Reduction of CSF monoamine metabolites in poststroke depression: a preliminary report

Poststroke Depression: An Update

The presence of neuropsychiatric disorders after stroke has been recognized for more than 100 years, but controlled systematic studies did not begin until the 1970s. The most clinically important advances, however, have been in the treatment and prevention of poststroke depression (PSD). Recent meta-analyses of randomized controlled trials (RCTs) for the treatment of PSD have demonstrated the efficacy of antidepressants. Similarly, RCTs for the prevention of PSD have shown that antidepressants significantly decrease the incidence of PSD compared with placebo. Early treatment of PSD with antidepressants also appears to enhance both physical and cognitive recovery from stroke and may increase survival up to 10 years. Genetic and epigenetic variations, white matter disease, cerebrovascular deregulation, altered neuroplasticity, and changes in glutamate neurotransmission may be relevant etiological factors.

Increased Risk of Developing Depression in Disability after Stroke: A Korean Nationwide Study

Stroke is a leading cause of mortality and a major cause of disability worldwide. A significant number of stroke survivors suffer from depression, impeding the activities of daily living and rehabilitation. Here, we examined the risk of depression among stroke survivors according to the severity of disabilities and compared its incidence with a matched control group. We included data from the Korean National Health Insurance Service of 207,678 stroke survivors. Cox proportional hazard models were used to calculate the risk of depression among stroke survivors. Stroke survivors had a greater risk of developing depression than the matched control group with an adjusted hazard ratio of 2.12 (95% confidence interval 2.09-2.15). Stroke survivors with more severe disabilities were associated with a higher risk of depression than those with mild disabilities. The risk of developing depression was prominently high within the first year after a stroke. Males and younger people (<65 years) were independent risk factors for depression in stroke survivors. This study demonstrated an increased risk of developing depression in stroke survivors compared to control subjects, and a higher risk of depression was associated with a more severe degree of disability. Clinicians should be aware of the risk of depression developing in stroke survivors, especially those with disabilities.

Risk, Determinants, and Pharmacologic Treatment of Depression Following Acute Ischemic Stroke

Background and Purpose: We assessed risk and determinants of new-onset depression in acute ischemic stroke (AIS) patients of all ages and no known history of depression. Additionally, we assessed patterns of post-stroke depression (PSD) treatment with pharmacotherapy. Methods: Retrospective cohort study of de-identified Marketscan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits Datasets for adults age ≥18 years admitted with AIS from July 1, 2016-July 1, 2017. We created Kaplan-Meier curves of cumulative risk of PSD up to 1.5 years following index AIS admission. We performed Cox regression to report hazard ratios for determinants of PSD up to 1.5 years following AIS. We summarized proportions treated with pharmacotherapy and identified the most commonly prescribed medications. Results: Of 8089 AIS patients, 1059 were diagnosed with PSD. At 1 year, cumulative risk of PSD was 13.4% (standard error .4) and 15.3% (standard error .5) at 1.5 years. History of anxiety was most strongly associated with PSD and discharge home least. Among those with PSD, 68.8% were prescribed an antidepressant and 8.4% an antipsychotic. The most commonly prescribed antidepressant was sertraline (28.5%). Conclusions: Among AIS patients of all ages, there is a persistently elevated cumulative risk of new diagnosis of PSD in the 1.5 years following AIS. Of the >2/3 treated with an antidepressant, sertraline was most commonly prescribed. Screening and treatment strategies for PSD require further study.

Effects of wheel-running on anxiety and depression-relevant behaviours in the MCAO mouse model of stroke: moderation of brain-derived neurotrophic factor and serotonin receptor gene expression

Stroke continues to be a major cause of mortality globally. Post-stroke treatment is complicated by the heterogenous nature of pathology and the emergence of secondary psychological symptoms are an additional challenge to the recovery process. Poststroke depression (PSD) is a common co-morbidity and is a major impediment to recovery. While selective serotonin reuptake inhibitors (SSRIs) have proven to be clinically efficacious in treating PSD, the pathogenic processes that underlie the manifestation of depressive mood post-stroke remains unclear. Furthermore, the use of SSRIs is associated with risks of intracerebral haemorrhage, so alternative treatment options need to be continuously explored. Exercise has been demonstrated to be beneficial for improving mood in humans and preclinical models of neurological conditions. Little is known of the mood-related benefits of physical exercise post-stroke. Using the middle cerebral artery occlusion (MCAO) mouse model of cerebral ischaemia, we investigated whether behavioural deficits emerge post-MCAO and could be rescued by voluntary wheel-running. We report that MCAO induced hypo-locomotion and anhedonia-related behaviours, with some improvements conferred by wheel-running. Serotonin transporter gene expression was increased in the MCAO hippocampus and frontal cortex, but this increase remained despite wheel-running. Wheel-running associated up-regulation of BDNF gene expression was unaffected in MCAO mice, reflecting conservation of key neuroplasticity molecular pathways. Taken together, our results highlight the need for further research into serotonergic modulation of the affective symptoms of stroke.

