Depressed Stroke Patients Research Articles

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

BackgroundEmotion processing deficits are known to accompany depressive symptoms and are often seen in stroke patients. Little is known about the influence of post-stroke depressive (PSD) symptoms and specific brain lesions on altered emotion processing abilities and how these phenomena develop over time. This potential relationship may impact post-stroke rehabilitation of neurological and psychosocial function. To address this scientific gap, we investigated the relationship between PSD symptoms and emotion processing abilities in a longitudinal study design from the first days post-stroke into the early chronic phase. MethodsTwenty-six ischemic stroke patients performed an emotion processing task on videos with emotional faces ('happy,' 'sad,' 'anger,' 'fear,' and 'neutral') at different intensity levels (20%, 40%, 60%, 80%, 100%). Recognition accuracies and response times were measured, as well as scores of depressive symptoms (Montgomery-Åsberg Depression Rating Scale). Twenty-eight healthy participants matched in age and sex were included as a control group. Whole-brain support-vector regression lesion-symptom mapping (SVR-LSM) analyses were performed to investigate whether specific lesion locations were associated with the recognition accuracy of specific emotion categories. ResultsStroke patients performed worse in overall recognition accuracy compared to controls, specifically in the recognition of happy, sad, and fearful faces. Notably, more depressed stroke patients showed an increased processing towards specific negative emotions, as they responded significantly faster to angry faces and recognized sad faces of low intensities significantly more accurately. These effects obtained for the first days after stroke partly persisted to follow-up assessment several months later. SVR-LSM analyses revealed that inferior and middle frontal regions (IFG/MFG) and insula and putamen were associated with emotion-recognition deficits in stroke. Specifically, recognizing happy facial expressions was influenced by lesions affecting the anterior insula, putamen, IFG, MFG, orbitofrontal cortex, and rolandic operculum. Lesions in the posterior insula, rolandic operculum, and MFG were also related to reduced recognition accuracy of fearful facial expressions, whereas recognition deficits of sad faces were associated with frontal pole, IFG, and MFG damage. ConclusionPSD symptoms facilitate processing negative emotional stimuli, specifically angry and sad facial expressions. The recognition accuracy of different emotional categories was linked to brain lesions in emotion-related processing circuits, including insula, basal ganglia, IFG, and MFG. In summary, our study provides support for psychosocial and neural factors underlying emotional processing after stroke, contributing to the pathophysiology of PSD.

Thrombolytic therapy in ischemic stroke patients with pre-stroke depression in the telestroke vs non-telestroke

Background and PurposeThrombolysis therapy remains the gold standard in acute ischemic stroke treatment, and rates of treatment with rtPA in ischemic stroke patients with comorbid depression has yet to be fully investigated. This study aims to examine clinical risk factors associated with inclusion or exclusion for rtPA in acute ischemic stroke populations with pre-stroke depression in the telestroke versus a non-telestroke setting. MethodsWe collected retrospective data from a regional stroke registry for pre-stroke depressed ischemic stroke patients from January 2010 to June 2016. Logistic regression was used to determine demographic and baseline clinical risk factors associated with inclusion and exclusion from rtPA. Results. In the adjusted analysis, increasing age (OR = 1.064, 95% CI, 1.006-1.125, P = 0.029), improved ambulation (OR = 3.513, 95% CI, (0.855–14.436, P = 0.018) and sleep apnea (OR = 4.458, 95% CI, 0.731–27.182, P = 0.05) were associated with inclusion for rtPA, while Caucasian race (OR = 0.119, 95% CI, 0.0168–0.908, P = 0.040), systolic blood pressure (OR = 0.945, 95% CI, 0.906–0.985, P = 0.008), and direct admission (OR = 0.028, 95% CI, 0.003–0.317, P = 0.004) were associated with exclusion from rtPA. In the telestroke setting, INR (OR = 1.016, 95% CI, 0–5.393, P = 0.163) was not significantly associated with rtPA inclusion or exclusion. ConclusionIdentifying contraindicators associated with exclusion from rtPA is significant to improve the use thrombolytic therapy in the telestroke and non telestroke settings.

