Epidemiology and treatment of post-stroke depression

Stroke Prevention and Management in Rural Georgia: Evaluating the Effectiveness of a Community Paramedicine Program

CONTEXT

Stroke remains a major public health concern in the state of Georgia with high mortality, disproportionately affecting rural and socioeconomically disadvantaged communities. Georgia's age-standardized stroke death rate is 10.8% higher than the national average, and related comorbidities remain elevated in adult Georgians, contributing to higher stroke prevalence.

PROGRAM

The Georgia Department of Public Health piloted a Community Paramedicine (CP) program in 2 rural counties to improve stroke management, readmissions, and mortality. Various supportive interventions to address barriers to chronic disease management were provided by a local emergency medical service agency for 90 days. This study aims to evaluate the effectiveness of the CP care delivery model in improving stroke outcomes among high-risk individuals.

IMPLEMENTATION

CP leverages emergency medical service infrastructure to provide community health services such as home visits, telemedicine, care coordination, education, and access to social support services. The Georgia Hospital Discharge data and Georgia death records were used to measure stroke rehospitalization and deaths at 30, 60, and 90 days post-discharge for stroke. We compared the health outcomes of high-risk individuals who participated in the CP program to those who did not.

EVALUATION

Multivariable analysis suggested a reduction in stroke mortality rates among the intervention groups in both counties.

DISCUSSION

The CP program demonstrated effectiveness in assisting patients with managing risk factors through medication adherence for conditions such as hypertension, hypercholesterolemia, and diabetes.

Medication Profiles at Hospital Discharge Predict Poor Outcomes After Acute Ischemic Stroke

Objectives: To examine the relationship between medications prescribed during the first 6-months post-stroke and functional outcome. Materials and Methods: A retrospective analysis of ischemic stroke survivors enrolled in an observational stroke recovery study from June-2017 to July-2019 was performed. Survivors with favorable outcomes (modified rankin scale (mRS) score 0-2) were compared to those with unfavorable outcomes (mRS ≥3) 6-months after stroke on the following: discharge medication classes prescribed, achievement of recommended targets for blood pressure control, glycemic control, and LDL ≤70 mg/dL, medication changes, medication interactions, and medication list discrepancies. Results: Unfavorable 6-month outcomes occurred in 36/78 (46.2%) of survivors. Survivors with unfavorable outcomes were more likely to be prescribed a central nervous system-acting agent (97.2% vs 71.4%; P = .0022) and/or an anti-hyperglycemic agent (25.0% vs 9.5%; P = .009) at discharge. After adjustment of baseline covariates, total number of medications prescribed was associated with unfavorable 6-month outcomes (OR 1.13, 95% CI 1.0-1.28). Secondary stroke prevention measures were not achieved in a high proportion of survivors. Medication changes during 6-month follow up were common and survivors with unfavorable outcomes were more likely to have clinically significant drug-drug interactions. Discussion: At 6-months, survivors with unfavorable outcomes were found to be prescribed more medications, particularly central nervous system-acting and anti-hyperglycemic agents. There were also more drug-drug interactions in the medications prescribed compared to those with favorable outcomes. Together, these data suggest the need for enhanced screening of high-risk stroke survivors focused on close monitoring of polypharmacy, drug-drug interactions, and adverse events with pharmacotherapy.

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

OBJECTIVE

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

DESIGN

Web-based cross-sectional study.

SETTING

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

PARTICIPANTS

Patients with PSD and their family members.

PRIMARY AND SECONDARY OUTCOME MEASURES

KAP scores.

METHOD

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

RESULTS

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

CONCLUSION

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

Risk of Recurrent Stroke and Mortality Among Black and White Patients With Poststroke Depression

BACKGROUND

Poststroke depression (PSD) is a treatable and common complication of stroke that is underdiagnosed and undertreated in minority populations. We compared outcomes of Black and White patients with PSD in the United States to assess whether race is independently associated with the risk of recurrent stroke and mortality.

METHODS

We used deidentified Medicare data from inpatient, outpatient, and subacute nursing facilities for Black and White US patients from January 1, 2016, to December 31, 2019, to perform this retrospective cohort analysis. International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with depression within 6 months of index stroke with no depression diagnosis 1-year preceding index stroke. We performed an unadjusted Kaplan-Meier analysis of the cumulative risk of recurrent stroke up to 3 years after index acute ischemic stroke admission and all-cause mortality following acute ischemic stroke stratified by Black and White race. We performed adjusted and reduced Cox regression to calculate hazard ratios for the main predictor of race (Black versus White), for recurrent stroke and all-cause mortality, adjusting for sociodemographic characteristics, comorbidities, characteristics of the hospitalization, and acute stroke interventions.

RESULTS

Of 474 770 Medicare patients admitted with acute index stroke, 443 486 were categorized as either Black or White race and 35 604 fulfilled our criteria for PSD. Within the PSD cohort, 25 451 (71.5%) had no death or recurrent stroke within 6 months and 5592 (15.7%) had no death or readmission of any cause within 6 months. Black patients with PSD had a persistently elevated cumulative risk of recurrent stroke compared with White patients with PSD up to 3 years following acute ischemic stroke (log-rank P=0.0011). In our reduced multivariable model, Black patients had a 19.8% (hazard ratio, 1.198 [95% CI, 1.022-1.405]; P=0.0259) greater risk of recurrent stroke than White patients. The unadjusted cumulative risk of all-cause mortality was higher in this cohort of older White patients with PSD compared with Black patients; however, this difference disappeared with adjustment for age and other cofactors.

CONCLUSIONS

Black patients with PSD face a persistently elevated risk of recurrent stroke compared with White patients but a similar risk of all-cause mortality. Our findings support that black race is an independent predictor of recurrent stroke in patients with PSD and highlight the need to address social determinants of health and systemic racism that impact poststroke outcomes among racial minorities.

Aphasia, depression, and psychological therapy (ADaPT): A single case design evaluation of a modified cognitive behavioural therapy to treat depressive symptoms in stroke survivors with aphasia

Cognitive behavioural therapy (CBT) can effectively treat depression in the general population, but there is a lack of studies evaluating CBT tailored to specific cognitive and communication needs of individuals with post-stroke aphasia. We aimed to evaluate the feasibility and preliminary efficacy of a modified CBT intervention to ameliorate depressive symptoms. An ABA withdrawal/reversal single case design with concurrent multiple baselines (2.5, 4.5, or 6.5 weeks) was repeated across 10 participants (six male, four female) with post-stroke aphasia and self-reported depression. Participants completed 10 individual intervention sessions with a clinical neuropsychologist and a 4-week follow-up. The primary outcome was self-rated depression, and secondary outcomes included observer-rated symptoms of depression and anxiety. Data were analysed visually and statistically controlling for baseline trend. Feasibility was addressed by analysing recruitment and retention rates, treatment adaptations, and fidelity ratings. Three participants self-reported decreased depression levels during the intervention phase, which was sustained for two participants. Four additional participants improved during the follow-up phase. Close others reported sustained improvements in depressive symptoms (six participants) and anxiety symptoms (seven participants). Modified CBT appears feasible and potentially efficacious in reducing depressive symptoms in post-stroke aphasia. A randomized controlled trial is warranted, and should consider additional treatment sessions.

Does Self-Reported BMI Modify the Association Between Stroke and Depressive Symptoms?

BACKGROUND

Depressive symptoms are common in stroke survivors. While obesity has been associated with stroke and depression, its influence on the association between stroke and depressive symptoms is unknown.

METHODS

Cross-sectional data from 2015 to 2016 Canadian Community Health Survey was used. History of stroke was self-reported and our outcome of interest was depressive symptoms in the prior 2 weeks, measured using the 9-item Patient Health Questionnaire. Self-reported body mass index (BMI) was modeled as cubic spline terms to allow for nonlinear associations. We used multivariable logistic regression to evaluate the association between stroke and depressive symptoms and added an interaction term to evaluate the modifying effect of BMI.

RESULTS

Of the 47,521 participants, 694 (1.0%) had a stroke and 3314 (6.5%) had depressive symptoms. Those with stroke had a higher odds of depressive symptoms than those without (aOR = 3.13, 95% CI 2.48, 3.93). BMI did not modify the stroke-depressive symptoms association (P interaction = 0.242) despite the observed variation in stroke-depressive symptoms association across BMI categories,: normal BMI [18.5-25 kg/m2] (aOR† = 3.91, 95% CI 2.45, 6.11), overweight [25-30 kg/m2] (aOR† = 2.63, 95% CI 1.58, 4.20), and obese [>30 kg/m2] (aOR† = 2.76, 95% CI 1.92, 3.94). Similar results were found when depressive symptoms were modeled as a continuous measure.

