Prevalence and Predictors of Depression after Stroke - Results from a Prospective Study

Gender differences in the association between cardiovascular diseases and major depressive disorder among older adults in India

Background

Despite the global disease burden associated with the co-occurrence of cardiovascular diseases (CVDs) and depression, depression remains underdiagnosed and undertreated in the CVD population, especially among older adults in India. As such, this study examines (1) the association between single and multiple CVDs and major depressive disorder among older Indians; (2) whether this association is mediated by older adults' self-rated health and functional limitations; and (3) whether these associations vary for older men and women.

Methods

Data come from the 2017-18 wave 1 of the Longitudinal Ageing Study in India. Multivariable logistic regression is used to explore the association between CVDs and major depressive disorder among older men and women. The Karlson-Holm-Breen (KHB) method is used to examine the mediation effects of self-rated health and functional difficulties in the observed associations.

Results

Overall, 5.08% of the older adults had multiple CVDs. Older women (9.71%) had a higher prevalence of major depressive disorder compared to men (7.50%). Multiple CVDs were associated with greater odds of major depressive disorder after adjusting the potential covariates (adjusted odds ratio [AOR]: 1.49; 95% confidence interval [CI]: 1.10-2.00). Older men with multiple CVDs had a greater risk of major depressive disorder (AOR: 1.64; 95% CI: 1.05-2.57) relative to women with CVDs (AOR: 1.39; 95% CI: 0.93-2.08). The association between multiple CVDs and depression was mediated by self-rated health (34.03% for men vs. 34.55% for women), ADL difficulty (22.25% vs. 15.42%), and IADL difficulty (22.90% vs. 19.10%).

Conclusions

One in five older Indians with multiple CVDs reports major depressive disorder, which is three times more common than the prevalence of depressive disorder in older adults without CVDs. This association is attenuated by self-rated health and functional limitations. Moreover, these associations are more pronounced in older men relative to older women. These findings depart from prior inferences that men with CVDs are less psychologically distressed than their female counterparts. Moreover, the findings underscore the importance of gender-specific approaches to interventions and therapeutics for CVD-related mental health.

The Oxford cognitive screen (OCS) as an acute predictor of long-term functional outcome in a prospective sample of stroke patients

The Oxford Cognitive Screen (OCS) was developed to measure cognitive impairment in stroke. Here, we test if the OCS administered acutely in stroke patients provides useful information in predicting long-term functional outcome. A group of first-time stroke patients (n = 74) underwent an acute behavioral assessment comprising the OCS and the NIHSS within one-week post-stroke. Functional outcome was evaluated using the Stroke Impact Scale 3.0 (SIS 3.0) and the Geriatric Depression Scale (GDS) at 6 and 12-months post-stroke. We compared the predictive ability of the OCS and NIHSS, separately or in combination, to predict different domains of behavioral impairment at a chronic evaluation. The OCS accounted for 61% of variance of SIS physical domain, 61% of memory domain, 79% of language domain, 70% of participation domain and 70% of recovery domain. The OCS accounted for a greater percentage of outcome variance than demographics and NIHSS. The most informative predictive model included the combination of demographics, OCS and NIHSS data. The OCS, performed early after stroke, is a strong independent predictor of long-term functional outcome and significantly improves the prediction of outcome when considered alongside the NIHSS and demographics.

Mediating effect of post-stroke depression between activities of daily living and health-related quality of life: meta-analytic structural equation modeling

BACKGROUND

Stroke survivors face various problems that affect their health-related quality of life (HRQoL). Reduced activities of daily living (ADL) may contribute to post-stroke depression (PSD) and low HRQoL, and depression might be associated with low HRQoL. However, these relationships are not well known. This study aimed to analyze correlations among ADL, PSD, and HRQoL in stroke survivors and further explore the mediating role of PSD between ADL and HRQoL.

METHODS

This study utilized meta-analytic structural equation modeling (MASEM) on systematically searched articles from six electronic databases, namely PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (China), Wanfang database (China), and SinoMed (China), from inception up to July 31, 2021. Two researchers independently assessed study eligibility, and data from the eligible studies were encoded and assessed for quality. MASEM was utilized to examine correlations among ADL, PSD, and HRQoL, with an estimation of a pooled correlation matrix under a random-effects model. The matrix was directly fitted to a structural equation model using webMASEM.

RESULTS

In total, 8580 articles were screened, and data from 27 studies involving 33 effect sizes were used in the MASEM analysis. Correlations among the three variables were significant (both P < 0.01). Furthermore, PSD partially mediated the correlation between ADL and HRQoL (β = 0.24, 95% confidence interval 0.15-0.30).

