Acessibilidade / Reportar erro

Clinical practice guidelines for post-stroke depression in China

Abstract

Post-stroke depression (PSD) is a very common complication that leads to increased physical disability, poor functional outcome, and higher mortality. Therefore, early detection and treatment are very important. Since there are currently no specific guidelines for this disorder in China, the purpose of this study was to develop PSD guidelines and provide suggestions for clinicians and related workers.

Post-stroke depression; diagnosis; treatment


Introduction

Post-stroke depression (PSD) is a common mood disorder characterized by a group of depressive symptoms in stroke survivors. PSD is similar to major depressive disorder (MDD), but differs in the frequency of certain symptoms.11. Gainotti G, Azzoni A, Marra C. Frequency, phenomenology and anatomical-clinical correlates of major post-stroke depression. Br J Psychiatry. 1999;175:163-7.,22. Lipsey JR, Spencer WC, Rabins PV, Robinson RG. Phenomenological comparison of poststroke depression and functional depression. Am J Psychiatry. 1986;143:527-9. For instance, PSD patients mostly present with mood fluctuations, retardation, irritability, or apathy, while anhedonia, pessimism, suicidal ideation, or attention deficits are more common in MDD. Importantly, it is difficult to determine whether retardation and apathy symptoms are due to depression or post-stroke neurological deficit. PSD diagnosis lacks specificity only in the symptoms common to MDD, such as self-guilt, suicidal ideation or behavior, weight loss, and early waking.33. Fedoroff JP, Starkstein SE, Parikh RM, Price TR, Robinson RG. Are depressive symptoms nonspecific in patients with acute stroke? Am J Psychiatry. 1991;148:1172-6. PSD reduces physical activity, quality of life44. Jiao JT, Cheng C, Ma YJ, Huang J, Dai MC, Jiang C, et al. Association between inflammatory cytokines and the risk of post-stroke depression, and the effect of depression on outcomes of patients with ischemic stroke in a 2-year prospective study. Exp Ther Med. 2016;12:1591-8. and substantially increases the risk of suicide.55. Pompili M, Venturini P, Campi S, Seretti ME, Montebovi F, Lamis DA, et al. Do stroke patients have an increased risk of developing suicidal ideation or dying by suicide? An overview of the current literature. CNS Neurosci Ther. 2012;18:711-21. Early antidepressant treatment for PSD appears to enhance both physical and cognitive recovery from stroke and might increase post-stroke survival up to 10 years.66. Robinson RG, Jorge RE. Post-stroke depression: a review. Am J Psychiatry. 2016;173:221-31. Thus, it is both challenging and important to recognize and distinguish the depressive symptoms specific to PSD.

A 2014 meta-analysis found that the incidence of PSD was nearly 31%,77. Hackett ML, Pickles K. Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. Int J Stroke. 2014;9:1017-25. while a narrative review reported that PSD prevalence ranged from 5 to 67% among all types of stroke patients.88. Ferro JM, Caeiro L, Santos C. Poststroke emotional and behavior impairment: a narrative review. Cerebrovasc Dis. 2009;27:197-203. According to a correlative study in China, PSD prevalence is 45.79%, including 34.21% early-onset PSD and 11.58% late-onset PSD (occurring at least two weeks after a stroke).99. You LL. [A correlative study of psychosocial risk factors and psychophysiological mechanisms of depression after ischemic stroke] [dissertation]. Suzhou: Suzhou University; 2016. In most studies, early-onset PSD is defined as depression occurring less than two weeks after a stroke, while late-onset PSD occurs more than two weeks after a stroke.99. You LL. [A correlative study of psychosocial risk factors and psychophysiological mechanisms of depression after ischemic stroke] [dissertation]. Suzhou: Suzhou University; 2016.

10. Shi Y, Xiang Y, Yang Y, Zhang N, Wang S, Ungvari GS, et al. Depression after minor stroke: prevalence and predictors. J Psychosom Res. 2015;79:143-7.
-1111. Sun N, Li QJ, Lv DM, Man J, Liu XS, Sun ML. A survey on 465 patients with post-stroke depression in China. Arch Psychiatr Nurs. 2014;28:368-71. This result is inconsistent with the 25-79% found in another study.1212. Gordon WA, Hibbard MR. Poststroke depression: an examination of the literature. Arch Phys Med Rehabil. 1997;78:658-63. This variation is influenced by many factors, the first of which is that different evaluation instruments yield different results: it was found that the rate of PSD diagnosis is higher when using adapted rating scales (e.g., the Hamilton Depression Rating Scale [HDRS]) than when using mood disorder diagnostic criteria (Structured Clinical Interview for DSM-IV).1313. Tang WK, Chan SS, Chiu HF, Ungvari GS, Wong KS, Kwok TC, et al. Poststroke depression in Chinese patients: frequency, psychosocial, clinical, and radiological determinants. J Geriatr Psychiatry Neurol. 2005;18:45-51.,1414. Andersen G, Vestergaard K, Riis J, Lauritzen L. Incidence of post-stroke depression during the first year in a large unselected stroke population determined using a valid standardized rating scale. Acta Psychiatr Scand. 1994;90:190-5. Second, the stroke patients in these studies were assessed at different stages.1515. Zhang T, Wang C, Liu L, Zhao X, Xue J, Zhou Y, et al. A prospective cohort study of the incidence and determinants of post-stroke depression among the mainland Chinese patients. Neurol Res. 2010;32:347-52.

16. Zhang N, Wang CX, Wang AX, Bai Y, Zhou Y, Wang YL, et al. Time course of depression and one-year prognosis of patients with stroke in mainland China. CNS Neurosci Ther. 2012;18:475-81.
-1717. Hackett ML, Yapa C, Parag V, Anderson CS. Frequency of depression after stroke: a systematic review of observational studies. Stroke. 2005;36:1330-40. Most patients develop PSD in the acute phase of stroke, and newly diagnosed PSD often decreases in the subsequent follow-up.1010. Shi Y, Xiang Y, Yang Y, Zhang N, Wang S, Ungvari GS, et al. Depression after minor stroke: prevalence and predictors. J Psychosom Res. 2015;79:143-7. Third, variations in study populations and environment (e.g., hospital vs. community) also lead to varied results, seeing that PSD in patients from neurological departments and rehabilitation centers is more prevalent than in outpatients.1818. Chemerinski E, Robinson RG. The neuropsychiatry of stroke. Psychosomatics. 2000;41:5-14. Finally, stroke patients often present with aphasia, agnosia, and cognition impairments, which add to the complexity of recognizing and diagnosing PSD.

PSD should consist of post-stroke depressive symptoms (PSDS) and post-stroke depressive disorder (PSDD). PSDS develop in parallel with stroke, possibly due to direct brain injury or acute psychosocial response to stroke, while PSDD is an endogenous depression induced by stroke or stroke sequelae, usually occurring six months post-stroke.

PSDS have a relatively short duration (approximately 12 weeks), while PSDD lasts an average of 39 weeks.1919. Morris PL, Robinson RG, Raphael B. Prevalence and course of depressive disorders in hospitalized stroke patients. Int J Psychiatry Med. 1990;20:349-64. Over 50% of new-onset PSD patients during the first six months after stroke can recover in an additional three to six months, but a considerable proportion of the patients will relapse within one year.1616. Zhang N, Wang CX, Wang AX, Bai Y, Zhou Y, Wang YL, et al. Time course of depression and one-year prognosis of patients with stroke in mainland China. CNS Neurosci Ther. 2012;18:475-81. PSD affects activities of daily living and reduces the cognitive recovery of stroke survivors, and patients with cognitive impairment show worse neurological function.2020. Chemerinski E, Robinson RG, Kosier JT. Improved recovery in activities of daily living associated with remission of poststroke depression. Stroke. 2001;32:113-7.

21. Fan QY, Qu QM, Zhang H, Liu JJ, Guo F, Qiao J. [The evolution of cognition and its influence factors after stroke]. Zhonghua Nei Ke Za Zhi. 2011;50:750-3.
-2222. Fultz NH, Ofstedal MB, Herzog AR, Wallace RB. Additive and interactive effects of comorbid physical and mental conditions on functional health. J Aging Health. 2003;15:465-81. A 2016 Chinese survey found that depression is associated with a five-year disability rate after stroke.2323. Yang Y, Shi YZ, Zhang N, Wang S, Ungvari GS, Ng CH, et al. The disability rate of 5-year post-stroke and its correlation factors: a national survey in China. PLoS One. 2016;11:e0165341. The incidence of suicidal ideation in PSD patients is reported to be 6.6 and 11.3% in the acute and late stages, respectively.2424. Kishi Y, Robinson RG, Kosier JT. Suicidal plans in patients with stroke: comparison between acute-onset and delayed-onset suicidal plans. Int Psychogeriatr. 1996;8:623-34. Furthermore, a recent nationwide study in China found that PSD is a possible risk factor for stroke-induced death.2525. Yang Y, Shi YZ, Zhang N, Wang S, Ungvari GS, Ng CH, et al. Suicidal ideation at 1-year post-stroke: a nationwide survey in China. Gen Hosp Psychiatry. 2017;44:38-42.

