Functional and neuroanatomic correlations in poststroke depression: the Sunnybrook Stroke Study

Delirium in acute stroke is associated with increased cognitive and psychiatric symptoms over time: The Nor-COAST study

BACKGROUND

Delirium, an acute and fluctuating mental disturbance of attention, cognition, and consciousness, commonly occurs in acute stroke. Research on long-term outcomes of stroke patients experiencing delirium is limited, especially regarding cognitive and psychiatric symptoms.

METHODS

As part of the Nor-COAST study, 373 patients were screened for delirium using the Confusion Assessment Method (CAM) in the acute phase of stroke. Patients were included in the mixed-model linear regression analyses if they had available data from the follow-ups at three, 18 or 36 months, totaling 334 (44.6 % women, mean (SD) age: 72.1 (12.5) years, 17 (5.1 %) diagnosed with delirium). Global cognition was measured using the Montreal Cognitive Assessment (MoCA). Psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q).

RESULTS

At three months, delirium was associated with a higher NPI-Q score (Mean (SD) 2.9 (3.6) vs 1.4 (2.2)). At 18 and 36 months, delirium was associated with a lower MoCA score (Mean (SD) 19.7 (6.6) vs 24.3 (5.0), and 20.6 (7.6) vs 24.6 (4.8)), higher HADS anxiety symptoms (5.0 (4.3) vs 3.3 (3.3), and 5.9 (4.1) vs 3.4 (3.6)), higher HADS depression symptoms (7.2 (4.7) vs 3.4 (3.3), and 6.6 (5.1) vs 3.7 (3.7)), and higher NPI-Q score (2.4 (4.4) vs 1.7 (2.3), 2.6 (4.5) vs 1.0 (1.9)). Delirium significantly predicted the psychiatric symptoms hallucinations and agitation.

CONCLUSIONS

Patients with delirium in the acute phase of stroke may be particularly vulnerable to developing cognitive and psychiatric symptoms in the chronic phase.

Behavioral and neuroanatomical correlates of facial emotion processing in post-stroke depression

BACKGROUND

Emotion processing deficits are known to accompany depressive symptoms and are often seen in stroke patients. Little is known about the influence of post-stroke depressive (PSD) symptoms and specific brain lesions on altered emotion processing abilities and how these phenomena develop over time. This potential relationship may impact post-stroke rehabilitation of neurological and psychosocial function. To address this scientific gap, we investigated the relationship between PSD symptoms and emotion processing abilities in a longitudinal study design from the first days post-stroke into the early chronic phase.

METHODS

Twenty-six ischemic stroke patients performed an emotion processing task on videos with emotional faces ('happy,' 'sad,' 'anger,' 'fear,' and 'neutral') at different intensity levels (20%, 40%, 60%, 80%, 100%). Recognition accuracies and response times were measured, as well as scores of depressive symptoms (Montgomery-Åsberg Depression Rating Scale). Twenty-eight healthy participants matched in age and sex were included as a control group. Whole-brain support-vector regression lesion-symptom mapping (SVR-LSM) analyses were performed to investigate whether specific lesion locations were associated with the recognition accuracy of specific emotion categories.

RESULTS

Stroke patients performed worse in overall recognition accuracy compared to controls, specifically in the recognition of happy, sad, and fearful faces. Notably, more depressed stroke patients showed an increased processing towards specific negative emotions, as they responded significantly faster to angry faces and recognized sad faces of low intensities significantly more accurately. These effects obtained for the first days after stroke partly persisted to follow-up assessment several months later. SVR-LSM analyses revealed that inferior and middle frontal regions (IFG/MFG) and insula and putamen were associated with emotion-recognition deficits in stroke. Specifically, recognizing happy facial expressions was influenced by lesions affecting the anterior insula, putamen, IFG, MFG, orbitofrontal cortex, and rolandic operculum. Lesions in the posterior insula, rolandic operculum, and MFG were also related to reduced recognition accuracy of fearful facial expressions, whereas recognition deficits of sad faces were associated with frontal pole, IFG, and MFG damage.

CONCLUSION

PSD symptoms facilitate processing negative emotional stimuli, specifically angry and sad facial expressions. The recognition accuracy of different emotional categories was linked to brain lesions in emotion-related processing circuits, including insula, basal ganglia, IFG, and MFG. In summary, our study provides support for psychosocial and neural factors underlying emotional processing after stroke, contributing to the pathophysiology of PSD.

Neuroanatomy of post-stroke depression: the association between symptom clusters and lesion location

Post-stroke depression affects about 30% of stroke patients and often hampers functional recovery. The diagnosis of depression encompasses heterogeneous symptoms at emotional, motivational, cognitive, behavioural or somatic levels. Evidence indicates that depression is caused by disruption of bio-aminergic fibre tracts between prefrontal and limbic or striatal brain regions comprising different functional networks. Voxel-based lesion-symptom mapping studies reported discrepant findings regarding the association between infarct locations and depression. Inconsistencies may be due to the usage of sum scores, thereby mixing different symptoms of depression. In this cross-sectional study, we used multivariate support vector regression for lesion-symptom mapping to identify regions significantly involved in distinct depressive symptom domains and global depression. MRI lesion data were included from 200 patients with acute first-ever ischaemic stroke (mean 0.9 ± 1.5 days of post-stroke). The Montgomery-Åsberg Depression Rating interview assessed depression severity in five symptom domains encompassing motivational, emotional and cognitive symptoms deficits, anxiety and somatic symptoms and was examined 8.4 days of post-stroke (±4.3). We found that global depression severity, irrespective of individual symptom domains, was primarily linked to right hemispheric lesions in the dorsolateral prefrontal cortex and inferior frontal gyrus. In contrast, when considering distinct symptom domains individually, the analyses yielded much more sensitive results in regions where the correlations with the global depression score yielded no effects. Accordingly, motivational deficits were associated with lesions in orbitofrontal cortex, dorsolateral prefrontal cortex, pre- and post-central gyri and basal ganglia, including putamen and pallidum. Lesions affecting the dorsal thalamus, anterior insula and somatosensory cortex were significantly associated with emotional symptoms such as sadness. Damage to the dorsolateral prefrontal cortex was associated with concentration deficits, cognitive symptoms of guilt and self-reproach. Furthermore, somatic symptoms, including loss of appetite and sleep disturbances, were linked to the insula, parietal operculum and amygdala lesions. Likewise, anxiety was associated with lesions impacting the central operculum, insula and inferior frontal gyrus. Interestingly, symptoms of anxiety were exclusively left hemispheric, whereas the lesion-symptom associations of the other domains were lateralized to the right hemisphere. In conclusion, this large-scale study shows that in acute stroke patients, differential post-stroke depression symptom domains are associated with specific structural correlates. Our findings extend existing concepts on the neural underpinnings of depressive symptoms, indicating that differential lesion patterns lead to distinct depressive symptoms in the first weeks of post-stroke. These findings may facilitate the development of personalized treatments to improve post-stroke rehabilitation.

