Eran Chemerinski

Improved recovery in activities of daily living associated with remission of poststroke depression.

Background and Purpose— Poststroke depression is associated with impaired recovery of activities of daily living (ADL) function compared with similar nondepressed patients. We examined the differences on recovery of ADL functions among poststroke depressed patients with remission of their depression compared with poststroke depressed patients without mood recovery over the first 3 to 6 months after stroke. Methods— On the basis of a semistructured psychiatric examination and DSM-IV diagnostic criteria, a consecutive series of patients with poststroke major or minor depression (n=55) were selected. Their impairment in ADL function was assessed by means of the Johns Hopkins Functioning Examination during acute hospitalization and either 3 or 6 months later. Results— Patients whose mood improved at follow-up (n=21) had significantly greater recovery in ADL functions at follow-up than patients whose mood did not improve (n=34). There were no differences in demographic variables, lesion characteristics, and neurological symptoms between the two groups. Furthermore, patients with either major or minor depression at the initial evaluation showed the same amount of recovery in ADL function if they improved at follow-up. Conclusions— Our findings suggest that remission of poststroke depression over the first few months after stroke is associated with greater recovery in ADL function than continued depression. Early effective treatment of depression may have a positive effect on the rehabilitation outcome of stroke patients.

The Neuropsychiatry of Stroke

Stroke represents a major public health problem in the United States, but relatively little work has been directed toward identifying and treating the common neuropsychiatric disorders occurring after stroke. This review discusses clinical and pathological correlates of depression, anxiety disorder, catastrophic reactions, pathological affect, or psychosis after stroke, as well as their epidemiology. Depressive disorder and anxiety disorder have been shown to inhibit physical recovery from stroke. It seems likely that other psychiatric disorders also inhibit recovery and limit quality of life. There are very few controlled trials examining the effectiveness of treatments for these disorders after stroke. Both depression and pathological affect, however, can be effectively treated with antidepressant medications.

Neuropsychological, Psychiatric, and Cerebral Blood Flow Findings in Vascular Dementia and Alzheimer’s Disease

BACKGROUND AND PURPOSE Psychiatric, neuropsychological, and cerebral blood flow differences between patients with ischemic vascular dementia (IVD) or Alzheimers disease (AD) were examined. METHODS A consecutive series of patients who met either the criteria of the National Institute of Neurological Disorders and Stroke and the Alzheimers Disease and Related Disorders Association for probable AD or the State of California AD Diagnostic and Treatment Centers criteria for probable IVD were included in the study. Twenty consecutive patients with IVD were matched for age, sex, and Mini-Mental State Examination scores with 40 consecutive patients with probable AD. Patients underwent a psychiatric interview, a neuropsychological assessment, and single-photon emission CT imaging with 99mTc-hexamethylpropyleneamine oxime. RESULTS Patients with IVD showed significantly more severe anosognosia (P<.05) and emotional lability (P<.01) than AD patients, but no significant between-group differences were found in the frequency and severity of depression. IVD patients showed significantly more severe deficits in tests of planning, sequencing (P<.05), and verbal fluency (P<.05) as well as significantly more severe cerebral blood flow deficits in the basal ganglia (P<.01) and the frontal lobes (P<.001) than AD patients. CONCLUSIONS Patients with IVD showed a relatively more severe dysfunction of the frontal lobes as demonstrated by single-photon emission CT and expressed in specific psychiatric and neuropsychological changes than AD patients matched for age, sex, and severity of dementia.

