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:

 
1. TCAs.  
2. SSRIs. (low side effect profile)  
3. Psychostimulants. (rapid response 24-72 hours)

REFERENCES
    1) Morris PPL et al: Association of depression with 10-year poststroke mortality. Am J Psychiatry 150:124-129, 1993.

    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.