Frequency and clinical determinants of poststroke depression

Research on patient-centered design for post-stroke depression patients based on SEM and comprehensive evaluation

Introduction

Since COVID-19, medical resources have been tight, making it inconvenient to go offline for the sequelae of diseases such as post-stroke depression (PSD) that require long-term follow-up. As a new digital therapy, VRTL began to gain popularity.

Method

The research is divided into two parts: pre-test and post-test. In the pre-test, an evaluation method integrating reality-based interaction (RBI), structural equation model (SEM), analytic hierarchy process (AHP), and entropy weight method is proposed. In the post-test the patients' physiological indicators (Diastolic blood pressure, systolic blood pressure and heart rate) are measured to verify the effectiveness of RBI-SEM model using T-test method.

Results

In the pre-test, using SEM, it was confirmed that P_i physical awareness, B_i body awareness, E_i environmental awareness, and S_i social awareness were significantly correlated and positively affected VRTL satisfaction (p >> F 0.217; B >> F 0.130; E >> F 0.243; S >> F 0.122). The comprehensive weight ranking based on RBI-SEM considered light environment (0.665), vegetation diversity (0.667), accessible roaming space (0.550) et al. relatively of importance. And T-tset in the post-test experiment considered that the data of the two measurements before and after the VRTL experience, systolic blood pressure (p < 0.01), diastolic blood pressure (p < 0.01), and blood pressure (p < 0.01) were significantly decreased; one-way ANOVA concluded that there was no significant difference in the changes of blood pressure and heart rate among participants of different ages and genders (p > 0.01).

Conclusion

This research validated the effectiveness of RBI theory for VRTL design guidelines, established an RBI-SEM based VRTL evaluation model, and the output VRTL for PSD in the older adults was confirmed to have significant therapeutic benefits. This lays the foundation for designers to decompose design tasks and integrate VRTL into traditional clinical treatment systems.

Contribution from the public or patients

Four public health department employees helped to improve the research's content.

Co-prevalence and incidence of myocardial infarction and/or stroke in patients with depression and/or anxiety: A systematic review and meta-analysis

OBJECTIVE

Co-prevalence and incidence of depression and/or anxiety with stroke and myocardial infarction are currently unclear. This paper explores the relationships, as these are important comorbidities affecting patient outcomes.

METHODS

A systematic search across five databases (PubMed, Scopus, PsycINFO, Embase, Cochrane) was conducted for observational studies reporting co-prevalence of depression or anxiety with stroke or myocardial infarction. We used random-effects models in all meta-analyses and evaluated heterogeneity using I².

RESULTS

This analysis included 48 studies with a total of 57,342 patients. In patients with depression, the pooled prevalence of stroke was 5.9% (95% CI = 5.53-6.37). In patients with myocardial infarction, the pooled prevalence of anxiety and depression was 9.1% (95% CI = 7.07-11.40, I² = 85.6%) and 25.9% (95% CI = 18.46-34.12, I² = 99.1%), respectively, and the pooled cumulative incidence of depression at one year was 20.5% (95% CI = 18.36-22.79). The pooled prevalence of anxiety and depression in patients with stroke was 13.5% (95% CI = 7.67-22.66, I² = 96.9%) and 23.0% (95% CI = 17.93-28.99, I² = 96.7%), respectively. The pooled cumulative incidences of depression at two weeks, three months, six months, and one year, were 29.1% (95% CI = 26.60-31.81), 17.0% (95% CI = 10.74-25.92, I² = 98.0%), 7.4% (95% CI = 6.52-8.49), and 9.1% (95% CI = 3.71-20.79, I² = 99.8%), respectively.

CONCLUSIONS

This meta-analysis outlines the co-morbid burden between depression/anxiety and stroke/myocardial infarction. Future research should be done to evaluate the effectiveness of screening anxiety/depression in myocardial infarction/stroke.

Effectiveness of smart health-based rehabilitation on patients with poststroke dysphagia: A brief research report

Objective

This study aimed to evaluate the effectiveness of smart health-based rehabilitation on patients with poststroke dysphagia (PSD).

Methods

We recruited 60 PSD patients and randomly allocated them to the intervention (n = 30) and control (n = 30) groups. The former received the smart health-based rehabilitation for 12 weeks, whereas the latter received routine rehabilitation. Water swallow test (WST), standardized swallowing assessment (SSA), swallow quality-of-life questionnaire (SWAL-QOL), stroke self-efficacy questionnaire (SSEQ), perceived social support scale (PSSS) and nutritional measurements including body weight, triceps skinfold thickness (TSF), total protein (TP), serum albumin (ALB) and serum prealbumin (PA) in both groups were measured.

Results

When the baseline WST, SSA, SWAL-QOL, SSEQ, PSSS and nutritional measurements were examined, there was no significant difference between the intervention group and the control group (P > 0.05). After rehabilitation interventions, the WST and SSA scores in the intervention group were significantly lower than those in the control group (P < 0.01). The SWAL-QOL, SSEQ and PSSS scores in the intervention group were significantly higher than in the control group (P < 0.01). Compared with the control group, the intervention group showed an increase in the serum levels of PA (P < 0.01). However, no statistically significant difference existed between the intervention group and the control group in terms of body weight, TSF, TP or ALB (P > 0.05).

Conclusions

Overall, our data revealed that smart health-based rehabilitation is significantly beneficial to the swallowing function, quality of life, self-efficacy, and social support for PSD patients when compared with routine rehabilitation. However, nutritional measurements were not significantly improved in such patients under the smart health-based rehabilitation when compared the routine rehabilitation. In the future, it is necessary to extend the intervention time to further evaluate the long-term efficacy of smart health-based rehabilitation on nutritional measurements of PSD patients.

The association between functional status and physical pain with depressive symptoms after a stroke event: A cross-sectional analysis of the China Health and Retirement Longitudinal Study 2018

BACKGROUND

Stroke is a major cause of mortality and long-term physical and cognitive impairment. This study aims to: (1) examine the prevalence of depressive symptoms, disability and pain among Chinese adults with stroke; (2) test the associations of functional limitations and body pain with occurrence of depressive symptoms; (3) investigate gender and urban-rural disparities in these associations.