Percutaneous mastoid electrical stimulator improves Poststroke depression and cognitive function in patients with Ischaemic stroke: a prospective, randomized, double-blind, and sham-controlled study

BackgroundPoststroke depression can lead to functional dependence, cognitive impairment and reduced quality of life. The aim of this study was to evaluate the effects of a percutaneous mastoid electrical stimulator (PMES) plus antidepressants on poststroke depression and cognitive function.MethodsThis study was a prospective, randomized, double-blind, and sham-controlled study. A total of 258 clinically depressed ischaemic stroke patients within 14 days of index stroke were randomly assigned to the PMES plus antidepressant (PMES group, N = 125) and sham plus antidepressant (sham group, N = 133) groups. All patients underwent the Montreal Cognitive Assessment (MoCA) and Hamilton Rating Scale for Depression (HRSD) test at 2 weeks (baseline), and 6 months(M6) after ischaemic stroke. Primary outcomes were the percentage of patients showing a treatment response (≥50% reduction in HRSD score) and depression remission (HRSD score ≤ 9) at 6 months. The secondary outcome was the percentage of patients with a MoCA score < 26.ResultsThe percentages of patients showing a treatment response and depression remission were significantly higher in the PMES group than in the sham group (57.60% vs 41.35%, P = 0.009; 44.00% vs 29.32%, P = 0.014 respectively). The mean value of the HRSD score change [M (month)6-baseline] was significantly higher in the PMES group than in the sham group at 6 months (− 11.93 ± 5.32 vs − 10.48 ± 6.10, P = 0.036, respectively). The percentage of patients with MoCA scores < 26 was lower in the PEMS group than in the sham group (12.0% vs 24.06%, P = 0.012,respectively), and the mean value of the MoCA score change (M6-baseline) was higher in the PMES group than in the sham group (3.50 ± 2.55 vs 2.72 ± 2.52, P = 0.005, respectively).ConclusionThese findings demonstrate that PMES adjunctive to antidepressant therapy is effective in reducing depression, achieving remission in the short term, and improving cognition.Trial registrationThis trial was retrospectively registered (registration number: ChiCTR1800016463) on 03 June 2018.

Abstract TMP56: Are Depressed Stroke Survivors Less Likely to Be Adherent to Secondary Prevention Therapies?

Introduction: Depression is common after ischemic stroke (IS). Stroke survivors who are depressed are at greater risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. However, how depression leads to poor IS outcomes is unclear and few studies have shown an association between depression after stroke and healthcare use. Objective: To evaluate the impact of depression on medication adherence after stroke. Methods: We analyzed the multicenter database comprising information drawn from electronic medical records and pharmacy records (Healthconnect, POINT). All ischemic stroke patients presenting to one of 11 medical centers within a health maintenance organization in California between January 1, 2007 and June 30, 2015 with at least 2 medication fills for a stroke prevention medication and six months of information were evaluated. Adherence was calculated for antihypertensive, hypoglycemic, and lipid lowering medications, but not for antiplatelet or anticoagulant medications as the latter may be obtained over the counter, or with variable daily dosing, which would bias adherence calculations. Adherence was calculated by using the continuous medication gap (CMG) methodology, which determines the cumulative period that no medication was available to the patient. The number of days for which the patient did not have the medication was divided by the number of days in the study window for that patient. Results: There were 9933 patients with ischemic stroke during the study period. Of these, 2019 had a diagnosis of depression made after the index stroke. Among the non-clinically depressed patients the CMG adherence was 0.22 (Standard Deviation +/- 0.29), while among clinically depressed patients it was 0.28 (SD +/-0.32, p&lt;0.0001). Conclusions: Ischemic stroke survivors diagnosed with depression after an index stroke are overall 26% less likely to be adherent to key secondary prevention drugs than their non-depressant counterparts. Poor medication adherence among depressed stroke patients may be an important contributor to their relatively poorer clinical outcomes.

An analysis of depressive symptoms in stroke survivors: verification of a moderating effect of demographic characteristics

BackgroundThe rehabilitation of depressed stroke patients is more difficult because poststroke depression is associated with disruption of daily activities, functioning, and quality of life. However, research on depression in stroke patients is limited. The aim of our study was to evaluate the interaction of demographic characteristics including gender, age, education level, the presence of a spouse, and income status on depressive symptoms in stroke patients and to identify groups that may need more attention with respect to depressive symptoms.MethodsWe completed a secondary data analysis using data from a completed cross-sectional study of people with stroke. Depression was measured using the Center for Epidemiologic Studies Depression Scale.ResultsIn this study, depressive symptoms in women living with a spouse were less severe than among those without a spouse. For those with insufficient income, depressive symptom scores were higher in the above high school group than in the below high school group, but were lower in patients who were living with a spouse than in those living without a spouse.ConclusionAssessing depressive symptoms after stroke should consider the interaction of gender, economic status, education level, and the presence/absence of a spouse. These results would help in comprehensive understanding of the importance of screening for and treating depressive symptoms during rehabilitation after stroke.

