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A clinical depression is a syndrome or constellation of signs
or symptoms beyond a normal reaction to life's difficulties.
Depression after stroke continues to be largely unrecognized and frequently untreated. (rates of recognition and treatment <10%)
I. Implications of depression for rehabilitation
In inpatient rehabilitation, depressed patients tend to use the
rehabilitation program less effectively, making less progress,
to have longer lengths of stay, to be less compliant with program
demands, and to minimize their depression. On discharge and follow-up,
depressed patients tend to leave the house less often, to remain
more passive in their recreational pursuits, to report less satisfaction
with leisure time activities, and to report reduced social contacts.
Patients with diagnoses of either major or minor depression were
3.4 times more likely to have died at 10-year follow-up than were
nondepressed patients, and this relationship was independent of
other measured risk factors such as age, sex, social class, type
of stroke, lesion location. and level of social functioning.
II. Incidence: 11-75%. (10-27% major depression, 15-40%
minor depression within 2 months after a stroke) --- In medical
rehabilitation settings, the figures fall toward the upper end
of the range.
Robinson et al: Depression is more frequent in left hemisphere stroke, particularly those that occur closer to the frontal pole.
Multiple studies were unable to find differences between patients with left or right hemisphere lesions.
III. Assessment of depression
DSM-III, IIIR; with scores derived from self-reports (Geriatric
Depression Scale, The Beck Depression Inventory, The Zung Self-Rating
Depression Scale), ratings on clinical examination (Hamilton Rating
Scale, Schedule of Affective Disorders and Schizophrenia-SADS,
The Structured Assessment of Depression in Brain Damaged Individuals-SADBD).
The assessment of depression in stroke remains problematic. There
is no consensus or "gold standard" for diagnosing depression
in the setting of a recent stroke.
1) Concerns that the criteria may not be valid.
2) Diagnostic confounders.
Standardized measures of depression have been based on data gathered
from psychiatric or normal populations where there might be expected
to be a high degree of reliance on the verbal report.
Dexamethasone suppression test (DST)- failure to suppress serum cortisol below 5 ug/ml following 1 mg of dexamethasone.
* When there is no standard for diagnosis, there can be no truly
valid study of a diagnostic test. Problem: high false positives.
The false positive DST increases with increasing lesion volume.
IV. Treatment
- Educational counseling.
- Psychotherapy.
- Pharmacological approaches:
2) Diller L, Bishop DS: Depression and stroke. Top Stroke Rehaibil 2(2):44-55, 1995
3) Black KJ: Diagnosing depression after stroke. Southern Medical Journal 88(7):699-708, 1995.
4) Ramasubbu R, Kennedy SH: Factors complicating the diagnosis of depression in cerebrovascular disease, part I- phenomenological and nosological issues. Can J Psychiatry 39(10):596-600.
5) Ramasubbu R, Kennedy SH: Factors complicating the diagnosis of depression in cerebrovascular disease, part II-neurological deficits and various assessment methods, Can J Psychiatry 39(10):601-607.
6) Berk SN, Schall RR: Psychosocial factors in stroke rehabilitation. Physical Medicine and Rehabilitation Clinics of North America 2(3):549-551, 1991.
7) Morris PPL, Robinson RG, Raphael B: Prevalence and course of depressive disorders in hospitalized stroke patients. Int'l J Psychiatry in Medicine 20(4):349-364, 1990.
8) Robinson RG et al: Two-year longitudinal study of poststroke mood disorders: diagnosis and outcome at one and two years. Stroke 18(5):837-843, 1987.
9) Robinson RG, Price TR: Post-stroke depressive disorder: a follow-up study of 103 patients. Stroke 13(5):635-641, 1982.
10) Astrom M, Adolfsson R, Asplund K: Major depression in stroke patients - a 3-year longitudinal study. Stroke 24(7):976-982.
11) Lazarus LW et al: Methylphenidate and nortriptyline in the treatment of poststroke depression: a retrospective comparison. Arch Phys Med Rehabil 75(4):403-406.
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