Association between homocysteine levels in acute stroke and poststroke depression: A systematic review and meta-analysis

BACKGROUND

Homocysteine (Hcy) has been confirmed to be associated with depression, but its relationship with poststroke depression (PSD) remains controversial. So far, there is no meta-analysis of the correlation between Hcy level in acute stroke and PSD.

METHODS

A systematic search of a sub-database of studies reporting the level of Hcy in the acute phase of ischemic stroke and PSD as of November 2021 was performed. Data extraction was performed strictly according to the inclusion and exclusion criteria. All data were analyzed using STATA 11.0. The standardized root mean square difference (SMD) and 95% confidence interval (CI) were used to compare continuous variables.

RESULTS

A total of 11 studies were included in this study, including 2789 participants. The results of this meta-analysis showed that admission the levels of Hcy were significantly higher in PSD survivors, compared to non-PSD survivors (SMD = 0.37, 95%CI = 0.07-0.66, P ＜ .001). Subgroup analysis showed that survivors with PSD diagnosed more than 3 months after stroke had significantly different the levels of from non-PSD survivors (6 months: SMD = 0.61, 95%CI = 0.40-0.82, 9 months: SMD = 1.00, 95%CI = 0.59-1.41).

CONCLUSION

The level of Hcy in the acute phase of ischemic stroke is a risk factor for PSD.

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.

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

Post-stroke patients in rehabilitation. The relationship between biological impairment (CT scanning), physical disability and clinical depression

A study of 128 consecutive patients with thromboembolic stroke in a rehabilitation hospital from July 1988 to September 1990 found a prevalence of major depression of 17%. The patient population was described according to the principles of the World Health Organization's (WHO) International Classification of Impairments, Disabilities and Handicaps (ICIDH) according to biological impairment, measured by computerized tomography (CT) scanning of the brain and side of hemiparesis and physical disability, measured by functional movement and activities of daily living. Handicap, referring to the interaction between disability and the environmental situation, often defined as the subjective disadvantage of being ill, was not measured in this study. A stroke index with four items was generated from the parameters describing biological impairment and physical disability. The psychiatric rating scales (the 17-item Hamilton Scale for Depression (HAM-D), the Melancholia Scale [MES]and the Newcastle Diagnostic Depression Scale), and the new stroke-index showed adequate coefficients of Cronbach's alpha and Loevinger, suggesting that these scales have both adequate item correlation and homogeneity (adequate hierarchical structure). The impairment disability index of stroke thus seems to be a meaningful measurement of the specific factors of this disease. There was no correlation between the stroke-index and the psychiatric rating scales measuring the emotional dimension of disability caused by the disease expressed as depression. The results suggest that the depression found among stroke patients is not a simple reaction to the physical disability of the stroke.

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.

The role of neuroinflammation and neurovascular dysfunction in major depressive disorder

Although depression has generally been explained with monoamine theory, it is far more multifactorial, and therapies that address the disease’s pathway have not been developed. In this context, an understanding of neuroinflammation and neurovascular dysfunction would enable a more comprehensive approach to depression. Inflammation is in a sense a type of allostatic load involving the immune, endocrine, and nervous systems. Neuroinflammation is involved in the pathophysiology of depression by increasing proinflammatory cytokines, activating the hypothalamus–pituitary–adrenal axis, increasing glucocorticoid resistance, and affecting serotonin synthesis and metabolism, neuronal apoptosis and neurogenesis, and neuroplasticity. In future, identifying the subtypes of depression with increased vulnerability to inflammation and testing the effects of inflammatory modulating agents in these patient groups through clinical trials will lead to more concrete conclusions on the matter. The vascular depression hypothesis is supported by evidence for the association between vascular disease and late-onset depression and between ischemic brain lesions and distinctive depressive symptoms. Vascular depression may be the entity most suitable for studies of the mechanisms of depression. Pharmacotherapies used in the prevention and treatment of cerebrovascular disease may help prevent vascular depression. In future, developments in structural and functional imaging, electrophysiology, chronobiology, and genetics will reveal the association between depression and brain lesions. This article aims to give a general review of the existing issues examined in the literature pertaining to depression-related neuroinflammatory and vascular functions, related pathophysiology, applicability to depression treatment, and directions for future research.

Clinical practice guidelines for post-stroke depression in China

Post-stroke depression (PSD) is a very common complication that leads to increased physical disability, poor functional outcome, and higher mortality. Therefore, early detection and treatment are very important. Since there are currently no specific guidelines for this disorder in China, the purpose of this study was to develop PSD guidelines and provide suggestions for clinicians and related workers.

Efficacy and tolerability of pharmacotherapy for post-stroke depression: a network meta-analysis

Background

Post-stroke depression (PSD) occurs in approximately one third of stroke survivors, leading to great disability and mortality. As there is no consensus on the optimal pharmacological treatment for PSD, we aimed to evaluate the relative efficacy and tolerability of the available pharmacological interventions.

