Maree L. Hackett

Predictors of Depression after Stroke A Systematic Review of Observational Studies

Background and Purpose— Although depression is an important sequelae of stroke, there is uncertainty regarding its frequency and outcome. Methods— We undertook a systematic review of all published nonexperimental studies (to June 2004) with prospective consecutive patient recruitment and quantification of depressive symptoms/illness after stroke. Results— Data were available from 51 studies (reported in 96 publications) conducted between 1977 and 2002. Although frequencies varied considerably across studies, the pooled estimate was 33% (95% confidence interval, 29% to 36%) of all stroke survivors experiencing depression. Differences in case mix and method of mood assessment could explain some of the variation in estimates across studies. The data also suggest that depression resolves spontaneously within several months of onset in the majority of stroke survivors, with few receiving any specific antidepressant therapy or active management. Conclusions— Depression is common among stroke patients, with the risks of occurrence being similar for the early, medium, and late stages of stroke recovery. There is a pressing need for further research to improve clinical practice in this area of stroke care.

Predictors of Depression after Stroke

Background and Purpose— Although depression is common after stroke, there is uncertainty over its etiology and risk factors, which complicates management. Knowledge of the predictors of depression associated with stroke may allow for the better targeting of therapy, both prevention and treatment. Methods— We undertook a systematic review of all published, nonexperimental, population-, hospital-, and rehabilitation-based stroke studies (to June 2004) with prospective, consecutive patient recruitment undertaken to identify variables associated with depressive symptoms (or “illness”) after stroke. Assessments were made of the quality of studies including the validity of prognostic models. Results— Data were available from 3 population-based studies including 492 patients, 8 hospital-based studies including 15 272 patients, and 9 rehabilitation-based studies including 2170 patients. Physical disability, stroke severity and cognitive impairment were consistently associated with depression. In addition to the common problem of selection bias, major limitations of these studies included variable selection and poor statistical quality and reporting; small sample sizes meant that only a limited range of variables were analyzed in multivariate models. Conclusions— There is a paucity of well-designed studies of sufficient size to allow stable multivariate predictive models of depression after stroke to be developed. Other than showing that depression is associated with more severe strokes, current evidence does not allow for ready identification of patients most at risk of developing this important complication of stroke.

Health outcomes 1 year after subarachnoid hemorrhage : An international population-based study

Background: There is limited information about the long-term consequences of subarachnoid hemorrhage (SAH). Methods: Data were obtained from a population-based study of aneurysmal SAH conducted in Australia and New Zealand between 1995 and 1998. The authors report health outcomes for survivors 1 year after the onset of SAH. Results: From a total of 432 first-ever cases of SAH (76% due to confirmed cerebral aneurysm rupture) registered in four cities in Australia and New Zealand, 242 (56%) were alive approximately 1 year later (mean time 1.2 years), with 230 (95%) available for interview. Of those interviewed, 105 (46%) reported an incomplete recovery, with ongoing problems with memory (50%), mood (39%), speech (14%), and self-care (10%). Compared with age- and sex-adjusted Australian population norms, health-related quality of life, as determined by Short Form–36, was significantly lower for cases in the domains of role limitations that result from physical problems. However, there were no patient or disease characteristics that predicted complete recovery from SAH. Conclusions: A high proportion of long-term survivors of SAH experience ongoing deficits in high level (neuropsychological) functioning. These deficits result in impairment in social roles.

Health-Related Quality of Life Among Long-Term Survivors of Stroke: Results From the Auckland Stroke Study, 1991–1992

BACKGROUND AND PURPOSE The consequences of stroke are a major health concern. This study was conducted to compare the health-related quality of life among long-term survivors of stroke with that of the general population. METHODS Our data are taken from a population-based case-control study of all 6-year survivors of stroke with an age- and sex-matched control population. SF-36 mean scores for cases were compared with raw and standardized control and New Zealand norm mean scores. RESULTS Of the original 1761 registered cases, 639 were still alive at 6-year follow-up, and all of these participated in the study. Case patients were more likely than control subjects to be dependent in all basic activities of daily living. Crude mean scores were lower for women; as age increased; for those living in institutions; when the SF-36 was completed by proxy; and when help was required with the activities of daily living. Cases had statistically lower mean scores than both the control group and New Zealand norms for physical functioning and general health. After standardization for age and sex, no differences were found between cases and controls in mental health and bodily pain. CONCLUSIONS Health-related quality of life appears to be relatively good for the majority of patients 6 years after stroke. Despite significant ongoing physical disability, survivors of stroke appear to adjust well psychologically to their illness.