The Global Disease Burden Study reported that in 2013 there were almost 103 million new-onset strokes (67% ischemic), 6.5 million deaths from stroke (51% from ischemic stroke), and 11.3 million disability-adjusted life years (DALYs) due to stroke (58% to ischemic stroke).2626. Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology. 2015;45:161-76. Stroke caused 1.7 million deaths and 2.1 million DALYs in China in 2010.2727. Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990-2010: findings from the global burden of disease study 2010. Lancet. 2013;381:1987-2015. The direct economic burden from stroke was almost 19.9 billion yuan, accounting for 3.79% of national medication expenses and 3.02% of national public health costs in 2005.2828. Liu KJ, Wang M. [Economic burden of main chronic non-infectious diseases in China]. Chin Health Econ. 2005;24:77-80. Although there have as yet been no assessments of the disease burden of PSD, depression does increase the post-stroke caring burden.2929. Han Y, Liu Y, Zhang X, Tam W, Mao J, Lopez V. Chinese family caregivers of stroke survivors: determinants of caregiving burden within the first six months. J Clin Nurs. 2017 Mar 2. doi: 10.1111/jocn.13793. [Epub ahead of print]
10.1111/jocn.13793...
Considering the high prevalence, mortality, and significant influence of PSD on neurological recovery, it is apparent that depression contributes substantially to the disease burden after stroke.

Although PSD is a serious problem for both stroke survivors and medical workers, a standardized guideline for the clinical management of PSD has not yet been developed in China. PSD misdiagnosis and delayed or no treatment are frequent in clinical settings nationwide. Even if current antidepressant treatment can improve depressive symptoms, neither the optimal drug nor the optimal length of treatment have been identified.3030. Paolucci S. Advances in antidepressants for treating post-stroke depression. Expert Opin Pharmacother. 2017;18:1011-7. Thus, a comprehensive introduction to PSD is urgently needed. This study aims to develop guidelines on PSD to provide suggestions for clinicians and related workers.

Risk factors for PSD

Previous studies have found that PSD is related to many factors, such as age,3131. Verdelho A, Henon H, Lebert F, Pasquier F, Leys D. Depressive symptoms after stroke and relationship with dementia: a three-year follow-up study. Neurology. 2004;62:905-11. sex,3232. Hadidi N, Treat-Jacobson DJ, Lindquist R. Poststroke depression and functional outcome: a critical review of literature. Heart Lung. 2009;38:151-62. ethnicity, cultural background,3333. Zhang WN, Pan YH, Wang XY, Zhao Y. A prospective study of the incidence and correlated factors of post-stroke depression in China. PLoS One. 2013;8:e78981. and education level,3434. De Ryck A, Brouns R, Fransen E, Geurden M, Van Gestel G, Wilssens I, et al. A prospective study on the prevalence and risk factors of poststroke depression. Cerebrovasc Dis Extra. 2013;3:1-13. but the results are not always consistent.

The social-psychological factors of PSD mainly include neurological impairment after stroke, work disability, and change of status in society and the family.3535. Göthe F, Enache D, Wahlund LO, Winblad B, Crisby M, Lökk J, et al. Cerebrovascular diseases and depression: epidemiology, mechanisms and treatment. Panminerva Med. 2012;54:161-70. It is reported that negative life events,1313. Tang WK, Chan SS, Chiu HF, Ungvari GS, Wong KS, Kwok TC, et al. Poststroke depression in Chinese patients: frequency, psychosocial, clinical, and radiological determinants. J Geriatr Psychiatry Neurol. 2005;18:45-51. a lack of social support,3636. Townend BS, Whyte S, Desborough T, Crimmins D, Markus R, Levi C, et al. Longitudinal prevalence and determinants of early mood disorder post-stroke. J Clin Neurosci. 2007;14:429-34. low family income,3737. Li D. [A study of related factors to post-stroke depression with first-onset] [dissertation]. Tongliao: Inner Mongolia University for Nationalities; 2013. premorbid neuroticism,3838. Storor DL, Byrne GJ. Pre-morbid personality and depression following stroke. Int Psychogeriatr. 2006;18:457-69. as well as type A behavior3939. Liang CP, Wang XM, Xu JX, Wang HB, Li ZF. [A study on the relationship of post-stroke depression and psychosocial factors]. Chin J Clin Psychol. 2005;13:470-1, 473. are associated with an increased risk of PSD.

Patients with PSD are more likely to have a family history of depression.1717. Hackett ML, Yapa C, Parag V, Anderson CS. Frequency of depression after stroke: a systematic review of observational studies. Stroke. 2005;36:1330-40. Molecular genetic studies have demonstrated that variation in several genes is associated with PSD, including those for the serotonin transporter (SLC6A4),4040. Kohen R, Cain KC, Mitchell PH, Becker K, Buzaitis A, Millard SP, et al. Association of serotonin transporter gene polymorphisms with poststroke depression. Arch Gen Psychiatry. 2008;65:1296-302. 5-HT 1A4141. Chen AM. [Relationship between 5-HTR1A C(-1019)G and G-protein β3 subunit C825T polymorphisms and post-stroke depression] [dissertation]. Guangzhou: Southern Medical University; 2011. and 2A4242. Chen C, Liu ZH, Chen AM, Zhao LX. [Association between polymorphism of 5-hydroxy tryptamine 2A receptor T102C gene and post-stroke depression]. Chin J Neuromed. 2011;10:1119-21. receptors (HTR1A and HTR2A), brain-derived neurotrophic factor (BDNF),4343. Kim JM, Stewart R, Bae KY, Kim SW, Kang HJ, Shin IS, et al. Serotonergic and BDNF genes and risk of depression after stroke. J Affect Disord. 2012;136:833-40. N5, N10-methylenetetrahydrofolate reductase (MTHFR),4444. Cao L, Liu ZH, Zhao LX. [Association analysis of serum homocysteine level and MTHFR genetic polymorphism with post-stroke depression]. Guangdong Med J. 2010;31:2946-9. catechol-O-methyltransferase (COMT),4545. Cai WW. [Association of polymorphisms of COMT and DAT gene in dopamine metabolism system with post-stroke depression] [dissertation]. Guangzhou: Southern Medical University; 2011. interleukin (IL)-10, IL-4,4646. Kim JM, Stewart R, Kim SW, Shin IS, Kim JT, Park MS, et al. Associations of cytokine gene polymorphisms with post-stroke depression. World J Biol Psychiatry. 2012;13:579-87. and cAMP response element binding protein (CREB),4747. He LM. [Post-stroke depression and CREB1 gene polymorphism analysis] [dissertation]. Guangzhou: Southern Medical University; 2010. among which 5-HT associated genes are the most preferred candidates in genetic research. Moreover, gene-gene and gene-environment interactions are also involved in the occurrence of PSD.4343. Kim JM, Stewart R, Bae KY, Kim SW, Kang HJ, Shin IS, et al. Serotonergic and BDNF genes and risk of depression after stroke. J Affect Disord. 2012;136:833-40. In addition, microRNA is considered to play an important role in the development of PSD and antidepressant therapy.4848. Zhao L, Li H, Guo R, Ma T, Hou R, Ma X, et al. miR-137, a new target for post-stroke depression? Neural Regen Res. 2013;8:2441-8.

Researchers have been very interested in changes of neurotransmitter function in the pathophysiology of PSD. A significant decrease has been demonstrated in norepinephrine, 5-HT, and its metabolite 5-hydroxyindol acetic acid (5-HIAA) in the cerebrospinal fluid of PSD patients in the acute phase of stroke.4949. Bryer JB, Starkstein SE, Votypka V, Parikh RM, Price TR, Robinson RG. Reduction of CSF monoamine metabolites in poststroke depression: a preliminary report. J Neuropsychiatry Clin Neurosci. 1992;4:440-2.,5050. Ghika-Schmid F, Bogousslavsky J. Affective disorders following stroke. Eur Neurol. 1997;38:75-81. Abnormal glutamate metabolism in the prefrontal lobe can also be found by single voxel proton magnetic resonance spectroscopy.5151. Glodzik-Sobanska L, Slowik A, McHugh P, Sobiecka B, Kozub J, Rich KE, et al. Single voxel proton magnetic resonance spectroscopy in post-stroke depression. Psychiatry Res. 2006;148:111-20.

Previous studies indicate that inflammation may participate in the incidence of PSD. Inflammatory cytokines, such as IL-1, IL-6, IL-18, and tumor necrosis factor (TNF)-alpha have been found to be significantly increased after stroke,5252. Maines MD. Zinc. protoporphyrin is a selective inhibitor of heme oxygenase activity in the neonatal rat. Biochim Biophys Acta. 1981;673:339-50. and the serum level of C-reactive protein is reported to be an important predictor of PSD occurrence and severity.5353. Kuo HK, Yen CJ, Chang CH, Kuo CK, Chen JH, Sorond F. Relation of C-reactive protein to stroke, cognitive disorders, and depression in the general population: systematic review and meta-analysis. Lancet Neurol. 2005;4:371-80.

Neuroendocrine research suggests that there may be impaired function of the hypothalamus-pituitary-adrenal axis, the hypothalamus-pituitary-thyroid axis, and the hypothalamus-pituitary-gonad axis in PSD patients.5454. Paolucci S, Autonucci G, Grasso MG, Morelli D, Troisi E, Coiro P, et al. Post-stroke depression, antidepressant treatment and rehabilitation result. A case-control study. Cerebrovasc Dis. 2001;12:264-71.,5555. Xiong GR, Zhao LY, Mao JP. [Study on the functionaI changes of hypothalamus-pituitary-gonad axis in senility women with post-stroke depression]. Nerv Dis Ment Health. 2007;7:180-210. In addition, it has been demonstrated that PSD is associated with low BDNF5656. Yang L, Zhang Z, Sun D, Xu Z, Yuan Y, Zhang X, et al. Low serum BDNF may indicate the development of PSD in patients with acute ischemic stroke. Int J Geriatr Psychiatry. 2011;26:495-502. and ferritin,5757. Zhu L, Han B, Wang L, Chang Y, Ren W, Gu Y, et al. The association between serum ferritin levels and post-stroke depression. J Affect Disord. 2016;190:98-102. as well as with elevated neopterin.5858. Tang CZ, Zhang YL, Wang WS, Li WG, Shi JP. Elevated serum levels of neopterin at admission predicts depression after acute ischemic stroke: a 6-month follow-up study. Mol Neurobiol. 2016;53:3194-3204.