CONCLUSION

The association between stroke and depressive symptoms is not modified by BMI, needing additional work to understand the role of obesity on depression after stroke.

Impact of depression on stroke outcomes among stroke survivors: Systematic review and meta-analysis

BACKGROUND

Depression may negatively affect stroke outcomes and the progress of recovery. However, there is a lack of updated comprehensive evidence to inform clinical practice and directions of future studies. In this review, we report the multidimensional impact of depression on stroke outcomes.

METHODS

Data sources. PubMed, PsycINFO, EMBASE, and Global Index Medicus were searched from the date of inception. Eligibility criteria. Prospective studies which investigated the impact of depression on stroke outcomes (cognition, returning to work, quality of life, functioning, and survival) were included. Data extraction. Two authors extracted data independently and solved the difference with a third reviewer using an extraction tool developed prior. The extraction tool included sample size, measurement, duration of follow-up, stroke outcomes, statistical analysis, and predictors outcomes. Risk of bias. We used Effective Public Health Practice Project (EPHPP) to assess the quality of the included studies.

RESULTS

Eighty prospective studies were included in the review. These studies investigated the impact of depression on the ability to return to work (n = 4), quality of life (n = 12), cognitive impairment (n = 5), functioning (n = 43), and mortality (n = 24) where a study may report on more than one outcome. Though there were inconsistencies, the evidence reported that depression had negative consequences on returning to work, functioning, quality of life, and mortality rate. However, the impact on cognition was not conclusive. In the meta-analysis, depression was associated with premature mortality (HR: 1.61 (95% CI; 1.33, 1.96)), and worse functioning (OR: 1.64 (95% CI; 1.36, 1.99)).

CONCLUSION

Depression affects many aspects of stroke outcomes including survival The evidence is not conclusive on cognition and there was a lack of evidence in low-income settings. The results showed the need for early diagnosis and intervention of depression after stroke. The protocol was pre-registered on the International Prospective Register of Systematic Review (PROSPERO) (CRD42021230579).

The association between circulating Hcy and Lp-PLA2 levels and poststroke depression: A meta-analysis

OBJECTIVE

To analyze the correlation between circulating homocysteine (Hcy) and lipoprotein-associated phospholipase A2 (Lp-PLA2) levels and poststroke depression (PSD).

MATERIALS AND METHODS

Chinese (Chinese National Knowledge Infrastructure, Wanfang, and VIP) and English (PubMed, EMBASE, MEDLINE, and Cochrane Library) databases on the correlation between circulating Hcy and Lp-PLA2 and PSD were collected. Meta-analysis was performed to compare the distinctions in circulating Hcy and Lp-PLA2 levels between PSD and non-PSD groups. Meta-analysis was conducted by using STATA 15.0 software.

RESULTS

A total of 20 literatures were included in this study. The level of circulating Lp-PLA2 in the PSD group was obviously higher than that in the non-PSD group (weighted mean differences: 2.75, 95%CI: 0.10-5.39, P = .002), which was an independent predictor of PSD (effect size = 0.05, 95%CI: 0.03, 0.07, P < .001). The level of circulating Hcy in the PSD group was obviously higher than that in the non-PSD group (weighted mean differences = 1.41, 95%CI: 1.01, 1.81, P < .001), which was an independent influencing factor for the occurrence of PSD (effect size = 0.07, 95%CI: 0.04, 0.09, P = .011).

CONCLUSION

Circulating Hcy and Lp-PLA2 levels are linked to the development of PSD, and can be applied as predictive or diagnostic indicators.

Improving Patient-Reported Outcomes in Stroke Care using Remote Blood Pressure Monitoring and Telehealth

BACKGROUND

Inequities in health care access leads to suboptimal medication adherence and blood pressure (BP) control. Informatics-based approaches may deliver equitable care and enhance self-management. Patient-reported outcomes (PROs) complement clinical measures to assess the impact of illness on patients' well-being in poststroke care.

OBJECTIVES

The aim of this study was to determine the feasibility of incorporating PROs into Telehealth After Stroke Care (TASC) and to explore the effect of this team-based remote BP monitoring program on psychological distress and quality of life in an underserved urban setting.

METHODS

Patients discharged home from a Comprehensive Stroke Center were randomized to TASC or usual care for 3 months. They were provided with a BP monitor and a tablet that wirelessly transmitted data to a cloud-based platform, which were integrated with the electronic health record. Participants who did not complete the tablet surveys were contacted via telephone or e-mail. We collected the Patient-Reported Outcomes Measurement Information System Managing Medications and Treatment (PROMIS-MMT), Patient Activation Measure (PAM), Neuro-QOL (Quality of Life in Neurological Disorders) Cognitive Function, Neuro-QOL Depression, and Patient Health Questionnaire-9 (PHQ-9). T-tests and linear regression were used to evaluate the differences in PRO change between the arms.

RESULTS

Of the 50 participants, two-thirds were Hispanic or non-Hispanic Black individuals. Mechanisms of PRO submission for the arms included tablet (62 vs. 47%), phone (24 vs. 37%), tablet with phone coaching (10 vs. 16%), and e-mail (4 vs. 0%). PHQ-9 depressive scores were nominally lower in TASC at 3 months compared with usual care (2.7 ± 3.6 vs. 4.0 ± 4.1; p = 0.06). No significant differences were observed in PROMIS-MMT, PAM, or Neuro-QoL measures.

CONCLUSION

Findings suggest the feasibility of collecting PROs through an interactive web-based platform. The team-based remote BP monitoring demonstrated a favorable impact on patients' well-being. Patients equipped with appropriate resources can engage in poststroke self-care to mitigate inequities in health outcomes.

Factors associated with mental health service access among Australian community-dwelling survivors of stroke

PURPOSE

To describe types of mental health treatment accessed by community-based stroke survivors and factors associated with access.

METHODS

A sub-group of registrants from the Australian Stroke Clinical Registry completed a supplementary survey 2.5 years post-stroke. Self-reported information about depression/anxiety and treatment access were collected. Demographic and clinical data were obtained through linkages with registry and government data. Staged multivariable logistic regression was conducted to examine factors associated with treatment access.

RESULTS

Among 623 registrants surveyed (37% female, median age 69 years), 26% self-reported a medical diagnosis of depression/anxiety at 2.5 years post-stroke. Of these, only 30% reported having accessed mental health services, mostly through government-funded Medicare schemes. Younger age (odds ratio (OR) 0.95, 95% CI 0.93, 0.98), history of mental health treatment (OR 3.38, 95% CI 1.35, 8.48), feeling socially isolated (OR 2.32, 95% CI 1.16, 4.66), self-reported medical diagnosis of depression/anxiety (OR 4.85, 95% CI 2.32, 10.14), and government-subsidised team care plan arrangement (OR 4.05, 95% CI 1.96, 8.37) were associated with receiving treatment.

CONCLUSIONS

Many stroke survivors have untreated depression/anxiety. Primary care practitioners should be supported in undertaking effective detection and management. Older and newly diagnosed individuals should be educated about depression/anxiety and available supports.Implications for rehabilitationPrimary care providers play a pivotal role in the pathway to mental health care, and therefore should always screen for depression/anxiety and provide comprehensive assessment and referral to specialist services where necessary.Targeted psychoeducation should be provided to survivors of stroke who are older and newly diagnosed with depression/anxiety, to increase awareness about mood problems following stroke.Primary care providers should collaborate with other health professionals (e.g., through coordinating a team care arrangement plan), to address patients' multiple and complex rehabilitation needs.Rehabilitation professionals should remain informed about current evidence-based treatments for post-stroke depression/anxiety and pathways that enable their patients to access these services.

Efficacy of Chinese herbal medicine on poststroke depression in animal models: A systematic review and meta-analysis

Background

Poststroke depression (PSD) is a common complication that can seriously affect patients' functional recovery and quality of life after a stroke. Various side effects have been found to be associated with the pharmacological therapies used for PSD. Studies have shown that Chinese herbal medicine (CHM) can effectively improve PSD-like behavior and neurological function in clinical and animal studies. The efficacy of CHM on PSD in animal models has not been systematically analyzed.

