Rates and correlates of suicidal ideation among stroke survivors: a meta-analysis

Knowledge, attitude and practice of poststroke depression among patients with poststroke depression and their family members in Heilongjiang Province, China: a cross-sectional study

OBJECTIVE

This study aimed to investigate the knowledge, attitude and practice (KAP) of poststroke depression (PSD) among patients with PSD and their family members.

DESIGN

Web-based cross-sectional study.

SETTING

This study was conducted in Heilongjiang Province between October 2022 and April 2023.

PARTICIPANTS

Patients with PSD and their family members.

PRIMARY AND SECONDARY OUTCOME MEASURES

KAP scores.

METHOD

The self-administered questionnaire comprised demographic characteristics, knowledge dimension, attitude dimension and practice dimensions.

RESULTS

A total of 489 valid questionnaires were collected, with the average age of the subjects was 54.68±13.80 years, and including 258 (53.09%) patients who had a stroke. The mean scores for KAP were 6.36±2.66 (possible range: 0-10), 29.07±5.18 (possible range: 8-40) and 37.50±8.49 (possible range: 10-50), respectively. Concerning KAP scores, no differences were found between patients with PSD and their family members. Multivariate logistic regression analysis showed that retirement (OR=0.29, 95% CI 0.11 to 0.77, p=0.012) and monthly income less than ¥2000 (OR=0.46, 95% CI 0.27, 0.79, p=0.005) were independently associated with adequate knowledge. Knowledge (OR=2.12, 95% CI 1.44 to 3.14, p<0.001) was independently associated with positive attitude. Knowledge (OR=3.85, 95% CI 2.53 to 5.86, p<0.001) and attitude (OR=1.62, 95% CI 1.06 to 2.47, p=0.024) were independently associated with proactive practice.

CONCLUSION

Patients and their family members had insufficient knowledge, positive attitude and moderate practice towards PSD. Retirement and low monthly income were associated with insufficient knowledge, while knowledge was associated with positive attitude and proactive practice.

Post-Stroke Depression and Suicidal Ideations: Relationship with Gender and Marital Status: A Cross Sectional Study

OBJECTIVES

To determine the prevalence and contributing factors of depression and suicidal ideations among stroke survivors in Nigeria.

METHODS

This was a cross-sectional study comprising 75 consenting stroke survivors who were purposively recruited from 2 tertiary hospitals. Suicidal ideations and depression were measured using standard questionnaires. Obtained data was analyzed with appropriate statistical tools.

RESULTS

9.3% of the participants had depression while 4% reported suicidal ideations. Significant correlation existed between suicidal ideations and depression (ρ = .31, P = .01), and levels of depression and suicidal ideations (χ2 = 85.76; P < .01). Depression had a significant relationship with gender and marital status, while suicidal ideations had a significant relationship with marital status. Females were significantly more depressed than their male counterparts (U = 512.50, P = .04) and also had a higher score on suicidal ideations. The widowed/divorced recorded the highest scores on depression (χ2 = 8.77, P = .01) and suicidal ideations (χ2 = 6.62; P = .04).

CONCLUSION

A worrisome prevalence of depression was reported among the study participants. The level of suicidal ideations was quite low. Depression and suicidal ideations were higher among females and those who lost their life partners (either by divorce or death).

Accelerometer-measured physical activity at 3 months as a predictor of symptoms of depression and anxiety 1 year after stroke: a multicentre prospective cohort study in central Norway

OBJECTIVES

To study sedentary behaviour and physical activity at 3 months as predictors for symptoms of depression and anxiety at 1-year post-stroke.

DESIGN

A prospective cohort study.

PATIENTS

Patients with first-ever ischaemic stroke.

METHODS

Mood was assessed 3- and 12-months post-stroke using the Hospital Anxiety and Depression Scale. Sedentary behaviour and physical activity were measured using accelerometry 3 months post-stroke.

RESULTS

A total of 292 participants (116 (39.7%) females; mean age 71.7 (standard deviation 11.3) years) were included. At 12 months, 16.7% experienced depression and 19.5% anxiety, respectively. Adjusting for age and sex, regression analysis showed that comorbidity burden (β 0.26; 95% confidence interval (95% CI) 0.02, 0.51; p = 0.038), stroke severity (β 0.22; 95% CI 0.10, 0.35; p = 0.001), functional disability (β 0.89, 95% CI 0.49, 1.30; p = 0.000), and global cognition (β-0.15; 95% CI -0.25, -0.05; p = 0.004) predicted depression. Multi-adjusted analysis showed sedentary behaviour and physical activity did not significantly predict depression or anxiety (p > 0.05).

CONCLUSION

Sedentary behaviour and physical activity did not significantly predict mood after stroke. Comorbidity burden, stroke severity, functional disability, and global cognition were identified as possible predictors of depression. More research is needed to determine the impact of physical activity on depression and anxiety symptoms.

Psychological support after stroke: unmet needs and workforce requirements of clinical neuropsychological provision for optimal rehabilitation outcomes

Stroke services must detect and manage psychological and neuropsychological problems that occur after stroke, such as cognitive and language impairments, post-stroke apathy, post-stroke emotionalism, depression, anxiety, post-traumatic stress disorder, personality changes and suicidality. Stroke neuropsychology plays a key role in the assessment, understanding and management of these consequences of stroke, as well as contributing to complex case management, staff supervision and training. Where these provisions are absent from the stroke rehabilitation pathway, this significantly limits potential rehabilitation outcomes. To manage the scale of psychological and neuropsychological needs post stroke, clinical guidance recommends the use of a matched care system, in which these needs are triaged and matched with corresponding levels of support. Recent workforce guidelines provide clear professional recommendations for psychological staffing skill mix and threshold requirements for clinical oversight and clinical governance assurances.

Risk of suicide among stroke survivors in the United States

BACKGROUND

Stroke is the largest cause of disability and the 5th leading cause of death in the United States. Suicide is the 12th leading cause of death in the United States. However, little is known about the risk of suicide among people with a prior stroke.

OBJECTIVES

Using Multiple Cause of Death data (1999-2020) from the Centers for Disease Control and Prevention WONDER database, we examined via cross-sectional analysis the risk of suicide among survivors of stroke as compared to the general U.S. population and among subgroups within the United States.

METHODS

We assessed disparities in suicide rate among patients with stroke stratified by sex, race, urbanization levels, and census regions using the CDC WONDER multiple cause of death database. Standardized mortality rates were calculated to compare the suicide rate of stroke patients with the rates among demographic-matched cohorts and the general United States population.

RESULTS

As compared to the general population, stroke survivors had an elevated risk of suicide. Black stroke survivors had a lower rate of suicide as compared to the general population, while White stroke survivors and those in nonmetropolitan areas had an elevated risk compared to the general population.

CONCLUSION

There was a slightly elevated risk of suicide among people with a prior stroke in the United States. This risk may be elevated among White people and among people living in nonmetropolitan areas.

Higher serum lipocalin 2 is associated with post-stroke depression at discharge

BACKGROUND AND AIMS

Post-stroke depression (PSD), as one of the common complications after stroke, seriously affects the physical and mental health and functional prognosis of patients. Previous studies have shown that the increase of inflammatory mediators is associated with the occurrence of PSD. Lipocalin 2 (LCN2), as an acute phase protein, is involved in the development of acute ischemic stroke (AIS), and its expression is up-regulated in patients with depression, suggesting that there is a potential correlation between serum LCN2 and depression. The aim of this study was to explore the relationship between serum LCN2 at admission and PSD at discharge.