Neuroanatomical abnormality may also play an important role. PSD is probably associated with damage of the frontal/temporal lobe-basal ganglia-ventral brainstem circuitry and deficits in corresponding chemical neurotransmission.5959. Kim JS, Choi-Kwon S. Poststroke depression and emotional incontinence: correlation with lesion location. Neurology. 2000;54:1805-10. Stroke lesion location and white matter hyperintensities (WMHs) have been extensively investigated as risk factors for PSD. There is still a matter of debate on the association between the lesion location and the occurrence of depression due to contradictory findings. This might be explained by the fact that the clinical characteristics of PSD differ depending on its anatomical correlates. For instance, affective depression is associated with left frontal stroke, while apathetic depression is related to damage of the bilateral basal ganglia.6060. Hama S, Yamashita H, Shigenobu M, Watanabe A, Kurisu K, Yamawaki S, et al. Post-stroke affective or apathetic depression and lesion location: left frontal lobe and bilateral basal ganglia. Eur Arch Psychiatry Clin Neurosci. 2007;257:149-52. It has also been found that there is an association between the frequency and severity of PSD and the proximity of the lesion to the frontal pole, i.e., the closer the lesion is to the frontal pole, the more severe the depression is.6161. Robinson RG, Kubos KL, Starr LB, Rao K, Price TR. Mood disorders in stroke patients Importance of location of lesion. Brain. 1984;107:81-93. Subgroup analyses according to different stroke stages highlight that the risk of depression is associated with left hemisphere stroke in the acute phase (<1 month), but relates to right hemisphere stroke in the subacute stage (1-6 months).6262. Wei N, Yong W, Li X, Zhou Y, Deng M, Zhu H, et al. Post-stroke depression and lesion location: a systematic review. J Neurol. 2015;262:81-90. Furthermore, WMHs have a relatively important influence on PSD in small infarctions, while the infarction itself plays a major part in PSD occurrence in patients with a large lesion.6363. Tang WK, Chen YK, Lu JY, Chu WC, Mok VC, Ungvari GS, et al. White matter hyperintensities in post-stroke depression: a case control study. J Neurol Neurosurg Psychiatry. 2010;81:1312-5.

Clinical assessment of PSD

Early recognition, prevention, and treatment of PSD are vital to the recovery and prognosis of stroke survivors. Since there are many risk factors for PSD, an integrated assessment should cover general information, functional level after stroke, and depressive symptoms.

General information

Present history

It is very important to screen for depressive symptoms in the acute phase of stroke and record the time of onset, characteristics, severity, and accompanying psychological and somatic symptoms of depression. Considering the close relationship between PSD and stroke, an overall evaluation of the stroke is also essential, including its type, location, size, severity, and the functional state of the patient.

Prior history

Previous attacks of stroke, depression, and other psychotic disease are all significant determinants of PSD. The existence and treatment outcome of these disorders should be assessed. In addition, the assessment of vascular risk factors is also necessary, since hypertension and angina pectoris are independent predictors of PSD.6464. de Man-van Ginkel JM, Hafsteinsdottir TB, Lindeman E, Ettema RG, Grobbee DE, Schuurmans MJ. In-hospital risk prediction for post-stroke depression: development and validation of the post-stroke depression prediction scale. Stroke. 2013;44:2441-5.,6565. Jiang XG, Lin Y, Li YS. Correlative study on risk factors of depression among acute stroke patients. Eur Rev Med Pharmacol Sci. 2014;18:1315-23.

Personal and family history

The factors associated with occurrence of PSD should be assessed, including age, gender, adverse life events, family income, living alone, social support, and personality traits.6666. Wang L, Tao Y, Chen Y, Wang H, Zhou H, Fu X. Association of post stroke depression with social factors, insomnia, and neurological status in Chinese elderly population. Neurol Sci. 2016;37:1305-10.

67. Schulz R, Beach SR, Ives DG, Martire LM, Ariyo AA, Kop WJ. Association between depression and mortality in older adults: the cardiovascular health study. Arch Intern Med. 2000;160:1761-8.
-6868. Aben I, Verhey F, Strik J, Lousberg R, Lodder J, Honig A. A comparative study into the one year cumulative incidence of depression after stroke and myocardial infarction. J Neurol Neurosurg Psychiatry. 2003;74:581-5. Family history of depression should also be assessed, since a family history of depression is common in PSD patients.1717. Hackett ML, Yapa C, Parag V, Anderson CS. Frequency of depression after stroke: a systematic review of observational studies. Stroke. 2005;36:1330-40.

Functional level after stroke

Motor disability is one of the most severe outcomes of stroke. The National Institutes of Health Stroke Scale (NIHSS),6969. Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864-70. modified Rankin Scale (mRS),7070. Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 1957;2:200-15. and Barthel Index (BI) are common assessment instruments for neurological deficit.7171. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14:61-5.

Depressive symptoms

The evaluation tools used in clinics are self-rating scales and observer-rating scales. Self-rating scales include the Self-Rating Depression Scale (SDS),7272. Zung WW. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63-70. Beck Depression Inventory (BDI),7373. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71. Patient Health Questionnaire-9 (PHQ-9),7474. Wang W, Bian Q, Zhao Y, Li X, Wang W, Du J, et al. Reliability and validity of the Chinese version of the patient health questionnaire (PHQ-9) in the general population. Gen Hosp Psychiatry. 2014;36:539-44. Hospital Anxiety and Depression Scale (HADS),7575. Snaith RP, Zigmond AS. The hospital anxiety and depression scale. Br Med J (Clin Res Ed). 1986;292:344. and Center for Epidemiologic Studies Depression Scale (CES-D),7676. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385-401. while the HDRS7777. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62. and Montgomery-Asbery Depression Rating Scale (MADRS) are observer-rating scales.7878. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382-9.

However, considering the different symptomatic distributions in MDD and PSD, the above-mentioned scales may have low specificity for PSD patients, given that they are all designed for MDD patients. Based on previous scales, Yue et al.7979. Yue Y, Liu R, Lu J, Wang X, Zhang S, Wu A, et al. Reliability and validity of a new post-stroke depression scale in Chinese population. J Affect Disord. 2015;174:317-23. developed a new PSD scale (PSD-S), a self-evaluation scale with excellent reliability and validity (available in the original article as online supplementary material7979. Yue Y, Liu R, Lu J, Wang X, Zhang S, Wu A, et al. Reliability and validity of a new post-stroke depression scale in Chinese population. J Affect Disord. 2015;174:317-23.). It can be used as an early screening tool for PSD in which scores of 6/24 and 15/24 are cut-points for mild and moderate/severe PSD respectively. The PHQ-9, which consists of nine symptomatic items derived from the DSM-5, is a screening instrument for depression, evaluating the frequency of depressive symptoms in the previous two weeks. Williams et al.8080. Williams LS, Brizendine EJ, Plue L, Bakas T, Tu WZ, Hendrie H, et al. Performance of the PHQ-9 as a screening tool for depression after stroke. Stroke. 2005;36:635-8. explored the performance of the PHQ-9 as a screening and diagnostic tool for depression in stroke survivors, finding 91% sensitivity and 89% specificity with a cutoff value of 10. The PHQ-9 is convenient, has good reliability and validity and is recommended for early screening of MDD and PSD.

Diagnosis and differential diagnosis of PSD

There are no accurate diagnostic criteria for PSD in the current generalized diagnosis and classification systems of mental disorders. Some studies have adopted the DSM-5’s diagnostic criteria for MDD or merely relied on depression assessment scales to diagnose PSD. The disorder was merely defined as a “depressive disorder due to another medical condition” and classified into three subtypes – with depressive features (F06.31), with a major depressive-like episode (F06.32), or with mixed features (F06.34) – in the DSM-5, which was published in May 2013 (293.83).8181. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington: American Psychiatric Publishing; 2013.

Generalized PSD should include PSDS and PSDD according to the diagnostic criteria. PSDS can be considered as a transition between normality and PSDD or the earlier stages of PSD, which can either progress to PSDD, maintain its original condition or recover spontaneously (Figure 1). Yue et al.7979. Yue Y, Liu R, Lu J, Wang X, Zhang S, Wu A, et al. Reliability and validity of a new post-stroke depression scale in Chinese population. J Affect Disord. 2015;174:317-23. further proposed a set of diagnostic criteria for PSDS (Table 1), which can be used for diagnosis one week post-stroke. Meanwhile, PSDD is considered post-stroke MDD, and should first fulfill the PSDS criteria and then the DSM-5’s MDD criteria.8282. Yue Y, Liu R, Cao Y, Wu Y, Zhang S, Li H, et al. New opinion on the subtypes of poststroke depression in Chinese stroke survivors. Neuropsychiatr Dis Treat. 2017;13:707-13. To confirm this diagnosis, clinicians should discriminate PSD from post-stroke apathy, post-stroke anxiety (PSA), post-stroke fatigue (PSF) and post-stroke psychotic disorder (PSPD).

Figure 1
Diagram presenting the progression of PSD (cited from Yue et al.8282. Yue Y, Liu R, Cao Y, Wu Y, Zhang S, Li H, et al. New opinion on the subtypes of poststroke depression in Chinese stroke survivors. Neuropsychiatr Dis Treat. 2017;13:707-13.). PSD = post-stroke depression; PSDD = post-stroke depressive disorder; PSDS = post-stroke depressive symptoms.