Individualized fMRI connectivity defines signatures of antidepressant and placebo responses in major depression

Though sertraline is commonly prescribed in patients with major depressive disorder (MDD), its superiority over placebo is only marginal. This is in part due to the neurobiological heterogeneity of the individuals. Characterizing individual-unique functional architecture of the brain may help better dissect the heterogeneity, thereby defining treatment-predictive signatures to guide personalized medication. In this study, we investigate whether individualized brain functional connectivity (FC) can define more predictable signatures of antidepressant and placebo treatment in MDD. The data used in the present work were collected by the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study. Patients (N = 296) were randomly assigned to antidepressant sertraline or placebo double-blind treatment for 8 weeks. The whole-brain FC networks were constructed from pre-treatment resting-state functional magnetic resonance imaging (rs-fMRI). Then, FC was individualized by removing the common components extracted from the raw baseline FC to train regression-based connectivity predictive models. With individualized FC features, the established prediction models successfully identified signatures that explained 22% variance for the sertraline group and 31% variance for the placebo group in predicting HAMD17 change. Compared with the raw FC-based models, the individualized FC-defined signatures significantly improved the prediction performance, as confirmed by cross-validation. For sertraline treatment, predictive FC metrics were predominantly located in the left middle temporal cortex and right insula. For placebo, predictive FC metrics were primarily located in the bilateral cingulate cortex and left superior temporal cortex. Our findings demonstrated that through the removal of common FC components, individualization of FC metrics enhanced the prediction performance compared to raw FC. Associated with previous MDD clinical studies, our identified predictive biomarkers provided new insights into the neuropathology of antidepressant and placebo treatment.

Determinants of post-stroke depression among stroke survivors at University of Gondar Hospital, Northwest Ethiopia: a case-control study

BACKGROUND

Stroke is one of the most common causes of disability among adults. Post-stroke depression (PSD) is a frequent neuropsychiatric complication in stroke patients. Despite the increasing prevalence of stroke, there is a paucity of data on PSD and its determinants among stroke survivors in developing countries like Ethiopia. We aim to assess the factors associated with PSD in survivors of stroke.

METHOD

A hospital-based unmatched case-control study was conducted during the period of February to July 2020 at University of Gondar Hospital among stroke survivors. Study subjects were recruited consecutively. Socio-demographic and clinical data were obtained from patients' interviews and medical record reviews. A diagnosis of PSD was made using the Patient Health Questionnaire (PHQ-9). EpiData version 3.1 was used to enter data, and SPSS version 26 was used to analyze it. Bivariate and multivariate logistic regressions were fitted to identify associated variables. The adjusted odds ratio (AOR) with 95% confidence interval (CI) and p-value 0.05 were used to determine the significance of the association.

RESULT

A total of 240 stroke survivors were included in the study (80 cases and 160 controls). The mean age was 60.8 years (SD ± 14.3) with an equal sex distribution. Variables statistically associated with PSD were male gender (AOR = 3.5, 95% CI: 1.64-7.46 C, P-value = 0.001), subcortical location of the largest lesion (AOR = 2.42, 95% CI: 1.06-5.56, p-value = 0.036), severity of the stroke (AOR = 52.34, 95% CI:10.64-256.87, p-value = 0.000), physical disability (AOR = 5.85. 95% CI:1.94-17.65, p-value = 0.002), previous history of stroke or transient ischemic attack (AOR = 5.90, 95% CI:2.04-17.10, p-value = 0.001) and ischemic heart disease (AOR = 9.97, 95% CI:3.4-29.22, p-value = 0.000).

CONCLUSION

Important factors in the occurrence of PSD in this study include prior history of stroke, physical disability, severity of the stroke, subcortical location of the lesion, male gender, and ischemic heart disease. Stroke patients with such factors need routine screening for PSD, particularly in LMICs where there is uncoordinated post-stroke care, a shortage of neurologists and mental health practitioners.

Musicokinetic and exercise therapies decrease the depression level of elderly patients undergoing post-stroke rehabilitation: The moderating effect of health regulatory focus

This study aims to investigate the impact of musicokinetic and exercise therapies on the depression level of elderly patients undergoing post-stroke rehabilitation and its possible moderators, the promotion focus (i.e., achieve gains) and prevention focus (i.e., avoid losses or non-gains), which are the two motivational orientations of health regulatory focus. An eight-week randomized controlled trial was employed. Sixty-five elderly patients undergoing post-stroke rehabilitation in a hospital in Shanghai, China. Patients were randomly assigned to the musicokinetic (n = 32) therapy group or the exercise (n = 33) therapy group. The Mini-mental State Examination Scale measuring the patients’ cognitive functions was used to screen participants. The Hamilton Depression Rating Scale and the Health Regulatory Focus Scale were applied to assess their levels of depression and health regulatory focus on weeks 0, 4, and 8, respectively. The musicokinetic therapy had a significantly better effect than the exercise therapy for individuals who had a lower level of prevention focus, whereas the exercise therapy had a significantly better effect than the musicokinetic therapy for individuals who had a higher level of prevention focus. Musicokinetic therapy and exercise therapy were both effective in decreasing post-stroke depression for elderly patients. But it is important to choose an appropriate type of therapy per the health regulatory focus of elderly patients with post-stroke rehabilitation.

Depressive symptoms due to stroke are strongly predicted by the volume and location of the cerebral infarction, white matter hyperintensities, hypertension, and age: A precision nomothetic psychiatry analysis

OBJECTIVES

To delineate the effects of white matter hyperintensities (WMHs) as measured by Fluid-attenuated inversion recovery (FLAIR) and infarction volume as measured by Diffusion-weighted imaging (DWI) on post-stroke depression symptoms.

METHODS

Baseline National Institutes of Health Stroke Score (NIHSS) and Modified Rankin Scale (mRS) scores, and FLAIR and DWI MRIs to assess WMHs and acute infarct volumes, respectively, were assessed in 47 patients (≥55 years) with acute ischemic stroke and 17 normal controls. The Montgomery-Åsberg Depression Rating Scale (MDRS) was assessed three months after the stroke.

RESULTS

The MADRS score was significantly increased in stroke patients as compared with normal controls. The MADRS scale is not unidimensional and cannot be used as an accurate indicator of depression severity in stroke patients. Three months after stroke, key depressive (sadness and inability to feel) and concentration-tension symptoms, and lassitude are significantly predicted by the infarct volume. Right side infarction strongly predicts key depressive symptoms and left side infarction strongly predicts concentration-tension and lassitude scores. Total WMHs significantly predict key depressive and concentration-tension symptoms, and lassitude, with these effects being mediated by right and left DWI stroke volumes and associated disabilities.

CONCLUSIONS

Interactions between age, hypertension, a chronic atherosclerotic process, and acute stroke account for the onset of key depressive symptoms three months after the acute infarct. Chronic and acute neuro-immune and neuro-oxidative stress pathways associated with the formation of WMHs and acute stroke may explain the incidence of post-stroke key depressive and concentration-tension symptoms, and lassitude.

The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study

OBJECTIVE

Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later.

METHOD

As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia.

RESULTS

Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)).

CONCLUSIONS

Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.

Neural Substrates of Poststroke Depression: Current Opinions and Methodology Trends

Poststroke depression (PSD), affecting about one-third of stroke survivors, exerts significant impact on patients’ functional outcome and mortality. Great efforts have been made since the 1970s to unravel the neuroanatomical substrate and the brain-behavior mechanism of PSD. Thanks to advances in neuroimaging and computational neuroscience in the past two decades, new techniques for uncovering the neural basis of symptoms or behavioral deficits caused by focal brain damage have been emerging. From the time of lesion analysis to the era of brain networks, our knowledge and understanding of the neural substrates for PSD are increasing. Pooled evidence from traditional lesion analysis, univariate or multivariate lesion-symptom mapping, regional structural and functional analyses, direct or indirect connectome analysis, and neuromodulation clinical trials for PSD, to some extent, echoes the frontal-limbic theory of depression. The neural substrates of PSD may be used for risk stratification and personalized therapeutic target identification in the future. In this review, we provide an update on the recent advances about the neural basis of PSD with the clinical implications and trends of methodology as the main features of interest.