METHODS

A total of 358 AIS patients were retrospectively included. All patients had fasting venous blood taken within 24 h of admission to detect serum LCN2. The patients were evaluated by 17-item Hamilton Depression Scale (HAMD) before discharge. Patients with HAMD score > 7 were diagnosed with PSD. The correlation between serum LCN2 and PSD was tested using binary logistic regression analysis.

RESULTS

In our study, 92 (25.7%) patients were diagnosed with PSD at discharge. According to the serum LCN2 value, the patients were divided into three layers (Tertile1 ≤ 105.24ng/ml; Tertile2: 105.24-140.12ng/ml; Tertile3 ≥ 140.12ng/ml), with T1 layer (the lowest levels) as a reference, after adjusting for multiple potential confounding factors, T3 layer (the highest levels) was independently associated with the occurrence of PSD (odds ratio [OR] = 2.639, 95% confidence interval [CI]: 1.317-5.287, P = 0.006). Similar results were found when the serum LCN2 was analyzed as a continuous variable. The optimal cut-off value of serum LCN2 at admission to predict PSD at discharge was 117.60ng/ml, at this threshold, the sensitivity was 77.2%, and the specificity was 53.4%.

CONCLUSIONS

High serum LCN2 levels at admission are an independent risk factor for PSD in patients with AIS at discharge.

Liver function test indices-based prediction model for post-stroke depression: a multicenter, retrospective study

BACKGROUND

Post-stroke depression (PSD) was one of the most prevalent and serious neuropsychiatric effects after stroke. Nevertheless, the association between liver function test indices and PSD remains elusive, and there is a lack of effective prediction tools. The purpose of this study was to explore the relationship between the liver function test indices and PSD, and construct a prediction model for PSD.

METHODS

All patients were selected from seven medical institutions of Chongqing Medical University from 2015 to 2021. Variables including demographic characteristics and liver function test indices were collected from the hospital electronic medical record system. Univariate analysis, least absolute shrinkage and selection operator (LASSO) and logistic regression analysis were used to screen the predictors. Subsequently, logistic regression, random forest (RF), extreme gradient boosting (XGBoost), gradient boosting decision tree (GBDT), categorical boosting (CatBoost) and support vector machine (SVM) were adopted to build the prediction model. Furthermore, a series of evaluation indicators such as area under curve (AUC), sensitivity, specificity, F1 were used to assess the performance of the prediction model.

RESULTS

A total of 464 PSD and 1621 stroke patients met the inclusion criteria. Six liver function test items, namely AST, ALT, TBA, TBil, TP, ALB/GLB, were closely associated with PSD, and included for the construction of the prediction model. In the test set, logistic regression model owns the AUC of 0.697. Compared with the other four machine learning models, the GBDT model has the best predictive performance (F1 = 0.498, AUC = 0.761) and was chosen to establish the prediction tool.

CONCLUSIONS

The prediction model constructed using these six predictors with GBDT algorithm displayed a promising prediction ability, which could be used for the participating hospital units or individuals by mobile phone or computer.

Leukoaraiosis as a Predictor of Depression and Cognitive Impairment among Stroke Survivors: A Systematic Review

Stroke survivors are at increased risk of developing depression and cognitive decline. Thus, it is crucial for both clinicians and stroke survivors to be provided with timely and accurate prognostication of post-stroke depression (PSD) and post-stroke dementia (PSDem). Several biomarkers regarding stroke patients' propensity to develop PSD and PSDem have been implemented so far, leukoaraiosis (LA) being among them. The purpose of the present study was to review all available work published within the last decade dealing with pre-existing LA as a predictor of depression (PSD) and cognitive dysfunction (cognitive impairment or PSDem) in stroke patients. A literature search of two databases (MEDLINE and Scopus) was conducted to identify all relevant studies published between 1 January 2012 and 25 June 2022 that dealt with the clinical utility of preexisting LA as a prognostic indicator of PSD and PSDem/cognitive impairment. Only full-text articles published in the English language were included. Thirty-four articles were traced and are included in the present review. LA burden, serving as a surrogate marker of "brain frailty" among stroke patients, appears to be able to offer significant information about the possibility of developing PSD or cognitive dysfunction. Determining the extent of pre-existing white matter abnormalities can properly guide decision making in acute stroke settings, as a greater degree of such lesioning is usually coupled with neuropsychiatric aftermaths, such as PSD and PSDem.

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.

Effectiveness of mindfulness-based stress reduction and mindfulness-based cognitive therapy on depression in poststroke patients-A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) on depressive symptoms in people with stroke.

METHODS

The PubMed, CINAL, Web of Science, Embase, The Cochrane Library, CNKI, and Wangfang databases were searched for relevant articles from inception to September 1st^, 2022. Only randomized controlled trials (RCTs) examining the effect of MBSR and MBCT on depressive symptoms in poststroke patients were included. Data extraction and critical appraisal were conducted independently by two investigators.

RESULTS

Seven trials with 502 participants were included. Using standardized mean differences, the meta-analysis showed evidence of a significant effect in depression (SMD = -0.93, 95% CI (-1.34 to -0.53), Z = 4.48, p < 0.001). MBSR and MBCT both affected depressive emotions in poststroke participants with depression (SMD = -1.27, 95% CI (-1.71 to -0.84), p < 0.001) and poststroke participants without clinically defined depression (SMD = -0.46, 95% CI (-0.75 to -0.17), p = 0.002).

CONCLUSION

Although populations with stroke seem to potentially improve moods from MBSR/MBCT intervention, the impact on the physiological parameters of the disease has not been determined. Further studies with long-term follow-up and higher qualities are warranted for such interventions to determine the full effectiveness.

Risk of self-harm in post TIA patients: A population-based cohort study

OBJECTIVE

The purpose of this study was to determine whether individuals who have experienced a transient ischemic attack (TIA) have an increased risk of self-harm behaviors.

METHODS

In this matched cohort study, we reviewed the electronic health records of all patients admitted for any reason to Hong Kong public hospitals between January 1, 1993, and December 31, 2019. We selected a post-TIA cohort consisting of 37,356 patients and a comparison cohort comprising 37,352 subjects. All participants enrolled in this study were followed up until a diagnosis of self-harm, death from other causes, or the end of 2020, whichever occurred first. Univariate Cox proportional hazards regression models were used to calculate the risk of self-harm since the onset of TIA.

RESULTS

Throughout the 27-year study period, the number of individuals exhibiting self-harm behavior in the TIA and comparison groups was 1031 (2.76%) and 512 (1.37%), respectively. The TIA group had a higher proportion of subjects with self-harm (χ² = 178, p < .001). The incidence rates of self-harm were 33.94 and 19.27 per 10,000 person-years in TIA patients and comparators, respectively. Compared with the comparators, the adjusted hazard ratio for self-harm in TIA patients was 1.63 (95% confidence interval, 1.46-1.82).

CONCLUSIONS

TIA is associated with an increased risk of self-harm. Healthcare professionals should help identify patients at heightened risk and provide efficient and targeted prevention strategies for this population.

Blood biomarkers of post-stroke depression after minor stroke at three months in males and females

BACKGROUND

Post-stroke depression (PSD) is one of the most common neuropsychiatric complications after stroke. Studies on the underlying mechanisms and biological markers of sex differences in PSD are of great significance, but there are still few such studies. Therefore, the main objective of this study was to investigate the association of biomarkers with PSD at 3 months after minor stroke in men and women.