Repetitive Transcranial Magnetic Stimulation as treatment of poststroke depression: A preliminary study

BACKGROUND Depression has a significant impact on poststroke recovery and mortality. There are a proportion of patients with poststroke depression (PSD) who do not respond to antidepressants. Repetitive Transcranial Magnetic Stimulation (rTMS) might be a safe and effective alternative in these refractory cases. METHODS We conducted a randomized, parallel, double-blind study of active versus sham left prefrontal rTMS in patients with refractory PSD. After discontinuing antidepressants, patients were randomly assigned to receive 10 sessions of active (10 Hz, 110% of the motor threshold, 20 trains of 5 seconds duration) or sham left prefrontal rTMS. Efficacy measures included HAM-D scores, response and remission rates. Patients completed a neuropsychological battery at baseline and after completing the protocol. RESULTS When compared with sham stimulation, 10 sessions of active rTMS of the left dorsolateral prefrontal cortex were associated with a significant reduction of depressive symptoms. This reduction was not influenced by patients age, type or location of stroke, volume of left frontal leukoaraiosis or by the distance of the stimulating coil to the prefrontal cortex. However, there was a significant positive correlation between the percentage of reduction of Ham-D scores and frontal gray and white matter volumes. There were no significant changes in cognitive functioning between the active and the sham stimulation groups. In addition, there were few and mild adverse effects that were equally distributed among groups. CONCLUSIONS Taken together, these preliminary findings suggest that rTMS may be an effective and safe treatment alternative for patients with refractory depression and stroke.

A double-blind, placebo-controlled study of fluoxetine in depressed patients with Alzheimer's disease.

OBJECTIVE To examine the efficacy of fluoxetine in the treatment of depression in patients with probable Alzheimers disease (AD). METHODS This double-blind, parallel-design study included a consecutive series of 41 AD subjects meeting DSM-IV criteria for major or minor depression who were randomized to receive fluoxetine (up to 40 mg/day) or identical-appearing placebo. All patients received biweekly evaluations consisting of the Hamilton Depression Scale (HAM-D) and the Clinical Global Impression as primary efficacy measures, and the Mini-Mental State Exam, Hamilton Rating Scale for Anxiety, and the Functional Independence Measure as secondary efficacy measures. RESULTS Complete remission of depression was found in 47% of subjects treated with fluoxetine and in 33% of subjects treated with placebo. Both the fluoxetine and the placebo groups showed a significant decline in HAM-D scores over time, but the magnitude of mood improvement was similar for both groups. Fluoxetine was well tolerated, and most side effects were mild. CONCLUSION Fluoxetine treatment for depression in AD did not differ significantly from treatment with placebo. Our study also confirms the presence of a placebo effect in the treatment of depression in AD.

Frontal lobe syndrome reassessed: comparison of patients with lateral or medial frontal brain damage

Examination of mood and behaviour changes after frontal damage may contribute to understanding the functional role of distinct prefrontal areas in depression and anxiety. Depression and anxiety disorders, symptoms, and behaviour were compared in eight patients with single lateral and eight patients with single medial frontal lesions matched for age, sex, race, education, socioeconomic status, side, and aetiology of lesion 2 weeks and 3 months after brain injury. DSM IV major depressive and generalised anxiety disorders were more frequent in patients with lateral compared with medial lesions at 2 weeks but not at 3 months. At 3 months, however, patients with lateral damage showed greater severity of depressive symptoms, and greater impairment in both activities of daily living and social functioning. At initial evaluation depressed mood and slowness were more frequent, whereas at 3 months slowness, lack of energy, and social unease were more frequent in the lateral than the medial group. Patients with lateral lesions showed greater reduction of emotion and motivation (apathy) during both examinations. Medial frontal injury may fail to produce emotional dysregulation or may inhibit experience of mood changes, anxiety, or apathy. Lateral prefrontal damage may disrupt mood regulation and drive while leaving intact the ability to experience (negative) emotions.

The effect of remission of poststroke depression on activities of daily living in a double-blind randomized treatment study.

Poststroke depression has been associated with impaired recovery of activities of daily living (ADL) during the first 2 years after stroke. This study examined the effect of remission of poststroke depression on recovery in ADL in a double-blind randomized treatment study. Based on a semistructured psychiatric exam and DSM-IV diagnostic criteria, a consecutive series of 23 patients who met criteria for major depression (N = 16) or minor depression (N = 7) were selected and randomly assigned to either active treatment (nortriptyline) or placebo. Functional physical (i.e., ADL) impairment was assessed using the Johns Hopkins Functioning Inventory (JHFI). Patients whose depressive disorder remitted at follow-up had significantly greater recovery in ADL functions compared with patients whose depression did not remit. There were no differences in demographic variables, lesion characteristics, and neurological symptoms between the two groups, which would explain the significantly greater improvement among the remitted patients. Because both major and minor depression patients who remitted showed greater improvement in ADL than nonremitted patients some of whom were treated with active and some with placebo medication, nonpharmacotherapeutic mechanisms related to recovery from depression appear to mediate this enhanced recovery.