METHODS

This study utilized the data from the China Health and Retirement Longitudinal Study in 2018, involving 969 patients with stroke among 17,970 participants aged ≥ 45 years. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression (CES-D) Scale. We performed multivariable logistic regression models to estimate the associations between activities of daily life (ADL), instrumental activities of daily life (IADL) and pain with depressive symptoms.

RESULTS

Depressive symptoms were found among 40.2% of stroke patients, with a higher prevalence in females (48.2%) than males (32.7%). Prevalence of ADL limitations, IADL limitations and pain among stroke patients were 39.2, 49.8 and 14.0%, respectively. ADL and IADL limitations and pain were more prevalent among females and residents in rural areas. Multivariable regression analyses showed a significant association between ADL limitation (OR = 1.535, 95% CI = 1.168, 2.018), IADL limitation (OR = 1.666, 95% CI = 1.260, 2.203) and pain (OR = 2.122, 95% CI = 1.466, 3.073) with depressive symptoms. Stratified analyses revealed stronger associations among urban residents. Females had a higher association of ADL and IADL with depressive symptoms but similar in that of pain to the males. The impact of ADL and IADL in male patients is higher than in females, but the impact of pain on depressive symptoms is higher in female patients.

CONCLUSION

Depressive symptoms are common amongst post-stroke patients in China and are significantly associated with functional disability and physical pain. Our findings have implications for practitioners on the early assessment of pain and depression after stroke. Future research should explore effective intervention measures for physical-mental stroke complications.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

Depression after stroke

Stroke treatment has dramatically improved in recent decades. However, although new treatments have reduced its mortality and the severity of its physical and cognitive sequelae, many people still have incapacitating disabilities following a stroke. Depression is the most common psychiatric disorder following stroke; it is important to recognise and treat as it limits motor and cognitive rehabilitation. Antidepressant medication is an effective treatment and can improve adherence to clinically recommended physical and cognitive tasks, thereby enhancing functional remodelling of neuronal pathways and improving rehabilitation outcomes.

Effect of intravenous alteplase on post-stroke depression in the WAKE UP trial

BACKGROUND AND PURPOSE

The aim was to study the effect of intravenous alteplase on the development of post-stroke depression (PSD) in acute stroke patients, and to identify predictors of PSD.

METHODS

This post hoc analysis included patients with unknown onset stroke randomized to treatment with alteplase or placebo in the WAKE-UP trial (ClinicalTrials.gov number, NCT01525290), in whom a composite end-point of PSD was defined as a Beck Depression Inventory ≥10, medication with an antidepressant, or depression recorded as an adverse event. Multiple logistic regression was used to identify predictors of PSD at 90 days. Structural equation modelling was applied to assess the indirect effect of thrombolysis on PSD mediated by the modified Rankin Scale.

RESULTS

Information on the composite end-point was available for 438 of 503 randomized patients. PSD was present in 96 of 224 (42.9%) patients in the alteplase group and 115 of 214 (53.7%) in the placebo group (odds ratio 0.63; 95% confidence interval 0.43-0.94; p = 0.022; adjusted for age and National Institutes of Health Stroke Scale at baseline). Prognostic factors associated with PSD included baseline medication with antidepressants, higher lesion volume, history of depression and assignment to placebo. While 65% of the effect of thrombolysis on PSD were caused directly, 35% were mediated by an improvement of the mRS.

CONCLUSIONS

Treatment with alteplase in patients with acute stroke resulted in lower rates of depression at 90 days, which were only partially explained by reduced functional disability. Predictors of PSD including history and clinical characteristics may help in identifying patients at risk of PSD.

Patient Health Questionnaire-9 predicts the functional outcome of stroke patients in convalescent rehabilitation ward

INTRODUCTION

Poststroke depression (PSD) negatively affects the functional outcome of stroke patients. Patient Health Questionnaire-9 (PHQ-9) is a validated screening tool for detecting PSD. This study investigated the relationship between PHQ-9 score and functional outcomes in stroke patients in a convalescent rehabilitation ward by evaluating functional independence measure (FIM) gain scores and the proportion of patients discharged.

METHODS

In this retrospective study conducted from January 2017 to September 2019, consecutive stroke patients who were admitted to the convalescent rehabilitation ward and could answer PHQ-9 were assessed. The association between PHQ-9 scores at the time of admission to the convalescent rehabilitation ward and outcomes (FIM gain score and the proportion of patients discharged) was statistically analyzed.

RESULTS

Among the 215 patients enrolled in the study, 62 (28.8%) were assessed as having depression, in whom PHQ-9 scores were 5 or above. Multivariate analysis revealed that the PHQ-9 score on admission to the convalescent rehabilitation ward was a significant independent factor influencing the FIM gain score (p = .009). In addition, a multivariate analysis revealed that the PHQ-9 score at the time of admission to the convalescent rehabilitation ward was a significant independent factor influencing the inability to discharge a patient (odds ratio 1.24, 95% confidence interval 1.12-1.39, p < .001).

CONCLUSIONS

The PHQ-9 score is a useful tool for predicting patient functional outcome, admission to the facility, and screening for poststroke depression.

Early Depression Independently of Other Neuropsychiatric Conditions, Influences Disability and Mortality after Stroke (Research Study-Part of PROPOLIS Study)

Post-stroke depression (PSD) is the most frequent neuropsychiatric consequence of stroke. The nature of the relationship between PSD and mortality still remains unknown. One hypothesis is that PSD could be more frequent in those patients who are more vulnerable to physical disability, a mediator variable for higher level of physical damage related to higher risk of mortality. Therefore, the authors' objective was to explore the assumption that PSD increases disability after stroke, and secondly, that mortality is higher among patients with PSD regardless of stroke severity and other neuropsychiatric conditions. We included 524 consecutive patients with acute stroke or transient ischemic attack, who were screened for depression between 7-10 days after stroke onset. Physical impairment and death were the outcomes measures at evaluation check points three and 12 months post-stroke. PSD independently increased the level of disability three (OR = 1.94, 95% CI 1.31-2.87, p = 0.001), and 12 months post-stroke (OR = 1.61, 95% CI 1.14-2.48, p = 0.009). PSD was also an independent risk factor for death three (OR = 5.68, 95% CI 1.58-20.37, p = 0.008) and 12 months after stroke (OR = 4.53, 95% CI 2.06-9.94, p = 0.001). Our study shows the negative impact of early PSD on the level of disability and survival rates during first year after stroke and supports the assumption that depression may act as an independent mediator for disability leading to death in patients who are more vulnerable for brain injury.