METHODS

This was a prospective multicenter cohort study that enrolled 530 patients with minor stroke (males, 415; females, 115). Demographic information and blood samples of patients were collected within 24 h of admission, and followed up at 3 months after stroke onset. PSD was defined as a depressive disorder due to another medical condition with depressive features, major depressive-like episode, or mixed-mood features according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V). Univariate analysis was performed using the chi-square test, Mann-Whitney U test, or t-test. Partial least-squares discriminant analysis (PLS-DA) was used to distinguish between patients with and without PSD. Factors with variable importance for projection (VIP) > 1.0 were classified as the most important factors in the model segregation.

RESULTS

The PLS-DA model mainly included component 1 and component 2 for males and females. For males, the model could explain 13% and 16.9% of the variables, respectively, and 29.9% of the variables in total; the most meaningful predictors were exercise habit and fibrinogen level. For females, the model could explain 15.7% and 10.5% of the variables, respectively, and 26.2% of the variables in total; the most meaningful predictors in the model were brain-derived neurotrophic factor (BDNF), magnesium and free T3. Fibrinogen was positively correlated with the Hamilton Depression Scale-17 items (HAMD-17) score. BDNF, magnesium, and free T3 levels were negatively correlated with the HAMD-17 score.

CONCLUSIONS

This was a prospective cohort study. The most important markers found to be affecting PSD at 3 months were fibrinogen in males, and free T3, magnesium, and BDNF in females.

TRIAL REGISTRATION

ChiCTR-ROC-17013993 .

Efficacy and safety of electroacupuncture for post-stroke depression: a randomized controlled trial

OBJECTIVE

The objective of this study is to evaluate the efficacy and safety of electroacupuncture (EA) treatment for post-stroke depression (PSD).

METHODS

This study was a single-center, single-blinded, parallel-arm randomized controlled trial. In total, 65 patients with PSD were randomly allocated into EA and sham EA groups. Treatment was administered at GV20, Sishencong, SP6, LR3 and BL18 in both groups. The EA group received EA treatment, while the sham EA group received sham EA treatment using the Park device. Treatment was given three times a week for 4 weeks. The primary outcome was the Hamilton Rating Scale for Depression (HRSD). Secondary outcomes included the Zung Self-Rating Depression Scale (SDS), National Institutes of Health Stroke Scale (NIHSS), Barthel Daily Living Index (BI) and depression scale of traditional Chinese medicine (TCM). Primary and secondary outcomes were assessed at baseline, week 2 after treatment, week 4 after treatment and week 8 of follow-up. Safety assessment was conducted at each visit for 4 weeks of treatment.

RESULTS

Significant differences in HRSD, SDS, NIHSS, BI and TCM scale scores were found in the EA group before and after acupuncture treatment (all p < 0.001). Compared with the sham EA group, HRSD scores improved significantly in the EA group at the end of week 2 (F = 31.33, p < 0.001), week 4 (F = 35.58, p < 0.001) and week 8 after treatment onset (F = 25.03, p < 0.001). Similarly, significant improvements were observed in SDS, NIHSS and BI scores. Two participants in the EA group suffered a local hematoma, while no adverse events were reported in the sham EA group.

CONCLUSION

EA appears to be an efficacious and safe treatment for PSD. According to our results, EA may alleviate depressive symptoms, and improve neurological function and capabilities with respect to activities of daily living (ADLs).

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-17012610 (Chinese Clinical Trial Registry).

Meta-analysis of risk factors associated with suicidal ideation after stroke

BACKGROUND

Over the past decade, increasing attention has been paid on post stroke suicide (PSS), which is one of complications of stroke. The rates of stroke and suicide are relatively high, especially in Asian populations. Thus, a deeper understanding of the prevalence and epidemiological impact of suicide after stroke is urgently needed. Clinical diagnosis and prevention of PSS are at the incipient stage, but the risk factors responsible for the occurrence of PSS in different regions and stages of the disease remain largely unknown. The present meta-analysis aimed to determine the incidence of PSS at different stages and time courses, and to identify the underlying risk factors for PSS.

METHODS

We systematically searched the Cochrane library, Embase, PubMed, CNKI and Web of Science databases from their inception until April 2019.The research articles reporting on the risk factor for PSS were screened and included in the meta-analysis. The data from the included studies were extracted according to the predefined criteria.

RESULTS

A total of 12 studies (n = 2,693,036) were included for meta-analyses. Of these studies, 7 reporting suicide prevalence were meta-analyzed. The pooled estimate of suicidal ideation rates after stroke was 12%, which could be influenced by multiple risk factors, including sex, smoking, depression, sleep disorders, previous stroke and low household income. Studies conducted in Asia demonstrated higher suicide prevalence (approximately 15%) compared to other regions. Smoking, low family income, depression, heart disease and sleep disorders were important risk factors for PSS. When compared to PSS of more than 1 year, the incidence of suicide within 1 year after stroke was more likely to be statistically significant. It was found that 4 out of every 1000 stroke survivors tended to commit suicide. The results of this meta-analysis showed that depression (OR = 2.32; p < 0.01) was significantly associated with suicidal ideation, regardless of stroke duration.

CONCLUSION

PSS is one of the common complications of stroke. Despite some limitations, we successfully identified the risk factors associated with suicidal ideation after stroke. Notably, depression was significantly associated with suicidal ideation, regardless of stroke duration. Targeting this risk factor may be helpful to improve stroke patient care and prevent suicidal ideation after stroke. Future research will be carried out to assess whether suicidal ideation or thoughts and actual suicide attempts are strongly predictive of suicide deaths after stroke (Registration No. CRD42019128813).

Does urinary metabolite signature act as a biomarker of post-stroke depression?

BACKGROUND

It is difficult to conduct the precise diagnosis of post-stroke depression (PSD) in clinical practice due to the complex psychopathology of depressive disorder. Several studies showed that gas chromatography-mass spectrometry (GC-MS)-identified urinary metabolite biomarkers could significantly discriminate PSD from stroke survivors.

METHODS

A systematic review was performed for the keywords of "urinary metabolite" and "PSD" using Medline, Cochrane Library, Embase, Web of Science, PsycINFO, Wanfang, CNKI, CBM, and VIP database from inception to 31 March 2022.

RESULTS

Four related studies were included in the review. Differential urinary metabolites including lactic acid, palmitic acid, azelaic acid, and tyrosine were identified in all the included studies. As a significant deviation in the metabolite biomarker panel, glyceric acid, azelaic acid, phenylalanine, palmitic acid, pseudouridine, and tyrosine were found in at least 2 included studies, which indicated good potential for the differentiation of PSD.

CONCLUSION

The systematic review provided evidence that differential urinary metabolites analyzed by the GC-MS-based approach might be used as a biomarker for the diagnosis and prognosis of PSD.

Family Functioning is Associated with Post-Stroke Depression in First-Ever Stroke Survivors: A Longitudinal Study

BACKGROUND

Post-stroke depression (PSD) can aggravate the mortality and recurrence rate in stroke patients. The relationship between family functioning and PSD at different phases after a first-ever stroke is unclear. The purpose of this longitudinal study was to investigate the patterns and relationship of family functioning and PSD at acute hospitalization and 6 months post-discharge in first-ever stroke survivors.

METHODS

This is a longitudinal study conducted in Guangzhou, China. Family functioning and depression were measured by the Short Form Family Assessment Device (SF-FAD) and Self-Rating Depression Scale (SDS) at baseline and 6 months post-discharge. Multiple linear regression analysis was used to explore the relationship between family functioning and PSD.

