Monica Åström

Major depression in stroke patients. A 3-year longitudinal study.

Background and Purpose This prospective study was designed to examine the contributions of neurobiological, functional, and psychosocial factors to major depression after stroke. In addition, the prevalence and longitudinal course of major depression were studied. Methods Major depression, functional ability, and social network were assessed repeatedly for a period of 3 years in a population-based cohort of 80 patients with acute stroke (mean age, 73 years). Cerebral atrophy and brain lesion parameters were determined from computed tomographic scans performed acutely and after 3 years. Results The prevalence of major depression was 25% at the acute stage and approximately the same at 3 months (31%). It decreased to 16% at 12 months, was 19% at 2 years, and increased to 29% at 3 years. The most important predictors of immediate major depression were left anterior brain lesion, dysphasia, and living alone. Dependence in activities of daily living was the most important predictor at 3 months. From 12 months on, the patients having few social contacts outside the immediate family contributed most to depression, and at 3 years cerebral atrophy also contributed. At 1 year, 60% of the patients with early depression (0 to 3 months) had recovered; those not recovered at this follow-up had a high risk of development of chronic depression. Conclusions The study has provided evidence of a differentiation of factors likely to be implicated in the development of depression after stroke based on the period of time since the stroke event.

Generalized Anxiety Disorder in Stroke Patients A 3-Year Longitudinal Study

BACKGROUND AND PURPOSE This prospective study examined the prevalence and longitudinal course of generalized anxiety disorder (GAD) after stroke and its comorbidity with major depression over time. The contributions of lesion characteristics, functional impairment, and psychosocial factors to the development of GAD after stroke were studied. METHODS In a population-based cohort of 80 patients with acute stroke, we assessed GAD and comorbid major depression, functional ability, and social network at regular time points over 3 years. Cerebral atrophy and brain lesion parameters were determined from CT scans performed at the acute stage and after 3 years. RESULTS The prevalence of GAD after stroke was 28% in the acute stage, and there was no significant decrease through the 3 years of follow-up. At 1 year, only 23% of the patients with early GAD (0 to 3 months) had recovered; those not recovered at this follow-up had a high risk of a chronic development of the anxiety disorder. Comorbidity with major depression was high and seemed to impair the prognosis of depression. At the acute stage after stroke, GAD plus depression was associated with left hemispheric lesion, whereas anxiety alone was associated with right hemispheric lesion. Cerebral atrophy was associated with both depression and anxiety disorder late but not early after stroke. Dependence in activities of daily living and reduced social network were associated with GAD at all follow-up periods except at the acute stage. CONCLUSIONS GAD after stroke is a common and long-lasting affliction that interferes substantially with social life and functional recovery. There is a differentiation of factors implicated in its development based on the period of time since the stroke event.

Psychosocial function and life satisfaction after stroke.

This prospective study was designed to describe different aspects of psychosocial function after stroke and the development of changes over time. A major aim has been to identify mental, functional, and social factors associated with low life satisfaction late after stroke. Methods Social network, functional ability, leisure-time activities, experience of ill health, major depression, and life satisfaction were assessed repeatedly over 3 years in a population-based sample of 50 long-term survivors of stroke (mean age 71.4 years). Results Compared with a general elderly population, patients 3 years poststroke had more psychiatric symptoms, lower functional ability, and reduced life satisfaction. Contacts with children were maintained over the 3-year follow-up period, whereas contacts with friends and neighbors declined early after stroke and remained lower than in the general elderly population (p<0.05). When time dependency was analyzed, activities of daily living and somatic/neurological symptoms were found to change little after 3 months, while psychiatric symptoms showed changes later. Between 3 and 12 months poststroke, the prevalence of major depression decreased, leisure-time activities and social contacts were partly resumed, and life satisfaction improved (p<0.01). Once good life satisfaction was restored it was maintained, and poor life satisfaction at 1 year remained poor for the entire 3 years. Conclusions It is concluded that major depression early after stroke, functional disability, and an impaired social network interact to reduce life satisfaction for the long-term survivors of stroke.