Methods

The following electronic databases were searched for articles published up to September 2022: PubMed, Web of Science, the Cochrane Library, and Embase. Studies that reported the efficacy of CHM in animals with PSD and were written in English were included. Depression-like behavior and the neurological deficit score were assessed as measures of efficacy. The included studies assessed depression-like behavior using sucrose preference, open-field, forced swimming, and tail suspension tests, as well as body weight. The Review Manager version 5.4 and STATA version 13.1 software packages were used for the meta-analysis. The standardized mean difference (SMD) with 95% confidence intervals was used to assess all the outcomes. Subgroup analyses were performed to explore the sources of heterogeneity. The Egger's test and funnel plots were used to assess the potential publication bias. Sensitivity analyses were used to identify the stability of the results.

Results

A total of 14 studies, including 12 CHMs involving 442 rats, fulfilled the inclusion criteria for meta-analysis. The pooled results showed that CHM significantly alleviated neurological deficits (-1.72 SMD, -2.47- -0.97) and was efficacious in improving the depression-like behavior of rats in the sucrose preference (2.08 SMD, 1.33-2.84), open-field (2.85 SMD, 1.88-3.83), forced swimming (-1.83 SMD, -2.23-1.44), and tail suspension tests (-1.35 SMD, -1.94-0.76).

Conclusion

Our results suggest that CHM could significantly improve depression-like behavior and neurological function in animals with PSD. The current results should be interpreted with caution because only animal studies were included.

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.

Design and implementation of a Stroke Rehabilitation Registry for the systematic assessment of processes and outcomes and the development of data-driven prediction models: The STRATEGY study protocol

BACKGROUND

Stroke represents the second preventable cause of death after cardiovascular disease and the third global cause of disability. In countries where national registries of the clinical quality of stroke care have been established, the publication and sharing of the collected data have led to an improvement in the quality of care and survival of patients. However, information on rehabilitation processes and outcomes is often lacking, and predictors of functional outcomes remain poorly explored. This paper describes a multicenter study protocol to implement a Stroke rehabilitation Registry, mainly based on a multidimensional assessment proposed by the Italian Society of Physical and Rehabilitation Medicine (PMIC2020), in a pilot Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation, to provide a systematic assessment of processes and outcomes and develop data-driven prediction models of functional outcomes.

METHODS

All patients with a diagnosis of ischemic or haemorrhagic stroke confirmed by clinical assessment, admitted to intensive rehabilitation units within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled. Measures will be taken at admission (T0), at discharge (T1), and at follow-up, 3 months (T2) and 6 months (T3) after the stroke. Assessment variables include anamnestic data, clinical and nursing complexity information and measures of body structures and function, activity and participation (PMIC2020), rehabilitation interventions, adverse events and discharge data. The modified Barthel Index will be our primary outcome. In addition to classical biostatistical analysis, learning algorithms will be cross-validated to achieve data-driven prognosis prediction models.

CONCLUSIONS

This study will test the feasibility of a stroke rehabilitation registry in the Italian health context and provide a systematic assessment of processes and outcomes for quality assessment and benchmarking. By the development of data-driven prediction models in stroke rehabilitation, this study will pave the way for the development of decision support tools for patient-oriented therapy planning and rehabilitation outcomes maximization.

CLINICAL TIAL REGISTRATION

The registration on ClinicalTrials.gov is ongoing and under review. The identification number will be provided when the review process will be completed.

Beneficial effects of arthrocen on neuroinflammation and behavior like depression in stroke in a murine model

Stroke is a considerable reason for death, disability, socioeconomic loss, and depression in the world. Notably, many attempts to the reduction of the complications of poststroke injuries like depression have failed so far. In this study, we aimed to evaluate the anti-inflammatory effect of arthrocen, avocado/soybean unsaponifiables (ASU), in the poststroke injuries like depression improvement in a mice model. We examined the antidepressant-like effect of arthrocen using the forced swimming test and tail suspension test in mice subjected to stroke. Furthermore, immunohistochemistry of proinflammatory cytokines, IL-10 and TNF-α, and neural cell count were performed in the ischemic brain hippocampus of mice. Oral arthrocen reduced significantly (p < .001) the immobility time in the forced swimming test and tail suspension test in the stroke animals. Also, immunohistochemistry analysis of the hippocampus indicated significantly (p < .01) the reduction of IL-10 and TNF-α cytokines production. Nissl staining showed a significant (p < .0001) increase in the number of viable neurons in stroke mice receiving arthrocen. In conclusion, our data revealed the antidepressant activity of arthrocen in the stroke mice which may be the result of its anti-inflammatory and neuroprotective role.

Evaluation and Treatment of Depression in Stroke Patients: A Systematic Review

Those who received early diagnosis and treatment for poststroke depression had lower mortality rates, cognitive impairments, improved long-term disability, a higher quality of life, and lower rates of suicidal thoughts than those who did not. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 standards were used to conduct this systematic review. Until May 1, 2022, a systematic search was conducted utilizing ScienceDirect, Cochrane, PubMed, Google Scholar, and PubMed central databases, which have been used during the previous 10 years. Randomized controlled trials (RCTs), observational studies, systematic reviews, review articles, case reports, clinical studies, and meta-analyses were included in the research, which covered post-stroke depression patients and how to identify and treat them.

There were 545 possibly related titles found in the database search. Finally, each publication was given a quality rating, and 10 studies with a score of higher than 70% were allowed into the review. Because of their brevity and ease of use, they employed the Patient Health Questionnaire-9 (PHQ-9) and PHQ-2 screening instruments in stroke patients. According to pooled studies, the risk of acquiring post-stroke depression (PSD) was lower in participants undergoing pharmacological therapy with selective serotonin reuptake inhibitors (SSRIs), especially after a year. Identifying further features of the PSD process, we believe, is the most pressing need for future study since it might lead to a more precise treatment strategy.

Extended Repetitive Transcranial Magnetic Stimulation Therapy for Post-stroke Depression in a Patient With a Pre-frontal Cortical Lesion: A Case Study

Approximately one-third of stroke survivors experience post-stroke depression. Repetitive transcranial magnetic stimulation (rTMS) of the prefrontal cortex has shown promise as a treatment for depression with few side effects and high tolerability. However, previous post-stroke depression trials have not considered the effect of lesion location, the persistence of clinical improvements, nor the value of ongoing maintenance treatments. These questions are important to determine the therapeutic value of rTMS as a treatment for post-stroke depression. We report a unique case study of a 71-year-old male who had experienced a left hemispheric ischemic stroke 4 years prior. The patient was screened with the Beck Depression Inventory and Patient Health Questionnaire and found to be experiencing moderate levels of depression. Ten daily sessions of left dorsolateral pre-frontal cortex rTMS were applied over a two-week period. A clinically meaningful reduction in depression was achieved. Approximately 10 weeks following rTMS treatment, improvements in depression were attenuating. Weekly maintenance rTMS was delivered to the left dorsolateral pre-frontal cortex for 10 sessions. At the conclusion of maintenance rTMS, clinical assessments indicated depressive symptoms had reduced to a minimal to nil level. Clinically meaningful improvements in depression were maintained at 3 months after rTMS treatment had ceased. These findings provide novel insight to suggest rTMS may reduce depressive symptoms in stroke survivors with a lesion at the site of stimulation. Ongoing maintenance treatments might prove beneficial to enhance persistence of clinical improvements.

Psychometric Comparisons of Three Depression Measures for Patients With Stroke

IMPORTANCE

Psychometric examinations for patients with stroke remain insufficient. The Center for Epidemiologic Studies Depression Scale (CES-D), Beck Depression Inventory-II (BDI-II), and Geriatric Depression Scale (GDS) are promising outcome measures.

OBJECTIVE

To examine and compare the reliability and validity of three depression measures in a sample of patients with stroke.

DESIGN

Repeated-measures design.

SETTING

A hospital in southern Taiwan.

PARTICIPANTS

Fifty-nine outpatients, who completed three depression measures.

OUTCOMES AND MEASURES

Cronbach's α and intraclass correlation coefficients (ICCs) were used to examine the internal consistency and test-retest reliability, respectively, of the three measures. An independent-samples t test was conducted to compare two groups of patients with different levels of disability to investigate discriminative validity. Pearson's rs were calculated among the three measures to examine concurrent validity.