CONCLUSIONS

The findings suggest that both decreased ADL and PSD may reduce HRQoL, while a decrease in ADL tends to cause depression after stroke. Therefore, ADL and PSD reductions should be improved to achieve better HRQoL of stroke survivors. Future studies should continue to discuss other factors affecting HRQoL to achieve optimal recovery in stroke survivors.

Time-Varying Risk Factors Associated With the Progress of Functional Recovery and Psychological Distress in First-Ever Stroke Patients

ABSTRACT

BACKGROUND: Evaluation of stroke recovery outcome is crucial and a major goal of clinical practice. A recovery trajectory model serves as a prognostic tool that enables development of effective intervention and long-term management to improve poststroke recovery outcomes. This study explored time-varying risk factors associated with the progression of functional recovery and psychological distress poststroke. METHODS: Participants were patients with first-ever stroke who underwent assessment for activities of daily living, psychological distress, and social support at the onset (within 72 hours) and at 1, 3, and 6 months. A generalized estimation equation was used to account for the correlation between the repeated measurements. RESULTS: Of the 101 patients, 60.4% were men, and the mean (SD) age was 63.06 (13.12) years. Over time, the physical functions of patients after stroke significantly increased, and anxiety and depression significantly decreased. Approximately 50% of patients achieved full functional recovery after 6 months. The time-varying risk factors for National Institutes of Health Stroke Scale scores and depression levels affected the trajectory of functional recovery during follow-up. Factors associated with patient anxiety levels were National Institutes of Health Stroke Scale scores and depression levels. Factors associated with patient depression levels included education, anxiety, and social support levels. CONCLUSION: This study demonstrates the progression of time-varying risk factors for functional recovery and psychological distress in patients with first-ever stroke. We recommend that nurses work with patients and their families in the early poststroke stages to identify comprehensive goals based on individual needs and related factors at different stages and that they educate patients on what is required for them to regain independence.

[The effective post-stroke adaptation behavior model requires a family support system]

PURPOSE

This study aimed to explain the effective post-stroke adaptation behavior based on the Roy's adaptation model (RAM) through the patient experiences when undergoing the adaptation process after stroke.

METHODS

This study was qualitative used a phenomenological approach. The participants were patients undergoing post-stroke recovery at home with the following inclusion criteria: post-discharge from the hospital 2-3 months, and in stable medical condition. The data were collected through in-depth interviews. The data analysis was performed through content analysis. We used Lincoln and Guba's criteria to establish the trustworthiness of the study.

RESULTS

Three thematic categories structured the meaning of the stroke survivor's experience: (1) Problems after stroke; (2) Adaptive coping strategies and (3) Effective adaptation response.

CONCLUSION

A thematic analysis integrated with Roy's adaptation model generated an effective post-stroke adaptation model. We recommend the development of a family empowerment intervention framework to improve the adaptation behavior of stroke survivors.

Functional Disability After Ischemic Stroke: A Community-Based Cross-Sectional Study in Shanghai, China

Objective: This study aimed to understand the demographics, functional disabilities, cognitive impairment, and depressive mood among stroke patients and to explore the correlation between functional disability and the other health conditions so as to provide some data for community rehabilitation among stroke patients. Methods: A cross-sectional study was conducted to investigate the functional status of ischemic stroke patients with stroke history between 1 month and 2 years by applying the modified Rankin Scale (mRS). Data were collected during October 2016 and January 2017 from 11 communities in two districts of Shanghai, China. We used face-to-face questionnaire interviews to collect information on sociodemographics, vascular risks associated with stroke, cognitive function [Mini-Mental State Examination (MMSE)], and depression [Patient Health Questionnaire-9 (PHQ-9)]; and we applied SPSS 24.0 for data analysis. Results: In this study, 305 patients with ischemic stroke were finally recruited, including 189 (61.97%) men, with an average age of 67 years. According to the mRS score, ischemic stroke patients were divided into patients without symptoms (controls, mRS = 0), patients without obvious disability (mRS = 1), and patients with mild to severe disability (mRS = 2-5). Ischemic stroke patients with different mRS levels demonstrated significant differences in age, tobacco smoke exposure, previous stroke history, cognitive function, and depression status. Compared with patients without symptoms (mRS = 0), patients with mRS = 1 had a lower MMSE score [odds ratio (OR): 0.48, 95% confidence interval (CI): 0.26-0.90]; and patients with mRS = 2-5 had a lower MMSE score [OR = 0.16, 95% CI: 0.08-0.33], had a higher PHQ-9 score [OR = 5.36, 95% CI: 2.19-13.11], and were more likely to have previous stroke history [OR = 2.18, 95% CI: 1.01-4.79]. Conclusion: Lower degrees of functional independence are related to cognitive impairment, as well as the previous stroke history and depression status.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effective post-stroke adaptation behavior model requires a family support system

PURPOSE

This study aimed to explain the effective post-stroke adaptation behavior based on the Roy's adaptation model (RAM) through the patient experiences when undergoing the adaptation process after stroke.