Materials and Methods

We did a network meta-analysis to incorporate evidence from relevant trials providing direct and indirect comparisons. We searched PubMed, the Cochrane Library Central Register of Controlled Trials, Embase and the reference lists of relevant articles up to March, 2017 for randomized controlled trials (RCTs), for different pharmacotherapies of PSD. For efficacy analysis, the primary outcome was the mean change in Hamilton Depression Scale (HAMD) score between baseline and endpoint. For tolerability analysis, the outcome was presented by the discontinuation for any reason. This study is registered with PROSPERO, number CRD42016049049.

Results

From a total of 869 citations, 15 RCTs with 876 participants were included. 13 drugs were considered. For efficacy, paroxetine ranked the best for HAMD reduction, followed by imipramine, reboxetine, nortriptyline, citalopram and fluoxetine at the end of treatment. However, duloxetine ranked the best at 4-week and 8-week duration for HAMD reduction. For tolerability, paroxetine ranked the best but there is no significant result between any comparisons.

Conclusions

Paroxetine is probably the best option to consider for patients with PSD. To get a quicker relief of depression, duloxetine might be useful for its rapid onset of antidepressant action. The tolerability was comparable among all the antidepressants. But more high-quality RCTs are needed.

Diversiform Etiologies for Post-stroke Depression

After the onset of stroke, many patients suffer from emotional behavior changes. Approximately, one-third of stroke survivors are affected by post-stroke depression (PSD), making it a serious social and public health problem. Post-stroke depression (PSD) has an important impact on the course, recovery, and prognosis of stroke. The pathogenesis of PSD is very complex, involving many factors such as biological mechanism and social psychological mechanisms. This article provides a brief review of the hot issues related to etiologies of 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.

Early dysautonomia detected by heart rate variability predicts late depression in female patients following mild traumatic brain injury

Depression is one of the frequent complications following a mild traumatic brain injury (mTBI). Recent research indicated that abnormalities in the autonomic nervous system (ANS) can be evaluated by a noninvasive power spectral analysis of the heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV was correlated with late depression in mTBI patients. In total, 181 patients diagnosed with mTBI and 83 volunteers as healthy controls were recruited in 2010-2014. Beck Depression Inventory (BDI) scores were used to evaluate depression in the 1st week of assessment and at 1.5-, 3-, 6-, 12-, and 18-month follow-ups. Correlation and logistic regression analyses of the 1st week HRV parameters with BDI scores at 18 months were performed in individual female mTBI patients. Female mTBI patients were more vulnerable to depression accompanied by reduced HRV compared to healthy controls. Over time, depression was aggravated in female mTBI patients but was alleviated in male mTBI patients. A significantly lower parasympathetic proportion of the ANS was noted at 18 months with respect to the 1st week in female mTBI patients. In addition, depression in female mTBI patients at 18 months after injury was significantly correlated with a decrease in the parasympathetic proportion of the ANS in the 1st week (ρ = -0.411; p < .05). Dysautonomia resulted in higher risks of depression in female mTBI patients. We concluded that early dysautonomia following an mTBI contributes to late depression in female mTBI patients.

Pontine microbleeds and depression in stroke

OBJECTIVES

Depression is the most common affective disorder following stroke yet the neuroanatomical model of poststroke depression (PSD) remains unclear. This study examined the association between PSD and cerebral microbleeds (CMBs) and hypothesized that CMBs in specific regions would be associated with PSD.

METHODS

Of the 4766 patients with first ever or recurrent acute ischemic stroke admitted to the Acute Stroke Unit of the Prince of Wales Hospital between June 2004 and October 2010, 229 met the entry criteria and formed the study sample. Patients with a Geriatric Depression Scale score of 7 or above were classified as having PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging.

RESULTS

Compared to the non-PSD group, patients with PSD were more likely to have pontine CMBs (32.0% vs 18.2%; P = .019). The presence of pontine CMBs remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.2 (P = .016).

CONCLUSION

The results suggest that pontine CMBs are associated with a higher risk of developing PSD.

Personality type as a predictor for depressive symptoms and reduction in quality of life among stroke survivals

OBJECTIVE

Although poststroke depression (PSD) and reduction in quality of life (QOL) are prevalent among stroke patients, little is known about the contribution of personality traits to such impairments. This study examines whether particular personality traits predict PSD symptoms (PSDS) and reduction in QOL among stroke survivals using Cloninger's biopsychosocial personality model. We hypothesized that harm avoidance (HA), expressing the tendency to respond intensely to adverse stimuli, characterizes stroke survivors at risk for PSDS and reduction in QOL.

METHODS

Hospitalized stroke patients (N = 84, age 63.5 ± 9.7 years) prospectively completed Cloninger's Tridimensional Personality Questionnaire, defining HA dominancy by scoring the three personality dimensions: reward dependence, novelty seeking, and HA. The level of neurologic deficit was evaluated by the National Institutes of Health Stroke Scale. At the 3-month follow-up visit, depressive symptoms and QOL scores were assessed using the Beck Depression Inventory and the Stroke Specific Quality of Life questionnaire.