RESULTS

The prevalence of PSD at acute hospitalization and 6 months post-discharge was 32.9% and 20.0%, respectively. SDS scores decreased significantly from baseline to 6 months post-discharge, while SF-FAD scores did not change significantly during this period. The Pearson correlation coefficient showed that SF-FAD scores were positively associated with SDS scores at the two time points (r ₁ = 0.341, r ₂ = 0.510, P < 0.05). Multiple linear regression analyses indicated that SF-FAD scores could predict PSD at baseline (unstandardized coefficient: 7.010, P < 0.05) and 6 months post-discharge (unstandardized coefficient: 9.672, P < 0.001).

CONCLUSION

This study found that first-ever stroke survivors had good family functioning at baseline and 6 months post-discharge. The findings in this study verified that poor family functioning is positively associated with PSD at different phases post-stroke. Good family functioning is an important protective factor against PSD.

Depression, Anxiety, and Suicide After Stroke: A Narrative Review of the Best Available Evidence

Depression and anxiety each affect around 1 in 3 people during the first year after a stroke. Suicide causes the death of about 3 to 4/1000 stroke survivors during the first 5 years. This narrative review describes the best available evidence for the epidemiology of depression, anxiety, and suicide; their prevention; and the treatment of anxiety and depression. We conclude with directions for future research.

"Hard to Say, Hard to Understand, Hard to Live": Possible Associations between Neurologic Language Impairments and Suicide Risk

In clinical practice, patients with language impairments often exhibit suicidal ideation (SI) and suicidal behavior (SB, covering the entire range from suicide attempts, SA, to completed suicides). However, only few studies exist regarding this subject. We conducted a mini-review on the possible associations between neurologic language impairment (on the motor, comprehension, and semantic sides) and SI/SB. Based on the literature review, we hypothesized that language impairments exacerbate psychiatric comorbidities, which, in turn, aggravate language impairments. Patients trapped in this vicious cycle can develop SI/SB. The so-called “affective prosody” provides some relevant insights concerning the interaction between the different language levels and the world of emotions. This hypothesis is illustrated in a clinical presentation, consisting of the case of a 74-year old woman who was admitted to a psychiatric emergency department (ED) after a failed SA. Having suffered an ischemic stroke two years earlier, she suffered from incomplete Broca’s aphasia and dysprosody. She also presented with generalized anxiety and depressive symptoms. We observed that her language impairments were both aggravated by the exacerbations of her anxiety and depressive symptoms. In this patient, who had deficits on the motor side, these exacerbations were triggered by her inability to express herself, her emotional status, and suffering. SI was fluctuant, and—one year after the SA—she completed suicide. Further studies are needed to ascertain possible reciprocal and interacting associations between language impairments, psychiatric comorbidities, and SI/SB. They could enable clinicians to better understand their patient’s specific suffering, as brought on by language impairment, and contribute to the refining of suicide risk detection in this sub-group of affected patients.

Suicide in obstructive lung, cardiovascular and oncological disease

Healthcare institutions face increasing demands stemming from the burden of noncommunicable diseases. The personal, social, financial and societal impact of these diseases are well-documented. However, the mental health concerns and trajectories of patients afflicted by chronic medical diseases have been under-recognized and are under-resourced. Despite that chronic diseases are associated with substantially increased risk of suicide, the medical world has largely failed to properly address suicide in the medically ill. Considering their high prevalence and mortality rate, this review article will highlight the mental health burden and suicide risk in obstructive lung, cardiovascular (including stroke) and oncological disease, in light of relevant data and conceptual models of suicide. Finally, general evidence-based suicide intervention strategies and potential selective adaptation of these strategies to the chronic medically ill patient populations and medical settings will be reviewed.

Comparative Analysis of Stroke Patients with and without Sequelae: A Cross-Sectional Analysis Using the KOREA National Health and Nutrition Examination Survey (2016-2019)

(1) Background: We aimed to evaluate the association between sociodemographic factors and mental health problems and the sequelae of stroke in South Korea by analyzing the annual Korea National Health and Nutrition Examination Surveys (KNHANES) conducted from 2016 to 2019. (2) Methods: Data were obtained from 32,379 participants who participated in the KNHANES (2016-2019). A total of 567 participants diagnosed with stroke were included in this study. Patients were divided into two groups based on the presence of sequelae: (a) stroke patients with sequelae (n = 227, 40.0%) and (b) stroke patients without sequelae (n = 340, 60.0%). (3) Results: Compared to stroke patients without sequelae, those with sequelae were significantly associated with sex (male, 61.2% vs. 47.6%, p = 0.002), household income (lower half, 78.9% vs. 67.4%, p = 0.005), owning a house (60.4% vs. 68.5%, p = 0.048), marital status (unmarried, 7.05% vs. 1.76%, p < 0.001), depression (13.2% vs. 7.35%, p = 0.045), suicidal ideation (6.17% vs. 3.24%, p = 0.010), and suicide attempts (2.64% vs. 0.88%, p = 0.012). (4) Conclusions: Our study showed that poor sociodemographic factors and mental health problems were significantly associated with sequelae from stroke. Clinical physicians should therefore carefully screen for depression and suicidality in stroke patients with sequelae, especially in those with poor sociodemographic factors.

Early screening for post-stroke depression, and the effect on functional outcomes, quality of life and mortality: a protocol for a systematic review and meta-analysis

INTRODUCTION

Post-stroke depression (PSD) is a severe complication of cerebrovascular stroke affecting about one-third of stroke survivors. Moreover, PSD is associated with functional recovery and quality of life (QOL) in stroke survivors. Screening for PSD is recommended. There are, however, differences in the literature on the impact of early screening on functional outcomes. In this systematic review, we synthesise the currently available literature regarding the associations between timing and setting of PSD screening and mortality, QOL and functional outcomes in stroke survivors.

METHODS AND ANALYSIS

We will systematically search electronic databases including PubMed, Embase, APA PsycINFO, Web of Science, Scopus and CINAHL from inception to August 2021. Four reviewers will screen the title and abstract and full-text level records identified in the search in a blinded fashion to determine the study eligibility. Any selection disagreements between the reviewers will be resolved by the study investigator. Data extraction of eligible studies will be conducted by two reviewers using a predefined template. We will complete the quality assessment of included articles independently by two reviewers using the Newcastle Ottawa Scale. Eventual discrepancies will be resolved by the principal investigator.

ETHICS AND DISSEMINATION

Due to the nature of the study design, ethical approval is not required. The systematic review and meta-analysis findings will be published and disseminated in a peer-reviewed journal. Our results will also be disseminated through posters and presentations at appropriate scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42021235993.

Associations between suicidal ideation and health-related quality of life among community-dwelling stroke survivors: 2013-2017 Korea National Health and Nutrition Examination Survey

PURPOSE

The study aimed to identify differences between individuals with stroke and the general population regarding socioeconomic, mental health, and Health-related quality of life (HRQOL) factors, and associations among Suicidal ideation (SI), HRQOL, and mental health.

METHODS

Data of individuals with stroke (n = 592) and without stroke (n = 23,562) aged 20 or older from the 2013-2017 Korea National Health and Nutrition Examination Survey were analyzed. Chi-square tests examined differences in socioeconomic status, mental health, and HRQOL (EQ-5D) between groups. Independent associations between each EQ-5D dimension and SI were analyzed through multivariable logistic regression.