Table 1
Diagnostic criteria for post-stroke depressive symptoms

Post-stroke apathy

Post-stroke apathy is so similar to PSD that it is difficult to distinguish them. The differentiation could depend on varying psychiatric symptoms, emotional properties, or facial expressions. In psychiatric symptomatology, apathy is related to disinhibition, declining cognitive function, and aberrant motor behaviors, while depression is associated with anxiety, agitation, and irritability.8383. Withall A, Brodaty H, Altendorf A, Sachdev PS. A longitudinal study examining the independence of apathy and depression after stroke: the Sydney stroke study. Int Psychogeriatr. 2011;23:264-73. Regarding emotional properties, apathetic patients are indifferent, have a neutral mood, and are usually without suicidal ideation,8484. Ishizaki J, Mimura M. Dysthymia and apathy: diagnosis and treatment. Depress Res Treat. 2011;2011:893-905. but depressed patients show a clearly negative mood. With respect to facial expression, apathetic patients often present a flat affect and lack of eye contact, while most depressed individuals have a typical expression of sadness, with emotion in their eyes.

Post-stroke anxiety (PSA)

PSA is usually seen in the chronic phase of stroke, with the incidence rising over time,8585. Campbell Burton CA, Murray J, Holmes J, Astin F, Greenwood D, Knapp P. Frequency of anxiety after stroke: a systematic review and meta-analysis of observational studies. Int J Stroke. 2013;8:545-59. while most PSD occurs in the acute stage. Although the occurrence of PSD is loosely linked to prior history of depression, it is rather strongly influenced by the stroke itself; however, PSA is closely associated with prior anxiety.8686. Schottke H, Giabbiconi CM. Post-stroke depression and post-stroke anxiety: prevalence and predictors. Int Psychogeriatr. 2015;27:1805-12. PSD patients mostly show a constantly depressed mood and loss of interest, accompanied by somatic or mental anxieties such as worrying, tension, and palpitation, which are all attributable to depressive mood. In comparison, PSA patients present fear, tension, worry, irritability, or restlessness.

Post-stroke fatigue (PSF)

PSF is a subjective feeling of physical or mental weariness and lack of energy independent of exercise or prior activity, with abnormal, transitional, and chronic characteristics that lead to difficulty maintaining even routine activities.8787. Staub F, Bogousslavsky J. Fatigue after stroke: a major but neglected issue. Cerebrovasc Dis. 2001;12:75-81. It is necessary to differentiate PSF from PSD when depressed mood presents in fatigue and when symptoms such as fatigue and loss of energy accompany PSD.

Post-stroke psychotic disorder (PSPD)

PSPD refers to many types of psychiatric syndromes in the acute, rehabilitation, and sequelae stages of stroke. It is reportedly a complex of many symptoms, including hallucination, delusion, and delirium, which hinders functional outcome and quality of life.8888. Almeida OP, Xiao J. Mortality associated with incident mental health disorders after stroke. Aust N Z J Psychiatry. 2007;41:274-81. Although usually with a slow and fluctuating course that may rapidly worsen when aggravated by a stroke or improve due to compensating collateral circulation, PSPD will generally develop into dementia despite its various clinical presentations.

PSD treatment

Drug therapy

Timely and reasonable antidepressant treatment is not only helpful for relieving depression, but also benefits neurological outcome and long-term prognosis. PSD treatment depends on a good doctor-patient relationship, establishing a therapeutic alliance consisting of the patients and their family members, who are encouraged to cooperate with clinicians for the patient’s recovery. Antidepressant treatment should begin as soon as stroke survivors have been diagnosed with PSDS, including medication, physical therapy, psychological therapy, etc.

Antidepressants are the preferred treatment of PSD.8989. Xu XM, Zou DZ, Shen LY, Liu Y, Zhou XY, Pu JC, et al. Efficacy and feasibility of antidepressant treatment in patients with post-stroke depression. Medicine (Baltimore). 2016;95:e5349. The choice of antidepressant depends on the patient’s depressive symptoms and the side effects, especially for the elderly. Meanwhile, doctors should be aware of the interaction of the chosen drug with other medications and its influence on the disease. Clinicians should closely observe and assess the response to therapy, constantly focus on the probable side effects and thoroughly communicate with patients to maintain their compliance, since antidepressants are not as well tolerated due to certain adverse events.8989. Xu XM, Zou DZ, Shen LY, Liu Y, Zhou XY, Pu JC, et al. Efficacy and feasibility of antidepressant treatment in patients with post-stroke depression. Medicine (Baltimore). 2016;95:e5349. Furthermore, there is also the risk of a manic attack during PSD treatment. If this occurs, the antidepressant dose should be reduced or stopped immediately and replaced with a mood stabilizer.

Regarding the efficacy of antidepressants, a multicenter randomized controlled trial (RCT) with 788 PSD patients demonstrated that the effectiveness of an eight-week treatment with paroxetine is 93.1%.9090. Horváth S, Karányi Z, Harcos P, Nagy Z, Németh G, Andor G. [Clinical effectiveness and safety of paroxetine in post-stroke depression: results from a phase 4, open label, multicenter clinical trial with 26 weeks of follow-up]. Orv Hetil. 2006;147:2397-404. A small number of clinical studies have had success with citalopram,9191. Andersen G, Vestergaard K, Lauritzen L. Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram. Stroke. 1994;25:1099-104. escitalopram,9292. Wu WJ, Wang HH, Peng ZW, Wang Y, Zhang YH, He H, et al. [Comparisons of effect of four different SSRIs on post-stroke depression]. J Neurosci Ment Health. 2013;13:16-9. sertraline,9393. Spalletta G, Caltagirone C. Sertraline treatment of post-stroke major depression: an open study in patients with moderate to severe symptoms. Funct Neurol. 2003;18:227-32. fluvoxamine,9494. Sunami E, Usuda K, Nishiyama Y, Otori T, Katsura K, Katayama Y. A preliminary study of fluvoxamine maleate on depressive state and serum melatonin levels in patients after cerebral infarction. Intern Med. 2012;51:1187-93. and mirtazapine.9595. Niedermaier N, Bohrer E, Schulte K, Schlattmann P, Heuser I. Prevention and treatment of poststroke depression with mirtazapine in patients with acute stroke. J Clin Psychiatry. 2004;65:1619-23. A meta-analysis of 11 RCTs indicated that fluoxetine has superior effects as a PSD treatment,9696. Yi ZM, Liu F, Zhai SD. Fluoxetine for the prophylaxis of poststroke depression in patients with stroke: a meta-analysis. Int J Clin Pract. 2010;64:1310-7. whereas another meta-analysis of 32 RCTs reported that venlafaxine is more effective than selective serotonin reuptake inhibitors (SSRIs).9797. Smith D, Dempster C, Glanville J, Freemantle N, Anderson I. Efficacy and tolerability of venlafaxine compared with selective serotonin reuptake inhibitors and other antidepressants: a meta-analysis. Br J Psychiatry. 2002;180:396-404. A meta-analysis on the effectiveness of citalopram shows there may be no significant difference in the efficacy of different SSRIs.9898. Tan S, Huang X, Ding L, Hong H. Efficacy and safety of citalopram in treating post-stroke depression: a meta-analysis. Eur Neurol. 2015;74:188-201. However, the validity of evidence in many of these studies is weak due to a small sample size or a non-RCT design.

Traditional Chinese medicine has also been used in PSD treatment. In clinical studies, traditional Chinese medicine has been used alone for mild depression or combined with antidepressants for moderate and severe depression. The results showed that the Wuling capsule and the Shuganjieyu capsule are effective for PSD patients.9999. Sun XY, Chen AQ, Xu XF, Zhang HG, Tang QS, Zhang HY. [Randomized, double blind, placebo-controlled trial of Shuganjieyu capsule in the treatment of mild and moderate depression]. Chin J New Drugs. 2009;18:413-6, 457.,100100. Wang YQ, Song SJ, Jiang X. [Clinical trial of Wuling capsule combined with Zoloft in the treatment of post-stroke depression]. Zhejiang Chin Med J. 2007;42:202-3.

However, it is still unclear when to start antidepressant treatment and how long it should continue. A longitudinal follow-up study by Fruehwald et al.101101. Fruehwald S, Gatterbauer E, Rehak P, Baumhackl U. Early fluoxetine treatment of post-stroke depression--a three-month double-blind placebo-controlled study with an open-label long-term follow up. J Neurol. 2003;250:347-51. found that three-months of fluoxetine treatment in PSD patients can significantly increase emotional and functional recovery at 18 months post-stroke, although no significant effects were observed in the early stages of drug administration. A single-blind RCT in a Chinese population also found that the effects of a three-month citalopram treatment program were more efficient six months post-stroke.102102. Gao J, Lin M, Zhao J, Bi S, Ni Z, Shang X. Different interventions for post-ischaemic stroke depression in different time periods: a single-blind randomized controlled trial with stratification by time after stroke. Clin Rehabil. 2017;31:71-81. These studies indicate that the drugs’ effects might be masked by other clinical factors, and further studies should be conducted to determine whether PSD treatment should follow the acute, consolidation, or maintenance phases, as with MDD. In the 2015 update of the Canadian Stroke Best Practice Recommendations, it was advised that drug therapy should continue for at least period is 6 to 12 months if the chosen drugs are effective.103103. Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11: 459-84. With respect to PSDS, the maintenance stage of treatment could be reduced, continuing 2 to 3 months after the depressive symptoms disappear.