RESULTS

Regression analyses revealed that higher HA scores independently predicted PSDS and reduction in QOL. After controlling for the relative contribution of stroke type and health-related variables, HA and neurologic deficit were significant risk factors for poststroke negative outcomes.

CONCLUSION

Our findings emphasize the relevance of Cloninger's theory (manifested by individual HA behavior) as a distinctive means to identifying patients at risk for PSDS and lower QOL after stroke. The role of specific psychological and neurologic aspects involved in the mechanism of PSD should be further explored using biopsychosocial models.

Premorbid personality traits are associated with post-stroke behavioral and psychological symptoms: a three-month follow-up study in Perth, Western Australia

BACKGROUND

Previous research has found an association between post-stroke depressive symptoms and premorbid personality. This study sought to investigate further the relationship between premorbid personality and a number of common post-stroke behavioral and psychological symptoms in a three-month follow-up study.

METHODS

This prospective study was conducted between May 2003 and January 2005 in a Perth metropolitan teaching hospital. The pre-stroke personality of stroke survivors was assessed by interviewing a close family member (informant) within four weeks of the index stroke using the NEO Personality Inventory-Revised. Three months after the stroke, patients were followed up and assessed with the Cambridge Cognitive examination and Hospital Anxiety and Depression Scale, and their informants completed the Neuropsychiatric Inventory-carer distress version (NPI) and instrumental activities of daily living scale.

RESULTS

Depressive symptoms were the most commonly reported post-stroke symptom (45.1%). Spearman's correlations showed that high neuroticism was positively correlated with NPI total scores (rho = 0.37, p = 0.007), NPI total distress scores (rho = 0.47, p = 0.001), and specifically with agitation and irritability NPI composite scores. Agreeableness was inversely correlated with agitation (rho = -0.40, p = 0.004) and irritability (rho = -0.37, p = 0.007) composite scores.

CONCLUSIONS

Premorbid personality traits of high neuroticism and low agreeableness are associated with the presence of post-stroke agitation, irritability, and carer distress. This knowledge may contribute to the development of strategies designed to identify patients and families who require more intense supervision and support during post-stroke rehabilitation.

The neuroanatomical model of post-stroke depression: towards a change of focus?

One third of all stroke survivors develop post-stroke depression (PSD). Depressive symptoms adversely affect rehabilitation and significantly increase risk of death in the post-stroke period. One of the theoretical views on the determinants of PSD focuses on psychosocial factors like disability and social support. Others emphasize biologic mechanisms such as disruption of biogenic amine neurotransmission and release of proinflammatory cytokines. The "lesion location" perspective attempts to establish a relationship between localization of stroke and occurrence of depression, but empirical results remain contradictory. These divergences are partly related to the fact that neuroimaging methods, unlike neuropathology, are not able to assess precisely the full extent of stroke-affected areas and do not specify the different types of vascular lesions. We provide here an overview of the known phenomenological profile and current pathogenic hypotheses of PSD and present neuropathological data challenging the classic "single-stroke"-based neuroanatomical model of PSD. We suggest that vascular burden due to the chronic accumulation of small macrovascular and microvascular lesions may be a crucial determinant of the development and evolution of PSD.

Neuroprotective effect of atypical antipsychotics in cognitive and non-cognitive behavioral impairment in animal models

Antipsychotic drugs are divided into two groups: typical and atypical. Recent clinical studies show atypical antipsychotics have advantages over typical antipsychotics in a wide variety of neuropsychiatric conditions, in terms of greater efficacy for positive and negative symptoms, beneficial effects on cognitive functioning, and fewer extra pyramidal side effects in treating schizophrenia. As such, atypical antipsychotics may be effective in the treatment of depressive symptoms associated with psychotic and mood disorders, posttraumatic stress disorder and psychosis in Alzheimer disease. In this paper, we describe the effects and potential neurochemical mechanisms of action of atypical antipsychotics in several animal models showing memory impairments and/or non-cognitive behavioral changes. The data provide new insights into the mechanisms of action of atypical antipsychotics that may broaden their clinical applications.

Methylphenidate modulates activity within cognitive neural networks of patients with post-stroke major depression: A placebo-controlled fMRI study

BACKGROUND

Methylphenidate (MP) is a dopamine- and noradrenaline-enhancing agent beneficial for post-stroke depression (PSD) and stroke recovery due to its therapeutic effects on cognition, motivation, and mood; however, the neural mechanisms underlying its clinical effects remain unknown. This study used functional magnetic resonance imaging (f MRI) to investigate the effect of MP on brain activity in response to cognitive tasks in patients with PSD.