RESULTS

Individuals with stroke were more likely to have problems on all EQ-5D dimensions. Significant univariate associations were identified between four EQ-5D dimensions and SI among individuals with stroke. Pain/discomfort (odds ratio [OR] = 1.32; 95% confidence interval [CI], 1.01-1.75, p = 0.048) and anxiety/depression (OR = 4.66; 95% CI, 3.69-5.89, p < .0001) of the EQ-5D were associated with SI when adjusting for all socioeconomic variables; anxiety/depression (OR = 2.80; 95% CI, 2.18-3.60, p < .0001) was the only risk factor for SI after controlling for socioeconomic and mental health variables.

CONCLUSION

Individuals with stroke showed higher rates for problems on the EQ-5D, SI, and depression compared to the general population. They also demonstrated significant associations between SI and each EQ-5D dimension except physical activity, especially pain/discomfort and depression/anxiety. The study's findings can be referred to when predicting suicide risk in individuals with stroke by analyzing their EQ-5D scores.

The Nurse or Midwife at the Crossroads of Caring for Patients With Suicidal and Rigid Religious Ideations in Africa

Nurses and midwives are the majority of healthcare professionals globally, including Africa, and they provide care at all levels of the health system including community levels. Nurses and midwives contribute to the care of patients with rigid or dogmatic religious beliefs or those with suicidal ideations. This review paper discusses acute and chronic diseases that have suicidal tendencies such as terminal cancer, diseases with excruciating pain, physical disability, stroke, end-stage renal failure, and diabetics who are amputated. It was reiterated that nurses and midwives taking care of these patients should be alert and observant to identify their suicidal tendencies. The paper also discusses religious or spiritual inclinations that negatively affect healthcare access and adherence, especially to biomedical or western medicine. It was emphasized that some religious beliefs do not allow their followers to employ biomedical treatment and nurses and midwives should not impose their faith on patients and their families. The paper ends with a discussion on the specific roles of nurses and midwives in the care of patients with suicidal ideations such as assessment, counseling, administering medication, observation, social interaction, ensuring safety measures, and providing an enabling environment for the family to part of the care and for the observation of religious coping strategies. Nurses and midwives should enhance their knowledge and skills on suicide and increase public education on suicide prevention and identification of those at risk.

Association Between Stroke and Subsequent Risk of Suicide: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Poor mental health and depression are well-recognized sequelae of stroke; however, the association between stroke and subsequent risk of suicide is unknown.

METHODS

We systematically searched MEDLINE, Embase, PsycINFO, and Google Scholar from their inception to September 15, 2020, using keywords and database-specific subjects. We independently adjudicated and selected observational studies that reported suicide attempts or death by suicide in stroke survivors and a comparison group, consisting either of people without a history of stroke or the general population. We evaluated study quality using the Newcastle Ottawa scale. Using random-effects meta-analysis, we calculated the pooled adjusted risk ratio (RR) of suicide in stroke survivors and separately calculated the pooled adjusted RR of suicide attempt and death by suicide. Using prespecified analyses, we explored study-level factors to explain heterogeneity.

RESULTS

We screened 4093 articles and included 23 studies of fair quality, totaling over 2 million stroke survivors, of whom 5563 attempted suicide or died by suicide. Compared to the nonstroke group, the pooled adjusted RR of suicide in stroke survivors was 1.73 (95% CI, 1.53-1.96, I²=93%), with a significantly (P=0.03) higher adjusted risk of suicide attempt (RR, 2.11 [1.73-2.56]) than of death by suicide (RR, 1.61 [1.41-1.84]). A longer follow-up time in cohort studies was associated with a lower risk of suicide (RR, 0.97 [0.95-0.99] for every 1-year increase).

CONCLUSIONS

Stroke should be considered as a risk factor for suicide. Comprehensive strategies to screen and treat depression and suicidal ideation in stroke survivors should be developed to reduce the burden of suicide in stroke survivors.

High Serum Levels of iNOS and MIP-1α are Associated with Post-Stroke Depression

PURPOSE

Post-stroke depression (PSD) is one of the emotional disorders after the onset of stroke. Many studies have indicated that inflammatory processes can promote the occurrence and development of PSD. The purpose of our study was to explore the potential relationship between PSD and two inflammatory biomarkers: inducible nitric oxide synthase (iNOS) and macrophage inflammatory protein 1α (MIP-1α).

METHODS

In total, 80 patients diagnosed with depression after the first-ever acute ischemic stroke were enrolled in PSD group consecutively. During the same period, 40 non-depressed patients following the first-ever acute ischemic stroke and 40 healthy control subjects were recruited as non-PSD group and normal group, respectively. All participants have performed serum iNOS and MIP-1α level examination with enzyme-linked immunosorbent assay (ELISA). The severity of depressive symptoms was evaluated by the 24-item Hamilton Depression Scale (HAMD-24).

RESULTS

Serum iNOS and MIP-1α levels were significantly higher in PSD group than those in non-PSD and normal groups (P < 0.001). Serum iNOS and MIP-1α levels of PSD patients with varying degrees of depression were significantly different, serum iNOS and MIP-1α levels became higher as the depressive symptoms became more severe (P < 0.05). There was a positive correlation between the elevated levels of iNOS, MIP-1α and HAMD scores (r = 0.262, 0.209, P < 0.05). Logistic regression analysis showed that both serum iNOS and MIP-1α levels were independently associated with PSD (OR = 2.790, 95% CI: 0.712-10.933, P < 0.05 and OR = 1.922, 95% CI: 0.648-9.815, P < 0.05, respectively) after adjustment for possible relevant confounders.

CONCLUSION

High serum levels of iNOS and MIP-1α were found to be associated with the development of PSD and closely related to its severity.

Suicide in Parkinson's Disease: A Systematic Review

Psychiatric disorders and suicide have been reported in patients suffering from Parkinson's disease. The aims of the present paper were to determine whether patients with Parkinson's disease have an increased rate of suicide and to identify the clinical features possibly associated with suicide risk in Parkinson's disease. We also reviewed the studies on suicide risk in Parkinson's disease in patients after deep brain stimulation. We performed a Medline, Excerpta Medica, PsycLit, PsycInfo and Index Medicus search to identify all articles published on this topic from 1970 to 2019. The following search terms were used: suicide OR suicide attempt OR suicidal ideation OR suicide risk AND Parkinson's disease AND Parkinson's disease and deep brain stimulation. The studies we identified that assessed the suicide rate associated with Parkinson's disease yielded contrasting results, although an increase in suicidal ideation did emerge. The studies on the effect of deep brain stimulation on suicide risk in Parkinson's disease also reported mixed findings. Psychiatric symptoms, including depression, appear to be associated with suicide risk in patients with Parkinson's disease undergoing medical and after surgical treatment. The studies reviewed suggest that suicidal ideation is increased in Parkinson's disease. Further longitudinal studies designed to assess suicidality in this condition are still needed.

Post-stroke depression: A 2020 updated review

BACKGROUND

Post-stroke depression (PSD) is common and associated with higher mortality, poorer recovery, more pronounced cognitive deficits, and lower quality of life than is stroke without depression. This manuscript will conduct an updated, comprehensive and clinically-useful review of the risk factors, pathophysiology, assessment, prevention, and treatment of PSD.

METHODS

This narrative review summarizes articles obtained on PubMed, Medline, EMBase, Google Scholar and the Cochrane Database. This review prioritized articles with a more robust level of evidence, such as original articles with longitudinal data and/or larger samples, randomized controlled trials, systematic reviews, and metaanalyses.

RESULTS

One hundred twenty-four articles were reviewed, of which 44 (35%) were published before 2016 and 80 (65%) that were published since 2016.