Depression and anxiety during pregnancy and six months postpartum: a follow-up study

Aims. To investigate the relationship between antenatal and postpartum depression and anxiety and to explore associated maternal characteristics. Methods. From a population‐based sample of 1,555 women attending two obstetric clinics in Sweden, all women with an antenatal psychiatric diagnosis (n=220) and a random selection of healthy women (n=500) were contacted for a second assessment three to six months postpartum. The Primary Care Evaluation of Mental Disorders was used for evaluation on both occasions. Results. Fewer cases of depressive and/or anxiety disorders were prevalent postpartum compared with the second trimester screening. Depression and/or anxiety were prevalent in 16.5% of postpartal women versus 29.2% of pregnant women. There was a significant shift from a majority of subthreshold diagnoses during pregnancy to full Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnoses during the postpartum period. A history of previous psychiatric disorder, living single, and obesity were significantly associated with a new‐onset postpartum psychiatric disorder. The absence of a previous psychiatric disorder was significantly associated with a postpartum recovery of depression or anxiety. Conclusions. Depression and anxiety appear to be less common postpartum than during pregnancy.

Implications of antenatal depression and anxiety for obstetric outcome.

OBJECTIVE: To investigate the obstetric outcome and health care consumption during pregnancy, delivery, and the early postpartum period in an unselected population-based sample of pregnant women diagnosed with antenatal depressive and/or anxiety disorders, compared with healthy subjects. METHODS: Participants were 1,495 women attending 2 obstetric clinics in Northern Sweden. The Primary Care Evaluation of Mental Disorders was used to evaluate depressive and anxiety disorders in the second trimester of pregnancy. To assess demographic characteristics, obstetric outcome, and complications, the medical records of the included women were reviewed. RESULTS: Significant associations were found between depression and/or anxiety and increased nausea and vomiting, prolonged sick leave during pregnancy and increased number of visits to the obstetrician, specifically, visits related to fear of childbirth and those related to contractions. Planned cesarean delivery and epidural analgesia during labor were also significantly more common in women with antenatal depression and/or anxiety. CONCLUSION: There is an association between antenatal depressive and/or anxiety disorders and increased health care use (including cesarean deliveries) during pregnancy and delivery. LEVEL OF EVIDENCE: II-2

Epidemiology and Treatment of Post-Stroke Depression

SummaryDepression is a common and serious complication after stroke. According to epidemiological studies, at least 30% of stroke patients experience depression, both early and late after stroke. However, in clinical practice only a minority of the patients are diagnosed and even fewer are treated.There are several studies confirming the magnitude of the problem but the main conclusion which can be drawn from the few treatment studies published is that tricyclic antidepressants cannot be recommended for the treatment of post-stroke depression, mainly because of the high frequency of contraindications and adverse effects. Until now there has only been 1 double-blind, placebo-controlled treatment study from which some general conclusions can be drawn. The study evaluated a selective serotonin reuptake inhibitor (citalopram) and concluded that the drug was well tolerated and effective for the treatment of post-stroke depression. However, when treatment was initiated very early, both the treatment group and the placebo group improved equally during the first 7 weeks after stroke. This finding could indicate diagnostic difficulties during the first few weeks after stroke.Arecent study, although small, comparing the combination of drugs with either noradrenergic (desipramine plus mianserin) or noradrenergic and serotonergic effects (imipramine plus mianserin) for post-stroke depression, indicated that drugs with the dual effect may be more effective. Many more double-blind placebo-controlled treatment studies and studies comparing the efficacy and adverse effects of various antidepressants in patients with post-stroke depression need to be conducted. According to 3 small studies, electroconvulsive therapy (ECT) seems to be quite well tolerated and therefore ECT may also be considered in the treatment of post-stroke depression. Future studies should also address the long term efficacy of treatment for post-stroke depression.