METHODS

Nine stroke outpatients with DSM IV defined major depression underwent fMRI during two cognitive tasks (2-back and serial subtraction) on four occasions, on the first and third day of a three-day treatment of MP and placebo. Nine healthy control (HC) subjects matched for age and sex scanned during a single session served as normative data for comparison. The main outcome measure was cognitive task-dependent brain activity.

RESULTS

For the 2-back task, left prefrontal, right parietal, posterior cingulate, and temporal and bilateral cerebellar regions exhibited significantly greater activity during the MP condition relative to placebo. Less activity was detected in rostral prefrontal and left parietal regions. For serial subtraction, greater activity was detected in medial prefrontal, biparietal, bitemporal, posterior cingulate, and bilateral cerebellar regions, as well as thalamus, putamen, and insula. Further, underactivation observed during the placebo condition relative to HC improved or reversed during MP treatment. No significant differences in behavioral measures were found between MP and placebo conditions or between patients and HC.

CONCLUSIONS

Short-term MP treatment may improve and normalize activity in cognitive neuronal networks in patients with PSD.

Exclusion and inclusion criteria for people with aphasia in studies of depression after stroke: a systematic review and future recommendations

BACKGROUND/AIMS

A third of individuals are depressed following stroke. A similar proportion have aphasia. The extent of their inclusion in depression following stroke studies affects the generalizability of findings.

METHODS

We systematically reviewed published studies (to December 2005) that diagnosed depression following stroke. We identified aphasia screening methods, aphasia exclusion and inclusion criteria and respective numbers of individuals with aphasia.

RESULTS

Of 129 studies (n = 19,183), aphasia screening methods were only reported by 57 (31 described a published aphasia-specific tool). No mention of aphasia was made in 13 studies. Most studies (92, 71%) reported some exclusion of people with aphasia (49 reported how many: n = 3,082, range = 2-554). Almost half of the studies (60, 47%) actually reported participants with aphasia (37 specified numbers: n = 829, range = 5-60). Aphasia exclusion or inclusion was not associated with sample source (community, acute hospital, other) or study purpose (observation, intervention, screening). Studies that reported screening for aphasia were more likely to describe aphasia exclusion and inclusion criteria and include participants with aphasia.

CONCLUSION

Aphasia screening, exclusion and inclusion criteria reporting across studies of depression following stroke has been highly inconsistent. This impairs the interpretation of generalizability. Improved aphasia screening and reporting of exclusion and inclusion criteria are urgently recommended.

The etiology of poststroke depression: a review of the literature and a new hypothesis involving inflammatory cytokines

Although poststroke depression is unlikely to represent a single disorder and numerous etiologies for different kinds of poststroke depression will likely emerge as the result of future research, we believe that a number of poststroke depressive disorders are likely to be the result of specific changes in brain pathology and neurophysiology. Nevertheless, there are relatively few hypotheses about the pathophysiology of poststroke depression. This paper, therefore, proposes a new hypothesis for poststroke depression involving increased production of proinflammatory cytokines resulting from brain ischemia in cerebral areas linked to the pathogenesis of mood disorders. This paper reviews the evidence supporting the hypothesis that proinflammatory cytokines are involved in the occurrence of stroke as well as mood disorders linked to the brain damage. The increased production of proinflammatory cytokines such as IL-1beta, TNF-alpha or IL-18 resulting from stroke may lead to an amplification of the inflammatory process, particularly in limbic areas, and widespread activation of indoleamine 2,3-dioxygenase (IDO) and subsequently to depletion of serotonin in paralimbic regions such as the ventral lateral frontal cortex, polar temporal cortex and basal ganglia. The resultant physiological dysfunction may lead to poststroke depression. Future investigations may explore this hypothesis through more extensive studies on the role of proinflammatory cytokines, such as IL-1beta, TNF-alpha or even IL-18, in patients with poststroke depression.

Cerebrovascular disease basis of depression: post-stroke depression and vascular depression

The close association between cerebrovascular disease and depression has been known for more than a century, yet much of the progress in understanding the cerebrovascular basis of depression in late life has been spurred by development of two concepts: 'post-stroke depression' and 'vascular depression'. The purpose of this review is to examine the epidemiology, diagnostic features, course, pathophysiology and prognosis of post-stroke depression and vascular depression, to highlight their common features, and to contrast the distinct aspects of these two subtypes of geriatric depression.

Plasma precursors of brain catecholaminergic and serotonergic neurotransmitters in rehabilitation patients with ischemic stroke11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To determine levels of plasma amino acid tyrosine and tryptophan, precursors of brain catecholamine and serotonin neurotransmitters, respectively, in rehabilitative patients with ischemic stroke.

DESIGN

Controlled, pre-post analysis, consecutive sample.

SETTING

Rehabilitation center.

PARTICIPANTS

Twenty men with ischemic stroke (age, 68+/-11.3y) consecutively admitted into rehabilitation 15+/-10 days (range, 7-28d) after an acute cerebrovascular insult; 15 healthy sedentary subjects (controls 1); and 13 healthy hypoactive individuals who had recently had knee arthroplasty (controls 2). Both control groups were matched to stroke subjects for age, gender, and body weight.