METHODS

This study was qualitative used a phenomenological approach. The participants were patients undergoing post-stroke recovery at home with the following inclusion criteria: post-discharge from the hospital 2-3 months, and in stable medical condition. The data were collected through in-depth interviews. The data analysis was performed through content analysis. We used Lincoln and Guba's criteria to establish the trustworthiness of the study.

RESULTS

Three thematic categories structured the meaning of the stroke survivor's experience: (1) Problems after stroke; (2) Adaptive coping strategies and (3) Effective adaptation response.

CONCLUSION

A thematic analysis integrated with Roy's adaptation model generated an effective post-stroke adaptation model. We recommend the development of a family empowerment intervention framework to improve the adaptation behavior of stroke survivors.

The impact of availability and identity of the caregiver on the post-stroke patient

Background

After having a stroke, most patients are helped by a caregiver with activities that they cannot perform by themselves. The caregiver presence and actions are an important variable that may affect rehabilitation in many ways. The aim of this review study was to evaluate the impact of caregiver presence (or absence) and identity (spouse, family, or foreign domestic worker) on therapeutic exercise performance, depression symptoms, patient–spouse relations and total functional outcomes of stroke patients. Assessing these effects may help health care professionals and families to prioritise/choose the caregiver for their patient/family member.

Methods

A narrative literature review was conducted, focusing on one-direction effects (caregiver on patient effects) on the topics of interest mentioned, in a post-stroke population. PubMed, CINAHL, PEDro, Trip database, and Google Scholar were searched, and included studies of most designs and research qualities. The search strategy had not been specified before commencing the review. Each study was analysed individually with the purpose of synthesising the available evidence to achieve a greater understanding of this topic.

Results

A total of 17 relevant papers were included: six randomised controlled trials, six observational studies, two systematic reviews, two survey-based studies, and one case series. Trials were consistent with the positive effect that caregivers have on therapeutic exercise performance. Studies have shown a positive effect of caregivers on the patient's depressive symptoms, but only at the chronic phase after stroke. A spouse caregiver seems to more positively affect the patient–spouse relations in the acute phase of rehabilitation, while foreign domestic workers can improve these relations at more chronic phases. The presence of a caregiver is shown to decrease functional outcomes within institutionalised rehabilitation centres, while it is necessary and positively affects functionality at more chronic phases within community settings.

Conclusions

The advantages and disadvantages of employing a caregiver depend in many cases on the rehabilitation phase. The caregiver might be beneficial or harmful to the patient's functional progress, depressive symptoms and marital relationship depending on the rehabilitation phase. More studies are needed to assess the caregiver effects on post-stroke patients' rehabilitation and quality of life.

PREDICTORS OF EARLY-ONSET DEPRESSION AFTER FIRST-EVER STROKE

Post-stroke depression (PSD) is a severe and frequent stroke complication and one of the crucial factors for the outcome of rehabilitation and life quality after stroke. However, mood disorders frequently remain unnoticed and therefore untreated. The aim of the study was to examine all the potential risk factors and determine the independent predictors of early-onset depression after first-ever stroke, which would help identify high-risk patients, establish early diagnosis and timely treatment that would improve the course and prognosis of this disorder. This prospective study included 60 patients treated for their first-ever stroke; there were 30 patients diagnosed with depression and 30 patients without depression. The study included collection and analysis of all socio-demographic and clinical risk factors for PSD. Testing was performed two weeks after stroke. Depression was diagnosed according to the Mini International Neuropsychiatry Interview, DSM-IV diagnostic criteria, and depression severity was quantified by the Hamilton Depression Rating Scale. Cognitive impairment was assessed by the Mini Mental State Examination. Neurological deficit was assessed by the US National Institute of Health Stroke Scale. Our results showed that the independent predictors of early-onset depression after stroke were previous depressive episodes, cognitive dysfunction, and more severe neurological deficit.