Efficacy of antidepressants in animal models of ischemic stroke: a systematic review and meta-analysis.

Poststroke depression is a prevalent complication of stroke with unclear pathogenesis. The benefits of antidepressants in this context and their effects on stroke recovery other than effects on mood are not clearly defined, with some studies suggesting efficacy in improving functional outcome in both depressed and nondepressed stroke patients. We have analyzed the preclinical animal data on antidepressant treatment in focal cerebral ischemia, modeled±depression, to help inform clinical trial design. We performed a systematic review and meta-analysis of data from experiments testing the efficacy of antidepressants versus no treatment to reduce infarct volume or improve neurobehavioral or neurogenesis outcomes in animal models of stroke. We used random-effects metaregression to test the impact of study quality and design characteristics and used trim and fill to assess publication bias. We identified 44 publications describing the effects of 22 antidepressant drugs. The median quality checklist score was 5 of a possible 10 (interquartile range, 4-7). Overall, antidepressants reduced infarct volume by 27.3% (95% confidence interval, 20.7%-33.8%) and improved neurobehavioral outcomes by 53.7% (46.4%-61.1%). There was little evidence for an effect of selective serotonin reuptake inhibitors on infarct volume. For neurobehavioral outcomes there was evidence of publication bias. Selective serotonin reuptake inhibitors were the most frequently studied antidepressant subtype and improved neurobehavioral outcome by 51.8% (38.6%-64.9%) and increased neurogenesis by 2.2 SD (1.3-3.0). In line with current clinical data and despite some limitations, antidepressant treatments seem to improve infarct volume and neurobehavioral outcome in animal models of ischemic stroke.

Abstract WP326: Randomized-Controlled Study on the Effects of Hand Bathing on Stroke Patients in Convalescence - Subjective Improvements in Hand Movement and Increased Positiveness in Talking

Background and Purpose: Depressed stroke patients are more likely to drop out of rehabilitation. Hand bathing is a term used to describe a uniquely Japanese hygiene care in which a nurse washes and stimulates the patient’s hands in warm water while talking to each other. The purpose of this study was to verify, by a randomized-controlled study, the hypothesis indicated in the author’s preliminary studies that hand bathing makes stroke patients more conscious of their hand movement on the affected side and talk more positively. Methods: Stroke patients in convalescent phase in the Brunnstrom stages I to V were randomly allocated to the hand-bathed group (23 patients) or the control (21 patients). Both groups received a 15-minute intervention four times within a week. Before and after each intervention, the visual analogue scale (VAS) was assessed for hand movement, edema, and numbness/pain, the tip palm distance was measured, and the QOL was assessed using the QUIK-R. The t-test and repeated measures ANOVA were used to analyze the data. A verbatim record of all conversation was subjected to morphological analysis, TF-IDF, and TF analysis of nouns and adjectives. Results: The hand-bathed group felt improved hand movement significantly more after the first and fourth interventions (F=4.41,p=.013). No significant difference was detected between the two groups in the VAS for edema, numbness/pain, and heavy feeling in hands. Positive adjectives were used more often by the hand-bathed group after the second, third and fourth interventions (F=3.58, p=.016). In the hand-bathed group, the average score of QOL questions on socializing and sense of contentment/well-being improved significantly after interventions (p=.003) Conclusions: The finding supported the said hypothesis in that hand bathing leads to subjective improvement in hand movement of stroke patients in convalescent phase and makes them talk more positively. It has additionally been indicated that hand bathing also helps them become more sociable and have a better sense of contentment and well-being.