Efficacy of sequential N-butylphthalide therapy on psychiatric and behavioral functions in acute ischemic stroke

BACKGROUND

Stroke can cause physical and mental problems. This study examined how the sequential therapy of N-butylphthalide (NBP) could effectively improve physical movement, life activities, and psychological disorders in stroke patients.

METHODS

This double-blind, randomized controlled trial included middle-aged or elderly patients with acute ischemic stroke that had commenced within 48 hours before enrolment in the study. The experimental group was administered 100 mL NBP injections twice a day in the first 14 days, and a sequential 200 mg NBP soft capsule 3 times a day for the next 76 days. The control group was administered 100 mL NBP placebo injections twice a day in the first 14 days and 200 mg sequential NBP placebo soft capsule 3 times a day for the next 76 days. Primary outcomes were the National Institutes of Health Stroke Scale, the Barthel Index of activities of daily living, and Modified Rankin Scale which were evaluated at day 0, day 14, and month 1 or at day 14, month 3, and month 6. Secondary outcomes included the Hamilton Anxiety Scale and the Hamilton Depression Scale, all were evaluated on day 0, month 3, and month 6. Moreover, the adverse reaction of NBP or other serious adverse events were evaluated at each time.

RESULTS

Our therapy significantly increased the Barthel Index of activities of daily living scores, decreased the National Institutes of Health Stroke Scale and Modified Rankin Scale scores, and the incidence of the Hamilton Anxiety Scale and the Hamilton Depression Scale of ischemic stroke patients (P < .05).

CONCLUSION

Our results indicated that 90 days' sequential therapy with NBP as an additional therapy in the treatment of ischemic stroke can better improve patients' psychological and behavioral functions without significant side effects.

Understanding Why Post-Stroke Depression May Be the Norm Rather Than the Exception: The Anatomical and Neuroinflammatory Correlates of Post-Stroke Depression

Ischemic Stroke precedes depression. Post-stroke depression (PSD) is a major driver for poor recovery, negative quality of life, poor rehabilitation outcomes and poor functional ability. In this systematic review, we analysed the inflammatory basis of post-stroke depression, which involves bioenergetic failure, deranged iron homeostasis (calcium influx, Na influx, potassium efflux etc), excitotoxicity, acidotoxicity, disruption of the blood brain barrier, cytokine-mediated cytotoxicity, reactive oxygen mediated toxicity, activation of cyclooxygenase pathway and generation of toxic products. This process subsequently results in cell death, maladapted, persistent neuro-inflammation and deranged neuronal networks in mood-related brain regions. Furthermore, an in-depth review likewise reveals that anatomic structures related to post-stroke depression may be localized to complex circuitries involving the cortical and subcortical regions.

Lesions in the right Rolandic operculum are associated with self-rating affective and apathetic depressive symptoms for post-stroke patients

Stroke survivors majorly suffered from post-stroke depression (PSD). The PSD diagnosis is commonly performed based on the clinical cut-off for psychometric inventories. However, we hypothesized that PSD involves spectrum symptoms (e.g., apathy, depression, anxiety, and stress domains) and severity levels. Therefore, instead of using the clinical cut-off, we suggested a data-driven analysis to interpret patient spectrum conditions. The patients’ psychological conditions were categorized in an unsupervised manner using the k-means clustering method, and the relationships between psychological conditions and quantitative lesion degrees were evaluated. This study involved one hundred sixty-five patient data; all patients were able to understand and perform self-rating psychological conditions (i.e., no aphasia). Four severity levels—low, low-to-moderate, moderate-to-high, and high—were observed for each combination of two psychological domains. Patients with worse conditions showed the significantly greater lesion degree at the right Rolandic operculum (part of Brodmann area 43). The dissimilarities between stress and other domains were also suggested. Patients with high stress were specifically associated with lesions in the left thalamus. Impaired emotion processing and stress-affected functions have been frequently related to those lesion regions. Those lesions were also robust and localized, suggesting the possibility of an objective for predicting psychological conditions from brain lesions.

Dimensions of Poststroke Depression and Neuropsychological Deficits in Older Adults

OBJECTIVE

Poststroke depression (PSD) has a heterogeneous presentation and is often accompanied by cognitive impairment. This study aimed to identify distinct dimensions of depressive symptoms in older adults with PSD and to evaluate their relationship to cognitive functioning.

DESIGN

Cross-sectional factor and correlational analyses of patients with poststroke depression.

SETTING

Patients were recruited from the community and from acute inpatient stroke rehabilitation hospitals.

PARTICIPANTS

Participants had suffered a stroke and met DSM-IV criteria for major depression (≥18 Montgomery Åsberg Depression Scale; MADRS).

INTERVENTION

None.

MEASUREMENTS

MADRS was used to quantify depression severity at study entry. Neuropsychological assessment at the time of study entry consisted of measures of Global Cognition, Attention, Executive Function, Processing Speed, Immediate Memory, Delayed Memory, and Language.

RESULTS

There were 135 (age ≥50) older adult participants with PSD and varying degrees of cognitive impairment (MMSE Total ≥20). Factor analysis of the MADRS identified three factors, that is sadness, distress, and apathy. Items comprising each factor were totaled and correlated with neuropsychological domain z-score averages. Symptoms of the apathy factor (lassitude, inability to feel) were significantly associated with greater impairment in executive function, memory, and global cognition. Symptoms of the sadness and distress factors had no relationship to cognitive impairment.

CONCLUSION

PSD consists of three correlated dimensions of depressive symptoms. Apathy symptoms are associated with cognitive impairment across several neuropsychological domains. PSD patients with prominent apathy may benefit from careful attention to cognitive functions and by interventions that address both psychopathology and behavioral deficits resulting from cognitive impairment.

Post-stroke depression and functional impairments - A 3-year prospective study

BACKGROUND

Post-Stroke Depression (PSD) is a severe condition, affecting about 30% of stroke survivors within a five-year period after stroke. Post-stroke functional impairments (FI) and social support are associated with PSD. It is inconclusive, whether one of the factors, post-stroke FI and PSD, shows a stronger predictive value on the respective other over time. The aims of the present study were to 1) investigate the relationship between PSD, FI, and social support of stroke patients in a 3-year prospective design, and 2) address methodological shortcomings of previous studies.

METHODS

We investigated 174 stroke survivors and assessed PSD with a structured clinical interview and a dimensional symptom rating scale. We conducted regression analyses and applied the approach of multiple imputations (MI) for missing data due to dropout during follow-up.

RESULTS

PSD prevalence was 32.2% in the acute phase after stroke. Individuals with a PSD in this phase revealed a fivefold higher risk for PSD 3 years later. FI in the acute phase did not additionally contribute to the prediction of PSD at follow-up. Compared to individuals without PSD in the acute phase, individuals with PSD had an increased risk for FI at follow-up. Limitations regarding sample characteristics, design, and dropout are discussed.

CONCLUSIONS

Results indicate that PSD rather than FI represents a crucial risk factor for negative long-term consequences regarding physical and psychological health after stroke. Post-stroke treatment might be optimized by a routine assessment of PSD and FI after stroke and considering the results for personalized treatment options.

Is there a correlation between depressive symptoms and motor skills in post-stroke patients?

Deficits in motor skills and depressive symptoms are common effects observed after stroke, so it is necessary to understand how these variables interact with each other. Therefore, the aim of this study was to investigate the relationship between these two variables in post-ischemic stroke patients. We evaluated 135 patients with a mean age of 60 years (± 15). The Fugl-Meyer assessment of motor function was used to assess motor skills in the upper limbs, lower limbs, balance, and sensitivity and the Beck Depression Inventory was applied to evaluate depressive symptoms. To assess the relationship between both components, Spearman's correlation was performed. Depressive symptoms were negatively correlated with all variables of motor skills. This study suggests that higher motor skills in post-stroke patients may be associated with fewer depressive symptoms. Thus, a better understanding of how post-stroke symptoms are interrelated may improve patient treatment and care, contributing to a better quality of life.