High Prevalence of Poststroke Depression in Ischemic Stroke Patients in Ethiopia

Background

There is limited information and research carried out regarding the prevalence of poststroke depression (PSD) in the study area. Psychiatric disorders complicate a significant proportion of patients suffering from stroke. This of course have a great negative impact on our knowledge about poststroke depression in Ethiopia, and poststroke depression complicates a significant number of stroke patients and their rehabilitation.

Methods

A cross-sectional study on all patients aged above 18 years and diagnosed with stroke in the past two years who attended the neurology follow-up clinics of Tikur Anbessa Specialized Hospital (TASH) and Zewditu Memorial Hospital (ZMH) was done by using a structured questionnaire containing Patient Health Questionnaire-9 (PHQ-9) depression screening tool.

Result

Of 84 patients who were eligible for the study, 32.2% of patients have depressive symptoms. Women (OR 0.001, 95% CI 0.12-0.87) and aphasic patients (OR 0.034, 95% CI 0.19-1.27) were more likely to have depressive symptoms.

Conclusion

Depressive symptoms after stroke are common in Ethiopian patients. Our study demonstrates female and aphasic patients are more likely to screen positive for PSD. Hence, screening all poststroke patients with different screening tools is practical, and further studies are needed to assess the validity of these screening tools and also to assess PSD as a predictor of stroke outcome.

The effects of sunlight exposure therapy on the improvement of depression and quality of life in post-stroke patients: A RCT study

Previous studies have suggested that nearly 30% of the stroke victims present with signs of depression within the first 5 years of illness. Since post-stroke depression significantly affects the patient both physically and psychologically, the emotional disturbances impede the progress and effectiveness of rehabilitation. To utilize sunlight therapy in post-stroke patients in order to improve the depression and daily activity function. This study was a single-blind design randomized controlled intervention with sunlight exposure design. The population were stroke patients with tendency to depression. Exposed to sunlight for at least 30 min per day, at least 14 days of exposure duration of 4 weeks. A total of 46 patients were 23 patients in the experimental group and the control group. The research tools include: depression status (Taiwanese depression scale, TDS), physical activity function (Barthel Index), and cognitive status (MMSE). The CONSORT guideline was used in this study. After the data was analyzed with the generalized estimating equation (GEE), significant improvement was noted among the experimental ground in 2^nd post-test depression score, daily function in the first and second post-test Barthel Index score. There was no significant improvement in cognitive function. This study confirms that sunlight therapy improves the mental health of post-stroke patients with depressed mood. It also enhances daily activity and facilitates the recovery to a health state.

Prevalence of pre-stroke depression and its association with post-stroke depression: a systematic review and meta-analysis

BACKGROUND

Depression is a common post-stroke complication. Pre-stroke depression may be an important contributor, however the epidemiology of pre-stroke depression is poorly understood. Using systematic review and meta-analysis, we described the prevalence of pre-stroke depression and its association with post-stroke depression.

METHODS

We searched multiple cross-disciplinary databases from inception to July 2017 and extracted data on the prevalence of pre-stroke depression and its association with post-stroke depression. We assessed the risk of bias (RoB) using validated tools. We described summary estimates of prevalence and summary odds ratio (OR) for association with post-stroke depression, using random-effects models. We performed subgroup analysis describing the effect of depression assessment method. We used a funnel plot to describe potential publication bias. The strength of evidence presented in this review was summarised via 'GRADE'.

RESULTS

Of 11 884 studies identified, 29 were included (total participants n = 164 993). Pre-stroke depression pooled prevalence was 11.6% [95% confidence interval (CI) 9.2-14.7]; range: 0.4-24% (I2 95.8). Prevalence of pre-stroke depression varied by assessment method (p = 0.02) with clinical interview suggesting greater pre-stroke depression prevalence (~17%) than case-note review (9%) or self-report (11%). Pre-stroke depression was associated with increased odds of post-stroke depression; summary OR 3.0 (95% CI 2.3-4.0). All studies were judged to be at RoB: 59% of included studies had an uncertain RoB in stroke assessment; 83% had high or uncertain RoB for pre-stroke depression assessment. Funnel plot indicated no risk of publication bias. The strength of evidence based on GRADE was 'very low'.

CONCLUSIONS

One in six stroke patients have had pre-stroke depression. Reported rates may be routinely underestimated due to limitations around assessment. Pre-stroke depression significantly increases odds of post-stroke depression.Protocol identifierPROSPERO identifier: CRD42017065544.

Comparison of Treatment Rates of Depression After Stroke Versus Myocardial Infarction: A Systematic Review and Meta-Analysis of Observational Data

OBJECTIVE

Depression after stroke and myocardial infarction (MI) is common but often assumed to be undertreated without reliable evidence being available. Thus, we aimed to determine treatment rates and investigate the application of guidelines in these conditions.

METHODS

Databases MEDLINE, EMBASE, PsycInfo, Web of Science, CINAHL, and Scopus were systematically searched without language restriction from inception to June 30, 2017. Prospective observational studies with consecutive recruitment reporting any antidepressant treatment in adults with depression after stroke or MI were included. Random-effects models were used to calculate pooled estimates of treatment rates.

RESULTS

Fifty-five studies reported 32 stroke cohorts (n = 8938; pooled frequency of depression = 34%, 95% confidence interval [CI] = 29%-38%) and 17 MI cohorts (n = 10,767; pooled frequency of depression = 24%, 95% CI = 20%-28%). In 29 stroke cohorts, 24% (95% CI = 20%-27%) of 2280 depressed people used antidepressant medication. In 15 MI cohorts, 14% (95% CI = 8%-19%) of 2381 depressed people used antidepressant medication indicating a lower treatment rate than in stroke. Two studies reported use of psychosocial interventions, indicating that less than 10% of participants were treated.

CONCLUSIONS

Despite the high frequency of depression after stroke and MI and the existence of efficacious treatment strategies, people often remain untreated. Innovative strategies are needed to increase the use of effective antidepressive interventions in patients with cardiovascular disease.

Depressive symptoms in stroke patients treated and non-treated with intravenous thrombolytic therapy: a 1-year follow-up study

INTRODUCTION

This is a prospective study, first to compare the frequency of depressive symptoms in stroke survivors treated, and non-treated, with intravenous thrombolysis and second, to explore relationships between post-stroke depression (PSD) and stroke treatment modalities, taking into account other possible determinants of PSD, including post-traumatic stress symptoms.