Physical therapy

Repetitive transcranial magnetic stimulation (rTMS) might be an effective and safe treatment method for refractory PSD patients.104104. Jorge RE, Robinson RG, Tateno A, Narushima K, Acion L, Moser D, et al. Repetitive transcranial magnetic stimulation as treatment of poststroke depression: a preliminary study. Biol Psychiatry. 2004;55:398-405. However, the method presents certain complications, such as headaches, gastrointestinal reaction, dry mouth, tinnitus, and even seizures.105105. Shen X, Liu M, Cheng Y, Jia C, Pan X, Gou Q, et al. Repetitive transcranial magnetic stimulation for the treatment of post-stroke depression: a systematic review and meta-analysis of randomized controlled clinical trials. J Affect Disord. 2017;211:65-74. It is appropriate to carry out rTMS six months post-stroke. More clinical evidence is needed to confirm the best frequency and stimulation intensity for PSD patients. Electroconvulsive therapy (ECT) is an alternative for nonacute PSD patients with severe suicidal ideation, refractoriness, or intolerance to drugs. However, ECT often induces or aggravates cognitive impairment and ECT-associated complications, thus it is not preferred for PSD treatment.106106. Currier MB, Murray GB, Welch CC. Electroconvulsive therapy for post-stroke depressed geriatric patients. J Neuropsychiatry Clin Neurosci. 1992;4:140-4. It has been indicated that early treatment is favorable for the long-term prognosis of PSD patients. However, attention should also be paid to adverse events in rTMS or ECT, since many stroke survivors, especially those with cerebral stent or hemorrhage, cannot tolerate rTMS or ECT.

Psychotherapy

Supportive psychotherapy and cognitive behavior therapy (CBT) have been found effective in PSD treatment.107107. Friedland JF, McColl M. Social support intervention after stroke: results of a randomized trial. Arch Phys Med Rehabil. 1992;73:573-81.,108108. Nicholl CR, Lincoln NB, Muncaster K, Thomas S. Cognitions and post-stroke depression. Br J Clin Psychol. 2002;41:221-31. Social support interventions are very helpful for returning patients to society and reestablishing the patients’ relationships with others. PSD can be avoided or decreased in severity with social support from family, friends, and colleagues, who are advised to visit more frequently, providing more company and encouraging the patient to accept the therapy and rehabilitation exercises positively. CBT aims to change the cognitive activity of stroke patients, pointing out inappropriate modes of thought and their counterproductive ideations, inspiring patients to adopt reasonable thoughts and abandon self-destructive ideas and emotions, and then re-constructing neuronal circuits to correct cognition and behavior. Balancing psychotherapy (BPT) is a treatment approach based on eastern philosophical systems that combines different psychological schools. Initially, psychosomatic balancing theory and methods are used to clear away the causes of PSD and mental blockage, which imbalance internal homeostasis. The patients are then provided with clues toward an overall and intrinsic knowledge of their problems. Afterwards, patients learn to observe themselves resolutely and reconstruct their cognition, obtaining inner balance by comparing their experiences with similar events in the lives of others. Psychotherapy is preferable as a supplementary tool in the treatment of mild and moderate depression.

Other therapy

Music therapy, acupuncture therapy,109109. Zhang ZJ, Chen HY, Yip KC, Ng R, Wong VT. The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis. J Affect Disord. 2010;124:9-21. Taijiquan, and hyperbaric oxygen therapy110110. Yan D, Shan J, Ze Y, Xiao-Yan Z, Xiao-Hua H. The effects of combined hyperbaric oxygen therapy on patients with post-stroke depression. J Phys Ther Sci. 2015;27:1295-7. have all been tried in PSD treatment, but, unfortunately, they lack well-designed RCTs to support their efficacy at present.

Preventive treatment of PSD

It has been found that early prevention can reduce the occurrence of PSD and induce effective recovery of neurological function.111111. Wang F. [The influence of early prevention of post-stroke depression on the rehabilitation of patients with acute stroke]. Chin J Mod Drug Appl. 2013;7:98-9. Both antidepressants and psychotherapy have been shown to improve activities of daily living and cognitive function, as well as to decrease the mortality of stroke patients.112112. Ramasubbu R. Therapy for prevention of post-stroke depression. Expert Opin Pharmacother. 2011;12:2177-87.

Preventive application of antidepressants, especially SSRIs, can significantly reduce the incidence of PSD and improve the prognosis of stroke patients.113113. Flaster M, Sharma A, Rao M. Poststroke depression: a review emphasizing the role of prophylactic treatment and synergy with treatment for motor recovery. Top Stroke Rehabil. 2013;20:139-50.

Traditional Chinese medicine, such as the Wuling capsule, can also have a preventive effect, reducing incidence rates, delaying occurrence, and alleviating PSD symptoms.114114. Zhu J, Hu CM, Guo SS, Wang F, Zhou Y, Zhang SY. [Wuling capsule played an assistant role in primary prevention of post-stroke depression: a clinical research]. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2014;34:676-9.

A motor relearning program (MRP) is a type of physical therapy with task-oriented strategies that rehabilitate motor function after damage to the central nervous system as a relearning or retraining process. Early combined MRP with regular stroke treatment can greatly decrease the prevalence of PSD.115115. Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clin Rehabil. 2000;14:361-9.

It has been demonstrated that services performed by community health professionals can effectively reduce the severity of PSD and improve health-related quality of life. Intervention methods include telephone interviews, obtaining written information, home visits, contacting health professionals, and health service referrals.116116. Graven C, Brock K, Hill K, Ames D, Cotton S, Joubert L. From rehabilitation to recovery: protocol for a randomized controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke. BMC Neurol. 2011;11:73.

The occurrence of PSD has been associated with physiological, psychological, and social factors. CBT, problem-solving therapy, and home-based therapies have all been found efficient in stroke patients and beneficial to cognitive function and the quality of life of PSD patients.117117. Desmond DW, Remien RH, Moroney JT, Stern Y, Sano M, Williams JB. Ischemic stroke and depression. J Int Neuropsychol Soc. 2003;9:429-39.

Overall, early prophylaxis is important for decreasing the incidence of PSD and helping regain function. However, there is still controversy about the strategies and timing of the prophylaxis. It has been suggested that early nondrug preventive methods, including lifestyle education, psychological counseling, and intervention should be used.116116. Graven C, Brock K, Hill K, Ames D, Cotton S, Joubert L. From rehabilitation to recovery: protocol for a randomized controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke. BMC Neurol. 2011;11:73.,117117. Desmond DW, Remien RH, Moroney JT, Stern Y, Sano M, Williams JB. Ischemic stroke and depression. J Int Neuropsychol Soc. 2003;9:429-39.

PSD nursing

Hospital nursing staff and family caregivers play an important role in the recovery of PSD patients, who are in need of specific care measures.118118. Clark PC, Dunbar SB, Aycock DM, Courtney E, Wolf SL. Caregiver perspectives of memory and behavior changes in stroke survivors. Rehabil Nurs. 2006;31:26-32. Caregiver understanding of the disorder can have a powerful influence on its development and prognosis,119119. Bennett B. How nurses in a stroke rehabilitation unit attempt to meet the psychological needs of patients who become depressed following a stroke. J Adv Nurs. 1996;23:314-21. and caregiver workload and mental health are also associated with PSD patient outcomes.120120. Evans RL, Bishop DS, Haselkorn JK. Factors predicting satisfactory home care after stroke. Arch Phys Med Rehabil. 1991;72:144-7.,121121. Suh M, Kim K, Kim I, Cho N, Choi H, Noh S. Caregiver's burden, depression and support as predictors of post-stroke depression: a cross-sectional survey. Int J Nurs Stud. 2005;42:611-8. Therefore, nursing care and psychological intervention are very important for PSD patients in both the acute and recovery phases.

Appropriate nursing care should be based on comprehensive nursing assessments, including physical conditions, mental status, and associated risk factors. Affective nursing support is necessary to help patients adapt to unfamiliar environments and reduce their emotional insecurity as quickly as possible. A family-based nursing strategy should be introduced in the early phase of PSD.

General nursing objectives include providing a comfortable environment, appropriate personal care (including nutrition supplements), and creating a relaxing sleeping environment to ensure adequate rest. Since post-stroke apathy and hypersomnia are among the leading obstacles to rehabilitation,122122. Harris AL, Elder J, Schiff ND, Victor JD, Goldfine AM. Post-stroke apathy and hypersomnia lead to worse outcomes from acute rehabilitation. Transl Stroke Res. 2014;5:292-300. the nursing staff should help patients overcome these problems and guide them through the rehabilitation process as soon as possible. Effective bedside exercise can improve the emotional and physical functioning of stroke patients and thus elevate their quality of life.123123. Kang JH, Park RY, Lee SJ, Kim JY, Yoon SR, Jung KI. The effect of bedside exercise program on stroke patients with dysphagia. Ann Rehabil Med. 2012;36:512-20.

The role of psychological nursing includes promoting health, reducing stress and increasing coping skills.124124. Eldred C, Sykes C. Psychosocial interventions for carers of survivors of stroke: a systematic review of interventions based on psychological principles and theoretical frameworks. Br J Health Psychol. 2008;13:563-81. PSD patients inevitably feel failure when faced with physical dysfunction.125125. Kouwenhoven SE, Kirkevold M, Engedal K, Kim HS. “Living a life in shades of grey”: experiencing depressive symptoms in the acute phase after stroke. J Adv Nurs. 2012;68:1726-37. Therefore, the nursing staff should respect and care for the patients, educate them about the disease, rebuild their self-confidence, and properly conduct the supportive psychotherapy.

