Depression in Patients after Cerebral Vascular Accident

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Introduction

Cerebral vascular accident (CVA) is the abrupt disruption in brain function due to disturbance in the cerebral blood supply (Warlow, 2007). A third of these patients eventually develop depression. Depression is a mood disorder which significantly impairs the psychosocial functioning of a person, and further leads to somatic symptoms. Such depression is also known as post stroke depression (PSD) (Warlow, 2007). Therefore, it is imperative to identify aspects pertaining to this disorder that will help in affording the best cure or prevention. In order to do these, this paper seeks to explore the topic of depression in post stroke patients by utilization of critically appraised articles and past literature.

Background

Stroke is identified as the third leading cause of death and the most devastating and disabling disease. It has devastating emotional impact on the patient, family and society. According to Schwartz, Speed and Brunberg (2001), about 30% of the patients diagnosed with stroke develop depression within their lifetime. Following stroke, depression id often persistent and severe interfering with the rehabilitation process of the patient. The exact etiology of post stroke depression has not been identified. However, this type of depression is responsive to treatment.

Various research studies have been conducted seeking to identify the factors contributing to post-stroke depression. Advancements in technology have enhanced neuropsychiatric studies in understanding post-stroke depression. According to Astrom, Adolfsson & Asplund (2003), age and socio-economic status of the patient play no role in the development of post-stroke depression. Poor social function of the patient following stroke results from the depression rather than a cause of it. Astrom , Adolfsson & Asplund (2003) argue that the degree of disability following stroke is related to the development of depression. Previous social functioning, personality and mood disturbance play a crucial role in the development of post-stroke depression. Alcoholism and drug abuse before the stroke also contribute to the development of post-stroke depression.

Literature suggests a relation between the location and size of lesion after stroke and depression. Large, anterior lesions located in the left cerebral hemisphere have been shown to be associated with post-stroke depression. A study conducted by Herman (2001) revealed that post-stroke depression may be attributed to biochemical derangement. In the study, depressive stroke patients exhibited abnormalities in the neurotransmitter concentration, alteration of the sensitivity of the cortical receptor and derangement of the electrophysiological parameters. In addition, these patients have decreased cerebral blood flow.

Robinson (2003) highlighted that higher incidence of post-stroke depression are seen in patients with left hemisphere lesions. According to the author, the severity of depression is related to the distance between the anterior pole of the left hemisphere and the location of the distance. Literature also suggests that lesions located on the basal ganglia and left frontal lobe are linked with severe post-stroke depressive disease. In addition, lesions located in the left hemisphere basal ganglia play a vital role in the development of major depressive disease following acute stage of stroke.

According to the biological theory, children who are genetically predisposed to depression and suffer loss at an early age experience alteration of the biochemical state resulting in depression. According to this theory, family genetics and environment at an early age play a crucial role in developing depression during one’s lifetime. In the cognitive behavioral theory, depression results from low self esteem. Literature on the transactional theory reveals that depression results from interaction between the society and environment (Wade, Legh-Smith and Hewer, 1997). Certain disruptive changes, for example, family disruption and drug abuse, in the society and environment predispose an individual to depression. Stressful events, for example, separation at an early age, have been implicated as antecedents or precipitants of depression.

Post-stroke depression is associated with poor clinical outcome. This is because depression interferes with the recovery and rehabilitation process of the patient following stroke. The patient is not able to improve or maintain improvement following intensive rehabilitation if they are depressed. Clinically important results of post-stroke depression were found to be poor long term functional recovery, reduced social functioning, social contacts and quality of life (Lishman, 2008). This significantly interferes with the prognosis of the patient following stroke. Therefore, it is crucial to manage depression before engaging the patient in intensive rehabilitation.—————- Please can you reduce the background to 250 words

Literature Review

3.1 Search Methodology

Inclusion Criteria

The articles included in this study are journal publications between 1st January 2002 and 2012. This particular data was chosen as it would reflect the current state of technology and not rely on outdated research (Vishweshwars, 2000). There were several databases used including Medline, CINAHL (EBSCO Host), BMJ, E-Journal, MEDLINE and PsyArticle and the Cochrane Library.

The studies included research on both males and females, and the type of papers that were included were clinical trials, meta-analysis and randomized control trials. Data was included from adult patients who developed stroke after the age of 18 years onwards. In the beginning of the review, 12 studies were obtained but, after reading through the abstract only 5 articles were found to be related to the topic. 7 articles hand searched were also included as they were relevant to the topic area. Altogether 12 articles were in included and appraised . Majority of the articles included in the study focused on the management of patients with depression following CVA.

The qualitative studies reviewed in this research included Vickerey (2008), Hackett (2010), Schonberger (2006), Williamson (2011), Tang (2011) and Yi (2010). Vickerey (2008) focused on the relationship between self-esteem and recovery in stroke patients while Hackett (2010) discussed the development of negative cognition in stroke patients. Schonberger (2006) described the relationship between stroke brain injury and various parameters of patient compliance during stroke rehabilitation. On the other hand, Williamson (2011) elaborated on validating various tests in patients with acute stroke to identify neglect. Tang (2011) demonstrated the link between cerebral micro bleeds and development of post-stroke depression. Yi (2010) described the assessment of the anti-depressant flouxetine in the management of PSD.