Effect of Lifestyle-Focused Text Messaging on Risk Factor Modification in Patients With Coronary Heart Disease: A Randomized Clinical Trial

IMPORTANCE Cardiovascular disease prevention, including lifestyle modification, is important but underutilized. Mobile health strategies could address this gap but lack evidence of therapeutic benefit. OBJECTIVE To examine the effect of a lifestyle-focused semipersonalized support program delivered by mobile phone text message on cardiovascular risk factors. DESIGN AND SETTING The Tobacco, Exercise and Diet Messages (TEXT ME) trial was a parallel-group, single-blind, randomized clinical trial that recruited 710 patients (mean age, 58 [SD, 9.2] years; 82% men; 53% current smokers) with proven coronary heart disease (prior myocardial infarction or proven angiographically) between September 2011 and November 2013 from a large tertiary hospital in Sydney, Australia. INTERVENTIONS Patients in the intervention group (n = 352) received 4 text messages per week for 6 months in addition to usual care. Text messages provided advice, motivational reminders, and support to change lifestyle behaviors. Patients in the control group (n=358) received usual care. Messages for each participant were selected from a bank of messages according to baseline characteristics (eg, smoking) and delivered via an automated computerized message management system. The program was not interactive. MAIN OUTCOMES AND MEASURES The primary end point was low-density lipoprotein cholesterol (LDL-C) level at 6 months. Secondary end points included systolic blood pressure, body mass index (BMI), physical activity, and smoking status. RESULTS At 6 months, levels of LDL-C were significantly lower in intervention participants, with concurrent reductions in systolic blood pressure and BMI, significant increases in physical activity, and a significant reduction in smoking. The majority reported the text messages to be useful (91%), easy to understand (97%), and appropriate in frequency (86%). [table: see text]. CONCLUSIONS AND RELEVANCE Among patients with coronary heart disease, the use of a lifestyle-focused text messaging service compared with usual care resulted in a modest improvement in LDL-C level and greater improvement in other cardiovascular disease risk factors. The duration of these effects and hence whether they result in improved clinical outcomes remain to be determined. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611000161921.

Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies

Background Approximately 15 million people who suffer a stroke globally each year are at risk of developing depression. Aim To update our systematic review and meta-analysis of the frequency of depression after stroke published in 2005, including studies published before July 2004. Methods We included all published observational studies (to 31 May 2013) with prospective consecutive recruitment and quantification of the proportion of people with depression after stroke. We included studies of adult (>18 years) patients with a clinical diagnosis of stroke, where an assessment of depression or depressive symptom burden was performed at a pre-specified time-point for all study participants. Results Data were available from 61 studies including 25 488 people. The proportional frequency of depression varied considerably across studies; however, the pooled frequency estimate of 31% (95% confidence interval 28% to 35%) was not significantly different from the 33% (difference of 2%, 95% confidence interval <1% to 3%) reported in the 2005 review. The proportion with depression between one and five-years (25%; 95% confidence interval 16 to 33%) and at five years after stroke (23%; 95% confidence interval 14 to 31%) was significantly lower. Conclusion Despite systematic review evidence describing validated depression screening tools and effective treatment and prevention strategies for depression after stroke, there has not been a significant reduction in the proportion of people experiencing depression after stroke. There is a pressing need for increased clinical uptake of evidenced-based strategies to screen for, prevent, and treat depression after stroke.

Management of Depression After Stroke A Systematic Review of Pharmacological Therapies

Background and Purpose— Although depression may affect recovery and outcome after stroke, it is often overlooked or inadequately managed, and there is uncertainty regarding the benefits of antidepressant therapy in this setting. We aimed to assess the effectiveness of antidepressants for the treatment and prevention of depression after stroke. Methods— We undertook a systematic review using Cochrane methods of randomized placebo-controlled trials of antidepressants for the treatment or prevention of depressive illness and “abnormal mood” after stroke. Treatment effects on physical and other outcomes were also examined. Results— Outcome data were available for 7 treatment trials including 615 patients and 9 prevention trials including 479 patients. Because of the considerable variation in research design, trial quality, and method of reporting across studies, we did not pool all the outcome data. In the treatment trials, antidepressants reduced mood symptoms but had no clear effect on producing a remission of diagnosable depressive illness. There was no definitive evidence that antidepressants prevent depression or improve recovery after stroke. Conclusions— There is insufficient randomized evidence to support the routine use of antidepressants for the prevention of depression or to improve recovery from stroke. Although antidepressants may improve mood in stroke patients with depression, it is unclear how clinically significant such modest effects are in patients other than those with major depression. There is a pressing need for further research to better define the role of antidepressants in stroke management.