A health education course can reduce the depressive symptoms of PSD patients.126126. Du F, Li ZQ, Yu Q, Ruan JQ. [The effect of whole course integrated health education on improvement of depressive emotion and psychological disorders in depressive patients]. Chin J Behav Med Brain Sci. 2011;20:434-6. The full course contains three phases: the acute phase (1-2 weeks post-stroke) involves supportive psychotherapy; the stable phase (3-4 weeks post-stroke) involves collective multi-media instruction; during the recovery phase (4-6 weeks post-stroke), caregivers should consolidate achievements and prevent relapse, encouraging the patients to return to society and their work and family responsibilities.126126. Du F, Li ZQ, Yu Q, Ruan JQ. [The effect of whole course integrated health education on improvement of depressive emotion and psychological disorders in depressive patients]. Chin J Behav Med Brain Sci. 2011;20:434-6.

Nurses should work out a personalized and complete nursing program depending on the specific needs and conditions of patients. Patients should receive health guidance prior to discharge and be interviewed by telephone one to two weeks after discharge to resolve any further questions. The health education course enables patients to voluntarily follow a healthy lifestyle, eliminate negative emotions, and increase their trust in the treatment program. As a result, they can fully engage themselves in treatment and rehabilitation and find relief from their PSD symptoms.

Diagnostic and treatment procedures of PSD

Figure 2 shows the diagnostic and treatment procedures used for PSD.

Figure 2
The diagnostic and treatment procedures of PSD. MDD = major depressive disorder; PSD = post-stroke depression.

Prevention and management of PSD

Medical staff training

It is very important for sustainable PSD prevention that medical staff be actively trained under the auspices of the health department. Major training bases should be set up in psychiatric organizations nationwide. Systematic training in PSD diagnosis and treatment should be developed for psychiatrists, nonpsychiatrists, psychological consultants, psychological therapists, and medical nursing staff in general hospitals, special hospitals, health centers, and nursing homes of different scales, so that a basic mental service team composed of available human resources can be drawn from medical organizations on different levels for extensive and effective PSD prevention.

Education on mental health

Different types of media should be mobilized to promote public awareness of PSD and facilitate identification and treatment, maximizing the effects of such campaigns through conferences, speeches, family interviews, posters, popular science articles, and broadcasts.

Formation of an assessment and monitoring system

Medical workers should comprehensively evaluate the mental and physical conditions, dysfunction, and quality of life of their stroke patients to find high risk populations and carry out psychosocial interventions in time. Psychiatric units should be available to give advice on PSD diagnosis and treatment for inpatients in neurological and rehabilitation wards.

Building up favorable doctor-patient relationship and three-grade prevention

A good doctor-patient relationship based on appropriate communication will result in better patient compliance, which can improve therapy outcomes and cure rates. In addition, due to the limited therapeutic modes available for mental disorders, successful implementation of a three-step prevention program is an efficient strategy for decreasing the burden of disability and related mental and behavioral disorders on the family and society. The first step in prevention focuses on etiologies, reducing the prevalence of PSD with the most active measures. The second step emphasizes early identification, diagnosis, and treatment to obtain a favorable prognosis. The third step is to prevent relapse, which requires good rehabilitation to thoroughly promote functional recovery and quality of life.

Conclusion

Since PSD is a frequent phenomenon in stroke survivors and strongly impacts physical and cognitive outcomes, diagnosis and treatment are essential for the management of stroke patients. However, the etiology and pathogenesis of PSD is not clear. Comprehensive assessment of stroke patients can help recognize individuals at high risk. Thus, the present set of PSD classification and diagnostic criteria have been proposed. Antidepressant treatment is required as soon as the patients are diagnosed with PSD. The treatment choice depends on the patient’s characteristics and overall condition, the severity of the symptoms, and adverse effects. Identifying the mechanism of PSD is important for future research, since it may lead to a specific therapeutic interventions. In conclusion, clinicians and related workers should be aware of PSD and be able to recognize the disease in a timely manner to help patients out of their depressive mood as quickly as possible.

Acknowledgements

This work was supported by Jiangsu Provincial Special Program of Medical Science (BL2012025, YY).