RESULTS

The three measures had good internal consistency (α = .85-.92) and sufficient test-retest reliability (ICC = .84-.91). The minimal detectable change (percentage of minimal detectable change) was 10.6 (63.3%), 13.5 (98.3%), and 5.8 (49.9%) for the CES-D, BDI-II, and GDS, respectively. There was a statistically significant difference between the two groups in CES-D score (p = .032) and no significant differences on the other two measures (p = .095-.187). The correlations among the three measures ranged from .79 to .89.

CONCLUSION AND RELEVANCE

All three depression measures had sound internal consistency, test-retest reliability, and concurrent validity in patients with stroke. What This Article Adds: Of the three measures, the CES-D had better discriminative validity, and the GDS demonstrated greater reliability and smaller random measurement error in patients with stroke.

Repetitive Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation as Treatment of Poststroke Depression: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies showed that the application of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) during stroke rehabilitation improve the depression symptoms in poststroke depression (PSD). However, some studies showed inconsistent results. The study was designed to make a meta-analysis to evaluate the effect of noninvasive brain stimulation (tDCS and rTMS) on PSD.

METHODS

Articles published before July 2021 were searched in databases: PubMed, Web of Science, and Google Scholar. STATA 12.0 software was utilized to make meta-analysis. We extracted or calculated mean values and SD of reduction or increase rate of depression-related scales. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated as effect size.

RESULTS

The study showed increased immediate and long-term improvement in depression in rTMS group compared with sham rTMS group after treatment with random-effects models (immediate: SMD=4.92, 95% CI=2.69-7.15, I2 =95.2%, P -value for Q test <0.001; long term: SMD=7.21, 95% CI=3.50-10.92, I2 =93.9%, P -value for Q test <0.001). Meta-analysis showed increased substantially immediate improvement in depression in tDCS group compared with sham tDCS group with a random effect model (SMD=5.30, 95% CI=1.30-9.30, I2 =97.3%, P- value for Q test <0.001).

CONCLUSIONS

rTMS and tDCS were demonstrated to be effective and safe treatment techniques for PSD. More large-scale studies were essential to explore the effect of rTMS with different frequencies and tDCS on PSD.

Using an Implementation Framework to Survey Outcome Measurement and Treatment Practices in Aphasia

PURPOSE

Best practices in the field of aphasia rehabilitation increasingly acknowledge a whole-person approach that values interventions aimed at reducing impairments, while also recognizing the impact of aphasia on participation and quality of life. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to examine whether current clinical practices along levels of service provision reflect this whole-person, multifaceted approach.

METHOD

Speech-language pathologists (SLPs) in the United States who provide intervention to people with aphasia across the continuum of care completed this cross-sectional online survey. Current outcome measurement and treatment practices were evaluated within the Living With Aphasia: Framework for Outcome Measurement via multiple-choice and open-text response questions. Data were analyzed descriptively and using ordinal logistic regression models to compare clinical practices along levels of service provision.

RESULTS

Data from 90 SLPs revealed that language and cognitive skills are assessed with equal consistency across clinical settings; however, functional communication, participation, and quality of life domains are prioritized in settings providing care to clients within the community. Psychological well-being is rarely assessed within clinical practice along most of the rehabilitation process and prioritized within the university clinic setting when clients are in the chronic stage of recovery.

CONCLUSIONS

Clinical practices related to a multifaceted approach to aphasia intervention are variable across levels of service provision. Further exploration of barriers and facilitators to multifaceted aphasia care along the domains of the CFIR is needed to provide an informed approach to implementing change.

Reward System Dysfunction and the Motoric-Cognitive Risk Syndrome in Older Persons

During aging, many physiological systems spontaneously change independent of the presence of chronic diseases. The reward system is not an exception and its dysfunction generally includes a reduction in dopamine and glutamate activities and the loss of neurons of the ventral tegmental area (VTA). These impairments are even more pronounced in older persons who have neurodegenerative diseases and/or are affected by cognitive and motoric frailty. All these changes may result in the occurrence of cognitive and motoric frailty and accelerated progression of neurodegenerative diseases, such as Alzheimer’s and Parkinson’s diseases. In particular, the loss of neurons in VTA may determine an acceleration of depressive symptoms and cognitive and motor frailty trajectory, producing an increased risk of disability and mortality. Thus, we hypothesize the existence of a loop between reward system dysfunction, depression, and neurodegenerative diseases in older persons. Longitudinal studies are needed to evaluate the determinant role of the reward system in the onset of motoric-cognitive risk syndrome.

Lithium upregulates growth-associated protein-43 (GAP-43) and postsynaptic density-95 (PSD-95) in cultured neurons exposed to oxygen-glucose deprivation and improves electrophysiological outcomes in rats subjected to transient focal cerebral ischemia following a long-term recovery period

OBJECTIVES

Lithium has numerous neuroplastic and neuroprotective effects in patients with stroke. Here, we evaluated whether delayed and short-term lithium treatment reduces brain infarction volume and improves electrophysiological and neurobehavioral outcomes following long-term recovery after cerebral ischemia and the possible contributions of lithium-mediated mechanisms of neuroplasticity.

METHODS

Male Sprague Dawley rats were subjected to right middle cerebral artery occlusion for 90 min, followed by 28 days of recovery. Lithium chloride (1 mEq/kg) or vehicle was administered via intraperitoneal infusion once per day at 24 h after reperfusion onset. Neurobehavioral outcomes and somatosensory evoked potentials (SSEPs) were examined before and 28 days after ischemia-reperfusion. Brain infarction was assessed using Nissl staining. Primary cortical neuron cultures were exposed to oxygen-glucose deprivation (OGD) and treated with 2 or 20 μM lithium for 24 or 48 h; subsequent brain-derived neurotrophic factor (BDNF), growth-associated protein-43 (GAP-43), postsynaptic density-95 (PSD-95), and synaptosomal-associated protein-25 (SNAP-25) levels were analyzed using western blotting.

RESULTS

Compared to controls, lithium significantly reduced infarction volume in the ischemic brain and improved electrophysiological and neurobehavioral outcomes at 28 days post-insult. In cultured cortical neurons, BDNF, GAP-43, and PSD-95 expression were enhanced by 24- and 48-h treatment with lithium after OGD.

CONCLUSION

Lithium upregulates BDNF, GAP-43, and PSD-95, which partly accounts for its improvement of neuroplasticity and provision of long-term neuroprotection in the ischemic brain.Abbreviations: BDNF: brain-derived neurotrophic factor; ECM: extracellular matrix; EDTA: ethylenediaminetetraacetic acid; GAP-43: growth-associated protein-43; GSK-3β: glycogen synthase kinase-3β; HBSS: Hank's balanced salt solution; LCBF: local cortical blood perfusion; LDF: laser-Doppler flowmetry; MCAO: middle cerebral artery occlusion; MMP: matrix metalloproteinase; NMDA: N-methyl-D-aspartate; NMDAR: N-methyl-D-aspartate receptor; OCT: optimal cutting temperature compound; OGD: oxygen-glucose deprivation; PSD-95: postsynaptic density-95; SDS: sodium dodecyl sulfate; SNAP-25: synaptosomal-associated protein-25; SSEP: somatosensory evoked potential.

Potential Mechanisms and Clinical Effectiveness of Acupuncture in Depression

Major depressive disorder is the most common mental disorder with significant economic burden and limited treatments. Acupuncture has emerged as a promising non-pharmacological treatment for reducing depressive symptoms. However, the potential mechanisms and clinical effectiveness of acupuncture are not fully understood. This review aimed to: (1) summarize the available evidence on the mechanisms and clinical effectiveness of acupuncture for depression, and then (2) compare with pharmacological interventions, guiding future studies. Studies with animal models of depression and patients have shown that acupuncture could increase hippocampal and network neuroplasticity and decrease brain inflammation, potentially to alleviating depressive disorders. Overall clinical studies indicated that acupuncture could relieve primary depression, particularly milder cases, and was helpful in the management of post-stroke depression, pain-related depression, and postpartum depression both as an isolated and adjunct treatment. It was emphasized that acupuncture combined with antidepressant pharmacological treatment not only enhanced the improvement of primary and secondary depressive symptoms but also reduced the side effects of the medical treatment, which is the main cause for high dropout rates with drug treatment. In summary, substantial evidence from animal and human researches supported the beneficial effect of acupuncture in depression. However, most clinical trials of acupuncture were small, and it is unclear whether their findings can be generalized, so more studies are needed.