Depression Increases Stroke Hospitalization Cost: An Analysis of 17,010 Stroke Patients in 2008 by Race and Gender

Objective. This analysis focuses on the effect of depression on the cost of hospitalization of stroke patients. Methods. Data on 17,010 stroke patients (primary diagnosis) were extracted from 2008 Tennessee Hospital Discharge Data System. Three groups of patients were compared: (1) stroke only (SO, n = 7,850), (2) stroke + depression (S+D, n = 3,965), and (3) stroke + other mental health diagnoses (S+M, n = 5,195). Results. Of all adult patients, 4.3% were diagnosed with stroke. Stroke was more prevalent among blacks than whites (4.5% versus 4.2%, P < 0.001) and among males than females (5.1% versus 3.7%, P < 0.001). Nearly one-quarter of stroke patients (23.3%) were diagnosed with depression/anxiety. Hospital stroke cost was higher among depressed stroke patients (S+D) compared to stroke only (SO) patients ($77,864 versus $47,790, P < 0.001), and among S+D, cost was higher for black males compared to white depressed males ($97,196 versus $88,115, P < 0.001). Similar racial trends in cost emerged among S+D females. Conclusion. Depression in stroke patients is associated with increased hospitalization costs. Higher stroke cost among blacks may reflect the impact of comorbidities and the delay in care of serious health conditions. Attention to early detection of depression in stroke patients might reduce inpatient healthcare costs.

Abstract P32: Potential Underuse of Antidepressants in Post Stroke Depression: Data From the AVAIL Registry

Background: Post-stroke depression is common, yet little is known about factors associated with antidepressant use in this population Methods: Data from the multicenter, prospective Adherence eValuation After Ischemic stroke-Longitudinal (AVAIL) registry was used to identify patients with post-stroke depression and to describe factors associated with antidepressant use. The analysis was performed after 3 months in 1751 ischemic stroke patients who had been admitted to 97 hospitals nationwide; 12 month follow-up was available for 1637 patients. The Get with the Guidelines-Stroke database was used to collect baseline data. Patients were classified as depressed based on a self-report scale (the Patient Health Questionnaire-8; score range 0 to 24, score ≥10 indicating depression). Frequencies were compared with Pearson X 2 and unadjusted ORs were calculated. Results: The prevalence of post stroke depression was similar at 3 and 12 months (19% [331/1751] vs 17% [280/1637], respectively, p=0.17). Regardless of depression status, antidepressant use was higher at 12 months (16% [287/1751] vs 20% [334/1637], p=0.002). Antidepressant use was also higher at 12 months in depressed patients (25% [84/331] vs 35% [98/280], p=0.009). The odds of antidepressant use at 3 months was higher in women than men (OR 1.6, 95% CI 1.2-2.1), Whites vs. Blacks (OR 1.7, 95% CI 1.1-2.8), in patients with vs. without cognitive deficits (OR 1.6, 95% CI 1.2-2.1) and in those with more severe disabilities (mRS≥3 vs. mRS&lt;3, OR 1.7, 95% CI 1.3-2.3). Use did not vary with educational level, marital status, living situation, medication insurance coverage, or stroke recurrence. Similar trends were present at 12 months, except with higher use in those with recurrent stroke or TIA (OR 2.1, 95% CI 1.4-3.1). Conclusion: Three-quarters of depressed stroke patients at 3-months and nearly two-thirds at 12 months were not receiving antidepressants. Regardless of depression status, utilization of antidepressants after 3 and 12 months varied based on gender, race/ethnicity, cognitive status, disability level, and after 12-months, stroke recurrence. The reasons for the apparent underuse of antidepressants in patients with prevalent post-stroke depression require further study.

A Study of Suicidal Thoughts in Acute Stroke Patients

In previous studies, suicidal thoughts in stroke patients were related to depression and recurrent stroke. The aim of this study was to describe the presence and correlates of suicidal thoughts in acute stroke patients. We assessed the presence of suicidal thoughts in a sample of 177 consecutive acute stroke patients (≤ 4 days), using the item "suicidal thoughts" of the Montgomery and Asberg Depression Rating Scale. Fifteen percent of acute stroke patients had suicidal thoughts, 22% of them with explicit plans to complete suicide. Suicidal thoughts were more frequent in patients with a lower educational level (Chi-square 4.69; P = .05), previous mood disorder (Chi-square 12.80; P = .001), diabetes (Chi-square 5.48; P = .04), and acute depression (Chi-square 16.59; P = .001). In logistic regression, a lower educational level (odds ratio [OR] 5.13; 95% confidence interval [CI] 0.80-33.29), diabetes (OR 3.15; 95% CI 0.81-12.28), a previous mood disorder (OR 4.22; 95% CI 1.12-15.86), and depression (OR 7.82; 95% CI 1.58-38.71) were independent factors predicting suicidal thoughts (R(2) = 0.39%). The 23 depressed acute stroke patients with suicidal thoughts were similar in demographic, clinical, and lesion variables, and were similar in profile of depression to the 63 patients with depression but without suicidal thoughts, except for a higher frequency of a previous mood disorder in the former group (Chi-square 7.87; P = .01). Suicidal thoughts may develop shortly after the onset of acute stroke, especially in patients with a lower educational level, a previous mood disorder, and those who developed depressive symptoms in the acute phase of stroke. The high frequency of suicidal thoughts makes the assessment of suicidal behavior in patients with acute stroke an important clinical issue.

