-month follow-up in patients with mild to moderate acute ischemic stroke.

Proposing a new stroke-specific screening tool for depression: Examination of construct validity and reliability

Objectives

The optimal tool for identifying depression after stroke is yet to be identified. In the present study, we propose a new context-specific screening tool for PSD and examined its construct validity and reliability within existing data on recent stroke survivors.

Methods

We assessed baseline data being collected as part of an intervention to improve one-year blood pressure control among recent (≤ one month) stroke survivors. Depression was measured using the Hospital Anxiety and Depression Scale (HADS-D). We also independently administered the 26-items Health Related Quality of Life in Stroke Patients (HRQOLISP-26), a stroke-specific measure developed from a large cross-cultural sample. Using standard protocol, we identified 6 psychoemotional-domain items of the HRQOLISP-26 fitting a single dimensional model with phenomenological and conceptual overlap with the depression framework in the 10th revision of the International Classification of Diseases (ICD-10). We examined construct validity by comparing HRQOLISP-E with the HADS-D, and known group validity by comparing with age, gender, and stroke severity using both the Pearson product moment coefficient and multivariate regression analyses. Internal consistency and split-half reliability were also determined.

Results

Each HRQOLISP-E item (r = − 0.40 to − 0.53, all p < 0.001), as well as the total HRQOLISP-E score (− 0.53, p < 0.001) showed significant correlation with the HADS-D. The HRQOLISP-E scores also correlated significantly with age and stroke severity. Depression assessed using the HRQOLIPS-E was independently associated with older age and stroke severity. All HRQOLISP-E items scale correlations were > 0.8 (0.81–0.93) compared with 0.56–0.68 for the HADS-D (Cronbach's alpha = 0.939, versus 0.742 for the HADS-D, Split-half reliability = 0.899, versus 0.739 for HADS-D).

Conclusion

These results provides preliminary support for further development of the HRQOLISP-E as a context-specific screening tool for PSD through an investigation comparing the proposed measure against a referent-standard clinical diagnostic criteria such as the ICD 10 or Diagnostic and Statistical Manual of Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders.

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The optimal tool for identifying post-stroke depression (PSD) is yet to be identified.

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We derived HRQOLISPE from a context-specific tool, the Health Related Quality of Life in Stroke Patients.

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HRQOLISPE demonstrated good construct validity.

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HRQOLISPE had better reliability compared with Hospital Anxiety and Depression Rating Scale.

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We propose the HRQOLISPE as a context-specific screening tool for PSD.

A scoping review of the needs of children and other family members after a child's traumatic injury

OBJECTIVE

To review children's and their families' needs after a child's traumatic injury and assessment tools to measure needs.

DATA SOURCES

Medline, Embase, CINAHL and PsycINFO databases (2005-September 2017) were searched and screened for papers (of any design) investigating children's and families' needs after a child's traumatic physical injury.

REVIEW METHODS

Data regarding children's and families' needs were extracted by two independent raters. Methodological quality of the identified papers was not assessed. Thematic content analysis drew out the key needs.

RESULTS

A total of 12 studies were identified, involving 932 participants including 105 injured adolescents and 827 family members or professionals. The needs of children under 12 years were identified indirectly from families or professionals. Most studies focussed on traumatic brain injuries. Two groups of needs were identified: person-related and service-related. Person-related needs were categorized into adolescent-specific needs, need for support with cognitive, emotional, social and physical problems and help with practical problems. Service-related needs were categorized into the need for information, educational needs and support during care transitions (specifically access to community-based services). These needs were largely unmet, particularly regarding information, emotional support and care transitions, which were compounded by professionals' limited understanding of the children's difficulties. We found no published measurement tools to assess children's and families' needs after a child's traumatic injury.

CONCLUSION

The evidence about children's and families' needs following a child's traumatic injury was limited, but needs for information, emotional support and access to community-based services were consistently unmet.

Criterion Validity of the "HRQOLISP-E": A New Context-Specific Screening Tool for Poststroke Depression

Objectives

The optimal tool for identifying postsroke depression (PSD) is yet to be identified. In the present study, we rely on the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) as a meaningful criterion to investigate the psychometric properties of the HRQOLISP-E, a new context-specific screening tool for PSD developed from a large cross-cultural sample.

Methods

We assessed baseline data being collected as part of an intervention to improve one-year blood pressure control among recent (≤one month) stroke survivors. Depression was measured using the HADS-D and the HRQOLISP-E. We determined sensitivity, specificity, likelihood ratios, and posttest probability. The area under a receiver operator curve (AUC) and the most appropriate HRQOLISP-E cut-off were also determined using standard procedures.

Results

Using data derived from 387 recent stroke survivors, the HRQOLISP-E showed high agreement with the HADS-D, sensitivity = 73.7%, specificity = 79.3%, and posterior test probability = 88% (95% CI = 84%–91%). The AUC was 0.81 (95% CI = 0.76–0.86). The HRQOLISP-E cut-off, corresponding to HADS-D score ≥ 8, was 20/21 (out of a total score of 30).

Conclusions

Within limitations of using the HADS-D as a referent criterion, the present results provide justification for further development of the HRQOLISP-E as the first stroke-specific screening tool for depression.