Association of post-stroke-depression and health-related quality of life three months after the stroke event. Results from the Stroke Cohort Augsburg (SCHANA) study

Approximately one-third of patients with stroke show depressive symptoms. The so-called post-stroke depression (PSD) has a negative influence on mortality as well as physical and mental conditions. The aim of this study was to analyse the association between PSD and health-related quality of life (HRQOL) in patients with stroke. The analysis was based on data of 326 patients from the Stroke Cohort Augsburg (SCHANA Study) collected after the stroke event by interview and three months later using a postal survey. Depressive symptoms were measured with the Patient-Health Questionnaire (PHQ-9), subjective health status with the EuroQol 5D visual analogue scale (EQ-5D VAS), and HRQOL with the Stroke Impact Scale (SIS). Patients with depressive symptoms were compared to those without depressive symptoms in terms of sociodemographic characteristics and scores of the SIS and the EQ-5D VAS. Multiple linear regression models were calculated to investigate the association between PSD and subjective health status and HRQOL. Three months after the stroke, 17.8% of patients had depressive symptoms. Patients with PSD showed significantly worse SIS and EQ-5D VAS scores. In addition, an independent negative linear association between PSD and subjective health status and between PSD and all domains of SIS could be found. The study confirmed that PSD is common in patients with mild stroke and negatively related to all stroke-specific HRQOL domains. The results underline the importance of early screening for PSD in stroke patients since it may hinder a successful rehabilitation.

A Network Meta-Analysis of the Clinical Efficacy and Safety of Commonly Used Chinese Patent Medicines in the Auxiliary Treatment of Poststroke Depression

Background

Poststroke depression (PSD) is a serious complication of clinical cerebrovascular disease. Patients not only have depression-related emotional symptoms but also have physical symptoms, such as autonomic dysfunction. At the same time, patients with varying degrees of depression will delay the neurological function of stroke patients. The recovery time of cognitive function and limb function will increase the risk of accidental death and even aggravate the mortality of cerebrovascular disease. Through combining data analysis and related literature, seven types of Chinese patent medicines (CPMs) widely used in the clinical treatment of PSD have been screened out. These herbs exhibit some clinical comparability under the conditions that the syndrome type and dosage form are relatively uniform. Therefore, in this study, the network meta-analysis method was used to evaluate the safety and efficacy of the seven CPMs screened out, and the probability ranking was performed to screen the best clinical auxiliary treatment plan of CPM.

Methods

We searched the Chinese databases, including CNKI, WANFANG, and VIP, as well as the English databases, including the Cochrane Library, EMBASE, and PubMed, from inception to May 31, 2020, to identify randomized controlled trials (RCTs) on seven kinds of CPMs that were the subjects of the clinical research. The bias risk and quality of the included studies were analyzed with the Cochrane Handbook (version 5.1), ADDIS, and R software, and the results were compared in a network meta-analysis (NMA).

Results

In terms of clinical effectiveness, the seven kinds of CPMs all improved clinical curative effects, with Jieyu Anshen capsule adjuvant treatment having the most significant effect [odds ratio (OR) = 5.00, 95% CI (1.72–9.48)]. Wuling capsule AT can effectively reduce the score index of scale factors for the HAMD score, NIHSS score, and TESS score [mean difference (MD) = −3.95, 95% CI (−4.88–3.00); OR = −3.25, 95% CI (−5.46)–1.05); OR = 0.22, 95% CI (0.05–0.79), resp.].

Conclusion

The mechanisms of seven CPMs in the adjuvant treatment of PSD have advantages. In terms of safety and efficacy, the CPMs had better clinical adjuvant treatment performance. Although this study concluded that the Jieyu Anshen capsule is the preferred drug for clinical treatment, a clear conclusion still needs to be verified in a high-quality randomized controlled study. In clinical practice, accurate selection and application can be carried out according to the specific characteristics of patients.

Prevalence and Associated Factors of Poststroke Depression among Outpatient Stroke Patients Who Have a Follow-Up at the Outpatient Neurology Clinic of Zewditu Memorial Hospital in Addis Ababa, Ethiopia

BACKGROUND

Poststroke depression is the most common and burdensome poststroke psychiatric complication. Studies showed discrepancies in reporting frequencies and risk factors for poststroke depression. Updated local data are relevant for efficient strategies of poststroke depression screening and prevention.

OBJECTIVES

To determine the prevalence and associated factors of poststroke depression among outpatient stroke patients from the outpatient neurology clinic of Zewditu Memorial Hospital in Addis Ababa, Ethiopia.

METHODS

An institution-based cross-sectional study was conducted on 249 stroke patients. Data was collected through structured questionnaire using interviews and a review of medical charts. PHQ-9 depression questionnaire was used to diagnose poststroke depression. Descriptive analysis was used to see the nature of the characteristics of interests. Bivariate analysis was used to sort out variables at p values less than 0.05 for multivariate logistic regression. Significance level was obtained using an odds ratio with 95% CI and p value < 0.05.

RESULTS

Point prevalence for poststroke depression was 27.5 percent. Female gender, unemployment, low social support level, diabetes mellitus, and poststroke period under 2 years were statistically significant and independent predictors for poststroke depression.

CONCLUSIONS

The point prevalence estimate of poststroke depression was comparable with other studies. Low social support levels increased the odds for poststroke depression by more than eight folds. It appeared that external factors are more important in the pathogenesis of poststroke depression in the African population. Detection and prevention programs should consider disparities of poststroke depression incidence and risk factors.

A New NF-κB Inhibitor, MEDS-23, Reduces the Severity of Adverse Post-Ischemic Stroke Outcomes in Rats

Aim: Nuclear factor kappa B (NF-κB) is known to play an important role in the inflammatory process which takes place after ischemic stroke. The major objective of the present study was to examine the effects of MEDS-23, a potent inhibitor of NF-κB, on clinical outcomes and brain inflammatory markers in post-ischemic stroke rats. Main methods: Initially, a Toxicity Experiment was performed to determine the appropriate dose of MEDS-23 for use in animals, as MEDS-23 was analyzed in vivo for the first time. We used the middle cerebral artery occlusion (MCAO) model for inducing ischemic stroke in rats. The effects of MEDS-23 (at 10 mg/kg, ip) on post-stroke outcomes (brain inflammation, fever, neurological deficits, mortality, and depression- and anxiety-like behaviours) was tested in several efficacy experiments. Key findings: MEDS-23 was found to be safe and significantly reduced the severity of some adverse post-stroke outcomes such as fever and neurological deficits. Moreover, MEDS-23 significantly decreased prostaglandin E2 levels in the hypothalamus and hippocampus of post-stroke rats, but did not prominently alter the levels of interleukin-6 and tumor necrosis factor-α. Significance: These results suggest that NF-κB inhibition is a potential therapeutic strategy for the treatment of ischemic stroke.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Influence of Physical Activity and Socio-Economic Status on Depression and Anxiety Symptoms in Patients after Stroke

Stroke is a high-risk factor for depression. Neurological rehabilitation is greatly difficult and often does not include treatment of depression. The post-stroke depression plays an important role in the progress of treatment, health, and the life of the patient. The appropriate treatment of depression could improve the quality of life of the patient and their family. The study aimed to evaluate the impact of physical activity and socio-economic status of the patient on the effectiveness of recovery from depression and the severity of the symptoms of depression. The study was conducted with 40 patients after stroke aged 42–82 years, and included 10 women and 30 men who were hospitalized for two weeks. The severity of depression/anxiety (D/A) symptoms were evaluated two times; at admission and after two weeks of physical therapy. The hospital anxiety and depression scale (HADS) questionnaire was used for this purpose. Socio-economic status was evaluated by several simple questions. It was revealed that physical therapy has a positive influence on mental state. The severity of D/A symptoms after stroke is related to the financial status of the patients (χ² = 11.198, p = 0.024). The state of health (χ² = 20.57, p = 0.022) and physical fitness (χ² = 12.95, p = 0.044) changed the severity of symptoms of anxiety and depressive disorders. The kinesiotherapy in the group of patients with post-stroke depression had positive effects; however, economic and health conditions may influence the prognosis of the disease.

Stroke Survivors Experience Elevated Levels of Loneliness: A Multi-Year Analysis of the National Survey for Wales

Objective

Despite clinical observation that stroke survivors frequently experience loneliness, there is no large-scale empirical evidence to support this observation. Therefore, the primary objective of this research was to provide the first large-scale and comprehensive estimate of loneliness in the stroke survivor population.