References

  • 1
    Gainotti G, Azzoni A, Marra C. Frequency, phenomenology and anatomical-clinical correlates of major post-stroke depression. Br J Psychiatry. 1999;175:163-7.
  • 2
    Lipsey JR, Spencer WC, Rabins PV, Robinson RG. Phenomenological comparison of poststroke depression and functional depression. Am J Psychiatry. 1986;143:527-9.
  • 3
    Fedoroff JP, Starkstein SE, Parikh RM, Price TR, Robinson RG. Are depressive symptoms nonspecific in patients with acute stroke? Am J Psychiatry. 1991;148:1172-6.
  • 4
    Jiao JT, Cheng C, Ma YJ, Huang J, Dai MC, Jiang C, et al. Association between inflammatory cytokines and the risk of post-stroke depression, and the effect of depression on outcomes of patients with ischemic stroke in a 2-year prospective study. Exp Ther Med. 2016;12:1591-8.
  • 5
    Pompili M, Venturini P, Campi S, Seretti ME, Montebovi F, Lamis DA, et al. Do stroke patients have an increased risk of developing suicidal ideation or dying by suicide? An overview of the current literature. CNS Neurosci Ther. 2012;18:711-21.
  • 6
    Robinson RG, Jorge RE. Post-stroke depression: a review. Am J Psychiatry. 2016;173:221-31.
  • 7
    Hackett ML, Pickles K. Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies. Int J Stroke. 2014;9:1017-25.
  • 8
    Ferro JM, Caeiro L, Santos C. Poststroke emotional and behavior impairment: a narrative review. Cerebrovasc Dis. 2009;27:197-203.
  • 9
    You LL. [A correlative study of psychosocial risk factors and psychophysiological mechanisms of depression after ischemic stroke] [dissertation]. Suzhou: Suzhou University; 2016.
  • 10
    Shi Y, Xiang Y, Yang Y, Zhang N, Wang S, Ungvari GS, et al. Depression after minor stroke: prevalence and predictors. J Psychosom Res. 2015;79:143-7.
  • 11
    Sun N, Li QJ, Lv DM, Man J, Liu XS, Sun ML. A survey on 465 patients with post-stroke depression in China. Arch Psychiatr Nurs. 2014;28:368-71.
  • 12
    Gordon WA, Hibbard MR. Poststroke depression: an examination of the literature. Arch Phys Med Rehabil. 1997;78:658-63.
  • 13
    Tang WK, Chan SS, Chiu HF, Ungvari GS, Wong KS, Kwok TC, et al. Poststroke depression in Chinese patients: frequency, psychosocial, clinical, and radiological determinants. J Geriatr Psychiatry Neurol. 2005;18:45-51.
  • 14
    Andersen G, Vestergaard K, Riis J, Lauritzen L. Incidence of post-stroke depression during the first year in a large unselected stroke population determined using a valid standardized rating scale. Acta Psychiatr Scand. 1994;90:190-5.
  • 15
    Zhang T, Wang C, Liu L, Zhao X, Xue J, Zhou Y, et al. A prospective cohort study of the incidence and determinants of post-stroke depression among the mainland Chinese patients. Neurol Res. 2010;32:347-52.
  • 16
    Zhang N, Wang CX, Wang AX, Bai Y, Zhou Y, Wang YL, et al. Time course of depression and one-year prognosis of patients with stroke in mainland China. CNS Neurosci Ther. 2012;18:475-81.
  • 17
    Hackett ML, Yapa C, Parag V, Anderson CS. Frequency of depression after stroke: a systematic review of observational studies. Stroke. 2005;36:1330-40.
  • 18
    Chemerinski E, Robinson RG. The neuropsychiatry of stroke. Psychosomatics. 2000;41:5-14.
  • 19
    Morris PL, Robinson RG, Raphael B. Prevalence and course of depressive disorders in hospitalized stroke patients. Int J Psychiatry Med. 1990;20:349-64.
  • 20
    Chemerinski E, Robinson RG, Kosier JT. Improved recovery in activities of daily living associated with remission of poststroke depression. Stroke. 2001;32:113-7.
  • 21
    Fan QY, Qu QM, Zhang H, Liu JJ, Guo F, Qiao J. [The evolution of cognition and its influence factors after stroke]. Zhonghua Nei Ke Za Zhi. 2011;50:750-3.
  • 22
    Fultz NH, Ofstedal MB, Herzog AR, Wallace RB. Additive and interactive effects of comorbid physical and mental conditions on functional health. J Aging Health. 2003;15:465-81.
  • 23
    Yang Y, Shi YZ, Zhang N, Wang S, Ungvari GS, Ng CH, et al. The disability rate of 5-year post-stroke and its correlation factors: a national survey in China. PLoS One. 2016;11:e0165341.
  • 24
    Kishi Y, Robinson RG, Kosier JT. Suicidal plans in patients with stroke: comparison between acute-onset and delayed-onset suicidal plans. Int Psychogeriatr. 1996;8:623-34.
  • 25
    Yang Y, Shi YZ, Zhang N, Wang S, Ungvari GS, Ng CH, et al. Suicidal ideation at 1-year post-stroke: a nationwide survey in China. Gen Hosp Psychiatry. 2017;44:38-42.
  • 26
    Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology. 2015;45:161-76.
  • 27
    Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990-2010: findings from the global burden of disease study 2010. Lancet. 2013;381:1987-2015.
  • 28
    Liu KJ, Wang M. [Economic burden of main chronic non-infectious diseases in China]. Chin Health Econ. 2005;24:77-80.
  • 29
    Han Y, Liu Y, Zhang X, Tam W, Mao J, Lopez V. Chinese family caregivers of stroke survivors: determinants of caregiving burden within the first six months. J Clin Nurs. 2017 Mar 2. doi: 10.1111/jocn.13793 [Epub ahead of print]
    » 10.1111/jocn.13793
  • 30
    Paolucci S. Advances in antidepressants for treating post-stroke depression. Expert Opin Pharmacother. 2017;18:1011-7.
  • 31
    Verdelho A, Henon H, Lebert F, Pasquier F, Leys D. Depressive symptoms after stroke and relationship with dementia: a three-year follow-up study. Neurology. 2004;62:905-11.
  • 32
    Hadidi N, Treat-Jacobson DJ, Lindquist R. Poststroke depression and functional outcome: a critical review of literature. Heart Lung. 2009;38:151-62.
  • 33
    Zhang WN, Pan YH, Wang XY, Zhao Y. A prospective study of the incidence and correlated factors of post-stroke depression in China. PLoS One. 2013;8:e78981.
  • 34
    De Ryck A, Brouns R, Fransen E, Geurden M, Van Gestel G, Wilssens I, et al. A prospective study on the prevalence and risk factors of poststroke depression. Cerebrovasc Dis Extra. 2013;3:1-13.
  • 35
    Göthe F, Enache D, Wahlund LO, Winblad B, Crisby M, Lökk J, et al. Cerebrovascular diseases and depression: epidemiology, mechanisms and treatment. Panminerva Med. 2012;54:161-70.
  • 36
    Townend BS, Whyte S, Desborough T, Crimmins D, Markus R, Levi C, et al. Longitudinal prevalence and determinants of early mood disorder post-stroke. J Clin Neurosci. 2007;14:429-34.
  • 37
    Li D. [A study of related factors to post-stroke depression with first-onset] [dissertation]. Tongliao: Inner Mongolia University for Nationalities; 2013.
  • 38
    Storor DL, Byrne GJ. Pre-morbid personality and depression following stroke. Int Psychogeriatr. 2006;18:457-69.
  • 39
    Liang CP, Wang XM, Xu JX, Wang HB, Li ZF. [A study on the relationship of post-stroke depression and psychosocial factors]. Chin J Clin Psychol. 2005;13:470-1, 473.
  • 40
    Kohen R, Cain KC, Mitchell PH, Becker K, Buzaitis A, Millard SP, et al. Association of serotonin transporter gene polymorphisms with poststroke depression. Arch Gen Psychiatry. 2008;65:1296-302.
  • 41
    Chen AM. [Relationship between 5-HTR1A C(-1019)G and G-protein β3 subunit C825T polymorphisms and post-stroke depression] [dissertation]. Guangzhou: Southern Medical University; 2011.
  • 42
    Chen C, Liu ZH, Chen AM, Zhao LX. [Association between polymorphism of 5-hydroxy tryptamine 2A receptor T102C gene and post-stroke depression]. Chin J Neuromed. 2011;10:1119-21.
  • 43
    Kim JM, Stewart R, Bae KY, Kim SW, Kang HJ, Shin IS, et al. Serotonergic and BDNF genes and risk of depression after stroke. J Affect Disord. 2012;136:833-40.
  • 44
    Cao L, Liu ZH, Zhao LX. [Association analysis of serum homocysteine level and MTHFR genetic polymorphism with post-stroke depression]. Guangdong Med J. 2010;31:2946-9.
  • 45
    Cai WW. [Association of polymorphisms of COMT and DAT gene in dopamine metabolism system with post-stroke depression] [dissertation]. Guangzhou: Southern Medical University; 2011.
  • 46
    Kim JM, Stewart R, Kim SW, Shin IS, Kim JT, Park MS, et al. Associations of cytokine gene polymorphisms with post-stroke depression. World J Biol Psychiatry. 2012;13:579-87.
  • 47
    He LM. [Post-stroke depression and CREB1 gene polymorphism analysis] [dissertation]. Guangzhou: Southern Medical University; 2010.
  • 48
    Zhao L, Li H, Guo R, Ma T, Hou R, Ma X, et al. miR-137, a new target for post-stroke depression? Neural Regen Res. 2013;8:2441-8.
  • 49
    Bryer JB, Starkstein SE, Votypka V, Parikh RM, Price TR, Robinson RG. Reduction of CSF monoamine metabolites in poststroke depression: a preliminary report. J Neuropsychiatry Clin Neurosci. 1992;4:440-2.
  • 50
    Ghika-Schmid F, Bogousslavsky J. Affective disorders following stroke. Eur Neurol. 1997;38:75-81.
  • 51
    Glodzik-Sobanska L, Slowik A, McHugh P, Sobiecka B, Kozub J, Rich KE, et al. Single voxel proton magnetic resonance spectroscopy in post-stroke depression. Psychiatry Res. 2006;148:111-20.
  • 52
    Maines MD. Zinc. protoporphyrin is a selective inhibitor of heme oxygenase activity in the neonatal rat. Biochim Biophys Acta. 1981;673:339-50.
  • 53
    Kuo HK, Yen CJ, Chang CH, Kuo CK, Chen JH, Sorond F. Relation of C-reactive protein to stroke, cognitive disorders, and depression in the general population: systematic review and meta-analysis. Lancet Neurol. 2005;4:371-80.
  • 54
    Paolucci S, Autonucci G, Grasso MG, Morelli D, Troisi E, Coiro P, et al. Post-stroke depression, antidepressant treatment and rehabilitation result. A case-control study. Cerebrovasc Dis. 2001;12:264-71.
  • 55
    Xiong GR, Zhao LY, Mao JP. [Study on the functionaI changes of hypothalamus-pituitary-gonad axis in senility women with post-stroke depression]. Nerv Dis Ment Health. 2007;7:180-210.
  • 56
    Yang L, Zhang Z, Sun D, Xu Z, Yuan Y, Zhang X, et al. Low serum BDNF may indicate the development of PSD in patients with acute ischemic stroke. Int J Geriatr Psychiatry. 2011;26:495-502.
  • 57
    Zhu L, Han B, Wang L, Chang Y, Ren W, Gu Y, et al. The association between serum ferritin levels and post-stroke depression. J Affect Disord. 2016;190:98-102.
  • 58
    Tang CZ, Zhang YL, Wang WS, Li WG, Shi JP. Elevated serum levels of neopterin at admission predicts depression after acute ischemic stroke: a 6-month follow-up study. Mol Neurobiol. 2016;53:3194-3204.
  • 59
    Kim JS, Choi-Kwon S. Poststroke depression and emotional incontinence: correlation with lesion location. Neurology. 2000;54:1805-10.
  • 60
    Hama S, Yamashita H, Shigenobu M, Watanabe A, Kurisu K, Yamawaki S, et al. Post-stroke affective or apathetic depression and lesion location: left frontal lobe and bilateral basal ganglia. Eur Arch Psychiatry Clin Neurosci. 2007;257:149-52.
  • 61
    Robinson RG, Kubos KL, Starr LB, Rao K, Price TR. Mood disorders in stroke patients Importance of location of lesion. Brain. 1984;107:81-93.
  • 62
    Wei N, Yong W, Li X, Zhou Y, Deng M, Zhu H, et al. Post-stroke depression and lesion location: a systematic review. J Neurol. 2015;262:81-90.
  • 63
    Tang WK, Chen YK, Lu JY, Chu WC, Mok VC, Ungvari GS, et al. White matter hyperintensities in post-stroke depression: a case control study. J Neurol Neurosurg Psychiatry. 2010;81:1312-5.