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.

Poststroke Depression Biomarkers: A Narrative Review

Poststroke depression (PSD) is the most prevalent psychiatric disorder after stroke, which is independently correlated with negative clinical outcome. The identification of specific biomarkers could help to increase the sensitivity of PSD diagnosis and elucidate its pathophysiological mechanisms. The aim of current study was to review and summarize literature exploring potential biomarkers for PSD diagnosis. The PubMed database was searched for papers published in English from October 1977 to December 2017, 90 of which met inclusion criteria for clinical studies related to PSD biomarkers. PSD biomarkers were subdivided into neuroimaging, molecular, and neurophysiological. Some of them could be recommended to support PSD diagnosing. According to the data, lesions affecting the frontal-subcortical circles of mood regulation (prefrontal cortex, basal nuclei, and thalamus) predominantly in the left hemisphere can be considered as neuroimaging markers and predictors for PSD for at least 1 year after stroke. Additional pontine and lobar cerebral microbleeds in acute stroke patients, as well as severe microvascular lesions of the brain, increase the likelihood of PSD. The following molecular candidates can help to differentiate PSD patients from non-depressed stroke subjects: decreased serum BDNF concentrations; increased early markers of inflammation (high-sensitivity C-reactive protein, ferritin, neopterin, and glutamate), serum pro-inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-18, IFN-γ), as well as pro-inflammatory/anti-inflammatory ratios (TNF-α/IL-10, IL-1β/IL-10, IL-6/IL-10, IL-18/IL-10, IFN-γ/IL-10); lowered complement expression; decreased serum vitamin D levels; hypercortisolemia and blunted cortisol awakening response; S/S 5-HTTLPR, STin2 9/12, and 12/12 genotypes of the serotonin transporter gene SLC6A4, 5-HTR2a 1438 A/A, and BDNF met/met genotypes; higher SLC6A4 promoter and BDNF promoter methylation status. Neurophysiological markers of PSD, that reflect a violation of perception and cognitive processing, are the elongation of the latency of N200, P300, and N400, as well as the decrease in the P300 and N400 amplitude of the event-related potentials. The selected panel of biomarkers may be useful for paraclinical underpinning of PSD diagnosis, clarifying various aspects of its multifactorial pathogenesis, optimizing therapeutic interventions, and assessing treatment effectiveness.

Chronic Fluoxetine Induces Activity Changes in Recovery From Poststroke Anxiety, Depression, and Cognitive Impairment

Poststroke depression (PSD) is a common outcome of stroke that limits recovery and is only partially responsive to chronic antidepressant treatment. In order to elucidate changes in the cortical-limbic circuitry associated with PSD and its treatment, we examined a novel mouse model of persistent PSD. Focal endothelin-1-induced ischemia of the left medial prefrontal cortex (mPFC) in male C57BL6 mice resulted in a chronic anxiety and depression phenotype. Here, we show severe cognitive impairment in spatial learning and memory in the stroke mice. The behavioral and cognitive phenotypes were reversed by chronic (4-week) treatment with fluoxetine, alone or with voluntary exercise (free-running wheel), but not by exercise alone. To assess chronic cellular activation, FosB+ cells were co-labeled for markers of glutamate/pyramidal (VGluT1-3/CaMKIIα), γ-aminobutyric acid (GAD67), and serotonin (TPH). At 6 weeks poststroke versus sham (or 4 days poststroke), left mPFC stroke induced widespread FosB activation, more on the right (contralesional) than on the left side. Stroke activated glutamate cells of the mPFC, nucleus accumbens, amygdala, hippocampus, and raphe serotonin neurons. Chronic fluoxetine balanced bilateral neuronal activity, reducing total FosB and FosB/CamKII+ cells (mPFC, nucleus accumbens), and unlike exercise, increasing FosB/GAD67+ cells (septum, amygdala) or both (hippocampus, raphe). In summary, chronic antidepressant but not exercise mediates recovery in this unilateral ischemic PSD model that is associated with region-specific reversal of stroke-induced pyramidal cell hyperactivity and increase in γ-aminobutyric acidergic activity. Targeted brain stimulation to restore brain activity could provide a rational approach for treating clinical PSD.

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.

The association between lesion location, sex and poststroke depression: Meta-analysis

BACKGROUND

Poststroke depression (PSD) is a common form of stroke patients. Whether the risk of PSD is influenced by the stroke lesion location and sex remains a matter of debate. The objective of this study was to examine the association between the risk of PSD and the stroke lesion location and sex by performing a systematic meta-analysis.

METHODS

Subgroup analyses were performed according to the time interval after stroke onset to assessment for PSD. A total of 31 reports involving 5,309 subjects (for lesion location analysis) and 5,489 subjects (for sex analysis) suffering from stroke were included in this meta-analysis.

RESULTS

The pooled odds ratio (OR) of PSD after a left-hemisphere stroke, compared with a right-hemisphere stroke was 1.11 (95% confidence interval [CI] 0.82-1.49) and OR of PSD after a male stroke, compared with a female stroke was 0.68 (95% CI 0.58-0.81). Subacute poststroke subgroup (1-6 months) significantly favored PSD occurring after a left hemisphere stroke (OR = 1.50, 95% CI 1.21-1.87). Furthermore, there was a statistically significant association between PSD and female stroke for studies with acute poststroke group (OR = 0.73, 95% CI 0.62-0.86) and subacute poststroke stroke phase (OR = 0.69, 95% CI 0.56-0.86).

CONCLUSIONS

This systematic review suggests that patients with left hemisphere stroke may be more susceptible to PSD during subacute phase of stroke and female stroke may be more susceptible to PSD during acute and subacute phase of stroke.

Imaging Markers of Post-Stroke Depression and Apathy: a Systematic Review and Meta-Analysis

Several brain imaging markers have been studied in the development of post-stroke depression (PSD) and post-stroke apathy (PSA), but inconsistent associations have been reported. This systematic review and meta-analysis aims to provide a comprehensive and up-to-date evaluation of imaging markers associated with PSD and PSA. Databases (Medline, Embase, PsycINFO, CINAHL, and Cochrane Database of Systematic Reviews) were searched from inception to July 21, 2016. Observational studies describing imaging markers of PSD and PSA were included. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated to examine the association between PSD or PSA and stroke lesion laterality, type, and location, also stratified by study phase (acute, post-acute, chronic). Other imaging markers were reviewed qualitatively. The search retrieved 4502 studies, of which 149 studies were included in the review and 86 studies in the meta-analyses. PSD in the post-acute stroke phase was significantly associated with frontal (OR 1.72, 95% CI 1.34–2.19) and basal ganglia lesions (OR 2.25, 95% CI 1.33–3.84). Hemorrhagic stroke related to higher odds for PSA in the acute phase (OR 2.58, 95% CI 1.18–5.65), whereas ischemic stroke related to higher odds for PSA in the post-acute phase (OR 0.20, 95% CI 0.06–0.69). Frequency of PSD and PSA is modestly associated with stroke type and location and is dependent on stroke phase. These findings have to be taken into consideration for stroke rehabilitation programs, as this could prevent stroke patients from developing PSD and PSA, resulting in better clinical outcome.