Method

To address this issue, we completed two preregistered analyses of a nationally representative annual survey (N > 21,000). A two-phase approach was adopted combining both exploratory (Study 1) and confirmatory (Study 2) phases. The benefit of such an approach is that replication is built into the design, which considerably strengthens the inferences that can be made.

Results

Across two separate cohorts, the results consistently showed that human stroke survivors report higher levels of loneliness compared with healthy individuals, and this relationship could not be accounted for by demographic factors (e.g., age, sex) or objective measures of social isolation (e.g., marital status, number of household members).

Conclusions

These findings demonstrate that elevated levels of loneliness poststroke are robust in that they replicate in large nationally representative samples and cannot be reduced to objective measures of social isolation. The work has clinical and societal relevance by suggesting that loneliness poststroke is unlikely to be adequately “treated” if only the quantity and not the quality of social experiences are considered.

Neuroprotective phosphatidylserine liposomes alleviate depressive-like behavior related to stroke through neuroinflammation attenuation in the mouse hippocampus

OBJECTIVE

To investigate the protective effect of phosphatidylserine liposomes (PSL) on post-stroke (ST) injuries such as neuroinflammation and depression in mice.

METHODS

Brain ischemia was induced via the right unilateral common carotid artery occlusion model. Then, behavioral assessments including the forced swimming test (FST) and tail suspension test (TST) were used to evaluate the antidepressant-like effect of PSL. Moreover, inflammatory cytokines changes in the hippocampus including TNF-α and IL-10 levels as well as the number of survived neurons were evaluated in ST mice using immunohistochemistry (IHC).

RESULTS

A significant reduction of the immobility time in both behavioral tests indicated the antidepressant activity of PSL. Moreover, the number of viable neurons increased significantly with PSL treatment, which was similar to control group, compared to the untreated ST group. IHC analysis of ST mice receiving PSL showed a significant reduction in TNF-α and IL-10 levels in the inflamed hippocampus of mice.

CONCLUSION

Oral PSL may improve post-stroke depression (PSD) through its anti-inflammatory properties.

The advances of post-stroke depression: 2021 update

Post-stroke depression (PSD) is one of common and serious sequelae of stroke. Approximately, one in three stroke survivors suffered from depression after stroke. It heavily affected functional rehabilitation, which leaded to poor quality of life. What is worse, it is strongly associated with high mortality. In this review, we aimed to derive a comprehensive and integrated understanding of PSD according to recently published papers and previous classic articles. Based on the considerable number of studies, we found that within 2 years incidence of PSD has a range from 11 to 41%. Many factors contribute to the occurrence of PSD, including the history of depression, stroke severity, lesion location, and so on. Currently, the diagnosis of PSD is mainly based on the DSM guidelines and combined with various depression scales. Unfortunately, we lack a unified mechanism to explain PSD which mechanisms now involve dysregulation of hypothalamic-pituitary-adrenal (HPA) axis, increased inflammatory factors, decreased levels of monoamines, glutamate-mediated excitotoxicity, and abnormal neurotrophic response. At present, both pharmacotherapy and psychological therapies are employed in treating PSD. Although great advance has been made by researchers, there are still a lot of issues need to be addressed. Especially, the mechanism of PSD is not completely clear.

Redefining a minimal assessment protocol for stroke rehabilitation: the new "Protocollo di Minima per l'ICtus" - PMIC2020

BACKGROUND

The use of standardized assessment protocols is strongly recommended to identify patient's needs, outcomes, and predictors of response to specific interventions in Stroke rehabilitation. In 2008, the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal protocol for the person with stroke (PMIC), in reference to the International classification of Functioning, Disability and Health.

AIM

In 2019, the SIMFER appointed a working group (WG) to provide a revised, updated version in line with the most recent literature and suitable for all rehabilitation settings: the PMIC2020.

DESIGN

descriptive study based on the consensus of a panel of experts.

SETTING

all the rehabilitation settings.

POPULATION

stroke survivor people with disability.

METHODS

the coordinator of the SIMFER national Stroke Section appointed the WG, including the 8 Stroke Section board members, and 4 more experts (3 physiatrists; 1 neurologist). An extensive revision of the international literature on stroke assessment recommendations was performed; each proposed change from PMIC was written and motivated, discussed and voted.

RESULTS

The PMIC2020 is a single form, to be administered at any time of the rehabilitation pathway, including a minimum set of variables, consisting of a demographic/anamnestic section, and a clinical/functional assessment section. Newly introduced tools included measures of malnutrition (BMI<18,5); pain in verbal and non-verbal patients (Numeric Rating Scale-pain, Pain Assessment in Advanced Dementia Scale); neurological impairment (National Institute of Health-stroke scale); activity (Modified Barthel Index, Short Physical Performance Battery); and participation (Frenchay Activity Index).

CONCLUSIONS

The PMIC2020 provides an updated tool for the multidimensional rehabilitation assessment of the stroke patient, at any stage of the rehabilitation pathway; it aims to provide a shared minimum set of variables defining patient's needs and outcomes across different rehabilitation facilities and settings.

CLINICAL REHABILITATION IMPACT

The PMIC2020 identifies patient's needs, outcomes, and predictors of response to specific interventions in Stroke rehabilitation and provide ground for a highly needed Stroke Registry.

Real-time monitoring of barriers to patient engagement for improved rehabilitation: a protocol and representative case reports

PURPOSE

There is ample evidence that patient engagement is of major clinical importance in rehabilitation, and it seems this engagement is based upon effective allocation of attention to the tasks during the rehabilitation session. It is possible to discern two types of barriers which hinder attentive engagement: (1) dysfunctional affective coping and (2) limited cognitive recruitment and specifically attention deficit. These barriers might be general for a given patient, due to pre-morbid or co-morbid dysfunctions. But more often they are evoked by tasks or challenges during the rehabilitation session which might be too complicated or stressing for the specific patient who copes with potentially grave impairments. These barriers hinder rehabilitation progress and should be monitored and overcome, by the therapist, throughout the session.

METHODS

We have developed an easy-to-use tool for monitoring a patient's attentive engagement in real-time throughout a rehabilitation session based on analysing the electrophysiological signal sampled from a simple headset. The tool then analyzes the dynamics of the marker over time to identify cognitive and affective barriers during the session. It enables the therapist to insert feedback regarding the patient's functional performance and to combine it with the analysed barriers, in order to derive automatic recommendations for overcoming the cognitive and affective barriers (if identified) for significant enhancement of the rehabilitation session.

RESULTS AND CONCLUSIONS

In this work we present the principles of the tool as well as three detailed case reports to demonstrate its potential usefulness.IMPLICATIONS FOR REHABILITATIONCognitive and affective barriers hinder patient engagment and rehabilitation success.In this work we present an easy to use electrophysiology-based tool which monitors these barriers.Based on the measured barriers and patient's performance, the tool derives treatment suggestions.

Real-time gait metric estimation for everyday gait training with wearable devices in people poststroke

Hemiparetic walking after stroke is typically slow, asymmetric, and inefficient, significantly impacting activities of daily living. Extensive research shows that functional, intensive, and task-specific gait training is instrumental for effective gait rehabilitation, characteristics that our group aims to encourage with soft robotic exosuits. However, standard clinical assessments may lack the precision and frequency to detect subtle changes in intervention efficacy during both conventional and exosuit-assisted gait training, potentially impeding targeted therapy regimes. In this paper, we use exosuit-integrated inertial sensors to reconstruct three clinically meaningful gait metrics related to circumduction, foot clearance, and stride length. Our method corrects sensor drift using instantaneous information from both sides of the body. This approach makes our method robust to irregular walking conditions poststroke as well as usable in real-time applications, such as real-time movement monitoring, exosuit assistance control, and biofeedback. We validate our algorithm in eight people poststroke in comparison to lab-based optical motion capture. Mean errors were below 0.2 cm (9.9%) for circumduction, −0.6 cm (−3.5%) for foot clearance, and 3.8 cm (3.6%) for stride length. A single-participant case study shows our technique’s promise in daily-living environments by detecting exosuit-induced changes in gait while walking in a busy outdoor plaza.

Neuropsychiatric symptoms among young stroke survivors-frequency, patterns, and associated factors

BACKGROUND

Although neuropsychiatric symptoms are reported in stroke survivors, details of its prevalence and patterns among young stroke subjects are sparse.