METHODS

Groups of 73 thrombolysed and 73 non-thrombolysed patients matched for age and gender were examined at 3 and 12 months after discharge. PSD was assessed using the Beck Depression Inventory. Post-traumatic stress symptoms (PTSS), disability and social support were assessed with the Impact of Event Scale-Revised, the Barthel Index and the Berlin Social Support Scale.

RESULTS

At 3 months, PSD was present in 23.3% of the thrombolysed and 31.5% in the non-thrombolysed groups (p = 0.265). At 12 months, the frequencies were 29.2 and 20.6% (p = 0.229). Logistic regression of the combined group of thrombolysed and non-thrombolysed patients indicated that at 3 months, the adjusted predictors of PSD were disability (OR 24.35), presence of PTSS (OR 9.32), low social support (OR 3.68) and non-thrombolytic treatment (OR 3.19). At 12 months, the predictors were disability (OR 15.78) and low education (OR 3.61).

LIMITATIONS

The use of a questionnaire for the detection of depression, the relatively small sample size and a significant drop-out rate could limit the interpretation of these results.

CONCLUSIONS

(1) Thrombolysed and non-thrombolysed stroke survivors had similar frequency of depressive symptoms although the thrombolysed patients had more severe neurological deficits in the acute phase. It can be assumed that if thrombolysis had not been used, depressive symptoms would have been more frequent. (2) Lack of the rt-PA treatment was associated with three-time greater odds of screening for PSD at 3 months post-stroke, after adjustment for other PSD correlates. (3) Therefore, thrombolytic therapy seems to have a positive, but indirect, effect on patients' mood, especially in the first months after stroke. (4) All stroke patients, irrespective of the method of treatment, should be monitored for the presence of depression.

Pre-stroke employment results in better patient-reported outcomes after minor stroke: Short title: Functional outcomes after minor stroke

OBJECTIVE

Individuals with "minor stroke" lack a dense hemiparesis or aphasia; however, commonly endorse persistent cognitive and motor problems despite low NIHSS scores. They also report problems with mood, energy, and the ability to think clearly that are less well characterized. Socioeconomic factors and stroke severity can influence patient-reported outcomes. In this study we explore patient-reported outcomes and the influence of these factors after minor stroke.

PATIENTS AND METHODS

Patients returning to clinic post-stroke with an NIHSS of ≤ 4 were administered a scale to quantify problems with daily activities and resulting functional burden, along with measures of fatigue and depression. T-tests, chi square analysis, and linear regression were used to compare functional outcomes of patients to controls (TIA or stroke mimic (n = 40)), and evaluate the association between patient-reported outcomes, stroke characteristics, and socioeconomic factors.

RESULTS

151 stroke patients were seen a mean 83.6 days post-infarct. Patients reported more problems (11.7 versus 6.9, p = 0.02), resulting in higher functional burden (26.5 versus 12.3, p = 0.01), increased depression (p = 0.07), and greater fatigue (p = 0.02) compared to controls. There was no relationship between stroke characteristics (other than NIHSS), baseline education, income, marital status, or living situation and perception of recovery; however, those actively working prior to their stroke reported better outcomes across all categories (p for each <0.02), and differences persisted in multivariable regression models.

CONCLUSION

Prior occupational status may represent an important prognostic indicator for patients with minor stroke. Individuals working at the time of their infarct report better functional outcomes irrespective of age or stroke severity.

The factors related to early-onset depression after first stroke

BACKGROUND

The biological and psychological aspects of post-stroke depression (PSD) may vary based on the time since stroke onset. The sociodemographic and clinical correlates of early-onset PSD are not yet well understood. In the present study, we aimed to investigate the clinical correlates of early-onset depression following first stroke. We hypothesized that the severity of a stroke or disability (other than lesion characteristics) would likely be related to PSD in a sample of first stroke patients with single and unilateral lesions.

METHODS

Post-stroke patients with (n = 40) and without (n = 51) early-onset depression were compared with respect to several demographic and clinical variables.

RESULTS

There were no significant differences between the groups with respect to lesion location, lateralization, or volume. Scores on the Brief Disability Questionnaire, National Institutes of Health Stroke Scale, and Modified Rankin Scale were significantly higher in depressed post-stroke patients than in non-depressed patients. The anxiety, depression, and total scores of the Hospital Anxiety and Depression Scale were positively correlated with the Modified Rankin Scale, National Institutes of Health Stroke Scale, and Brief Disability Questionnaire scores. A previous history of depression and Brief Disability Questionnaire score were strongly associated with the occurrence of early-onset PSD.

CONCLUSION

Our findings suggest that early-onset PSD is likely to be correlated with the severity of stroke and functional disability.

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

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

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

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

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

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

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

Apathy, but not depression, is associated with executive dysfunction in cerebral small vessel disease

Objective

To determine the prevalence of apathy and depression in cerebral small vessel disease (SVD), and the relationships between both apathy and depression with cognition. To examine whether apathy is specifically related to impairment in executive functioning and processing speed.

Methods

196 patients with a clinical lacunar stroke and an anatomically corresponding lacunar infarct on MRI were compared to 300 stroke-free controls. Apathy and depression were measured using the Geriatric Depression Scale, and cognitive functioning was assessed using an SVD cognitive screening tool, the Brief Memory and Executive Test, which measures executive functioning/processing speed and memory/orientation. Path analysis and binary logistic regression were used to assess the relation between apathy, depression and cognitive impairment.

Results

31 participants with SVD (15.8%) met criteria for apathy only, 23 (11.8%) for both apathy and depression, and 2 (1.0%) for depression only. In the SVD group the presence of apathy was related to global cognition, and specifically to impaired executive functioning/processing speed, but not memory/orientation. The presence of depression was not related to global cognition, impaired executive functioning/processing speed or memory/orientation.

Conclusions

Apathy is a common feature of SVD and is associated with impaired executive functioning/processing speed suggesting the two may share biological mechanisms. Screening for apathy should be considered in SVD, and further work is required to develop and evaluate effective apathy treatment or management in SVD.