Long-range temporal correlations of broadband EEG oscillations for depressed subjects following different hemispheric cerebral infarction

Abnormal long-range temporal correlation (LRTC) in EEG oscillation has been observed in several brain pathologies and mental disorders. This study examined the relationship between the LRTC of broadband EEG oscillation and depression following cerebral infarction with different hemispheric lesions to provide a novel insight into such depressive disorders. Resting EEGs of 16 channels in 18 depressed (9 left and 9 right lesions) and 21 non-depressed (11 left and 10 right lesions) subjects following cerebral infarction and 19 healthy control subjects were analysed by means of detrended fluctuation analysis, a quantitative measurement of LRTC. The difference among groups and the correlation between the severity of depression and LRTC in EEG oscillation were investigated by statistical analysis. The results showed that LRTC of broadband EEG oscillations in depressive subjects was still preserved but attenuated in right hemispheric lesion subjects especially in left pre-frontal and right inferior frontal and posterior temporal regions. Moreover, an association between the severity of psychiatric symptoms and the attenuation of the LRTC was found in frontal, central and temporal regions for stroke subjects with right lesions. A high discriminating ability of the LRTC in the frontal and central regions to distinguish depressive from non-depressive subjects suggested potential feasibility for LRTC as an assessment indicator for depression following right hemispheric cerebral infarction. Different performance of temporal correlation in depressed subjects following the two hemispheric lesions implied complex association between depression and stroke lesion location.

Quantitative EEG abnormalities in major depressive disorder with basal ganglia stroke with lesions in different hemispheres

BACKGROUND

This study aimed to examine the aberrant EEG oscillation in major depressive subjects with basal ganglia stroke with lesions in different hemispheres.

METHODS

Resting EEG of 16 electrodes in 58 stroke subjects, 26 of whom had poststroke depression (13 with left-hemisphere lesion and 13 with right) and 32 of whom did not (18 with left lesion and 14 with right), was recorded to obtain spectral power analysis for several frequency bands. Multiple analysis of variance and receiver operating characteristic (ROC) curves were used to identify differences between poststroke depression (PSD) and poststroke non-depression (PSND), treating the different lesion hemispheres separately. Moreover, Pearson linear correlation analysis was conducted to test the severity of depressive symptoms and EEG indices.

RESULTS

PSD with left-hemisphere lesion showed increased beta2 power in frontal and central areas, but PSD with right-hemisphere lesion showed increased theta and alpha power mainly in occipital and temporal regions. Additionally, for left-hemisphere lesions, beta2 power in central and right parietal regions provided high discrimination between PSD and PSND, and for right-hemisphere lesions, theta power was similarly discriminative in most regions, especially temporal regions. We also explored the association between symptoms of depression and the power of abnormal bands, but we found no such relationship.

LIMITATIONS

The sample size was relatively small and included subjects with different lesions of the basal ganglia.

CONCLUSIONS

The aberrant EEG oscillation in subjects with PSD differs between subjects with lesions of the left and right hemispheres, suggesting a complex association between depression and lesion location in stroke patients.

The prevalence of depression in rheumatoid arthritis in China: A systematic review

This systematic review is to explore the prevalence of depression in patients with rheumatoid arthritis (RA) in China. Articles of prevalence rates for depression in adult RA patients published before October 2015 were identified from PubMed, Embase, The Cochrane Library, CNKI, CBM, VIP, and Wanfang database and other internet databases. Relevant journals and the recommendations of expert panels were also searched manually. Two independent reviewers searched and assessed the literature. Therelevant data were applied with Meta-Analyst 3.13 software, and the forest plot and funnel plot were performed. 21 studies with a total of 4447 patients were selected to be enrolled in this study. The prevalence of depression by analyzing the effect size was 48% [95% CI (41%, 56%)]. The prevalence of minor depression and dysthymic disorder was 30% [95%CI (23%, 38%)], and the moderate or major depression was 18% [95%CI (11%, 29%)], respectively. Subgroup analysis showed that the depression rate of female RA patients was higher than male. The depression rate in the central and western areas were higher than that of the eastern region of China, the prevalence level estimated by the Geriatric Depression Scale (GDS) was higher than estimated by other tools. Sensitivity analysis showed that the pooled effect size had good stability and reliability, To be conclusive, the prevalence rate of depression in RA patients is 48%, which suggesting that medical staff should pay more attention to depression in adult patients with RA.

Outstanding Symptoms of Poststroke Depression during the Acute Phase of Stroke

Poststroke depression (PSD) is a critical complication which might lead to unfavorable outcomes. However, most cases of PSD in the acute phase, during the 2 or 3 weeks following a stroke, are neglected because of the variable comorbid conditions. In this study, aimed at revealing the outstanding symptoms of PSD during the acute phase, consecutive patients with intracranial hemorrhage (ICH) or brain infarction (BI) were asked to fill out a depression questionnaire (Quick Inventory of Depressive Symptomatology Self-Report: QIDS-SR) at 1 week and 1 month following stroke onset. Patients with disturbed consciousness or aphasia were excluded from this study. Forty-nine ICH patients and 222 BI patients completed the QIDS-SR at 1 week and 27 of ICH and 62 of BI at 1 month. The PSD rate was 67% and 46% at 1 week in ICH and BI, respectively. Although sleep disturbance was the most frequent symptom of PSD, psychomotor agitation and appetite disturbance were the most distinguishing symptoms in ICH at 1 week and fatigue at 1 month. On the other hand, most of the depressive symptoms addressed in QIDS-SR were observed in PSD of BI patients both at 1 week and 1 month. In conclusion, while sleep disturbance was a frequent but non-specific symptom, appetite disturbance and fatigue might be critical symptoms to suggest PSD during the acute phase of stroke.

Post-stroke depression inhibits improvement in activities of daily living in patients in a convalescent rehabilitation ward

[Purpose] There have been no investigations into the improvement of activities of daily living among patients suffering from post-stroke depression on admission to convalescent rehabilitation wards in Japan. This study aimed to assess the improvement of activities in daily living in patients with or without post-stroke depression at the time of admission to a convalescent rehabilitation ward. [Subjects and Methods] This retrospective study included 108 stroke patients divided into two groups according to their Geriatric Depression Scale 15-item short form scores. Activities of daily living were assessed using the Functional Independence Measure. The degree of improvement on the Functional Independence Measure was defined as the difference between scores on admission and at discharge. [Results] The Functional Independence Measure gain score was significantly different from the Functional Independence Measure total score. There was a significant interaction between time period and post-stroke depression factors for the Functional Independence Measure total score. A multiple regression analysis revealed a significant association between Geriatric Depression Scale score and Functional Independence Measure total score. [Conclusion] The present study suggests that post-stroke depression has a negative impact on recovery of activities of daily living and on rehabilitation outcomes in a convalescent rehabilitation ward setting.

Incidence and risk factors of poststroke depression in patients with acute ischemic stroke: A 1-year prospective study in Taiwan

BACKGROUND

Poststroke depression (PSD) is one of the most frequent and devastating neuropsychiatric consequences of stroke. The purpose of this study was to investigate the incidence and risk factors for PSD in a general hospital in Taiwan.

METHODS

One hundred and one patients with ischemic stroke were enrolled initially, and 91 (90.1%) completed the 1-year study. Assessments were performed at baseline, and at the 1st, 3rd, 6th, 9th, and 12th month after enrolment. The definition of PSD was in accordance with the diagnostic criteria of major depressive episode in the Diagnostic and Statistical Manual, fourth edition (DSM-IV).

RESULTS

The accumulated incidence rates of PSD at the 1st, 3rd, 6th, and 9th, month were 4%, 8%, 9%, and 10%, respectively, and the overall incidence at 1 year was 11%. In multivariate regression analysis, female gender, higher depression score, and severity of stroke were significant risk factors. In subgroup analysis, a higher depression score was significantly associated with PSD, regardless of gender; however, stroke severity was a risk factor only in the female group.