METHODS

In a hospital-based cross-sectional study in India, we recruited 150 young stroke subjects (aged < 45 years) and their caregivers > 3 months from ictus. Neuropsychiatric symptoms were evaluated using the Neuropsychiatric Inventory-12 (NPI-12) and self-reported depression with the Centre for Epidemiological Studies - Depression (CES-D) scale. Descriptive statistics were used. Multivariate analysis was performed to identify associated factors. All statistical analyses were carried out using STATA ver. 14.2, StataCorp, TX, USA.

RESULTS

Eighty-four (56%; 95% CI: 47.7-64.1%) had ≥ 1 symptoms on the NPI-12 over median time from stroke of 2 years (IQR 2). Self-reported depression was seen in 71 (47.3%). Post-stroke epilepsy was associated with presence of at least one neuropsychiatric symptom. Dementia was associated with increased odds; and having spouse as principal caregiver with reduced odds, of self-reported depression. Multiple infarcts on imaging were associated with self-reported depression (OR: 3.29; 95%CI: 1.31-8.27) and presence of any neuropsychiatric symptom (OR: 3.55; 95% CI: 1.42-8.88).

CONCLUSION

Young stroke survivors frequently have neuropsychiatric symptoms with depression being most common. Presence of multiple infarcts on imaging was associated with self-reported depression and presence of any neuropsychiatric symptom.

Exercise interventions for post-stroke depression: A protocol for systematic review and meta-analysis

BACKGROUND

Post-stroke depression (PSD) is one of the most common neuropsychiatric complications after stroke and is associated with increased risk of death and poor functional outcomes. Strong evidence shows that exercise has benefits for depression. However, it is not clear whether exercise has benefits specifically for PSD. This study aims to explore the effects of exercise on PSD and to establish safe and effective exercise prescriptions.

METHODS AND ANALYSIS

The PubMed, Cochrane Library and EMBASE, databases will be searched using prespecified search strategies. Randomized controlled trials and non-randomized prospective controlled cohort studies regarding exercise for PSD will be included. The primary outcomes are depression scale and stroke outcome. The secondary outcomes are the occurrence of adverse events, cognitive function, quality of life indices, and the expression of nerve cell factors. The methodological quality of each study will be evaluated by the physiotherapy evidence database scale. The heterogeneity will be evaluated using the I2 test. If I2 > 50%, random effects models will be used in the analysis; otherwise, fixed effects models will be used to pool the data.

RESULTS

This study will assess the efficacy and safety of exercise for PSD.

CONCLUSIONS

Our findings will be helpful for clinicians to re-examine the clinical decision-making in the treatment of PSD, by assessing the efficacy of a promising treatment modality for patients with PSD.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is a secondary analysis. The results of this study will be disseminated through journals and academic exchanges.

SYSTEMATIC REVIEW REGISTRATION NUMBER

INPLASY202110100.

Post-stroke depression: Chaos to exposition

Cerebral ischemia contributes to significant disabilities worldwide, impairing cognitive function and motor coordination in affected individuals. Stroke has severe neuropsychological outcomes, the major one being a stroke. Stroke survivors begin to show symptoms of depression within a few months of the incidence that overtime progresses to become a long-term ailment. As the pathophysiology for the progression of the disease is multifactorial and complex, it limits the understanding of the disease mechanism completely. Meta-analyses and randomized clinical trials have shown that intervening early with tricyclic antidepressants and selective serotonin receptor inhibitors can be effective. However, these pharmacotherapies possess several limitations that have given rise to newer approaches such as brain stimulation, psychotherapy and rehabilitation therapy, which in today's time are gaining attention for their beneficial results in post-stroke depression (PSD). The present review highlights numerous factors like lesion location, inflammatory mediators and genetic abnormalities that play a crucial role in the development of depression in stroke patients. Further, we have also discussed various mechanisms involved in post-stroke depression (PSD) and strategies for early detection and diagnosis using biomarkers that may revolutionize treatment for the affected population. Towards the end, along with the preclinical scenario, we have also discussed the various treatment approaches like pharmacotherapy, traditional medicines, psychotherapy, electrical stimulation and microRNAs being utilized for effectively managing PSD.

Validation of the 10-item Center for Epidemiologic Studies Depression Scale Post Stroke

OBJECTIVE

To establish reliability and validity of the abbreviated (10-item) Center for Epidemiologic Studies Depression Scale (CESD-10) among individuals post stroke.

METHOD

The psychometric properties of the CESD-10 were evaluated in 1219 adults with stroke admitted to an eligible inpatient rehabilitation facilities (n = 11) across 9 different states post stroke during 2005 to 2006. This study was a secondary data analysis of the existing publicly available clinical trial dataset, Stroke Recovery in Underserved Populations study. Reliability, validity, factory structure and item-level psychometrics of the CESD-10 were examined. In addition, the predictive accuracy of the CESD-10 was compared against the CESD-20 (criterion).

RESULTS

The CESD-10 was highly correlated with the CESD-20 (r = 0.97). The CESD-10 had good internal reliability (Cronbach's α = 0.86). The CESD-20 and CESD-10 had similar accuracy in classifying individuals as depressed (Kappa = 0.85).

CONCLUSION

The 10-item CESD is a valid measure of depression for individuals post stroke.

Repetitive transcranial magnetic stimulation for post-stroke depression: a randomised trial with neurophysiological insight

OBJECTIVE

Despite high incidence of depression after stroke, few trials have investigated the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS). Here, we aimed to evaluate clinical benefit of delivering a higher dose of rTMS compared to previous stroke trials. Secondary aims were to document adverse effects and investigate the role of functional connectivity as a potential mechanism of clinical response to rTMS treatment.

METHODS

Eleven chronic stroke survivors were recruited to a double-blind, Sham-controlled, randomised trial to investigate 10 sessions of high-frequency rTMS for depression. Clinical assessments were obtained at baseline, after treatment and a 1-month follow-up. Adverse events were documented at completion of the treatment. Resting electroencephalography recordings were performed at baseline and after treatment to estimate functional connectivity.

RESULTS

There were no differences in baseline characteristics between groups (all p ≥ 0.42). Beck Depression Inventory scores decreased for the Active rTMS group from baseline to 1-month follow-up (p = 0.04), but did not change for the Sham group at post-treatment or follow-up (p ≥ 0.17). Stronger theta frequency functional connectivity between the left frontal cortex and right parietal cortex was associated with lower baseline depression (r = - 0.71, p = 0.05). This network strength increased following Active rTMS, with change in connectivity associated with improvement in BDI scores (r = 0.98, p = 0.001). Adverse events were transient and minor and were not statistically different between groups (p ≥ 0.21).

CONCLUSIONS

Active rTMS significantly improved depression and was well tolerated. The mechanistic role of theta frequency functional connectivity appears worthy of further investigation. The trial was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12619001303134) on September 23, 2019.

Depression impedes neuroplasticity and quality of life after stroke

Background and Purpose:

Depression following a stroke/poststroke depression (PSD) has been newly recognized as one of the most common complications after stroke. PSD may affect neuroplasticity and quality of life. The purpose of present study was to find out effects of depression on functional recovery, quality of life and neuroplasticity in patients with acute stroke.

Methods:

A total of 76 cases were recruited for the study and out of which 44 were available for the analysis after six months. Patients were divided into three groups according to severity of depression: Group A (without depression), Group B (mild-to-moderate depression), and Group C (severe depression) on the basis of Patient Health Questionnaire-9 (PHQ-9) scale scores. All patients were assessed for depression by PHQ-9, and for quality of life by Stroke Specific Quality of Life (SSQOL) scale. Neuroplasticity was assessed by measuring levels of serum brain-derived neurotrophic factor.

Results:

Quality of life was observed to be significantly affected by depression (P ≤ 0.05). The most commonly affected characteristics were energy, family roles, mobility, self-care, social roles, upper extremity function, and work productivity. Serum BDNF levels were also affected significantly by depression (P ≤ 0.05).

Conclusion:

PSD is a serious complication, affecting quality of life and neuroplasticity (BDNF) in patients. Decreased neuroplasticity further may affect functional improvement.

Factors Affecting Quality of Life among Post-Stroke Patients in the Sub-Himalayan Region

Background  Stroke is one of the most debilitating conditions contributing to significant disability and death globally. Identifying risk factors for quality of life (QoL) will enable to improve home-based rehabilitation in post-stroke phase.

Objective  This study was aimed to identify the risk factors of QoL in stroke patients in the sub-Himalayan region.