DISCUSSION

Rates of PSD range from 18 to 33%, yet it is vastly underdiagnosed and undertreated. Risk factors for PSD include female sex, history of psychiatric illness, large or multiple strokes, injuries in frontal/anterior areas or in the basal ganglia, stroke occurrence within the past year, poor social support, and pronounced disability. The pathophysiology of PSD is multifactorial and likely involves decreased levels of monoamines, abnormal neurotrophic response, increased inflammation with dysregulation of hypothalamic-pituitary-adrenal axis, and glutamate-mediated excitotoxicity. The evidence for preventive interventions for PSD is somewhat inconsistent and modest. The best treatment for PSD consists of the combination of pharmacological, psychosocial and stroke-focused interventions.

CONCLUSION

PSD is a common, treatable condition that is associated with several negative outcomes. Early detection and proper management are critical to obtain better outcomes in individuals with PSD.

Vitamin D deficiency and suicidal ideation: A cross-sectional study of 157,211 healthy adults

OBJECTIVES

Vitamin D deficiency has been reported to be associated with various neuropsychiatric disorders. However, there are few studies addressing deficient vitamin D levels and suicidal ideation.

METHODS

Serum vitamin D of 157,211 Korean adult participants were measured using electrochemiluminescence immunoassay. A self-reported questionnaire was used to assess whether participants experienced suicidal ideation. Logistic regression model was used to estimate the odds ratio (OR) of suicidal ideation according to vitamin D levels. The regression was adjusted for a range of covariates.

RESULTS

Compared with sufficient vitamin D levels (≥20 ng/mL), deficient vitamin D levels (<10 ng/mL) were significantly associated with the risk of suicidal ideation (OR = 1.138, 95% Cl = 1.027-1.262). However, the OR of suicidal ideation was not significantly different between the vitamin D insufficient group (10-19.99 ng/mL) and sufficient group (≥20 ng/mL) (OR = 0.988, 95% Cl = 0.932-1.047).

CONCLUSION

Deficient vitamin D levels were significantly associated with the risk of suicidal ideation. However, the risk of suicidal ideation was not significantly different between the vitamin D insufficient group and sufficient group.

Depression in the medically ill

BACKGROUND

Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill.

METHODS

Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary.

RESULTS

Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation.

LIMITATIONS

Non-systematic review of the literature.

CONCLUSION

Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.

Are they necessary? Preventive therapies for post-stroke depression: A meta-analysis of RCTs

To explore the necessity and feasibility of early anti-depressive therapies in acute stroke patients, we conducted a meta-analysis of currently available randomized control studies (RCTs). Literature search in six databases was done with keywords of cerebrovascular accident, depression and prevention. Only RCTs that met the inclusion criteria were enrolled for further analysis. Twelve eligible studies were included in this meta-analysis. Prophylactic anti-depressive therapies following acute stroke were shown to reduce the incidence of depression in the patients (RR = =0.33, 95% CI: 0.25 to 0.43, p < 0.001), improve symptoms of depression (WMD: 5.73, 95% CI: 4.18 to 7.29, p < 0.001), improve motor function (WMD: 12.56, 95%CI: 9.07 to 16.04, p < 0.001) and neurological function (WMD: 1.13, 95%CI: 0.57 to 1.69, p < 0.001). However, anti-depressive therapies showed no effects on mortality (RR = 1.63, 95%CI: 0.55 to 4.85, p = 0.377) and adverse events incidence (RR = 0.93, 95%CI: 0.53 to 1.64, p = 0.806). Anti-depressive therapies following acute stroke is effective thus deserves to be advocated.

Tedium vitae in stroke survivors: a comparative cross-sectional study

OBJECTIVES

Suicide is best studied by deconstructing the psychological experiences preceding suicidal death. We assessed the characteristics of tedium vitae (feeling tired of life) after first ever stroke in Nigerian survivors.

METHODS

Using the Schedule for Clinical Assessment in Neuropsychiatry, tedium vitae was assessed in 130 stroke survivors attending rehabilitation in a large Nigerian university hospital. Global cognitive and executive dysfunctions were evaluated, respectively, using the Mini Mental State Examination and the modified Indiana University Token test. All participants had their index stroke 3 to 24 months before recruitment into the study. We also examined a comparative group of 130 age, gender, and education matched apparently normal persons who were unrelated to the stroke survivors. Associations were explored using univariate and multivariate logistic regression analyses.

RESULTS

Tedium vitae was experienced by 16 (12.3%) stroke survivors compared with 5 (3.9%) in the comparative group (O. R = 3.5, 95% C. I = 1.3-9.9, p = 0.018). Among stroke survivors, those who were retired were more likely to experience tedium vitae (56.2%, p = 0.045). In analyses adjusting for the effect of systemic hypertension, cognitive dysfunction, retirement and marital separation, there was a 3.5-fold increase in the odds of experiencing tedium vitae after surviving a stroke (O. R = 3.5, 95% C. I = 1.1-11.6, p = 0.042).

CONCLUSIONS

Tedium vitae is a common suicidal experience after stroke and may be among the earliest perceptible pointer to impending poststroke suicide. It is easy to assess and may be less costly to obtain an adequate sample size in studies aiming to understand the phenomenon of suicide in the stroke population.

Post stroke depression and risk of stroke recurrence and mortality: A systematic review and meta-analysis

BACKGROUND

Post stroke depression is a significant neuropsychiatric manifestation, predicting a range of poor outcomes. There are several studies investigating the association between post stroke depression and stroke recurrence/mortality, but results have been inconsistent.

OBJECTIVE

A systematic review, meta-analysis and meta regression of observational studies assessing the association between post stroke depression and risk of stroke recurrence and mortality.

METHODS

A search of Medline (via PubMed), Web of Science databases, EMBASE, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews was conducted until August 2018. We extracted and pooled hazard ratios from observational studies that reported the risk estimates of stroke recurrence and mortality in stroke survivors with/without depression.

RESULTS

The reviewed sample comprised 15 prospective cohort studies with 250,294 participants, 139,276 cases, and follow-up periods ranging from 1 to 15 years. The meta-analysis concluded a hazard ratio for post stroke depression and all-cause mortality of 1.59 (95% CI, 1.30-1.96), but research to date has been insufficient to determine the association between post stroke depression and stroke recurrence.

CONCLUSION AND RELEVANCE

Post stroke depression is associated with a significantly increased risk of mortality in stroke survivors. More researches are required on the association with stroke recurrence.

Suicidal Thoughts and Contexts in Black African Stroke Survivors

OBJECTIVES

Poststroke suicide has not been studied in Black Africans. We assessed the characteristics and contexts of serious suicidal thoughts after first-ever stroke in Nigerians.

METHODS

Using a comparative cross-sectional design, we consecutively recruited 130 stroke survivors attending rehabilitation in a large university hospital. Also included were 130 age-, sex-, and education-matched caregivers who were unrelated to stroke survivors. Along with clinical and historical details, cognitive functions, experience of serious suicidal thoughts, and major depressive disorder (MDD) were independently assessed using validated semi-structured interviews.

RESULTS

Serious suicidal thoughts were present in 20 (15.4%) stroke survivors and 19 (14.6%) controls. Poststroke suicidal thoughts occurred in the contexts of MDD ( P < .001), marital separation ( P = .019), and cognitive dysfunction ( P = .037). In a multivariate logistic regression model including age, gender, MDD, marital separation, and cognitive dysfunction as covariates, poststroke MDD and marital separation led to 5.6-fold (95% confidence interval [CI]: 3.5-21.0) and 4-fold (95% CI: 1.2-14.0) increases, respectively, in the odds of serious suicidal thoughts.