The combination of plasma glutamate and physical impairment after acute stroke as a potential indicator for the early-onset post-stroke depression

OBJECTS

The present study aimed to investigate the relationship of plasma glutamate levels with the early-onset of post-stroke depression (PSD) and to further explore the prognostic value of plasma glutamate combined with clinical characteristics for the early-onset PSD in the acute ischemic stroke patients.

METHODS

Seventy-four patients who admitted to the hospital within 24h of acute ischemic stroke were consecutively recruited and followed up for 2weeks. The Beck Depression Inventory (BDI) and 17-item Hamilton Depression Rating Scale (HAMD-17) were used to screen for depressive symptoms 14days after stroke. Diagnoses of depression were made in accordance with DSM-IV. Plasma glutamate levels were determined by High Performance Liquid Chromatography (HPLC) on days 1 and 14 after stroke for all patients.

RESULTS

Plasma glutamate levels were significantly lower in PSD patients than those of non-PSD patients on day 1 after stroke. ROC curve analyses revealed an AUC (area under the ROC curve) of 0.724 (95% CI: 0.584-0.863, p=0.004) and of 0.669 (95% CI: 0.523-0.814, p=0.030) for National Institute of Health Stroke Scale (NIHSS) scores and plasma glutamate levels on day 1 respectively. Combined ROC analyses using the two factors revealed the highest AUC of 0.804 (95% CI: 0.685-0.922, P<0.0001).

CONCLUSIONS

These results indicated an association between the early-onset PSD and a low plasma glutamate level following acute ischemic stroke. The combination of reduced plasma glutamate levels and physical impairment (determined by NIHSS) 1day after acute ischemic stroke was a potential diagnostic indicator for early-onset PSD.

Depressive disorder may be associated with raphe nuclei lesions in patients with brainstem infarction

BACKGROUND

Depression is a common symptom after stroke, but its neural substrates remain unclear. The ascending serotonergic system originates from the raphe nuclei in the brainstem. We hypothesized that depressive disorder due to brainstem infarction is associated with damage to the raphe nuclei.

METHODS

We prospectively enrolled 19 patients who had the first-ever acute isolated brainstem infarction in an observational cross-sectional study. All patients were evaluated by using the Montgomery Åsberg Depression Rating Scale (MADRS), the clinician-rated version of Apathy Evaluation Scale (AES-C) and Mini-Mental State Examination (MMSE). Depressive disorder was diagnosed according to DSM-5 and MADRS score of 12 or greater. Diffusion tensor imaging and proton density-weighted images were used to identify damage in the raphe nuclei. Accordingly, patients were classified into either the raphe-nuclei-damaged or intact group. Prevalence of depressive disorder and the MADRS, AES-C, and MMSE scores were compared between the two groups.

RESULTS

Depressive disorder was more frequent in the damaged group (n=6) than in the intact group (n=13) (83% vs. 15%; P=0.01). MADRS scores were higher in the damaged group than in the intact group (mean±1 SD, 17.5±7.9 vs. 7.0±4.4; P=0.002), whereas the AES-C and MMSE scores did not differ between groups.

LIMITATIONS

We did not assess the damage to the ascending projection fibers from the raphe nuclei.

CONCLUSIONS

Our results suggest that damage to the raphe nuclei underlies depressive disorder due to brainstem infarction, possibly via serotonergic denervation.

[The significance of the rehabilitative potential for the combined medical rehabilitation of the patients presenting with acute cerebral circulation problems]

This article outlines the current WHO concepts of the process of rehabilitation with special reference to the consideration and the analysis of the concept of rehabilitation potential, its structure, levels, and functions of each level. The main stages and the aim of the comprehensive medical and psychological rehabilitation of the patients presenting with acute cerebrovascular accidents (ACVA) are discussed. The importance of the recoverable and reusable resources at the biological and psychological levels that may play the role of compensatory functions in the patients suffering from acute cerebral circulation disorders is emphasized. The three main stages of the rehabilitation process for the ACVA patients («diagnostic», «therapeutic», and «verifying») are described. The necessity of the development of the systemic strategy for medical and psychological rehabilitation of the post-stroke patients is substantiated taking into account the criteria for allocating them to the groups of either early or late rehabilitation and the group of patients suffering from the consequences of acute cerebral circulation disorders. It may allow to achieve the optimal level of the patients' well-being, in accordance with the rehabilitation potential currently attainable for the patients undergoing acute cerebrovascular accidents.

Nedley Depression Hit Hypothesis: Identifying Depression and Its Causes

Depression is often diagnosed using the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria. We propose how certain lifestyle choices and non-modifiable factors can predict the development of depression. We identified 10 cause categories (hits or “blows” to the brain) and theorize that four or more active hits could trigger a depression episode. Methods. A sample of 4271 participants from our community-based program (70% female; ages 17-94 years) was assessed at baseline and at the eighth week of the program using a custom test. Ten cause categories were examined as predictors of depression are (1) Genetic, (2)Developmental, (3)Lifestyle, (4)Circadian Rhythm, (5)Addiction, (6)Nutrition, (7)Toxic, (8)Social/Complicated Grief, (9)Medical Condition, and (10)Frontal Lobe. Results. The relationship between the DSM-5 score and a person having four hits categories in the first program week showed a sensitivity of 89.98 % (95% CI: 89.20 % - 90.73%), specificity 48.84% (CI 45.94-51.75) and Matthew Correlation Coefficient (MCC) .41 . For the eight-week test, the results showed a sensitivity 83.6% (CI 81.9-85.5), specificity 53.7% (CI 51.7-55.6) and MCC .38. Overall, the hits that improved the most from baseline after the eighth week were: Nutrition (47%), Frontal lobe (36%), Addiction (24%), Circadian rhythm (24%), Lifestyle (20%), Social (12%) and Medical (10%). Conclusions. The Nedley four-hit hypothesis seems to predict a depressive episode and correlates well with the DSM-5 criteria with good sensitivity and MCC but less specificity. Identifying these factors and applying lifestyle therapies could play an important role in the treatment of depressed individuals.