INTERVENTIONS

At 8:00 am, after overnight fasting, venous blood samples were drawn from patients to determine plasma tyrosine and tryptophan levels. A nutritional evaluation, including nitrogen balance, was made. The same procedures were repeated after 45 days of rehabilitation. Amino acid data were compared with those obtained from the controls.

MAIN OUTCOME MEASURE

Plasma concentrations of amino acids.

RESULTS

Patients with ischemic stroke, on admission, had lower plasma tyrosine concentration than did both controls 1 (P<.0005) and controls 2 (P<.001), but a similar tryptophan level. The plasma content of tyrosine was similar between the 2 control groups. After 45 days of rehabilitation, the stroke patients' tyrosine and tryptophan levels remained virtually unchanged, as did nutritional parameters. Nutritional intakes were adequate to meet body needs but insufficient to correct plasma tyrosine.

CONCLUSIONS

Patients experiencing a recent stroke may have low plasma tyrosine levels and, therefore, reduced brain catecholamine formation. It is possible that an imbalance of brain neurotransmitters may occur.

Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 2: Treatment alternatives

BACKGROUND

Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to the development of an evidence-based integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting, and is divided into two parts. In part 1 we reviewed the frequency of depression in stroke, its impact on functional recovery and the different methods for assessment.

AIMS AND OBJECTIVES

In part 2, we discuss the rationale for treatment of PSD, appraise the evidence for effectiveness of the different antidepressant drugs, and consider whether we can identify a recommended first-line treatment for use in our ICP.

METHODS

Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews.

MAIN FINDINGS

From the few controlled trials of anti-depressant therapy in PSD, both tricyclics and selective serotonin re-uptake inhibitors (SSRIs) appear to be effective, but the latter may be preferable in stroke because of their prompt action and better side-effect profiles. Within the group of SSRIs there is currently no direct evidence to guide the choice of agent. In the absence of firm guidance, sertraline was chosen on theoretical grounds as one of the most potent with minimal sedative effects and no reported interaction with warfarin. Citalopram may offer an appropriate second choice.

CONCLUSIONS

A suggested regimen for the use of sertraline in PSD was put forward. Development of an ICP may help to establish a more consistent approach to assessment and treatment of PSD, and form a basis for future comparison of different treatments as they become available.

Pathophysiologische und neuropsychologische Aspekte depressiver Störungen

Zusammenfassung: Bei depressiven Störungen sind zahlreiche neurobiologische Auffälligkeiten dokumentiert. Aufschluß darüber geben Untersuchungen bei primärer Depression sowie Untersuchungen bei depressiven Störungen, die sich im Zusammenhang mit Hirnschädigungen, wie etwa Schlaganfällen, manifestieren. Ebenfalls lassen neuropsychologische Befunde Rückschlüsse auf pathophysiologische Mechanismen zu. Vieles deutet darauf hin, daß es bei depressiven Störungen zu einer Störung eines komplexen neuronalen Netzwerkes kommt, insbesondere unter Beteiligung präfrontaler cortikaler Strukturen, der Amygdala und der Basalganglien sowie ihrer monoaminergen Afferenzen aus Hirnstamm und pontinem Tegmentum. Der Befund eines reduzierten Hippokampusvolumens bei Subtypen der Depression geht möglicherweise auf einen Hypercortisolismus zurück. Neurobiologische Auffälligkeiten stellen einen wichtigen Anknüpfungspunkt für antidepressive Therapien dar. Insgesamt ist die Depression als eine psychobiologische Störung konzeptualisierbar, bei der biologische und psychologische Faktoren eng miteinander verzahnt sind.

Psychosocial risk factors in poststroke depression: a systematic review

OBJECTIVE

To review systematically the psychosocial risk factors for poststroke depression.

METHODS

Medline was searched using the key words "poststroke depression" (PSD) for the period January 1, 1966, to June 30, 2000; using the key words "cerebrovascular disease" and "depression" it was searched from June 1, 1996, to June 30, 2000. Corollary articles were obtained from the bibliographies. Inclusion criteria were as follows: original research in French or English; prospective, case-control or cross-sectional study design; assessment of PSD in the first 6 months following the stroke; an acceptable definition of depression; an acceptable definition of stroke; and at least one psychosocial risk factor. Interrater reliability was tested for the selection and quality of the articles. A qualitative risk factor analysis was conducted.

RESULTS

The risk factors most consistently associated with PSD are a past history of depression, past personal psychiatric history, dysphasia, functional impairments, living alone, and poststroke social isolation. Risk factors not associated with PSD are dementia and cognitive impairment. Controversial risk factors are age, socioeconomic status (SES), prior social distress, dependency in regard to activities of daily living (ADL), and sex.

CONCLUSIONS

Over approximately 30 years, some 25 qualitative studies have addressed psychosocial risk factors for PSD. Further studies should aim for quantitative analysis. The results suggest that identifying psychiatric history and preventing social deterioration and impairment should be part of multidisciplinary efforts to care for poststroke patients.

