Vasileios-Arsenios Lioutas, MD
Depression is a well known post-stroke complication. What predicts development of depression in an individual patient is less well understood. In this interesting study, Dr. van Ginkel et al. attempt to develop a predictive model that will allow in-hospital identification of patients that will later develop depression.
To briefly describe the study methodology, a number of clinical (mainly stroke-related) and socio-demographic factors were recorded within the first post-stroke week and before patient’s discharge. Sociodemogrpahic factors included marital status and perceived level of social support. Subsequently, diagnosis of depression was made in the 6th-8th post stroke week. The prediction model was then internally validated.
As one would perhaps intuitively expect, past history of depression was strongly associated with post-stroke depression (OR 7.22). Angina pectoris showed a positive and hypertension an inverse association, although clearly no causative implications can be made on the basis of this study only. One interesting fact that emerged was the strong association of the “Dressing” element of Barthel Index with subsequent development of depression: Patients completely dependent on others’ help were more likely to be depressed in follow up (OR 1.57 but with CI 0.80-3.09) and more importantly, those needing only partial help were much less likely to develop depression (OR 0.26, CI 0.08-0.82). Although it is difficult to know whether there is a neurobiologic underpinning, it seems plausible from a purely psychologic standpoint that the subjective feeling of “helplessness” in performing such a rudimentary daily task plays a significant role in developing post-stroke depression.
The study has several limitations: Only communicative patients were included, therefore the sample is not accurately representative of the whole spectrum of a stroke patient population. Although internally validated, rigorous external validation is necessary to further assess its utility and explore its generelizability. It would be interesting to include the stroke location in the model, as it is very likely that certain brain areas are more strongly associated with post-stroke than others. Lastly, it would be interesting to alter the time-point at which diagnosis was made – perhaps choosing a later time (eg 10-12 weeks or later) would yield different results.
I agree that post stroke depression represents common, yet often unrecognized complication of stroke.
Continuous research on early recognition and treatment of post stroke depression is encouraging, yet we have to face some unexpected facts;
There is still no standardized tools (test) for cognitive or mood assessment after the stroke
Numerous studies have linked premorbid depression, young age and physical limitations with the post-stroke depression. (please keep in mind that some other neurologic, very disabling conditions, do not pose increased incidence of depression compared to the general population ie. ALS). Oddly, location or size of stroke are not predictive of depression.
Post stroke depression is mainly studied by psychiatrist. We, as stroke community have to do much better job in early recognition and treatment of post stroke depression and I support every effort that addresses this issue.
Our CNS was just telling me how the HADS scale that they have piloted to assess our in house patients isn't working so well. So if there's any other novel in hospital screening tools for post stroke depression, I'm all ears. otherwise perhaps we need to develop a better instrument. this tool has some promise but the limitations of communication, and history of prior dx of psych disorder I find quite limiting.
since i am doing a thesis work on this topic i had collected some information on evaluation of post stroke depression.i came across 2 studies which shows patient health care questionairre -9 (PHQ9) superior to Hamilton,Barthel,k-10,Phq2. Any comments on these studies.Phq-9 based on DSM-4 criteria.Refer:Stroke. 2012; 43: 1000-1005
Published online before print February 23, 2012, doi: 10.1161/
STROKEAHA.111.643296
for corelation between stroke lesion and post stroke depression refer to this study:The World Journal of Biological Psychiatry, 2011; 12: 539–548Stroke lesion in cortical neural circuits and post-stroke incidence
of major depressive episode: A 4-month prospective study
LUISA TERRONI 1 , EDSON AMARO JR 2 , DAN V. IOSIFESCU 3 , GISELA TINONE 4 ,
JO Ã O RICARDO SATO 5 , CLAUDIA COSTA LEITE 2 , MATILDES F. M. SOBREIRO 6 ,
MARA CRISTINA SOUZA LUCIA 7 , MILBERTO SCAFF 4 & REN É RIO FR Á GUAS 8
1
PSD is my thesis topic and i have done some review of literature on this topic. i agree it is very difficult to recognise post stroke depression early. however i came across a study which had one convincing point.This study pointed out that dependency on others post stroke is a significant risk factor for post stroke depression.Also when it comes to localisation we can say that left sided strokes are more commonly associated with depression because of its association with aphasia.