The role of hydrogen sulfide in stroke

Stroke is a kind of acute cerebrovascular disease characterized by the focal lack of neurological function, including ischemic stroke and hemorrhagic stroke. As society ages rapidly, stroke has become the second leading cause of disability and death, and also become the main threat to human health and life. In recent years, findings from increasing animal and clinical trials have supplied scientific evidences for the treatment of stroke. Hydrogen sulfide (H₂S), which has always been seen as a toxic gas, now has been thought to be the third gaseous signaling molecule following nitric oxide and carbon monoxide. Accumulating evidences indicate that H₂S plays an important role in stroke. Given that its neuroprotective effect is dose-dependent, only when its concentration is relatively low, H₂S can yield the neuroprotection, while high dose may lead to neurotoxicity. All these study results suggest that H₂S may offer a new promising application for the therapy of stroke. Here, our review will present the role of H₂S in stroke from its mechanism to animal and clinical studies.

The validity of questionnaire measures for assessing depression after stroke

Objective: Depression has been reported to occur frequently after stroke. The aim of the study was to assess the validity of questionnaire measures for screening for depression after stroke.

Design: Cross-sectional correlational study between questionnaire measures of mood and psychiatric interview.

Setting: Hospital and community.

Participants: Stroke patients were recruited from hospital wards and from a randomized controlled trial of cognitive behavioural therapy.

Main measures: Beck Depression Inventory, Wakefield Depression Inventory, General Health Questionnaire 28 and Schedules for Clinical Assessment in Neuropsychiatry.

Results: Poor agreement was found between psychiatric diagnosis and questionnaire measures of mood. The sensitivity of the questionnaire measures was high, but specificity was low. No cut-off points with satisfactory sensitivity and specificity could be identified from ROC curves.

Conclusions: Although questionnaire assessments of depression provide a satisfactory screening method, specificity values are too low to provide a basis for the diagnosis of depression. Measures need to be developed with higher specificity to facilitate screening for depression after stroke.

One session of whole body vibration increases voluntary muscle strength transiently in patients with stroke

Objective: To determine the effect of whole body vibration on isometric and eccentric torque and electromyography (EMG) variables of knee extensors on the affected side of stroke patients.

Design: A randomized controlled study.

Setting: A rehabilitation centre.

Subjects: Sixteen patients (age 58.2 ± 9.4 years) were enrolled in an inpatient rehabilitation programme 27.2 ± 10.4 days after a stroke.

Interventions: Eight patients were randomly assigned to the vibration group and received 20 Hz vibration (5 mm amplitude) while standing on a vibration platform for 1 minute six times in one session. Patients in the control group also stood on the platform but did not receive vibration.

Main measures: Maximum isometric and eccentric torque, rate of torque development, root-mean-squared EMG, median frequency of vastus lateralis, and co-activation of knee flexors.

Results: Isometric and eccentric knee extension torque increased 36.6% and 22.2%, respectively, after vibration (P < 0.05) and 8.4% and 5.3% in the control group. Vibration increased EMG amplitude 44.9% and the median frequency in the vastus lateralis by 13.1% (all P < 0.05) without changes in the control group (10.6% and 3.9%). Vibration improved the ability to generate mechanical work during eccentric contraction (17.5%). Vibration reduced biceps femoris co-activation during isometric (8.4%, ns) and eccentric (22.5%, P < 0.05) contraction.

Conclusion: These results suggest that one bout of whole body vibration can transiently increase voluntary force and muscle activation of the quadriceps muscle affected by a stroke.

Outcomes of progressive resistance strength training following stroke: a systematic review

Objective: To determine whether progressive resistance strength training reduces impairments, activity limitations and participation restrictions after stroke.

Methods: Electronic databases were searched to find trials conducted from 1966 to 2002. Articles were assessed independently by two reviewers according to the following inclusion criteria: (1) population: adults with stroke, (2) intervention: progressive resistive strength training in isolation, and (3) outcomes: changes in body function, physical activity or societal participation.

Results: From the 350 articles initially identified, eight met the criteria for detailed review. Three were randomized controlled trials, with the remainder being single-case time-series analyses or pre–post trials. The five trials that measured impairments of muscle strength showed positive outcomes for progressive resistance strength training, with large effect sizes ( d = 1.2–4.5). Few negative effects of strength training were reported, and these were minor. Only three of the eight trials that measured activity limitations reported improvements in activities such as walking and stair climbing. The effects of strength training on societal participation could not be determined due to insufficient data.

Conclusions: There is preliminary evidence that progressive resistance strength training programmes reduce musculoskeletal impairment after stroke. Whether strengthening enhances the performance of functional activities or participation in societal roles remains unknown.

Sevoflurane prevents stroke-induced depressive and anxiety behaviors by promoting cannabinoid receptor subtype I-dependent interaction between β-arrestin 2 and extracellular signal-regulated kinases 1/2 in the rat hippocampus

One of the most frequent psychological consequences of stroke is depression. Previous animal studies have demonstrated that post-conditioning with sevoflurane protects against focal cerebral ischemia and reperfusion injury. Thus, we hypothesized that repeated exposure to sevoflurane after transient ischemia can prevent the development of depressive-like behavior. To test this hypothesis, we induced transient cerebral ischemia via transient occlusion of bilateral common carotid arteries and examined the effects of subsequent repeated exposure to sevoflurane on sucrose preference, locomotor activity, and rearing activity in rats. To explore the putative neurobiological mechanisms, we further investigated the roles of hippocampal CB1 receptor in the behavioral effects of sevoflurane. We found that repeated sevoflurane exposures reversed ischemia-induced depressive-like behaviors. Furthermore, CB1 receptor inhibition in the dorsal hippocampus (DH) abolished the effects of sevoflurane exposures on ischemia-induced depressive-like behaviors. In addition, repeated sevoflurane exposures increased CB1 receptor expression and endocannabinoids levels in the DH of ischemic rats. Moreover, repeated sevoflurane exposures enhanced the expression of β-arrestin 2, increased the activation of extracellular signal-regulated kinases (ERK)1/2, and promoted the interaction of β-arrestin 2 and ERK1/2 in the DH, and such effects were reversed by CB1 receptor antagonism in the DH. Finally, β-arrestin 2 expression and ERK1/2 activation in the DH were critical for the preventative effects of sevoflurane exposures on ischemia-induced depressive-like behaviors. Taken together, our results suggested that sevoflurane exposure after brain ischemia may prevent the development of depression, and such preventative effects of sevoflurane are likely ascribed to the activation of CB1 receptor-mediated β-arrestin 2-ERK1/2 signaling pathways. We propose that the following mechanisms are critical for the preventative effects of sevoflurane against post-stroke depressive and anxiety behaviors: repeated sevoflurane exposure after transient brain ischemia enhances N-arachidonoylethanolamine (AEA) and 2-Arachidonoylglycerol (2-AG) levels and normalize cannabinoid receptor type 1 (CB1) receptor expression in the dorsal hippocampus, which results in enhanced interaction of β-arrestin 2 and extracellular signal-regulated kinases (ERK1/2) and increased ERK1/2 activation, leading to decreased depressive and anxiety behaviors. We think these findings should provide a new strategy for treatment of post-stroke depression.