CONCLUSIONS

Serious suicidal thoughts after stroke in this African sample were more common than the reported average prevalence in the global literature. Poststroke major depression was the key reversible risk factor for suicidal thoughts. Depression is treatable and prompt treatment may prevent suicidal deaths and reduce the burden of stroke in black Africans.

Fractures as a suicidal behavior risk factor: A nationwide population-based cohort study

This study aimed to evaluate the association between fracture history and sequential risk of suicidal behavior.A total of 82,804 patients with fractures and 82,804 control subjects without fractures were matched. The influence of fractures on the risk of suicidal behavior-related hospital visit was analyzed using a Cox proportional hazards model.The overall adjusted hazard ratio (aHR) of suicidal behavior-related hospital visit was 2.21 in fracture cohort. The aHR declined from 2.90 at the 1-year follow-up to 2.00 after 5 years or more. In fracture patients, the risk of suicidal behavior-related hospital visit was higher at age <35 years, with comorbidities of stroke and sleep disorder. Patients with multiple fractures had a 1.69-fold risk.Fractures are an independent risk factor for suicidal behavior. Individuals aged younger than 35 years, with comorbidities of stroke and sleep disorder, and those who have suffered multiple fractures have elevated risk of suicidal behavior among subjects in the fracture group. Furthermore, this increased risk remained even after 5 years had passed since the fracture incident.

Association between socioeconomic attainments and suicidal ideation by age groups in Korea

BACKGROUND:

Suicidal ideation is a strong antecedent of suicidal behavior, associated with increased likelihood of suicide. Thus, suicidal ideation serves to identify which groups are at more risk of suicide and has policy implications for targeting groups to prevent suicide.

AIMS:

A substantial body of research has addressed potential determinants of suicide ideation in Korea. Little attention has been paid, however, to analyzing the extent to which socioeconomic attainments (education, household income, and employment status) are associated with risk of suicidal ideation, drawing on nationally representative data.

METHODS:

Data were drawn from the 2012 Korea Welfare Panel Study (KOWEPS). Among the 12,606 respondents, the findings are based on 1,500 young adults (age 18-35) and 3,469 middle-aged adults (age 36-55) who answered a question about suicidal ideation.

RESULTS:

For young adults, respondents from 2-year and 4-year colleges and higher had lower probabilities of suicidal ideation compared with respondents from high school. People out of the labor force also exhibited an elevated risk of suicidal ideation compared with those in waged employment. Middle-aged adults displayed different patterns. Middle-aged respondents from 4-year colleges or higher had an increased likelihood of suicidal ideation. The likelihood of reporting suicidal ideation was predicted to decrease as household income increased only for middle-aged adults.

CONCLUSIONS:

The information about suicidal ideation was obtained from only one question of self-response, which limits the validity of the suicidal ideation measurement. The cross-sectional setting of the data prevents us from estimating causal relationships. Nevertheless, the findings imply that age-specific policy should be implemented to ameliorate differential risk for suicidal ideation and benefit public mental health in the long run.

Suicidal ideation, perceived disability, hopelessness and affective temperaments in patients affected by Parkinson's disease

BACKGROUND

Previous studies investigating the risk of suicide in patients with Parkinson's disease (PD) have reported conflicting results. This study evaluated suicide risk in PD and investigated the relationship between suicide risk and perceived disability, hopelessness and affective temperaments in PD.

METHODS

One-hundred and twenty PD patients were consecutively enrolled. The diagnosis of PD was based on clinical criteria. All patients underwent a psychiatric evaluation that included the administration of the Columbia-Suicide Severity Rating Scale, the Italian Perceived Disability Scale, the Beck Hopelessness Inventory and the TEMPS-A questionnaire. The results were compared with those of a control group of 91 patients affected by another chronic disease, ie, open angle glaucoma.

RESULTS

Parkinson's disease patients had higher suicidal ideation, higher perceived disability and lower hyperthymia than the control group. In PD, higher perceived disability was associated with higher current and lifetime suicidal ideation, lower hyperthymia, older age and higher scores on negative temperaments. Suicidal ideation, negative temperaments and hopelessness were risk factors for perceived disability, while hyperthymia was a protective factor for perceived disability.

DISCUSSION

Patients with PD have an increased risk of suicidal ideation. Increased suicidal ideation in PD is associated with the increased perceived disability. A psychiatric assessment that includes the investigation of suicide risk and perceived disability is recommended in patients with PD.

A Twelve-Week Moderate Exercise Programme Improved Symptoms of Depression, Insomnia, and Verbal Learning in Post-Aneurysmal Subarachnoid Haemorrhage Patients: A Comparison with Meningioma Patients and Healthy Controls

OBJECTIVES

Deficits in psychological functioning, cognitive functioning, and sleep are frequently experienced by individuals who have survived aneurysmal subarachnoid haemorrhage (aSAH). Exercise has been shown to improve these domains; to date, it has never been explored in patients following aSAH. The aim of this exploratory study is to compare the effects of an exercise programme in this population with another patient group, and a group of healthy controls.

METHODS

The present study explored the effects of 12 weeks of moderate aerobic exercise training on 15 aSAH patients, 16 meningioma patients, and 17 healthy controls. Data on symptoms of depression, hypochondria, perceived stress, satisfaction with life, verbal learning and memory, and subjective and objective sleep, were gathered at baseline, following intervention, and at 6-month follow-up.

RESULTS

aSAH patients and meningioma patients had decreased symptoms of depression and insomnia at follow-up. While perceived stress decreased in the meningioma group, in aSAH patients it increased. Total learning performance increased in all three groups.

CONCLUSIONS

An exercise programme had a positive effect on symptoms of depression, insomnia, and verbal learning in patients following aSAH. No positive changes in other domains were observed. This may be due to the cautious approach taken with regard to exercise intensity.

Further Evidence of the Positive Influence of Repetitive Transcranial Magnetic Stimulation on Speech and Language in Patients with Aphasia after Stroke: Results from a Double-Blind Intervention with Sham Condition

BACKGROUND

After a stroke, up to 20% of patients suffer from aphasia. The preferred treatment for stroke-related aphasia (SRA) is regular speech and language training (SLT). In the present study, we investigated to what extent adjuvant repetitive transcranial magnetic stimulation (rTMS) might enhance recovery. While there is growing evidence of the positive effect of adjuvant rTMS on aphasia, no study has yet been based on an Iranian sample.

METHOD

A total of 12 patients (mean age: 55 years; right-handed; 7 women) underwent treatment for SRA 1 month after stroke. The standard treatment consisted of regular 45-min SLT sessions 5 times a week for 2 consecutive weeks. Additionally, patients were randomly assigned either to adjuvant rTMS (5 times a week for 30 min) or to a sham condition (5 times a week for 30 min). At baseline and after 2 weeks of intervention, the degree of aphasia was assessed with the Farsi version of the Western Aphasia Battery. rTMS was applied to the inferior posterior frontal gyrus of the right hemisphere.

RESULTS

Speech and language improved over time, but more so in the rTMS than in the sham condition. Large effect sizes were observed for content, fluency, and the aphasia quotient; medium effect sizes were observed for command comprehension and repetition, while effect sizes were small for auditory comprehension and naming.

CONCLUSIONS

Among patients with SRA, compared to a sham condition, adjuvant rTMS improved speech and language skills. The present results add to the accumulating evidence that rTMS as a neuromodulation technique has the capacity to enhance the effect of conventional SLT.

