Predictors of psychological and somatic components of poststroke depression: a longitudinal study

A Microanalysis of Mood and Self-Reported Functionality in Stroke Patients Using Ecological Momentary Assessment

Post-stroke depression has been repeatedly associated with the degree of functional and cognitive impairment. The present study aimed to conduct a microanalysis on this association and examined the association between mood and self-reported functionality in 20 stroke patients (6 females, age: M = 59.9, SD = 5.2) using ecological momentary assessments (EMA), a structured diary method capturing moment-to-moment variations. Mood and self-reported functionality were recorded via a smartphone-app eight times a day for seven consecutive days during inpatient rehabilitation care. The patients answered on average to 73.2% of the received prompts. Variability in patients' responses was caused by differences both between and within patients. Multilevel regression analyses revealed that mood and self-reported functionality were significantly associated at the same point in time, but only patients' mood predicted their self-reported functionality at the next assessment point in time-lagged analyses. These results remained stable after controlling for between-person differences as patients' age, staff-ratings of their awareness of illness, and their degree of functional independence. Patients' mood appeared to affect their future ratings of their functionality but not the other way around.

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.

Predictivity of Early Depressive Symptoms for Post-Stroke Depression

OBJECTIVES

Depression is a frequent complication after stroke. However, little is known about the predictive value of early self-reported depressive symptoms (DS) for later development of post-stroke depression (PSD) 6 months after discharge.

DESIGN

Using a prospective longitudinal design, we investigated the prevalence of DS and examined their predictive value for depressive disorders 6 months after stroke while statistically controlling major established PSD risk factors.

SETTING AND PARTICIPANTS

During inpatient rehabilitation, 96 stroke patients were screened for DS. After 6 months, 71 patients were attainable for a follow-up.

MEASUREMENTS

DS was assessed using the 15-item Geriatric Depression Scale (GDS-15). At follow-up a telephone interview that included the Structured Clinical Interview for Psychiatric Disorders (SCID), which is based on DSM-IV criteria, and the GDS-15 was conducted. Patients with major depression (MD) at the follow-up were considered to have PSD.

RESULTS

Regression analyses were conducted to examine the influence of early DS on PSD after 6 months while controlling for age, premorbid depression, and functional and cognitive impairments. The percentage of patients who scored above the GDS-15 cut-off for clinically relevant DS increased significantly, from 37% to 44%, after 6 months. According to the SCID, 27% of stroke patients fulfilled the criteria for MD, and another 16% fulfilled those for minor depression. Logistic regression showed that DS at baseline significantly predicted PSD at follow-up (odds ratio: 1.43; 95% CI: 1.15-1.8).

CONCLUSION

Self-reported DS during inpatient rehabilitation are predictive for PSD 6 months after discharge. Assessment of early DS contributes to identifying stroke patients at risk for PSD, thereby facilitating prevention and treatment.

Predictors of Depression at One Year Post-stroke in Older Adults

The prevalence and determinates of depression in 67 older adults were assessed at 1 year post-stroke. The sample had an average age of 74 years (SD = 7, range = 60–87 years) at the time of their stroke and 52% were female. The relative contribution of demographic (gender, age), medical (history of previous stroke, hemispheric location of stroke), two measures of functional independence (Barthel Activities of Daily Living (ADL) Index and Nottingham Extended ADL Index) and aspects of cognitive functioning (IQ, attention, verbal memory and verbal fluency) to depression (Geriatric Depression Scale) was investigated. Results indicated that 51% of patients had impairment in activities of daily living, and 33% reported clinically significant levels of depression. Prevalence of cognitive impairment ranged from 28% on a measure of basic cognitive functioning through to 87% on a measure of complex attention. The results from a hierarchical multiple regression analysis showed that the combination of variables explained 40% of the variance in depression scores. In addition, the two individual variables of history of previous stroke and functional independence made significant unique contributions to the variance in depression scores. These results demonstrate the wide variety of factors involved and provide support for a biopsychosocial model of post-stroke depression.

The COMPlaints After Stroke (COMPAS) study: protocol for a Dutch cohort study on poststroke subjective cognitive complaints

BACKGROUND

Although many studies have assessed poststroke objective cognitive impairment, only a few have evaluated patients' subjective cognitive complaints (SCC). Although these SCC are found to be common in the early and chronic phases after stroke, knowledge about their risk factors, course over time, differences with healthy controls and their diagnostic relevance is limited. The aim of the COMPlaints After Stroke (COMPAS) study is therefore to determine the possible risk factors, prognosis, time course and predictive value of SCC in the first 2 years after stroke.

METHODS AND DESIGN

A prospective cohort study is conducted in which patients are compared to non-stroke controls at 3, 6, 12 and 24 months after stroke. Approximately 300 patients are recruited from the stroke units of three hospitals in the Netherlands, while 300 controls are sought among the relatives (spouses excluded) and social networks of participants. A wide range of subjective and objective variables is assessed in both groups using interviews, questionnaires and neuropsychological assessment. The primary outcomes include SCC and objective cognitive impairment, whereas secondary outcomes are quality of life, subjective recovery and daily life functioning.