Personality traits in chronic pain patients related to endorphin levels in cerebrospinal fluid

Interindividual differences in endorphin levels may relate to widespread changes in adaptive processes, and endorphin levels may thus be related to personality traits. In 40 patients with chronic pain syndromes of both psychogenic and organic origin, endorphin levels in cerebrospinal fluid (CSF) were determined, and the patients completed Eysencks Personality Inventory (EPI) and the Cesarek Marke Personality Scheme. Twenty-seven of the patients also completed the Zuckerman Sensation Seeking Scale (SSS). As a comparison group 30 healthy volunteers completed the personality inventories. The chronic pain patients were characterized by guilt feelings, need for order, low need for autonomy, and low tendency toward sensation seeking. Low levels of endorphins in CSF were found in patients with high scores on all the subscales in the SSS and low scores on the neuroticism subscale in the EPI.

Different linkage of depression to hypercortisolism early versus late after stroke. A 3-year longitudinal study.

Background and Purpose Using the dexamethasone suppression test, we studied the suppressibility of the Cortisol axis and its clinical determinants at various time points after stroke. A major aim was to examine the dexamethasone test as a diagnostic tool for the diagnosis of major depression in stroke patients. Methods The dexamethasone suppression test, major depression, functional ability, and disorientation were assessed in a cohort of 70 patients with acute stroke and after 3 months (n=63) and 3 years (n=43). Results Early after stroke, 24% of the patients were nonsuppressors, with about the same proportion at 3 months (22%) and 3 years (21%). None of the controls (17 healthy elderly volunteers) were nonsuppressors. High Cortisol levels early after stroke were significantly associated with functional impairment (r=0.35; p=0.003) and disorientation (r=0.27; p=0.03). Three years after stroke, high postdexamethasone Cortisol levels were significantly associated with major depression (r=0.57; p< 0.001). The sensitivity of the dexamethasone test was 70% and the specificity 97%. In a longitudinal analysis of the long-term survivors (n=42), postdexamethasone Cortisol values at 3 months predicted major depression at 3 years. Conclusions Hypercortisolism is associated with major depression late (3 years) but not early (0–3 months) after stroke. Patients with hypercortisolism 3 months after stroke are at risk of major depression later in the course and warrant careful follow-up from a psychiatric viewpoint.

Women's hearts--stress management for women with ischemic heart disease: explanatory analyses of a randomized controlled trial.

PURPOSE This randomized controlled study aimed to evaluate the effects on psychosocial variables of a 1-year group-based cognitive-behavioral stress management program developed specifically for women with ischemic heart disease. METHODS The present explanatory (per protocol) analyses include 80 women who were randomized to a 1-year cognitive-behavioral stress management program and 86 who were randomized to usual care (age = 35-77 years). Data were obtained before randomization and after 1 year, when the intervention group had completed the program. RESULTS There were no statistically significant differences between the intervention and usual care groups in the psychosocial endpoints at randomization. Both groups improved in all psychosocial variables during the 1-year study period, but the rate of improvement was significantly greater in the intervention group for self-rated stress behavior (P = .006) and vital exhaustion (P = .03). Although changes were in favor of the treatment group also for depressive mood and quality of life, the rates of improvement between the 2 groups did not reach statistical significance (P = .23 and P = .10, respectively). CONCLUSION A 1-year cognitive-behavioral stress management program designed specifically for women improved psychological well-being in some aspects in comparison with usual care.

Hypercortisolism revealed by the dexamethasone suppression test in patients [corrected] with acute ischemic stroke.

Using the dexamethasone suppression test, we studied the activity of the hypothalamic-pituitary-adrenal axis within the first week after onset in 62 patients with acute ischemic stroke. Compared with two control groups (one comprising 25 elderly patients with various acute medical disorders and the other comprising 33 80-year-old volunteers), stroke patients had higher postdexamethasone cortisol levels (p = 0.08 and p = 0.001, respectively). By multiple regression analysis, high postdexamethasone cortisol levels in the stroke patients were significantly associated with proximity of the lesion to the frontal pole of the brain (p = 0.008) and with disorientation (p = 0.03), whereas no association with major depression was seen. Many stroke patients are exposed to hypercortisolism, which may have negative consequences upon organ functions. The extent to which dexamethasone administration suppresses cortisol levels seems to be determined mainly by the site of brain lesion and cannot be used as an indicator of major depression early after stroke.