Post stroke depression

Depression following stroke is common. Although it is highlighted as an issue in stroke guidelines, guidance on diagnosis or management is not given. This paper presents the original research from a literature review of Medline and the Cochrane Database on stroke and depression, and discusses some of the clinical implications of the findings.

Site-specific activation of dopamine and serotonin transmission by aniracetam in the mesocorticolimbic pathway of rats

The effects of aniracetam on extracellular levels of dopamine (DA), serotonin (5-HT) and their metabolites were examined in five brain regions in freely moving stroke-prone spontaneously hypertensive rats (SHRSP) using in vivo microdialysis. Basal DA release in SHRSP was uniformly lower in all regions tested than that in age-matched control Wistar Kyoto rats. 3,4-Dihydroxyphenylacetic acid and homovanillic acid levels were altered in the basolateral amygdala, dorsal hippocampus and prefrontal cortex of SHRSP. While basal 5-HT release decreased in the striatum and increased in the basolateral amygdala, there was no associated change in 5-hydroxyindoleacetic acid levels. Systemic administration of aniracetam to SHRSP enhanced both DA and 5-HT release with partly associated change in their metabolite levels in the prefrontal cortex, basolateral amygdala and dorsal hippocampus, but not in the striatum and nucleus accumbens shell, in a dose-dependent manner (30 and/or 100 mg/kg p.o.). Microinjection (1 and 10 ng) of aniracetam or its metabolites (N-anisoyl-GABA and 2-pyrrolidinone) into the nucleus accumbens shell produced no turning behavior. These findings indicate that SHRSP have a dopaminergic hypofunction throughout the brain and that aniracetam elicits a site-specific activation in mesocorticolimbic dopaminergic and serotonergic pathways in SHRSP, possibly via nicotinic acetylcholine receptors in the ventral tegmental area and raphe nuclei. The physiological roles in the aniracetam-sensitive brain regions may closely link with their clinical efficacy towards emotional disturbances appearing after cerebral infarction.

The prolactin response to buspirone in poststroke depression: a preliminary report

BACKGROUND

The issue of whether a serotonergic abnormality is involved in poststroke depression (PSD) was investigated in a sample of poststroke patients.

METHODS

The severity of depression was assessed by Hamilton Rating Scale for Depression (HDRS). Buspirone was administered to 16 depressed poststroke (DPS), 10 non-depressed post-stroke (NDPS) patients, and 10 male healthy controls (HCs), to evaluate serotonin (5-HT) function.

RESULTS

The prolactin (PRL) response was significantly blunted in DPS patients compared to HCs. There was no significant relationship between the severity of depression and lesion lateralization. Also, no significant differences in buspirone-induced PRL responses were found between DPS patients with right- and left-sided lesions. The severity of depression in DPS patients was not correlated with the time since stroke.

CONCLUSIONS

Our results suggest that serotonergic dysfunction may involve in development of poststroke depression.

LIMITATIONS

The relatively small sample size and the failure to adequately control for age are major limitations of this study.

Cerebrovascular disease and late life depression: an age old association revisited

OBJECTIVES

To examine the relationship between depression and cerebrovascular disease in three distinct settings: depression in established cerebrovascular disease, cerebrovascular disease in established depression and depression in vascular dementia.

METHODS

Medline, EMBASE, PsychLit and PsychInfo databases were scanned to locate relevant articles. Data were also extracted from other articles, cited by those articles generated from the above databases.

RESULTS

Using operational criteria, the prevalence of depression is higher than controls only within the first year after stroke, but most studies have not employed control groups. The prevalence of depression in vascular dementia compared with Alzheimer's disease is higher in the majority of studies, but matching for sociodemographic factors and severity of cognitive impairment has been inconsistent. An association between frontal/subcortical cerebrovascular lesions and depression in later life has been observed, but there may be methodological flaws underlying this observation in some computerized tomography studies.

CONCLUSION

There is some evidence that cerebrovascular disease has an aetiopathological role in late life depression. The increased likelihood of damage to frontal/subcortical brain circuitry following stroke, transient ischaemia and hypertension may explain the high prevalence of depression in older people with vascular risk factors. More valid definitions of lesion location and the use of appropriately matched control groups would seek to clarify this issue. The extrapolation to care settings from the high prevalence of depression accompanying cerebrovascular disease and the prolongation of disability in depressed people with stroke, suggests closer liaison between old age psychiatrists, neurologists and physicians caring for the elderly.

Apathy and depression following stroke

Depression and apathy are the two most frequent behavioral complications of stroke. This article reviews the prevalence of these conditions in poststroke patients, as well as their clinical correlates, longitudinal course, and possible mediators. A number of controlled clinical trials of the efficacy of various drugs in the treatment of poststroke depression are also reviewed.