CONCLUSION

The 1-year incidence of PSD was 11%, based on the DSM-IV diagnostic criteria. More attention should be paid to patients with more risk factors to enable earlier detection and intervention.

Persistent post-stroke depression in mice following unilateral medial prefrontal cortical stroke

Post-stroke depression (PSD) is a common outcome following stroke that is associated with poor recovery. To develop a preclinical model of PSD, we targeted a key node of the depression-anxiety circuitry by inducing a unilateral ischemic lesion to the medial prefrontal cortex (mPFC) stroke. Microinjection of male C57/BL6 mice with endothelin-1 (ET-1, 1600 pmol) induced a small (1 mm(3)) stroke consistently localized within the left mPFC. Compared with sham control mice, the stroke mice displayed a robust behavioral phenotype in four validated tests of anxiety including the elevated plus maze, light-dark, open-field and novelty-suppressed feeding tests. In addition, the stroke mice displayed depression-like behaviors in both the forced swim and tail suspension test. In contrast, there was no effect on locomotor activity or sensorimotor function in the horizontal ladder, or cylinder and home cage activity tests, indicating a silent stroke due to the absence of motor abnormalities. When re-tested at 6 weeks post stroke, the stroke mice retained both anxiety and depression phenotypes. Surprisingly, at 6 weeks post stroke the lesion site was infiltrated by neurons, suggesting that the ET-1-induced neuronal loss in the mPFC was reversible over time, but was insufficient to promote behavioral recovery. In summary, unilateral ischemic lesion of the mPFC results in a pronounced and persistent anxiety and depression phenotype with no evident sensorimotor deficits. This precise lesion of the depression circuitry provides a reproducible model to study adaptive cellular changes and preclinical efficacy of novel interventions to alleviate PSD symptoms.

Comparing the Course of Mental Health Over the First Year After Stroke With Healthy Controls in Colombia, South America

BACKGROUND

Stroke is a primary cause of death and disability in upper-middle-income countries such as Colombia. Given the lack of comprehensive rehabilitation for stroke patients in Colombia, there is a need to assess longitudinal mental health problems poststroke in this region.

OBJECTIVE

To compare the course of mental health in stroke patients to healthy controls over the first year poststroke in Ibague, Colombia.

DESIGN

Cross-sectional study.

SETTING

The Psychological Attention Center of Antonio Nariño University in Ibague, Colombia.

PARTICIPANTS

Stroke patients (n = 50) and age- and gender-matched healthy controls (n = 50).

METHODS

Patients and controls completed self-report Spanish versions of demographic information, injury-related characteristics, and mental health questionnaires MAIN OUTCOME MEASUREMENTS: Outcomes assessed included mental health (depression, anxiety, and stress) at 3, 6, and 12 months poststroke.

RESULTS

Hierarchical linear models suggested that stroke patients had worse depression and anxiety over time than controls (P < .001). Among patients, depression and anxiety decreased over time (P < .001), whereas stress increased over time (P < .01). The findings suggest that although anxiety and depression improved over time in stroke patients, their mental health remained significantly lower than that of controls.

CONCLUSIONS

This is the first study to examine the course of mental health over the first year poststroke in Latin America, specifically in Ibague, Colombia. Despite the improvements in anxiety and depression over the first year poststroke, patient anxiety and depression were still worse in comparison to those in healthy controls. The current findings indicate a need for rehabilitation services in Colombia, especially targeting mental health issues.

LEVEL OF EVIDENCE

I.

Alterations in the corticotropin-releasing hormone (CRH) neurocircuitry: Insights into post stroke functional impairments

Although it is well accepted that changes in the regulation of the hypothalamic-pituitary adrenal (HPA) axis may increase susceptibility to affective disorders in the general population, this link has been less examined in stroke patients. Yet, the bidirectional association between depression and cardiovascular disease is strong, and stress increases vulnerability to stroke. Corticotropin-releasing hormone (CRH) is the central stress hormone of the HPA axis pathway and acts by binding to CRH receptors (CRHR) 1 and 2, which are located in several stress-related brain regions. Evidence from clinical and animal studies suggests a role for CRH in the neurobiological basis of depression and ischemic brain injury. Given its importance in the regulation of the neuroendocrine, autonomic, and behavioral correlates of adaptation and maladaptation to stress, CRH is likely associated in the pathophysiology of post stroke emotional impairments. The goals of this review article are to examine the clinical and experimental data describing (1) that CRH regulates the molecular signaling brain circuit underlying anxiety- and depression-like behaviors, (2) the influence of CRH and other stress markers in the pathophysiology of post stroke emotional and cognitive impairments, and (3) context and site specific interactions of CRH and BDNF as a basis for the development of novel therapeutic targets. This review addresses how the production and release of the neuropeptide CRH within the various regions of the mesocorticolimbic system influences emotional and cognitive behaviors with a look into its role in psychiatric disorders post stroke.

Association of post stroke depression with social factors, insomnia, and neurological status in Chinese elderly population

The purpose of this study was to investigate the association of post stroke depression (PSD) with social factors, insomnia, and neurological status among elderly Chinese patients with ischemic stroke. Six hundred and eight patients over 60 years of age, who had suffered from a first episode of ischemic stroke within 7 days, were enrolled into the study. They were divided into PSD and non-PSD groups according to the Self-rating Depression Scale (SDS) scores. The association of PSD with social factors, insomnia, and neurological status was analyzed using multivariable logistic regression analysis. Compared with the patients who did not develop PSD, those with PSD reported adverse life events more frequently, and more subjects with PSD lived alone, had left carotid artery infarction and cortical infarction (P < 0.05), history of insomnia, and high National Institute of Health Stroke Scale (NIHSS) scores and low Barthel Index (BI) scores (P < 0.01). The multivariable logistic regression analysis showed that the occurrence of PSD was associated with a history of insomnia (HR = 1.59, 95 % CI 1.12-2.36, P < 0.01), NIHSS scores (HR = 2.45, 95 % CI 1.42-3.91, P < 0.01) and BI scores (HR = 2.56, 95 % CI 1.39-4.25, P < 0.01). Insomnia and the degree of neurological deficit were associated with PSD in an elderly population of Chinese people.

Depression predictors within six months of ischemic stroke: The DEPRESS Study

Background

Depression negatively affects rehabilitation and quality of life after stroke. Identifying in the acute phase patients at high risk for post-stroke depression would facilitate early detection of depressive symptoms.

Methods

The DEPRESS (Depression Predictors after Ischemic Stroke) study was a prospective cohort study designed to identify baseline predictors of depression occurring within six months after ischemic stroke and high-risk patients for post-stroke depression. All patients without aphasia were screened for depression by a neurologist using the Patient Health Questionnaire, and the diagnosis was confirmed by a psychiatrist with the Mini International Neuropsychiatric Interview. In severely aphasic patients, depression was diagnosed using the Aphasic Depression Rating Scale and the Visual Analog Mood Scale.

Results

Depression was present in 61 of 251 (24%) patients enrolled in the DEPRESS study. Female gender, prior history of depression, major physical disability, prior history of stroke, stressful life event exposure in the month preceding stroke onset, and pathologic crying were significant predictors of depression within six months after ischemic stroke. Depression was more frequent in patients with left caudate and/or lenticular nucleus lesion (OR = 2.4, 95% confidence interval, 0.97–5.91), but the difference was not significant. The presence of ≥2 predictors identified the largest proportion of depressed patients (62%) in the smallest proportion of the cohort (36%).