ETHICS AND DISSEMINATION

The study is being carried out in agreement with the Declaration of Helsinki and the Medical Research Involving Human Subjects Act. The protocol has been approved by the medical ethics committees of the participating centres and all participants give written informed consent. The results will be published in peer-reviewed journals and disseminated to the medical society and general public.

DISCUSSION

The COMPAS study is the first to systematically evaluate poststroke SCC in a prospective longitudinal design, taking a wide range of subjective and objective variables into account. The results obtained can be used to accurately inform patients and their families, as well as to develop patient-tailored intervention programmes to ultimately improve stroke patient care.

Preliminary evidence for the development of a stroke specific geriatric depression scale

Measuring depression among persons with stroke faces many challenges; diagnostic tools are lengthy and do not measure the extent of depression; screening tools are not stroke-specific; and metrics from the available indices do not provide a value that is mathematically or clinically meaningful.

PURPOSE

To provide evidence for the development of a stroke specific Geriatric Depression Scale screening measure (SS-GDS) through Rasch methodology.

METHODS

Secondary analyses of a randomized controlled trial post-stroke. Interviews from 91 subjects aged 71 (SD 10) over three time points or 240 interviews were analyzed. Rasch Analysis helped transform the 30-item GDS onto a logit scale. Unidimensionality, item fit, redundancy, and differential item functioning (DIF) were assessed.

RESULTS

Seventeen items fit the model to form a hierarchical measure ranging in difficulty from +1.2 to -1.8 logits. Preliminary psychometric properties of reliability, validity, and responsiveness were adequate. Two items that demonstrated DIF, one for language and one for gender, were split.

CONCLUSION

The 17-item SS-GDS Rasch measure was developed to screen for post-stroke depression (PSD) and provide an important step toward quantifying PSD. If revalidated in a larger sample, the SS-GDS could provide a mathematically valid index to screen for depression in stroke survivors.

The biopsycho-ecological paradigm: a foundational theory for medicine

The current biomedical and psychosocial frameworks that form the conceptual basis of medicine today are insufficient to address the needs of the medically complex and environmentally challenged populations of patients often cared for by physical medicine and rehabilitation specialists. The expanded biopsycho-ecological model of health, illness, injury, and disability operating through mechanisms of Health Environmental Integration (HEI) encourages a more complete understanding of illness, injury, activity limitation, and participation restriction as arising at the interface between the person and the environment. HEI recognizes complex interacting multilevel functional hierarchies beginning at the cellular level and ending at the individual's experience of the environment. Although the foci of illness and injury are within the body and mind, the physical and social environments contain elements that can cause or exacerbate disease and barriers that interact in ways that lead to injuries and disabilities. Furthermore, these environments hold the elements from which treating agents, facilitators, and social supports must be fashioned. The highly integrative biopsycho-ecological framework provides an expanded basis for understanding the objective causes and subjective meanings of disabilities. Disabilities are reduced through HEI by seeking to maximally integrate the body and mind (the self) with both the surrounding physical environment and other people in society. HEI offers mechanisms for interdisciplinary research, an expanded framework for education and empowerment, and a blueprint for optimizing day-to-day clinical care at both the individual patient and treatment population levels in the ever-changing scientific, political, and policy environments.

Post-traumatic growth in people living with a serious medical condition and its relations to physical and mental health: a systematic review

PURPOSE

The diagnosis of a life-threatening illness can be an extremely stressful, traumatic experience. However, many survivors report also various positive changes, referred in empirical literature as post-traumatic growth (PTG). Empirical studies that documented stress disorders and PTG in patients and survivors of life-threatening diseases are reviewed in three areas: Predictors of PTG, relationships between PTG and indicators of mental health and the impact of PTG on the process of convalescence.

METHOD

The literature review was completed by making use of three major databases - PsycINFO, PILOTS and Medline.

RESULTS

The majority of the studies investigated PTG and its relationships to health indicators after the diagnosis of cancer, HIV/AIDS, cardiac disease, multiple sclerosis and rheumatoid arthritis. The review indicated that quality of social support, patients' coping strategies and several indicators of mental and physical health were consistently associated with post-traumatic growth. Associations between growth and health-related variables (e.g. physical deficits, pain, depression, anxiety) varied depending on different study design (cross-sectional versus longitudinal) and the sample composition (patients versus symptom-free survivors). Several findings are disease-specific.

CONCLUSIONS

The results point to the potential adaptive significance of PTG. More research is needed to investigate specific disease-related profiles of PTG and the complex mechanisms, which underlie the relationships between PTG and the process of convalescence. This knowledge may help to foster the overall positive adjustment of chronically ill patients.