Assessing the cognitive regulation of emotion in depressed stroke patients

This study evaluated the psychometric properties of a simple scale for measuring positive interpersonal attitudes of depressed stroke patients, with regard to their cognitive limitations. Two versions of the Attitudes Towards Relationships Scale were developed and administered to depressed stroke (n = 48) and control rheumatic/orthopaedic (n = 45) patients during a study that investigated the relationship between mood state, interpersonal attitudes and psychological distress. Both versions produced homogeneous results and showed acceptable concurrent validity, test-retest reliability, internal consistency and measurement specificity. A principal component analysis produced a three-factor structure highlighting the importance of attitudes towards future interpersonal relationships. These results suggest that the Attitude Towards Relationships Scale may be a psychometrically sound measure that shows some potential as a therapeutic measure of progress in stroke and other comparable samples.

Little evidence for different phenomenology in poststroke depression

It remains unclear whether mood depressive disorders after stroke have a distinct phenomenology. We evaluated the symptom profile of poststroke depression (PSD) and assessed whether somatic symptoms were reported disproportionately by stroke patients. The sample was 149 stroke patients at 18 months poststroke and 745 age- and sex-matched general population controls. A comprehensive psychiatric interview was undertaken and depression was diagnosed according to DSM-III-R criteria. Depressed controls reported more 'inability to feel' (P = 0.002) and 'disturbed sleep' (P = 0.008) than depressed stroke patients. Factor analysis of the 10 depressive symptoms identified two main factors, which appeared to represent somatic and psychological symptoms. There was no difference in scores on these two factors between stroke patients and controls. Phenomenology of depression at 18 months poststroke is broadly similar but not the same as that described by controls. Somatic symptoms of depression were not over-reported by stroke patients.

The relationship between mood state, interpersonal attitudes and psychological distress in stroke patients

This study investigated whether increasing positive mood improved interpersonal attitudes and relieved depression in depressed stroke patients despite levels of cognitive and emotional dysfunction. Depressed stroke (n = 30) and rheumatic/orthopaedic controls (n = 30) were compared on the effect of verbal and nonverbal positive and neutral mood induction on mood state, interpersonal attitudes, psychological distress and related cognitive and emotional processing deficits. Compared with the neutral mood induction condition, the positive mood induction significantly improved mood state, interpersonal attitudes and psychological distress, irrespective of cognitive and emotional processing deficits. The nonverbal material was effective for all patients but was more marked for the left hemisphere stroke group. There was no obvious influence of humour appreciation despite reduced understanding in the right hemisphere stroke group. Although the effect is likely to be short-lived, these results support the trial of positive mood induction within therapy programmes to relieve depression.

The symptomatology of post‐stroke depression: comparison of stroke and myocardial infarction patients

Depression is a frequent problem in stroke patients but, all too often, the problem goes unrecognized. How depression-like symptoms in post-stroke depression (PSD) should be interpreted is still subject to debate. If PSD has a distinct symptom profile of depression accompanying other chronic vascular somatic conditions then this could imply that PSD is a specific disease entity. To study whether depressed stroke patients exhibit other signs and symptoms than patients suffering from depression after myocardial infarction (MI). Depressive signs and symptoms were measured using the Hospital Anxiety and Depression Scale and the 17-item Hamilton Depression Rating Scale. The results of 190 stroke patients were compared with the results of 198 MI patients every 3 months during the first year after the event. Depressed stroke patients exhibited more loss of interest, psychomotor retardation, and gastro-intestinal complaints as compared to depressed MI patients. However, in multivariate analyses including both depressed and non-depressed stroke and MI patients, no specific symptom profile was found to differentiate between the two depressive syndromes by looking at the modifying effect of stroke vs MI on the occurrence of specific symptoms in depression. Although in their clinical presentation, depressed stroke patients exhibit a symptom profile different from depressed MI patients, this is not due to differences in the depressive syndrome in these two patient groups but it reflects differences between stroke and MI patients in general.