The post-stroke depression and its impact on functioning in young and adult stroke patients of a rehabilitation unit

BACKGROUND

Stroke is a leading cause of disability and a major public health problem.

AIMS

To determine frequency and degree of post-stroke depression (PSD) and its impact on functioning in young and adult stroke patients in a rehabilitation unit.

METHOD

The study included 72 stroke patients (aged 29-59 years) who were attending rehabilitation. The patients were assessed for depressive symptoms by Beck Depression Inventory (BDI), and their functioning by using the Stroke Impact Scale (SIS) and the Barthel Index of Activities of Daily Living (ADL).

RESULTS

Forty-eight patients had different degrees of depression: borderline clinical depression (13.8%), moderate depression (34.7%), severe depression (15.2%) or extreme depression (2.9%). There were no significant differences of BDI scores in 30-39, 40-49 and 50-59 years groups. Statistically significant correlations were between BDI score and SIS score, between BDI score and ADL index, and between SIS score and ADL index in men, women and total study patients.

CONCLUSIONS

More than half of the PSD patients had a moderate degree of depression. Significant correlations were noticed between depressive symptoms and functional status evaluated both by an instrument of assessing stroke impact upon general health and an instrument for assessing the everyday activities.

Age, subjective stress, and depression after ischemic stroke

The incidence of stroke among younger adults in the United States is increasing. Few studies have investigated the prevalence of depressive symptoms after stroke among different age groups or the extent to which subjective stress at the time of stroke interacts with age to contribute to post-stroke depression. The present study examined whether there exists an age gradient in survivors' level of depressive symptoms and explored the extent to which financial, family, and health-related stress may also impact on depression. Bivariate analyses (N = 322) indicated significant differences in depression and stress by age group, as well as differences in age and stress by 3-month depression status. Linear regression analyses indicated that survivors between the ages of 25-54 and 55-64 years old had, on average, significantly higher depressive symptom scores. Those with financial, family, and health-related stress at the time of stroke, irrespective of age, also had significantly higher scores.

Executive function and depressive symptoms of retardation in nonelderly stroke patients

The depression-executive dysfunction syndrome, a late-onset depression of vascular origin with executive dysfunction and psychomotor retardation, has also been described after stroke. We verified whether this syndrome also occurs in nonelderly stroke patients by investigating the association between domains of depressive symptoms with executive functions in 87 first-ever ischemic stroke patients. The retardation domain of the 31-item Hamilton Rating Scale for Depression was associated with decreased performance on verbal fluency (assessed with FAS). The association was maintained for younger patients (aged <60 years) after adjusting for confounders. This result supports the clinical presentation of depression-executive dysfunction syndrome in younger stroke patients. Confirmation of this finding, its neural correlates, and clinical implication deserve further investigation.

Adaptation to Stroke: A Longitudinal Study of Depressive Symptoms, Physical Health, and Coping Process

The purposes of this study were to describe the natural history of adaptation to stroke and to identify survivor and caregiver predictors of depressive symptoms. Data were collected for 53 stroke survivors at four times from acute rehabilitation (T1) to 2 years post discharge (T4). Significant improvement occurred in depressive symptoms and perception of health, but change in the rate of depression was not significant. Family functioning became less healthy. Significant predictors of greater levels of depressive symptoms were lower levels of total support, finding meaning, and avoidance coping (T1) and lower levels of family functioning and belonging support (T4). Treatments to promote adaptation can be developed based on these predictors.

Quality of Life Following Hemicraniectomy for Malignant MCA Territory Infarction

Objective:

Decompressive hemicraniectomy (DH) has been shown to reduce mortality in patients with malignant middle cerebral artery (MCA) territory infarction. However, many patients survive with moderate-to-severe disability and controversy exists as to whether this should be considered good outcome. To answer this question, we assessed the quality of life (QoL) of patients after DH for malignant MCA territory infarction in our milieu.

Methods:

The outcome of all patients undergoing DH for malignant MCAterritory infarction between 2001 and 2009 was assessed using retrospective chart analysis and telephone follow-up in survivors. Functional outcome was determined using Glasgow outcome scale, modifed Rankin scale (mRS), and Barthel index (BI). The stroke impact scale was used to assess QoL.

Results:

There were 14 patients, 6 men and 8 women, with a mean age of 44 years (range 27-57). All patients had reduced level of consciousness preoperatively. Five had dominant-hemisphere stroke. Median time to surgery was 45 hours (range 1- 96). Two patients died and one was lost to follow-up. Of 11 survivors, 7 (63.6%) had a favorable functional outcome (mRS<4). No patient was in persistent vegetative state. Despite impaired QoL, particularly in physical domains, the majority of interviewed patients and caregivers (7 of 8), including those with dominant-hemisphere stroke, were satisfied after a median follow-up of 18 months (range 6-43).

Conclusion:

Most patients report satisfactory QoL despite significant disability even in the face of moderate-to-severe disability and dominant-hemsiphere stroke. Dominant-hemisphere malignant MCA territory infarction should not be considered a contraindication to DH.

Post-stroke depression and lesion location: a systematic review

Post-stroke depression (PSD) is a frequent problem in stroke rehabilitation. Several studies have evaluated association between the lesion location and the risk of depression. Different conclusions and contradictory findings have been published. The aim of the present study was to perform a systematic meta-analysis to evaluate the relationship between PSD and lesion location. We researched PubMed, ISI Web of Science, EMBASE, and systematically reviewed available publications reporting investigations on stroke location and risk of PSD. Subgroup analyses were performed according to the time since stroke onset to assessment for PSD or the source of patients. Odds ratios (ORs) and 95 % confidence intervals (CIs) were used for pooled analyses. Heterogeneity was assessed with Cochran's Q test and I (2) test. Begg's funnel plot and Egger's test were used to examine the publication bias. A total of 43 studies involving 5,507 patients suffering from stroke were included in this meta-analysis. The pooled OR with 95 % CI for the overall association of stroke location and depression risk was 0.99 (0.88-1.11). Subgroups analyses highlighted that only studies with subacute post-stroke group (1-6 months) showed a statistical association between right hemisphere stroke and risk of depression (OR = 0.79, 95 % CI 0.66-0.93). This systematic review offered no support for the hypothesis that lesion of the left hemisphere was associated with an increased risk of depression after stroke. We only find significant association between right hemisphere stroke and incidence of depression for studies within subacute post-stroke phase.