Gender-specific factors related to suicidal ideation among community-dwelling stroke survivors: The 2013 Korean Community Health Survey

We assessed gender-specific factors associated with suicidal ideation among community-dwelling stroke survivors. In total, 4,322 stroke survivors who participated in the 2013 Korean Community Health Survey were included in the final analysis. Sociodemographic information, socio-family relationships, health behaviors, health status, and suicidal ideation were assessed using a standardized questionnaire. On fully adjusted analysis, suicidal ideation among males was more common in those who were widowed, rather than married (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.03–2.47), those who rarely contacted neighbors (OR 1.50, 95% CI 1.10–2.06), current smokers (OR 1.54, 95% CI 1.03–2.29), and frequent drinkers (OR 1.54, 95% CI 1.05–2.24). Suicidal ideation among females was more common in older subjects, those with lower monthly household incomes, the unemployed (OR 1.75, 95% CI 1.21–2.53), and housewives/students (OR 1.46, 95% CI 1.06–2.03), those who rarely contacted friends (OR 1.43, 95% CI 1.12–1.82), and diabetics (OR 1.35, 95% CI 1.05–1.73). Perceived persistent high-level stress, depressive mood, poor self-rated health, and a diagnosis of depression were commonly associated with suicidal ideation in both genders. Gender differences should be considered by medical practitioners and community policymakers when seeking to prevent and manage suicidal ideation in stroke survivors.

Suicidal drug overdose following stroke in elderly patients: a retrospective population-based cohort study

PURPOSE

The purpose of this study was to investigate the incidence and risk of suicidal drug overdose (SDO) after stroke in older patients.

METHODS

We enrolled patients aged 60-99 years who were diagnosed with new-onset stroke between 2002 and 2013 and age-, sex-, and index-year-matched controls who did not have stroke. Patients with a history of SDO before enrollment were excluded. Both groups were observed until December 31, 2013. The primary end point was the occurrence of newly diagnosed SDO. The cumulative incidence rates of the study and control groups were estimated using the Kaplan-Meier method. Furthermore, we used the Cox proportional hazards model to identify risk factors for SDO.

RESULTS

We selected 22,770 individuals. Among them, 11,385 were older patients (aged 60-99 years) who had newly diagnosed stroke and 11,385 were controls. Of the 22,770 individuals, 275 (1.21%) had SDO during a mean follow-up period of 5.33±3.30 years, comprising 191 (1.68%) from the stroke group and 84 (0.74%) from the control group. Older patients with stroke had a significantly higher risk of SDO than the controls (adjusted hazard ratio: 2.288, 95% confidence interval [CI]: 1.746-2.999, p<0.001). Moreover, in older patients with stroke, the risk significantly increased with the number of stroke events. Patients with depressive disorder or coronary disease had an increased risk of SDO. Additionally, benzodiazepines and anticoagulants were the two most commonly prescribed medications for SDO.

CONCLUSION

Clinicians should be aware of the risk of SDO and risk factors in older patients with stroke. Psychological assessment and medication monitoring should be incorporated into current clinical diagnoses in neurology and treatments following stroke.

Risk of Suicide Attempt in Poststroke Patients: A Population-Based Cohort Study

BACKGROUND

This nationwide population-based cohort study evaluated the risk of and risk factors for suicide attempt in poststroke patients in Taiwan.

METHODS AND RESULTS

The poststroke and nonstroke cohorts consisted of 713 690 patients and 1 426 009 controls, respectively. Adults (aged >18 years) who received new stroke diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM; codes 430-438) between 2000 and 2011 were included in the poststroke cohort. We calculated the adjusted hazard ratio for suicide attempt (ICD-9-CM codes E950-E959) after adjustment for age, sex, monthly income, urbanization level, occupation category, and various comorbidities. Kaplan-Meier analysis was used to measure the cumulative incidence of suicide attempt, and the Fine and Gray method was used as a competing event when estimating death subhazard ratios and 95% confidence intervals between groups. The cumulative incidence of suicide attempt was higher in the poststroke cohort, and the adjusted hazard ratio of suicide attempt was 2.20 (95% confidence interval, 2.04-2.37) compared with that of the controls. The leading risk factors for poststroke suicide attempt were earning low monthly income (<660 US dollars), living in less urbanized regions, doing manual labor, and having a stroke before age 50 years. The attempted suicide risk did not differ significantly between male and female patients in this study.

CONCLUSIONS

These results convey crucial information to clinicians and governments for preventing suicide attempt in poststroke patients in Taiwan and other Asian countries.

Assessment and Management of Cognitive and Psychosocial Dysfunctions in Patients With Major Depressive Disorder: A Clinical Review

Background: Full functional recovery is defined as a state in which patients are again able to enjoy their usual activities, return to work, and take care of themselves, and it should represent the end goal of treatment in patients with major depressive disorder (MDD). Patients with MDD report many unmet needs, including residual cognitive symptoms, lack of improvement in psychosocial functioning and life satisfaction, even during mood symptom remission. In this paper, we aim to: (a) identify the available assessment tools for evaluating cognitive and psychosocial functioning in patients with MDD; (b) provide an overview of therapeutic options that can improve full functional recovery in MDD also by improving cognitive symptoms. Methods: The relevant databases MEDLINE, ISI Web of Knowledge - Web of Science Index, Cochrane Reviews Library and PsychoINFO were searched for identifying papers on validated tools for the assessment of cognitive and personal functioning in patients with MDD. Results: New assessment tools (such as the THINC-it TOOL, the COBRA, the SCIP-D, and the UPSA-D) have been developed for evaluating the cognitive dysfunction in MDD patients. Adopting these tools in the clinical routine practice is useful to evaluate the improvement in cognitive functioning and, therefore, the achievement of full functioning recovery. The optimal management of patients with MDD include the combination of pharmacological compounds and psychosocial interventions for achieving full functional recovery in patients with MDD. Conclusions: Full functional recovery must be the target of any treatment programme for patients with MDD. In order to achieve this goal, it is necessary to develop personalized treatment and integrate psychosocial and psychopharmacological interventions.

Early Post-stroke Depression and Mortality: Meta-Analysis and Meta-Regression

Background: Post-stroke depression (PSD) is a common and serious complication after stroke. In this systematic review and meta-analysis, we evaluated the association between early PSD and mortality, considering depressive symptoms occurring within the first 3 months after the neurological event. Methods: This meta-analysis was conducted following Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines and based on studies indexed till May 2018 in PubMed and Web of Science databases. The relative risk (RR) for mortality in individuals with PSD, as compared with non-depressed ones, was estimated. Findings were pooled according to a random-effects model. Meta-regression and subgroup analyses were carried out. Results: We included seven studies, accounting for 119,075 individuals, of whom 17,609 suffering from an early PSD. We found higher rates of mortality in subjects with PSD as compared with non-depressed ones (RR = 1.50; 95%CI: 1.28 to 1.75; p < 0.001). Heterogeneity across studies was moderate (I ² = 50.7%). Subgroup analysis showed a slightly higher effect of PSD on short-term mortality (RR = 1.70; p < 0.001), as compared with long-term one (RR = 1.35; p = 0.01). According to relevant meta-regression analyses, the estimate was influenced by sample proportion of men (p = 0.043). Conclusions: Despite some limitations, our study shows the negative impact of early PSD on survival rates. Mechanisms underlying this association still need to be elucidated and several interpretations can be hypothesized. Future research should test if an early management of depression may increase life expectancy after stroke.