Catatonia in depression: prevalence, clinical correlates, and validation of a scale.

OBJECTIVES--To examine the clinical correlates of catatonia in depression, to validate a scale for catatonia, and to assess the validity of the DSM-IV criteria of the catatonic features specifier for mood disorders. METHODS--A series of 79 consecutive patients with depression and 41 patients with Parkinsons disease without depression were examined using the modified Rogers scale (MRS), the unified Parkinsons disease rating scale (UPDRS), and the structured clinical interview for DSM-III-R (SCID). RESULTS--Sixteen of the 79 depressed patients (20%) had catatonia. Depressed patients with catatonia had significantly higher scores on the MRS than non-catatonic depressed patients matched for severity of depression, or non-depressed patients with Parkinsons disease matched for severity of motor impairment. Depressed patients with catatonia were older, had a significantly higher frequency of major depression, more severe cognitive impairments, and more severe deficits in activities of daily living than depressed non-catatonic patients. The DSM-IV criteria of catatonia separated depressed catatonic patients from patients with Parkinsons disease matched for motor impairment, with a specificity of 100%. Catatonic signs did not improve after apomorphine. CONCLUSIONS--catatonia is most prevalent among elderly patients with severe depression. The study showed the validity of the MRS for the diagnosis of catatonia in depressed patients, as well as the specificity of the DSM-IV criteria of the catatonic features specifier.

Neuropsychological and psychiatric differences between Alzheimer's disease and Parkinson's disease with dementia.

OBJECTIVE: To examine neuropsychological and neuropsychiatric differences between patients with probable Alzheimers disease and patients with Parkinsons disease and dementia. METHODS: Thirty three patients with probable Alzheimers disease and 33 patients with Parkinsons disease and dementia were matched for age, sex, and mini mental state examination scores and given a battery of neuropsychological and neuropsychiatric tests. RESULTS: Patients with Parkinsons disease with dementia had a significantly higher prevalence of major depression than patients with Alzheimers disease; patients with Alzheimers disease showed more severe anosognosia and disinhibition than patients with Parkinsons disease. Whereas no significant between group differences were found on tests of memory and language, demented patients with Parkinsons disease had a significantly greater impairment on a test of visual reasoning than patients with Alzheimers disease. CONCLUSION: There were significant psychiatric differences between patients with Alzheimers disease and demented patients with Parkinsons disease, but neuropsychological differences were restricted to a single cognitive domain.

Morphology of the ventral frontal cortex in schizophrenia: relationship with social dysfunction

BACKGROUND Studies have reported premorbid as well as postonset social dysfunction in schizophrenia. This impairment has also been observed to emerge after lesions in the ventral aspect of the frontal cortex (i.e., straight gyrus and orbitofrontal cortex). METHODS Magnetic resonance imaging scans were obtained from 45 male patients with schizophrenia and 45 matched control subjects. Cortical gray matter volume and surface area were determined for the ventral frontal cortex (VFC), subdivided into the orbitofrontal cortex (OFC) and the straight gyrus (SG). RESULTS The global measures of gray matter volume and surface area in the VFC was not significantly different between patients and control subjects; however, there was a regional difference, with the right SG volume and surface area being smaller in patients compared with control subjects. Volume of the VFC had an inverse correlation with measurements of both premorbid and postdiagnosis social function. The smaller the gray matter in these regions, the greater the social dysfunction. There was no relationship between morphology of this brain region and any other clinical variable. CONCLUSIONS Morphology of the VFC is directly related to abnormal social function in schizophrenia, including measures of social dysfunction that predate the onset of illness.