Trends in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003

Background and Purpose— Long-term trends in stroke incidence in different populations have not been well characterized, largely as a result of the complexities associated with population-based stroke surveillance. Methods— We assessed temporal trends in stroke incidence using standard diagnostic criteria and community-wide surveillance procedures in the population (≈1 million) of Auckland, New Zealand, over 12-month calendar periods in 1981–1982, 1991–1992, and 2002–2003. Age-adjusted first-ever (incident) and total (attack) rates, and temporal trends, were reported with 95% confidence intervals (CIs). Rates were analyzed by sex and major age groups. Results— From 1981 to 1982, stroke rates were stable in 1991–1992 and then declined in 2002–2003, to produce overall modest declines in standardized incidence (11%; 95% CI, 1 to 19%) and attack rates (9%; 95% CI, 0 to 16%) between the first and last study periods. Some favorable downward trends in vascular risk factors such as cigarette smoking were counterbalanced by increasing age and body mass index, and frequency of diabetes, in patients with stroke. Conclusions— There has been a modest decline in stroke incidence in Auckland over the last 2 decades, mainly during 1991 to 2003, in association with divergent trends in major risk factors.

Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial

Aims/hypothesisThe relationship between cognitive function, cardiovascular disease and premature death is not well established in patients with type 2 diabetes. We assessed the effects of cognitive function in 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Furthermore, we tested whether level of cognitive function altered the beneficial effects of the BP-lowering and glycaemic-control regimens in the trial.MethodsCognitive function was assessed using the Mini Mental State Examination at baseline, and defined by scores 28-30 (‘normal’, n = 8,689), 24-27 (‘mild dysfunction’, n = 2,231) and <24 (‘severe dysfunction’, n = 212). Risks of major cardiovascular events, death and hypoglycaemia and interactions with treatment were assessed using Cox proportional hazards analysis.ResultsRelative to normal function, both mild and severe cognitive dysfunction significantly increased the multiple-adjusted risks of major cardiovascular events (HR 1.27, 95% CI 1.11–1.46 and 1.42, 95% CI 1.01–1.99; both p < 0.05), cardiovascular death (1.41, 95% CI 1.16–1.71 and 1.56, 95% CI 0.99–2.46; both p ≤ 0.05) and all-cause death (1.33, 95% CI 1.16–1.54 and 1.50, 95% CI 1.06–2.12; both p < 0.03). Severe, but not mild, cognitive dysfunction increased the risk of severe hypoglycaemia (HR 2.10, 95% CI 1.14–3.87; p = 0.018). There was no evidence of heterogeneity of treatment effects on cardiovascular outcomes in subgroups defined by cognitive function at baseline.Conclusions/interpretationCognitive dysfunction is an independent predictor of clinical outcomes in patients with type 2 diabetes, but does not modify the effects of BP lowering or glucose control on the risks of major cardiovascular events.Trial registration:ClinicalTrials.gov NCT00145925Funding:Supported by grants from Servier and from the National Health and Medical Research Council of Australia.

Ethnic disparities in incidence of stroke subtypes: Auckland Regional Community Stroke Study, 2002-2003

BACKGROUND Limited population-based data exist on differences in the incidence of major pathological stroke types and ischaemic stroke subtypes across ethnic groups. We aimed to provide such data within the large multi-ethnic population of Auckland, New Zealand. METHODS All first-ever cases of stroke (n=1423) in a population-based register in 940 000 residents (aged 15 years) in Auckland, New Zealand, for a 12-month period in 2002-2003, were classified into ischaemic stroke, primary intracerebral haemorrhage (PICH), subarachnoid haemorrhage, and undetermined stroke, according to standard definitions and results of neuroimaging/necropsy (in over 90% of cases). Ischaemic stroke was further classified into five subtypes. Ethnicity was self-identified and grouped as New Zealand (NZ)/European, Maori/Pacific, and Asian/other. Incidence rates were standardised to the WHO world population by the direct method, and differences in rates between ethnic groups expressed as rate ratios (RRs), with NZ/European as the reference group. FINDINGS In NZ/European people, ischaemic stroke comprised 73%, PICH 11%, and subarachnoid haemorrhage 6%, but PICH was higher in Maori/Pacific people (17%) and in Asian/other people (22%). Compared with NZ/European people, age-adjusted RRs for PICH were 2.7 (95% CI 1.8-4.0) and 2.3 (95% CI 1.4-3.7) among Maori/Pacific and Asian/other people, respectively. The corresponding RR for ischaemic stroke was greater for Maori/Pacific people (1.7 [95% CI 1.4-2.0]), particularly embolic stroke, and for Asian/other people (1.3 [95% CI 1.0-1.7]). The onset of stroke in Maori/Pacific and Asian/other people began at significantly younger ages (62 years and 64 years, respectively) than in NZ/Europeans (75 years; p<0.0001). There were ethnic differences in the risk factor profiles (such as age, sex, hypertension, cardiac disease, diabetes, hypercholesterolaemia, smoking status, overweight) for the stroke types and subtypes. INTERPRETATION Compared to NZ/Europeans, Maori/Pacific and Asian/other people are at higher risk of ischaemic stroke and PICH, whereas similar rates of subarachnoid haemorrhage were evident across ethnic groups. The ethnic disparities in the rates of stroke types could be due to substantial differences found in risk factor profiles between ethnic groups. This information should be considered when planning prevention and stroke-care services in multi-ethnic communities.