Conclusion

Female gender, prior history of depression, major physical disability, prior history of stroke, recent stressful life event exposure before stroke, and pathologic crying were significant predictors of post-stroke depression occurring within six months after stroke onset.

Comorbidity Factors and Brain Mechanisms Linking Chronic Stress and Systemic Illness

Neuropsychiatric symptoms and mental illness are commonly present in patients with chronic systemic diseases. Mood disorders, such as depression, are present in up to 50% of these patients, resulting in impaired physical recovery and more intricate treatment regimen. Stress associated with both physical and emotional aspects of systemic illness is thought to elicit detrimental effects to initiate comorbid mental disorders. However, clinical reports also indicate that the relationship between systemic and psychiatric illnesses is bidirectional, further increasing the complexity of the underlying pathophysiological processes. In this review, we discuss the recent evidence linking chronic stress and systemic illness, such as activation of the immune response system and release of common proinflammatory mediators. Altogether, discovery of new targets is needed for development of better treatments for stress-related psychiatric illnesses as well as improvement of mental health aspects of different systemic diseases.

[Poststroke depression - a common medical and social problem]

Poststroke depression (PD) is considered as a common medical and social problem. Depression is estimated to occur in 30-35% of the patients during the first year after stroke. Despite the high level of comorbidity, PD is frequently undetectedand and untreated. Psychological impairment from stroke has a negative effect on functional outcome, rehabilitation and quality of live. On the basis of literature review present prevalence, etiology, pathogenesis,diagnosis of PD and summarize current recommendations for therapeutic intervention. A rational approach to the treatment and prevention of PD is proposed.

The influence of horseback riding training on the physical function and psychological problems of stroke patients

[Purpose] The purpose of this study was to determine the influence of horseback riding training on the physical function and psychological problems of stroke patients. [Subjects and Methods] Thirty stroke patients were divided evenly into an experimental group and a control group. Both groups carried out neurodevelopmental treatment. The experimental group additionally performed mechanical horseback riding training for 30 minutes a day, 5 days a week, for 6 weeks. Physical function was evaluated using the Berg Balance Scale (BBS) and the Timed Up and Go Test (TUGT). Psychological problems were assessed using the Beck Depression Inventory (BDI). In order to compare differences within groups between before and after the experiment, the paired t test was conducted. In order to compare differences between groups before and after the experiment, the independent t test was conducted. [Results] In the experimental group, the BBS, TUGT, and BDI showed significant improvements after the intervention. The experimental group’s BBS, TUGT, and BDI post-intervention changes were significantly better than those observed in the control group. [Conclusion] According to our results, horseback riding training has a positive effect on the physical function and psychological problems of stroke patients.

The Assessment of Poststroke Depression

Poststroke depression (PSD) is a common clinical consequence of stroke. PSD is associated with poor functional and social outcomes, reduced quality of life, the presence of cognitive impairment, and increased mortality. Despite the potential benefit associated with the identification and treatment of PSD, it often remains unrecognized and undertreated. The present study provides a critical review and synthesis of measurement properties for 10 instruments used in the assessment of depression following stroke. Assessment considerations specific to PSD are addressed, and tools are reviewed within the context of stroke. To facilitate the timely detection, diagnosis, and initiation of treatment for PSD, a two-step assessment process is recommended, thereby taking strategic advantage of the strengths and limitations associated with self-report and observer-rating assessment tools.

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.

Poststroke depression and its multifactorial nature: results from a prospective longitudinal study

OBJECTIVE

Poststroke depression (PSD) is commonly observed in stroke patients and has a negative impact on functional outcome and quality of life. Therefore, a prospective, longitudinal epidemiological study was conducted aiming to determine prevalence and risk factors for PSD at 1, 3, 6, 12 and 18 months poststroke.

METHODS

A total of 222 patients were included in the study and 201 patients entered data analysis. Demographic data, vascular risk factors, stroke characteristics, functional and neurocognitive outcome measures and psychosocial factors were considered as potential risk factors for PSD. Clinically significant signs and symptoms of PSD were quantified by means of the Cornell Scale for Depression (CSD) and the Montgomery and Åsberg Depression Rating Scale (MADRS).

RESULTS

PSD was present at 1, 3, 6, 12 and 18 months poststroke in 24.5%, 27.1%, 28.3%, 19.8% and 26.3% of the patients respectively. Univariate regression analyses revealed that PSD was significantly associated with stroke severity, physical disability, cognitive impairment and stroke outcome during the 18 months time frame of the study. Reduced social activities and the presence of apraxia were consistently associated with PSD whereas aphasia was only significantly associated in the first 6 months after stroke. Patients with relational problems had a 3 times greater risk of becoming depressed at 18 months poststroke than patients without relational problems (OR=3.09; 95% CI=1.31-7.26).

CONCLUSIONS

Risk factors for PSD seem variable indicating the need for clinicians to consider the dynamic and multifactorial nature of PSD emphasizing the importance of a rigorous and long-term monitoring and support of stroke patients and their caregivers.

The relationship between frontal lobe lesions, course of post-stroke depression, and 1-year prognosis in patients with first-ever ischemic stroke

BACKGROUND AND PURPOSE

Most studies on post-stroke depression (PSD) have focused on a certain time point after stroke instead of the time course of PSD. The aim of this study was to determine the relationship between frontal lobe lesions, course of PSD over a year following the stroke onset, and the 1-year prognosis in patients with first-ever ischemic stroke.

METHODS

A total of 1067 patients from the prospective cohort study on the incidence and outcome of patients with post stroke depression in China who were diagnosed with first-ever ischemic stroke and attended 4 follow-up visits at 14±2 days, 3 months, 6 months, and 1 year after stroke onset, were enrolled in the study. PSD was diagnosed according to DSM-IV. The course of PSD was divided into the following two categories: persistent/recurrent depression and no/transient depression. Patients with any ischemic lesion responsible for the indexed stroke event located in the frontal lobe were defined as patients with frontal lobe lesions. Modified Rankin Scale (mRS) ≥2 at 1-year was considered to be poor prognosis.

RESULTS

There were 109 patients with and 958 patients without frontal lobe lesions that formed the frontal lobe (FL) and no-frontal lobe (NFL) groups, respectively. After adjusting for confounding variables, frontal lobe lesion was significantly associated with persistent/recurrent PSD (OR 2.025, 95%CI 1.039-3.949). Overall, 32.7% of patients in the FL group had poor prognosis at 1- year compared with 22.7% in the NFL group (P = 0.021). Compared with no/transient depression, persistent/recurrent depression was found to be an independent predictor of poor prognosis at 1-year both in FL and NFL groups.

CONCLUSIONS

Long-term and periodical screening, evaluation and treatment are needed for PSD after the onset of ischemic stroke, particularly for patients with frontal lobe infarction.

Subjective depressive mood and regional cerebral blood flow in mild Alzheimer's disease

BACKGROUND

Depressive symptoms are common in patients with Alzheimer's disease (AD) and increase the caregiver burden, although the etiology and pathologic mechanism of depressive symptoms in AD patients remain unclear. In this study, we tried to clarify the cerebral blood flow (CBF) correlates of subjective depressive symptoms in AD.

METHODS

Seventy-six consecutive patients with AD were recruited from outpatient units of the Memory Clinic of Okayama University Hospital. Subjective depressive symptoms were evaluated using the short version of the Geriatric Depression Scale (GDS). All patients underwent brain SPECT with 99mTc-ethylcysteinate dimer, and the SPECT images were analyzed by the Statistical Parametric Mapping 8 program.

RESULTS

No significant differences between groups with high and low GDS scores were found with respect to age, sex, years of education, and revised Addenbrooke's Cognitive Examination scores. Compared to patients with low scores on GDS, patients with high scores showed significant hypoperfusion in the left inferior frontal region.