Depression in small-vessel disease relates to white matter ultrastructural damage, not disability

Objective:

To determine whether cerebral small-vessel disease (SVD) is a specific risk factor for depression, whether any association is mediated via white matter damage, and to study the role of depressive symptoms and disability on quality of life (QoL) in this patient group.

Methods:

Using path analyses in cross-sectional data, we modeled the relationships among depression, disability, and QoL in patients with SVD presenting with radiologically confirmed lacunar stroke (n = 100), and replicated results in a second SVD cohort (n = 100). We then compared the same model in a non-SVD stroke cohort (n = 50) and healthy older adults (n = 203). In a further study, to determine the role of white matter damage in mediating the association with depression, a subgroup of patients with SVD (n = 101) underwent diffusion tensor imaging (DTI).

Results:

Reduced QoL was associated with depression in patients with SVD, but this association was not mediated by disability or cognition; very similar results were found in the replication SVD cohort. In contrast, the non-SVD stroke group and the healthy older adult group showed a direct relationship between disability and depression. The DTI study showed that fractional anisotropy, a marker of white matter damage, was related to depressive symptoms in patients with SVD.

Conclusion:

These results suggest that in stroke patients without SVD, disability is an important causal factor for depression, whereas in SVD stroke, other factors specific to this stroke subtype have a causal role. White matter damage detected on DTI is one factor that mediates the association between SVD and depression.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Part II: predictors of depression after stroke and impact of depression on stroke outcome: an updated systematic review of observational studies

BACKGROUND

We previously published a systematic review in 2005 on factors associated with the development of depression in people with stroke.

AIM

To update and expand that review to include published data on the impact of depression on stroke outcome.

METHODS

We included all published observational studies (to May 31, 2013) with prospective consecutive recruitment of people with a clinical diagnosis of stroke where an attempt was made to assess the variables associated with, or predictive of, the development of depression.

RESULTS

We included data from 23 studies including 18,374 people. Depression after stroke was associated with prestroke depression, more severe neurological deficit and physical disability in the acute phase, and later after stroke. No consistent relationship between depression and demographic parameters or stroke features was identified. The review of the impact of depression on stroke outcome included data from 14 cohorts, including 4498 people, and found that depression was negatively associated with functional outcome in stroke survivors.

CONCLUSIONS

Early identification of patients at high risk of depression after stroke, those with a history of depression and physical disability after stroke, would enable the early implementation of effective management and prevention strategies for depression. The reciprocal relationship between depression and physical disability highlights the need for interventions that reduce disability after stroke, which may in turn improve mood and overall recovery for an increasingly large number of stroke survivors.

Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies

BACKGROUND

Approximately 15 million people who suffer a stroke globally each year are at risk of developing depression.

AIM

To update our systematic review and meta-analysis of the frequency of depression after stroke published in 2005, including studies published before July 2004.

METHODS

We included all published observational studies (to 31 May 2013) with prospective consecutive recruitment and quantification of the proportion of people with depression after stroke. We included studies of adult (>18 years) patients with a clinical diagnosis of stroke, where an assessment of depression or depressive symptom burden was performed at a pre-specified time-point for all study participants.

RESULTS

Data were available from 61 studies including 25,488 people. The proportional frequency of depression varied considerably across studies; however, the pooled frequency estimate of 31% (95% confidence interval 28% to 35%) was not significantly different from the 33% (difference of 2%, 95% confidence interval <1% to 3%) reported in the 2005 review. The proportion with depression between one and five-years (25%; 95% confidence interval 16 to 33%) and at five years after stroke (23%; 95% confidence interval 14 to 31%) was significantly lower.

CONCLUSION

Despite systematic review evidence describing validated depression screening tools and effective treatment and prevention strategies for depression after stroke, there has not been a significant reduction in the proportion of people experiencing depression after stroke. There is a pressing need for increased clinical uptake of evidenced-based strategies to screen for, prevent, and treat depression after stroke.

Perfusion deficits, inflammation and aging precipitate depressive behaviour

Major depressive disorder (MDD) is a severe psychiatric illness that is associated with significant morbidity and mortality. Despite advances in the treatment of major depression, one-third of depressed patients fail to respond to conventional antidepressant medication. One pathophysiologic mechanism hypothesized to contribute to treatment resistance in depression is inflammation. Inflammation has been linked to depression by a number of putative mechanisms involving perfusion deficits that can trigger microglial activation and subsequent neuroinflammation in the elderly. However, the pathophysiological mechanisms remain to be further elucidated. This review focusses on recent studies addressing the complex relationships between depression, aging, inflammation and perfusion deficits in the elderly. We expect that a better understanding of neuroinflammatory mechanisms associated with age-related diseases may lead to the discovery of new biomarkers of MDD and development of new therapeutic interventions.

Of mice and men: modelling post-stroke depression experimentally

At least one-third of stroke survivors suffer from depression. The development of comorbid depression after stroke is clinically highly significant because post-stroke depression is associated with increased mortality, slows recovery and leads to worse functional outcomes. Here, we review the evidence that post-stroke depression can be effectively modelled in experimental rodents via a variety of approaches. This opens an exciting new window onto the neurobiology of depression and permits probing potential underlying mechanisms such as disturbed cellular plasticity, neuroendocrine dysregulation, neuroinflammation, and neurodegeneration in a novel context. From the point of view of translational stroke research, extending the scope of experimental investigations beyond the study of short-term end points and, in particular, acute lesion size, may help improve the relevance of preclinical results to human disease. Furthermore, accumulating evidence from both clinical and experimental studies offers the tantalizing prospect of 5-hydroxytryptaminergic antidepressants as the first pharmacological therapy for stroke that would be available during the subacute and chronic phases of recovery. Interdisciplinary neuropsychiatric research will be called on to dissect the mechanisms underpinning the beneficial effects of antidepressants on stroke recovery.