Predictors of life situation among significant others of depressed or aphasic stroke patients

The aim of this study was to examine predictors of the life situation of the significant other of depressed or aphasic stroke patients. Depression and aphasia are common consequences of stroke, and both may put pressure on the significant other who have to deal not only with a possible physical handicap but also with communication and/or serious psychiatric difficulties. Descriptive, cross-sectional study. The participants were significant others of 71 depressed and 77 aphasic stroke patients. Depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorder, and degree of aphasia was diagnosed with the Amsterdam Nijmegen Everyday Language Test. Assessments of the life situation, state of depression and aggression, personality change and need of assistance were made through questionnaires issued to the significant others. Perceived need of assistance was the only common predictor of life situation of the significant other in both groups (p < 0.001). With respect to the aphasic patients, perceived personality change (p < 0.001) and living with the patient (p = 0.004) were factors that had a negative effect on the life situation of the significant other. This study highlights that the perception of the patient's need of assistance is an important factor in predicting the life situation among spouses of depressed as well as aphasic stroke patients. A comparison of the two groups to explain the life situation of the significant others revealed greater explanatory power for the aphasic group. Assessments of the spouses' perception as well as of the patients' factual situation may identify those significant others at risk. With this new approach, necessary steps may be taken to alleviate pressure on the significant other.

Depression and cognitions after stroke: Validation of the Stroke Cognitions Questionnaire Revised (SCQR)

Purpose. The Stroke Cognitions Questionnaire Revised (SCQR) was developed to assess the frequency of positive and negative cognitions of stroke patients. This paper aims to examine the construct validity, internal consistency, test – retest and inter-rater reliability of the SCQR.Method. The SCQR was constructed by revising the Stroke Cognitions Questionnaire and developing new items from the cognitive-behavioural-therapy treatment notes of depressed stroke patients. Fifty hospitalised stroke patients were assessed on the SCQR and the Beck Depression Inventory II. Test – retest reliability over a 1-week interval and inter-rater reliability were evaluated with the first 20 patients.Results. Total scores on the SCQR and the total number of positive and negative cognitions reported were significantly correlated with scores on the Beck Depression Inventory II (r = 0.54 – 0.80, p < 0.001). The scale had high internal consistency (Cronbach's alpha coefficient of 0.91). Depressed patients reported significantly more negative cognitions and significantly less positive cognitions than those not depressed. Excellent agreement was found between two raters for all items on the SCQR (Kappa 0.89 – 1.00), and test – retest reliability was also good (r = 0.81, p < 0.001).Conclusions. The SCQR is a reliable and valid measure of cognitions relevant to stroke patients. The pattern of cognitions was similar to that found in primary depression (more negative and less positive cognitions), suggesting that therapies developed from the cognitive model of depression may be appropriate for stroke patients.

A pilot study to describe antidepressant prescriptions dispensed to veterans after stroke

Background Stroke is the third leading cause of death in the United States, following only heart disease and cancer. Approximately 500 000 strokes occur each year in the United States. Patients suffering from poststroke depression have higher rates of morbidity and mortality, slower physical recovery, and lower functional status than stroke patients without depression. Depressed stroke patients may benefit from early treatment with an antidepressant. Objectives The objectives of this study were to (1) describe antidepressant-dispensing patterns to veteran patients during the 6-month period before their stroke and 1-year time afterward and (2) examine the association of poststroke antidepressant treatment with mortality. Methods Veteran patients (n = 543) with one or more hospital discharges during FY2001 with a primary diagnosis of stroke were identified. The discharge date minus the length of stay indicated the index hospitalization date. Antidepressant prescription dispensing records were obtained from the Veterans Integrated System Network 8 Veteran's Affairs (VA) Pharmacy Benefits Management database. Results One-third of eligible veteran patients were dispensed one or more antidepressant prescriptions (n = 181) either before or after the index hospitalization. Of these veterans, 146 received an antidepressant after the index hospitalization. More than 80% of veteran patients survived the stroke for 1 year or longer (n = 448). Among the veteran patients who were discharged from the index hospitalization alive, those with no antidepressant or an antidepressant dispensed only before the stroke had a higher 1 year all cause mortality rate (8.0%) compared with those who were dispensed a prescription for one or more antidepressants afterward (4.8%). Conclusions Veterans dispensed an antidepressant after their stroke appeared to have benefited. Opportunities to reduce poststroke sequelae and improve recovery may be lost.