CONCLUSIONS

The left inferior frontal region may be significantly involved in the pathogenesis of subjective depressive symptoms in AD. Subjective and objective depressive symptoms may have somewhat different neural substrates in AD.

Apathy is an independent risk factor for incident cardiovascular disease in the older individual: a population-based cohort study

OBJECTIVE

Although depression is considered to be associated with cardiovascular disease (CVD), specifically symptoms of apathy have been strongly associated with a history of CVD in recent studies. In this study, we prospectively assess whether symptoms of apathy and depression are independent risk factors for incident CVD and stroke.

METHODS

We carried out a prospective cohort study of 1810 community-dwelling older individuals (70-78 years) without a history of CVD or stroke. Symptoms of apathy and depression were assessed with the 15-item Geriatric Depression Scale. Incident CVD and stroke were assessed after 2 years follow-up. The associations of symptoms of apathy and depression with incident CVD and stroke were analyzed separately using logistic regression analysis.

RESULTS

Symptoms of apathy and depression were present in 281 (15.5%) and 266 (14.7%) participants, respectively. Incident CVD occurred in 62 (3.5%) participants and stroke in 55 (3.1%) participants. Apathy was associated with incident CVD after adjustment for demographics and cardiovascular risk factors (odds ratio (OR) = 2.60, 95% CI = 1.46-4.65). Exclusion of subjects with depressive symptoms yielded a similar OR (2.94, 95% CI = 1.45-5.96, n = 1544). No association was found between depressive symptoms and incident CVD. Neither apathy symptoms nor depressive symptoms were associated with incident stroke.

CONCLUSIONS

Apathy, but not depression, is a strong, independent risk factor for incident CVD. It may be a marker of underlying vascular disease. By its nature, apathy may cause non-adherence to a healthy lifestyle, diminished activities, and possibly even withdrawal from clinical care aimed at improving vascular risk profiles.

Monoamine neurotransmitters and fibroblast growth factor-2 in the brains of rats with post-stroke depression

The aim of the present study was to investigate the changes in the levels of serotonin (5-HT), dopamine (DA), norepinephrine (NE) and fibroblast growth factor-2 (FGF-2) in the brains of rats with post-stroke depression (PSD). A rat model of stroke was established by middle cerebral artery occlusion and the rats were randomly divided into two groups: Control and modification groups. The rats in the modification group had PSD, while the rats in the control group had experienced a stroke only. The PSD model was established by applying chronic mild stress to the individually housed rats. High-performance liquid chromatography was used to detect the levels of 5-HT, DA and NE, while western blotting was used to detect the FGF-2 protein expression levels in the frontal lobe and hippocampus. Quantitative polymerase chain reaction was also used to determine the mRNA expression levels of FGF-2 in the frontal lobes of the two groups. The levels of 5-HT, DA and NE in the frontal lobe and hippocampus of the rats in the PSD group were significantly lower than the levels observed in the rats in the stroke group (P<0.01). In addition, protein expression levels of FGF-2 in the frontal lobe of the rats in the PSD group were significantly lower when compared with the control group rats (P<0.01), however, the protein expression levels of FGF-2 in the hippocampus did not exhibit a statistically significant difference (P>0.05). The mRNA expression levels of FGF-2 in the frontal lobe of the rats in the modification group were significantly lower than the levels in the control group rats (P<0.01). Therefore, reduced levels of monoamine neurotransmitters and FGF-2 expression in the brains of rats with PSD are associated with the incidence of PSD.

A prospective study of the incidence and correlated factors of post-stroke depression in China

BACKGROUND

Post-stroke depression (PSD) is commonly observed among stroke survivors. However, statistical analysis of such data is scarce in developing countries. The purpose of this study is to examine the incidence of PSD and its relationship with stroke characteristics in China.

METHODS

This was a prospective hospital-based study. Stroke patients were assessed within two weeks after acute ischemic stroke onset and then reevaluated at three months. Hamilton Depression Scale (HAMD) was used for screening depression (PSD). Subjects with HAMD score of ≥7 were further assessed with the World Health Organization Composite International Diagnostic Interview. Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS). Stroke outcome was measured by the modified Rankin Scale (mRS).

RESULTS

One hundred and two stroke patients were recruited, only ninety-one patients completed del period (men = 53, 63.74%), with mean age 60.0±10.4 years (range, 34-82 years). The incidence of PSD was 27.47% two weeks after stroke. The occurrence of PSD was unrelated with age, stroke type, stroke lesion and the history of disease. In univariate analysis gender, PSD was correlated with female gender. In multivariate logistic regression analysis, poor stroke outcome (mRS≥3) (OR 12.113, CI 1.169 to 125.59, P<0.05) was the important predictors of PSD.

CONCLUSIONS

The study indicated that gender, functional dependence and stroke outcome are determinants of PSD occurrence during the first 2 weeks after stroke in China.

Post-stroke depression and lesion location: A hospital based cross-sectional study

BACKGROUND

Depression is a common neuro-psychiatric consequence of stroke, affecting approximately 40% of the patients. Many studies show that in addition to the psychosocial stress, neurobiological factors such as site of infarct and brain atrophy may also be related to Post Stroke Depression (PSD). There are conflicting results in this area of research and paucity of such data in Indian literature. Thus the aim of this study is to weigh the importance of lesion location in PSD.

MATERIALS AND METHODS

Sixty two subjects with their first ever stroke were interviewed using a semi-structured proforma and PSD diagnosed using MINI Plus interview. Scales of Beck Depression Inventory and Montgomery Asberg Depression Rating Scale were used to assess severity of depression. Mini mental state examination was used to assess cognitive impairment and Barthel Index to measure Activities of Daily Living. Neuro-imaging provided information on site and side of lesion. Collected data was analysed using SPSS version 15.0.

RESULTS

PSD was diagnosed in 28 subjects, amongst who 19 had left sided lesions. Left sided cortical infarcts and sub cortical infarcts showed statistically significant association with PSD.

CONCLUSION

Results are in keeping with previous landmark studies. Differences in emotional reactions depending on hemisphere and site of the infarct as shown in this study suggest organic biological basis for post stroke depression. Understanding the etiological basis would allow clinicians to monitor patients at risk of developing PSD, enabling early detection and treatment thus improving their quality of life and rehabilitation.

Psychiatric morbidity in stroke patients attending a neurology clinic in Nigeria

BACK GROUND

Stroke produces a wide range of mental and emotional disorders. Neuropsychiatric complications associated with stroke may have negative effects on the social functioning, overall quality of life and the recovery of motor functioning of stroke survivors.

OBJECTIVE

To determine the prevalence and nature of psychiatric morbidity among stroke patients attending neurology outpatient clinic of the University of Ilorin Teaching Hospital (UITH), Ilorin-Nigeria.

METHODS

All patients with stroke aged 18 years and above at an outpatient neurology clinic in Ilorin, Nigeria were assessed for mental and emotional disorders using the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) over one year (March 2009 to February 2010).

RESULTS

Overall prevalence of psychiatric morbidity was 36.0% (30/83) among 83 patients who constituted the study population. Specific diagnoses recorded were depression (19.2%), generalised anxiety disorder (9.6%), harmful alcohol use (2.4%); dementia, somatoform disorder, phobia and delusional disorder each had a prevalence of 1.2%. Clinical and sociodemographic variables were not significantly associated with psychiatric morbidity.

CONCLUSION

Psychiatric disorders are often associated with stroke. Identifying and treating stroke patients with these psychiatric co-morbidities could thus help to improve the overall quality of life of these patients.