  • 64
    de Man-van Ginkel JM, Hafsteinsdottir TB, Lindeman E, Ettema RG, Grobbee DE, Schuurmans MJ. In-hospital risk prediction for post-stroke depression: development and validation of the post-stroke depression prediction scale. Stroke. 2013;44:2441-5.
  • 65
    Jiang XG, Lin Y, Li YS. Correlative study on risk factors of depression among acute stroke patients. Eur Rev Med Pharmacol Sci. 2014;18:1315-23.
  • 66
    Wang L, Tao Y, Chen Y, Wang H, Zhou H, Fu X. Association of post stroke depression with social factors, insomnia, and neurological status in Chinese elderly population. Neurol Sci. 2016;37:1305-10.
  • 67
    Schulz R, Beach SR, Ives DG, Martire LM, Ariyo AA, Kop WJ. Association between depression and mortality in older adults: the cardiovascular health study. Arch Intern Med. 2000;160:1761-8.
  • 68
    Aben I, Verhey F, Strik J, Lousberg R, Lodder J, Honig A. A comparative study into the one year cumulative incidence of depression after stroke and myocardial infarction. J Neurol Neurosurg Psychiatry. 2003;74:581-5.
  • 69
    Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864-70.
  • 70
    Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 1957;2:200-15.
  • 71
    Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14:61-5.
  • 72
    Zung WW. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63-70.
  • 73
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71.
  • 74
    Wang W, Bian Q, Zhao Y, Li X, Wang W, Du J, et al. Reliability and validity of the Chinese version of the patient health questionnaire (PHQ-9) in the general population. Gen Hosp Psychiatry. 2014;36:539-44.
  • 75
    Snaith RP, Zigmond AS. The hospital anxiety and depression scale. Br Med J (Clin Res Ed). 1986;292:344.
  • 76
    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385-401.
  • 77
    Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
  • 78
    Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382-9.
  • 79
    Yue Y, Liu R, Lu J, Wang X, Zhang S, Wu A, et al. Reliability and validity of a new post-stroke depression scale in Chinese population. J Affect Disord. 2015;174:317-23.
  • 80
    Williams LS, Brizendine EJ, Plue L, Bakas T, Tu WZ, Hendrie H, et al. Performance of the PHQ-9 as a screening tool for depression after stroke. Stroke. 2005;36:635-8.
  • 81
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington: American Psychiatric Publishing; 2013.
  • 82
    Yue Y, Liu R, Cao Y, Wu Y, Zhang S, Li H, et al. New opinion on the subtypes of poststroke depression in Chinese stroke survivors. Neuropsychiatr Dis Treat. 2017;13:707-13.
  • 83
    Withall A, Brodaty H, Altendorf A, Sachdev PS. A longitudinal study examining the independence of apathy and depression after stroke: the Sydney stroke study. Int Psychogeriatr. 2011;23:264-73.
  • 84
    Ishizaki J, Mimura M. Dysthymia and apathy: diagnosis and treatment. Depress Res Treat. 2011;2011:893-905.
  • 85
    Campbell Burton CA, Murray J, Holmes J, Astin F, Greenwood D, Knapp P. Frequency of anxiety after stroke: a systematic review and meta-analysis of observational studies. Int J Stroke. 2013;8:545-59.
  • 86
    Schottke H, Giabbiconi CM. Post-stroke depression and post-stroke anxiety: prevalence and predictors. Int Psychogeriatr. 2015;27:1805-12.
  • 87
    Staub F, Bogousslavsky J. Fatigue after stroke: a major but neglected issue. Cerebrovasc Dis. 2001;12:75-81.
  • 88
    Almeida OP, Xiao J. Mortality associated with incident mental health disorders after stroke. Aust N Z J Psychiatry. 2007;41:274-81.
  • 89
    Xu XM, Zou DZ, Shen LY, Liu Y, Zhou XY, Pu JC, et al. Efficacy and feasibility of antidepressant treatment in patients with post-stroke depression. Medicine (Baltimore). 2016;95:e5349.
  • 90
    Horváth S, Karányi Z, Harcos P, Nagy Z, Németh G, Andor G. [Clinical effectiveness and safety of paroxetine in post-stroke depression: results from a phase 4, open label, multicenter clinical trial with 26 weeks of follow-up]. Orv Hetil. 2006;147:2397-404.
  • 91
    Andersen G, Vestergaard K, Lauritzen L. Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram. Stroke. 1994;25:1099-104.
  • 92
    Wu WJ, Wang HH, Peng ZW, Wang Y, Zhang YH, He H, et al. [Comparisons of effect of four different SSRIs on post-stroke depression]. J Neurosci Ment Health. 2013;13:16-9.
  • 93
    Spalletta G, Caltagirone C. Sertraline treatment of post-stroke major depression: an open study in patients with moderate to severe symptoms. Funct Neurol. 2003;18:227-32.
  • 94
    Sunami E, Usuda K, Nishiyama Y, Otori T, Katsura K, Katayama Y. A preliminary study of fluvoxamine maleate on depressive state and serum melatonin levels in patients after cerebral infarction. Intern Med. 2012;51:1187-93.
  • 95
    Niedermaier N, Bohrer E, Schulte K, Schlattmann P, Heuser I. Prevention and treatment of poststroke depression with mirtazapine in patients with acute stroke. J Clin Psychiatry. 2004;65:1619-23.
  • 96
    Yi ZM, Liu F, Zhai SD. Fluoxetine for the prophylaxis of poststroke depression in patients with stroke: a meta-analysis. Int J Clin Pract. 2010;64:1310-7.
  • 97
    Smith D, Dempster C, Glanville J, Freemantle N, Anderson I. Efficacy and tolerability of venlafaxine compared with selective serotonin reuptake inhibitors and other antidepressants: a meta-analysis. Br J Psychiatry. 2002;180:396-404.
  • 98
    Tan S, Huang X, Ding L, Hong H. Efficacy and safety of citalopram in treating post-stroke depression: a meta-analysis. Eur Neurol. 2015;74:188-201.
  • 99
    Sun XY, Chen AQ, Xu XF, Zhang HG, Tang QS, Zhang HY. [Randomized, double blind, placebo-controlled trial of Shuganjieyu capsule in the treatment of mild and moderate depression]. Chin J New Drugs. 2009;18:413-6, 457.
  • 100
    Wang YQ, Song SJ, Jiang X. [Clinical trial of Wuling capsule combined with Zoloft in the treatment of post-stroke depression]. Zhejiang Chin Med J. 2007;42:202-3.
  • 101
    Fruehwald S, Gatterbauer E, Rehak P, Baumhackl U. Early fluoxetine treatment of post-stroke depression--a three-month double-blind placebo-controlled study with an open-label long-term follow up. J Neurol. 2003;250:347-51.
  • 102
    Gao J, Lin M, Zhao J, Bi S, Ni Z, Shang X. Different interventions for post-ischaemic stroke depression in different time periods: a single-blind randomized controlled trial with stratification by time after stroke. Clin Rehabil. 2017;31:71-81.
  • 103
    Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11: 459-84.
  • 104
    Jorge RE, Robinson RG, Tateno A, Narushima K, Acion L, Moser D, et al. Repetitive transcranial magnetic stimulation as treatment of poststroke depression: a preliminary study. Biol Psychiatry. 2004;55:398-405.
  • 105
    Shen X, Liu M, Cheng Y, Jia C, Pan X, Gou Q, et al. Repetitive transcranial magnetic stimulation for the treatment of post-stroke depression: a systematic review and meta-analysis of randomized controlled clinical trials. J Affect Disord. 2017;211:65-74.
  • 106
    Currier MB, Murray GB, Welch CC. Electroconvulsive therapy for post-stroke depressed geriatric patients. J Neuropsychiatry Clin Neurosci. 1992;4:140-4.
  • 107
    Friedland JF, McColl M. Social support intervention after stroke: results of a randomized trial. Arch Phys Med Rehabil. 1992;73:573-81.
  • 108
    Nicholl CR, Lincoln NB, Muncaster K, Thomas S. Cognitions and post-stroke depression. Br J Clin Psychol. 2002;41:221-31.
  • 109
    Zhang ZJ, Chen HY, Yip KC, Ng R, Wong VT. The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis. J Affect Disord. 2010;124:9-21.
  • 110
    Yan D, Shan J, Ze Y, Xiao-Yan Z, Xiao-Hua H. The effects of combined hyperbaric oxygen therapy on patients with post-stroke depression. J Phys Ther Sci. 2015;27:1295-7.
  • 111
    Wang F. [The influence of early prevention of post-stroke depression on the rehabilitation of patients with acute stroke]. Chin J Mod Drug Appl. 2013;7:98-9.
  • 112
    Ramasubbu R. Therapy for prevention of post-stroke depression. Expert Opin Pharmacother. 2011;12:2177-87.
  • 113
    Flaster M, Sharma A, Rao M. Poststroke depression: a review emphasizing the role of prophylactic treatment and synergy with treatment for motor recovery. Top Stroke Rehabil. 2013;20:139-50.
  • 114
    Zhu J, Hu CM, Guo SS, Wang F, Zhou Y, Zhang SY. [Wuling capsule played an assistant role in primary prevention of post-stroke depression: a clinical research]. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2014;34:676-9.
  • 115
    Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clin Rehabil. 2000;14:361-9.
  • 116
    Graven C, Brock K, Hill K, Ames D, Cotton S, Joubert L. From rehabilitation to recovery: protocol for a randomized controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke. BMC Neurol. 2011;11:73.
  • 117
    Desmond DW, Remien RH, Moroney JT, Stern Y, Sano M, Williams JB. Ischemic stroke and depression. J Int Neuropsychol Soc. 2003;9:429-39.
  • 118
    Clark PC, Dunbar SB, Aycock DM, Courtney E, Wolf SL. Caregiver perspectives of memory and behavior changes in stroke survivors. Rehabil Nurs. 2006;31:26-32.
  • 119
    Bennett B. How nurses in a stroke rehabilitation unit attempt to meet the psychological needs of patients who become depressed following a stroke. J Adv Nurs. 1996;23:314-21.
  • 120
    Evans RL, Bishop DS, Haselkorn JK. Factors predicting satisfactory home care after stroke. Arch Phys Med Rehabil. 1991;72:144-7.
  • 121
    Suh M, Kim K, Kim I, Cho N, Choi H, Noh S. Caregiver's burden, depression and support as predictors of post-stroke depression: a cross-sectional survey. Int J Nurs Stud. 2005;42:611-8.
  • 122
    Harris AL, Elder J, Schiff ND, Victor JD, Goldfine AM. Post-stroke apathy and hypersomnia lead to worse outcomes from acute rehabilitation. Transl Stroke Res. 2014;5:292-300.
  • 123
    Kang JH, Park RY, Lee SJ, Kim JY, Yoon SR, Jung KI. The effect of bedside exercise program on stroke patients with dysphagia. Ann Rehabil Med. 2012;36:512-20.
  • 124
    Eldred C, Sykes C. Psychosocial interventions for carers of survivors of stroke: a systematic review of interventions based on psychological principles and theoretical frameworks. Br J Health Psychol. 2008;13:563-81.
  • 125
    Kouwenhoven SE, Kirkevold M, Engedal K, Kim HS. “Living a life in shades of grey”: experiencing depressive symptoms in the acute phase after stroke. J Adv Nurs. 2012;68:1726-37.
  • 126
    Du F, Li ZQ, Yu Q, Ruan JQ. [The effect of whole course integrated health education on improvement of depressive emotion and psychological disorders in depressive patients]. Chin J Behav Med Brain Sci. 2011;20:434-6.

Publication Dates

  • Publication in this collection
    01 Feb 2018
  • Date of issue
    Jul-Sep 2018

History

  • Received
    25 May 2017
  • Accepted
    11 July 2017
Associação Brasileira de Psiquiatria Rua Pedro de Toledo, 967 - casa 1, 04039-032 São Paulo SP Brazil, Tel.: +55 11 5081-6799, Fax: +55 11 3384-6799, Fax: +55 11 5579-6210 - São Paulo - SP - Brazil
E-mail: editorial@abp.org.br