Psychometric evaluation of the Signs of Depression Scale with a revised scoring mechanism in stroke patients with communicative impairment

OBJECTIVES

To investigate (1) the diagnostic value of the Signs of Depression Scale (SODS) in a Likert scale format and (2) whether the Likert scale improves the diagnostic value compared with the original dichotomous scale.

DESIGN

Cross-sectional multicentre study.

SETTING

One general and one university hospital in the Netherlands.

SUBJECTS

A total of 116 consecutive hospitalized stroke patients, of whom 53 were patients with communicative impairment.

MAIN MEASURES

Depression was diagnosed with the Composite International Diagnostic Interview (CIDI) administered to the patients' relatives. The Barthel Index (BI) was used as an external validator.

RESULTS

The correlation between the CIDI and the SODS-Likert or the SODS was small ( r_b = 0.18), and the correlation between the Barthel Index and the SODS-Likert ( r_s = -0.30) or the SODS ( r_s = -0.33) was moderate. For both instruments, the discriminatory power for diagnosing depression when compared with the CIDI was best at a cut-off score of ⩾2. The internal consistency of the SODS-Likert was acceptable (α = 0.69) and slightly higher than that of the SODS (α = 0.57). The inter-rater reliability of the SODS-Likert and the SODS was acceptable (intraclass correlation coefficient (ICC) 0.66 and ICC 0.80, respectively). The clinical utility was rated good.

CONCLUSION

The diagnostic value of the SODS did not improve using a Likert scale format. However, the diagnostic value of the original dichotomous SODS is reasonable for the initial mood assessment of stroke patients with communicative impairment.

A systematic review of rehabilitation interventions to prevent and treat depression in post-stroke aphasia

PURPOSE

Stepped psychological care is the delivery of routine assessment and interventions for psychological problems, including depression. The aim of this systematic review was to analyze and synthesize the evidence of rehabilitation interventions to prevent and treat depression in post-stroke aphasia and adapt the best evidence within a stepped psychological care framework.

METHOD

Four databases were systematically searched up to March 2017: Medline, CINAHL, PsycINFO and The Cochrane Library.

RESULTS

Forty-five studies met inclusion and exclusion criteria. Level of evidence, methodological quality and results were assessed. People with aphasia with mild depression may benefit from psychosocial-type treatments (based on 3 level ii studies with small to medium effect sizes). For those without depression, mood may be enhanced through participation in a range of interventions (based on 4 level ii studies; 1 level iii-3 study and 6 level iv studies). It is not clear which interventions may prevent depression in post-stroke aphasia. No evidence was found for the treatment of moderate to severe depression in post-stroke aphasia.

CONCLUSIONS

This study found some interventions that may improve depression outcomes for those with mild depression or without depression in post-stroke aphasia. Future research is needed to address methodological limitations and evaluate and support the translation of stepped psychological care across the continuum. Implications for Rehabilitation Stepped psychological care after stroke is a framework with levels 1 to 4 which can be used to prevent and treat depression for people with aphasia. A range of rehabilitation interventions may be beneficial to mood at level 1 for people without clinically significant depression (e.g., goal setting and achievement, psychosocial support, communication partner training and narrative therapy). People with mild symptoms of depression may benefit from interventions at level 2 (e.g., behavioral therapy, psychosocial support and problem solving). People with moderate to severe symptoms of depression require specialist mental health/behavioral services in collaboration with stroke care at levels 3 and 4 of stepped psychological care.

Association between Stroke Status and Depression in a Community Setting: The 2014 Korea National Health and Nutrition Examination Survey

BACKGROUND AND PURPOSE

Previous studies have examined the risk factors for depression in stroke patients, but little information is available on the relationship between stroke status and depression in the community-dwelling general population. We evaluated the association between stroke status and depression using representative nationwide data.

METHODS

In total, 3,487 subjects (aged ≥40 years) who participated in version VI-2 of the sixth Korea National Health and Nutrition Examination Survey (KNHANES) performed in 2014 were included. We compared the prevalence of depression in 120 community-dwelling stroke patients and 3,367 nonstroke controls using the nine-item Patient Health Questionnaire (PHQ-9).

RESULTS

The prevalence of depression (PHQ-9 score ≥10) was 16.7% in stroke patients and 6.4% in controls. In the unadjusted model, depression was more common in stroke patients than in nonstroke controls [odds ratio (OR), 2.95; 95% confidence interval (CI), 1.79-4.86]. After adjusting for demographic characteristics, socioeconomic status, health-related behaviors, and comorbidities, stroke diagnosis was a significant risk factor for depression (OR, 1.85; 95% CI, 1.06-3.24). Specifically, a diagnosis of stroke in patients aged <60 years (OR, 3.82; 95% CI, 1.81-8.09) and the presence of stroke complications (OR, 2.77; 95% CI, 1.25-6.13) remained significant risk factors for depression even after adjusting for potential confounders.

CONCLUSIONS

In a community setting, poststroke survivors had a higher prevalence of depression, and stroke was an independent risk factor for depression. Public psychosocial interventions are needed to improve the mental health care of community-dwelling stroke survivors.