A neuroendocrine study of serotonin function in depressed stroke patients compared to non depressed stroke patients and healthy controls

OBJECTIVES

We employed a neuroendocrine challenge paradigm to study serotonergic abnormalities associated with poststroke depression.

METHOD

Twelve depressed stroke patients (major depression N= 5, minor depression N = 7), 8 nondepressed stroke patients and 12 healthy volunteers completed a single-blind, placebo-controlled, challenge tests. Baseline cortisol (CORT) and prolactin (PRL) values, and these hormonal responses to 30 mg of oral d-FEN and placebo over a 4 hour period were measured in the three groups.

RESULTS

There were intergroup differences for baseline adjusted PRL responses (change scores from baseline) to d-FEN (group effect F = 4.38, df = 2,29, p = 0.02) while these responses to placebo were comparable between groups (group effect F = 1.82, df = 2,29, p = 0.18). Peak PRL responses (post d-FEN maximal PRL change from baseline scores) in depressed stroke patients were significantly greater than in nondepressed patients (p = 0.005) but comparable to healthy normals (p = 0.47). However, these responses between major and minor depression were not significant (p = 0.34). There was a trend suggesting a negative correlation between peak PRL response and severity of depression (p = 0.056). Depressed patients were younger than the controls (p = 0.054). Also, the depressed group was more functionally impaired (p = 0.04) and more likely to have right-sided lesions (p = 0.009) compared with the nondepressed group. Differences in baseline adjusted PRL changes between depressed and nondepressed groups became non significant when the influence of laterality of lesions was covaried, whereas covariation of functional scores and age did not alter the significance. CORT responses did not show intergroup differences.

LIMITATIONS

The study group was small and was heterogenous in lesion characteristics, time since stroke and type of depression. A fixed-order design was used in the challenge test paradigm.

CONCLUSIONS

When laterality of stroke lesion was taken into account, depressed and nondepressed stroke patients did not differ in PRL responses to d-FEN.

Poststroke depression: an examination of the literature

OBJECTIVE

To examine literature on poststroke depression (PSD).

DATA SOURCES

More than 200 articles related to stroke and depression were selected from a computer-based search spanning 1985 to 1995.

STUDY SELECTION

All relevant articles on PSD. Articles in foreign languages, case studies, anecdotal reports, book chapters, and reviews were excluded.

DATA EXTRACTION

Summary findings were independently reviewed by the authors.

DATA SYNTHESIS

PSD remains a frequent sequela of stroke; its prevalence remains uncertain because of continued methodologic problems in defining subject groupings and in utilizing psychiatrically normed assessment tools with neurologically impaired individuals, and because of the poor specificity/sensitivity of neuroendocrine markers in determining a diagnosis. The etiology of PSD appears to be complex and not fully understood. Although there has been much research on PSD, this review highlights the sparsity of available literature on its treatment.

CONCLUSION

The review points out the further need for more carefully designed studies of PSD that examine both assessment and treatment.

On the Inseparability of Mental and Physical Health in Aged Persons: Lessons From Depression and Medical Comorbidity

Recent research findings demonstrate that general medical and mental health are inseparable in older individuals. The medical consequences of depression can be summarized with the unifying hypothesis that depression interacts with medical or neurological illness to modify the course of disease and to amplify its associated effects. The medical causes of depression can be divided into specific mechanisms of certain diseases or medications and general mechanisms that may integrate effects of a number of the common chronic disorders of late life. The authors discuss two general hypotheses: One suggests that depression may be associated with subclinical cerebrovascular disease in older patients with cerebrovascular risk factors; the other suggests that depression occurring in association with various conditions may be related to cytokine-mediated "sickness behavior." The research literature makes a compelling case for the need to address psychiatric-medical comorbidity in late life as a central issue in public policy and the design of health care systems.

Poststroke depression. Is there a pathoanatomic correlate for depression in the postacute stage of stroke?

BACKGROUND AND PURPOSE

This study is aimed at the pathoanatomic correlates of depression in the postacute stage of patients with stroke.

METHODS

Of a consecutive series of 104 stroke patients, a subgroup of 47 patients with single demarcated unilateral lesions was selected. Clinical examination, neuroradiological CT scan examination, and psychiatric assessment were performed within a 2-month period after the acute stroke. Depression was assessed with the Cornell Depression Scale, the Montgomery-Asberg Depression Rating Scale, and according to modified DSM-III-R criteria. The neuroradiological examination of all patients was performed on the same scanner, and lesion location, lesion volume, and ventricle-to-brain ratio were analyzed.

RESULTS

We found no significant differences in depression scores between patients with left and right hemisphere lesions and no correlation between the severity of depression and the anteriority and the volume of lesion or brain atrophy. Major depressive disorders were only found in nine patients with left hemisphere lesions, all involving the basal ganglia, whereas none of the patients with right hemisphere stroke exhibited major depression.

CONCLUSIONS

Lesions in the vicinity of the left hemisphere basal ganglia tend to play a crucial role in the development of major depression after the acute stage of stroke. The pathophysiological implications of this finding are discussed.