Factors relating to depression after stroke

Depression is common after stroke and can impede rehabilitation. The aim of this study was to determine which factors predicted the severity of depression at the time of recruitment to a treatment study and depression 6 months later. A questionnaire-based longitudinal study. A total of 123 depressed stroke patients who were between 1 and 6 months post-stroke and had mild to moderate disabilities were recruited to a randomized controlled trial of cognitive behavioural psychotherapy (CBT) to treat depression (Lincoln & Flannaghan, 2003). At recruitment and at 6 months follow-up, patients (N=112) were assessed on the Beck Depression Inventory (BDI), General Health Questionnaire-28 (GHQ-28), Wakefield Depression Inventory (WDI), Barthel index, Extended activities of daily living scale (EADL), Sheffield Screening Test for Acquired Language Disorders (SST) and Recovery locus of control scale (RLOC). Logistic regression showed that greater communication impairment on the SST at recruitment was predictive of severe depression on the BDI at recruitment (OR=0.72, p=.01). Patients with greater communication impairment (OR=0.69, p<.05) and a more external locus of control (OR=0.89, p<.05) at recruitment were more likely to remain depressed at follow-up. Patients who remained depressed at follow-up were more severely depressed at recruitment (p=.001). Locus of control and communication impairment were related to depression. Communication impairment was the strongest predictor of depression severity and prognosis. Mild depression was more likely to resolve. The regression models only accounted for a small proportion of the variance in depression scores. Therefore, further studies of psychosocial factors in a more representative sample are required.

Depresión postictus (II). Diagnóstico diferencial, complicaciones y tratamiento

Post-stroke depression (PSD) is the most frequent neuropsychiatric condition after a stroke. We review the differential diagnosis of PSD, PSD complications and the different therapeutic approaches to PSD.Differential diagnosis includes post-stroke fatigue and the pseudo-depressive manifestations of strategic infarctions (apathy, aprosody, lack of self psychic activation syndrome, pathological crying syndrome). Functional and cognitive complications of untreated PSD can be observed. Mortality in depressed stroke patients has been estimated between 3.5 and 10 times higher than in non depressed stroke patients; suicide ideation can be observed in 11.3% of stroke patients. Clinical trials controlled with placebo have shown the efficacy of fluoxetine, nortriptiline, trazodone and citalopram in the treatment of PSD. Other therapeutic approaches include cognitive and functional rehabilitation.PSD is a potentially treatable condition, infra-diagnosed, that has a negative effect on cognitive function, functional recovery and survival in stroke patients. State of the art of PSD pharmacological treatment are selective serotonin reuptake inhibitors. However, there are no data showing neither superiority of one specific drug nor the best moment to start treatment.

A Comparison of Depressive Symptoms in Stroke and Primary Care: Applying Rasch Models to Evaluate the Center for Epidemiologic Studies-Depression Scale

Objectives Clinical trials and community-based studies often include the Center for Epidemiologic Studies-Depression scale (CES-D) as a measure of depression outcome. We compared responses to symptom-related items on the CES-D by depressed stroke and primary-care patients for several purposes: 1) to illustrate the use of Item Response Theory (IRT)-based (Rasch) models for comparing scale functioning across different patient subgroups; and 2) to inform clinicians and outcome researchers about scale functioning and depressive symptomatology in stroke- compared with primary care-based depression. Methods Two data sources were analyzed, including 32 depressed patients who were 3 months poststroke, and 366 depressed primary-care patients. Presence of depression was based on a CES-D score 16 or higher. Rasch models were used to assess item fit and compare item hierarchies between depressed primary-care and stroke patients. Results Item hierarchies were similar for poststroke depression and primary care-based depression. Interpersonal disruption items were the most difficult to endorse for both groups. No items misfit the scale in primary-care depression. Items relating to restless sleep, unfriendliness, and crying slightly misfit the scale in stroke patients, that is, may measure a different trait. Differential item functioning (DIF) between the groups was identified for items relating to appetite, restless sleep, crying, and feeling disliked. Conclusions Results generally supported the use of the CES-D as measure of depression outcome, particularly in primary care-based depression. DIF may imply that slightly different clusters of depressive symptoms are reported by depressed stroke patients compared with primary care, but this is conjectural given the small stroke sample size and the same items have been previously associated with bias in studies of large nonstroke samples. This study found Rasch models to be useful tools to investigate scale performance for different clinical applications.