Materials and Methods  A cross-sectional hospital-based study assessed the QoL among stroke patients within a week after the onset of acute stroke and then re-evaluated at 3 months. World Health Organization QoL-BREF, Beck Depression Inventory, the Barthel Index, and Montreal Cognitive Assessment (MOCA) were used to seek data on QoL, depression, cognitive, and functional dependence status, respectively. Appropriate statistics were used to compute the results.

Results  In total, 129 stroke patients recruited, out of which 102 returned to a 3-month follow-up. QoL, MOCA, disability index, and depression score were compared using Wilcoxon Singed-rank test. In multivariate analysis, depression and disability together predicted 60% of the variance for physical QoL ( p < 0.0001). Similarly, poststroke depression and disability together predicted 61% of the variance for psychological QoL ( p < 0.0001) in stroke patients.

Conclusion  Findings indicated that depression and disability are leading risk factors of QoL in stroke patients. Early identification of poststroke depression and functional dependence status is, therefore, essential to devise screening procedure and to develop targeted intervention to improve rehabilitation outcomes.

Novel TMS for Stroke and Depression (NoTSAD): Accelerated Repetitive Transcranial Magnetic Stimulation as a Safe and Effective Treatment for Post-stroke Depression

Background: Post-stroke depression (PSD) affects up to 50% of stroke survivors, reducing quality of life, and increasing adverse outcomes. Conventional therapies to treat PSD may not be effective for some patients. Repetitive transcranial magnetic stimulation (rTMS) is well-established as an effective treatment for Major Depressive Disorder (MDD) and some small trials have shown that rTMS may be effective for chronic PSD; however, no trials have evaluated an accelerated rTMS protocol in a subacute stroke population. We hypothesized that an accelerated rTMS protocol will be a safe and viable option to treat PSD symptoms. Methods: Patients (N = 6) with radiographic evidence of ischemic stroke within the last 2 weeks to 6 months with Hamilton Depression Rating Scale (HAMD-17) scores >7 were recruited for an open label study using an accelerated rTMS protocol as follows: High-frequency (20-Hz) rTMS at 110% resting motor threshold (RMT) was applied to the left dorsolateral prefrontal cortex (DLPFC) during five sessions per day over four consecutive days for a total of 20 sessions. Safety assessment and adverse events were documented based on the patients' responses following each day of stimulation. Before and after the 4-days neurostimulation protocol, outcome measures were obtained for the HAMD, modified Rankin Scale (mRS), functional independence measures (FIM), and National Institutes of Health Stroke Scales (NIHSS). These same measures were obtained at 3-months follow up. Results: HAMD significantly decreased (Wilcoxon p = 0.03) from M = 15.5 (2.81)-4.17 (0.98) following rTMS, a difference which persisted at the 3-months follow-up (p = 0.03). No statistically significant difference in FIM, mRS, or NIHSS were observed. No significant adverse events related to the treatment were observed and patients tolerated the stimulation protocol well overall. Conclusions: This pilot study indicates that an accelerated rTMS protocol is a safe and viable option, and may be an effective alternative or adjunctive therapy for patients suffering from PSD. Future randomized, controlled studies are needed to confirm these preliminary findings. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04093843.

Microstructural changes in the reward system are associated with post-stroke depression

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Depressed stroke survivors exhibit abnormal frontal and subcortical structural connectivity.

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Microstructural changes resemble those reported in major depressive disorder.

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Subnetworks linked with reward processing are associated with poststroke depression.

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Localized tractography confirmed involvement of connections in these networks.

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Grey matter volume, fractional anisotropy and free-water collectively predict depression severity.

Background

Studies of lesion location have been unsuccessful in identifying mappings between single brain regions and post-stroke depression (PSD). Based on studies implicating the reward system in major depressive disorder without stroke, we investigated structural correlates within this system and their associations with PSD.

Methods

The study enrolled 16 healthy controls, 12 stroke patients with PSD and 34 stroke patients free of PSD. Participants underwent 3T structural and diffusion MRI. Graph theoretical measures were used to examine global topology and whole-brain connectome analyses were employed to assess differences in the interregional connectivity matrix between groups. Structural correlates specific to the reward system were examined from grey matter volumes and by reconstructing its main white matter pathways, namely the medial forebrain bundle and cingulum connections, using deterministic tractography. Fractional anisotropy (FA) was derived as a measure of microstructural organization, and extracellular free-water (FW) as a possible proxy of neuroinflammation.

Results

Subnetworks of decreased FA-weighted and increased FW-weighted connectivity were observed in patients with PSD relative to healthy controls. These networks subsumed the majority of regions constituting the reward system. Within the reward system, FA and FW of major connection pathways and grey matter volume were collectively predictive of PSD, explaining 37.8% of the variance in depression severity.

Conclusions

PSD is associated with grey matter volume loss, reduced FA and increased extracellular FW in the reward system, similar to features observed in major depression without stroke. Structural characterization of the reward system is a promising biomarker of vulnerability to depression after stroke.

Network meta-analysis of Chinese patent medicine adjuvant treatment of poststroke depression

BACKGROUND

Poststroke depression is one of the common complications of clinical cerebrovascular diseases. It is commonly seen in 3 to 6 months after the onset of stroke. The incidence rate is 22% to 75%. The patient not only has depression-related emotional symptoms, but also are accompanied by autonomic nervous disorders and other physical symptoms. It will also delay the recovery time of patients' neurological function, cognitive function, and limb function due to different degrees of depression, and even further aggravate the mortality and risk of accidental death of cerebrovascular disease. In recent years, Chinese patent medicine combined with western medicine has been widely used in the treatment of this disease. Many clinical practices have proved that the adjuvant treatment of pure Chinese herbal medicine can effectively alleviate the poststroke depression state and reduce the neurological deficits. The author has sorted out the relevant literature and data analysis to screen out the seven most representative and commonly used Chinese patent medicine preparations in clinical treatment of poststroke depression, which have certain clinical comparability when the dosage form and syndrome type are relatively unified. The network meta-analysis method is used to select the best clinical treatment plan, so as to provide reference value and evidence-based medicine evidence for the clinical optimization of drug selection.

METHODS

Using computer retrieval technology, comprehensive retrieval of CNKI, VIP, CBM, and WANFANG Chinese electronic database and the Cochrane Library, PubMed, Web of Science and EMBASE foreign electronic database. Search the clinical randomized controlled trials of these 7 kinds of Chinese patent medicines for adjuvant treatment of poststroke depression, and set a period of time is from the establishment of the database to May 31, 2020. The 3 authors will screen the literatures that meets the inclusion criteria, extract the data independently according to the predesigned rules, and evaluate the literature quality and bias risk of the included research according to the Cochrane 5.1 manual standard. R and the Aggregate Data Drug Information System software were used for data consolidation and network meta-analysis to evaluate the ranking probability of all interventions.

RESULTS

This network meta-analysis and probability ranking will identify the best Chinese patent medicine adjuvant treatment for poststroke depression.

CONCLUSION

This study will provide systematic evidence-based medicine evidence for Chinese patent medicine adjuvant treatment for poststroke depression, and help clinicians, patients with poststroke depression and decision-makers to make more effective, safer, and economic optimal treatment plan in the decision-making process.

PROSPERO REGISTRATION NUMBER

CRD42020164543.

An Integrative Neuro-Psychotherapy Treatment to Foster the Adjustment in Acquired Brain Injury Patients-A Randomized Controlled Study

Adjustment disorders (AjD) with depressive symptoms following an acquired brain injury (ABI) is a common phenomenon. Although brain injuries are increasing more and more, research on psychological therapies is comparably scarce. The present study compared, by means of a randomized controlled trial (RCT), a newly developed integrative treatment (Standard PLUS) to a standard neuropsychological treatment (Standard). Primary outcomes were depressive symptoms assessed with the Beck Depression Inventory (BDI-II) at post-treatment and 6-month follow-up assessment. In total, 25 patients (80% after a stroke) were randomized to one of the two conditions. Intention-to-treat analyses showed that the two groups did not significantly differ either at post-treatment nor at follow-up assessment regarding depressive symptoms. Both treatments showed large within-group effect sizes on depressive symptoms. Regarding secondary outcomes, patients in the Standard PLUS condition reported more emotion regulation skills at post-assessment than in the control condition. However, this difference was not present anymore at follow-up assessment. Both treatments showed medium to large within-group effects sizes on most measures for patients suffering from an AjD after ABI. More research with larger samples is needed to investigate who profits from which intervention.