The quantitative studies included Kim (2012), Fatoye (2009), Buijck (2012), Tsai (2011), Schmid (2012) and Mikami (2011). These studies were conducted to demonstrate the quantitative parameters of evidence including higher incidence of depression in stroke at a community level (Kim, 2012), greater incidence of PSD in poor nations (Fatoye, 2009), the presence of a greater number of neuropsychiatric symptoms in elderly patients following stroke (Buijck, 2012), importance of social role functioning in the rehabilitation of PSD (Schmid 2012), and the prevalence of PSD following treatment with antidepressants (Mikami , 2011).———— please take off all the red higlited not necessary

Exclusion Criteria

These included books, non-medical journals, journal reviews, letters, comments and clinical practice guidelines. In addition, articles that focused on depression in children following CVA were excluded from the study. Further, articles that did not provide clear scientific methodological approaches were excluded from the study.

3.2Qualitative Studies ——you don’t have to put this as a sub heading . you need to just mention that the study is a qualitative as you appraise the paper .

All studies used appropriate tools to collect and analyse the data as per the study designs. Vickery (2008) elaborated on the relationship between self-esteem and functional recovery in patients with acute stroke by conducting a bivariate correlational analysis and multivariate regression analysis on the functional status and self-esteem of patients with depressive symptoms. The research methodology utilized in the study was appropriate.what is the rationale of using appropariate method with textbook reference . The survey was conducted in an acute in-patient rehabilitation hospital which was appropriate for the study. The researchers recruited 176 participants for the research. This sample size is sufficient to give reliable results that can be used to demonstrate on the general population what is the rationale of using appropariate sample size with textbook reference .. However, information generated from this sample population can only be applied in patients who have suffered an acute CVA attack. The analysis method used in the survey was adequate and appropriate to produce reliable results. The authors concluded that self-esteem ratings may have a moderating role in the relationship between emotional outcome and function. The information generated from this survey can be used for future studies. However, the authors did not consider the potential biasness resulting from the relationship between the participants and surveyor.

Hackett (2010) conducted a prospective, hospital based cohort study that sought to find out whether significant negative cognition measures were missed in conventional approaches used for screening patients with acute stroke for depression. The methodology and analysis technique utilized by the researchers was appropriate for the study what is the rationale of using appropariate method with textbook reference . However, the sample size recruited for the study was not adequate to generate results that can be reproduced on the general population. In addition, the follow-up period for the study generated inconsistencies as a majority of the patients recruited in the initial study did not return to the hospital for follow-up results.

Schonberger (2006) used tools such as WAI, EBIQ, awareness and compliance levels to collect data, and prospective tools to analyse the data. The methodology used was appropriate for the study. However, the sample size was not adequate to generate results that reflect the general population. In addition, the analysis techniques used was adequate to address the hypothesis of the study. The information generated in this study is reliable and can be applied in future studies.

Williamson (2011) reported on the validation and functional correlation of patients in chronic and acute stroke using Apple’s Test. The study was conducted in three stages seeking the functional and validation correlation of patients diagnosed with acute and chronic stroke. The methodology was extensive generating complex data that address the purpose of the study. The analysis procedure was adequate and information generated from the study is reliable. However, the sample size used in the study is not adequate to generate results that can be practical for the general population. In addition, the methodology used in this study generated complex and cumbersome results, which served as a source of limitation when analyzing the results.

Tang (2011) examines the relationship between cerebral microbleeds and post-stroke depression. The methodology and analysis used in the study was appropriate. The research setting and population size was adequate to generate reliable results. The use of an MRI to confirm the diagnosis of cerebral microbleeds and structural brain changes resulting in post-stroke depression is appropriate for this study as the findings are scientific based. However, the relationship between the researcher and patients during the follow-up period introduced potential bias in the study results.

Yi (2010) collected data using relevant information from the literature reviews on fluoxetine. Statistical tools like odds ratio and weighed mean difference were used to analyse the data. The literature review adequately addressed the research questions for the study. In addition, the methodology and analysis method employed by the researchers was appropriate for the study. The sample population was adequate to generate reliable information that can be applied in the general population.

3.3 Quantitative Studies——–take off

Kim (2012) used the data collection tools CESD (Centre for Epidemiology Studies – Depression including the components Exploratory factor analysis (EFA) and Confirmatory factor analysis (CFA)), and Mini-mental state Examination (Korean Version). For the analysis, he used SPSS 17.0 and AMOS 7.0, for CFA, EFA, and internal consistency of Cronbach’s alpha. Kim (2012) had a sample size of 203 patients undergoing stroke rehabilitation in primary care settings, in Korea. This was nearly similar to the 118 patients who were undergoing rehabilitation in a Nigerian Teaching Hospital demonstrated in Fatoye (2009). The results of Kim (2012) study suggested that CESD scale is an imperative tool when it comes to screening for depressive symptoms. Comprehending the psychometric properties of the CESD scale would help health professionals in the assessment of community-residing stroke patients.

Fatoye (2009) used Beck’s Depression Inventory and the Mini-mental state examination (MMSE) to collect data, and statistical methods used to analyse the data. The method employed to conduct the study was a clinical trial of comparing cases with controls, and was relevant as it involved comparing cases with controls in a third-world nation (Nigeria). The results were that there were three variables that had a significant correlation with depressive symptoms. This included low education, paresis and cognitive impairment. Post stroke depression patients with any of these variables had higher symptoms.

Buijck (2012) undertook a study to determine that course and prevalence of neuropsychiatric symptoms in post-stroke elderly patients admitted to rehabilitation facilities. It was a longitudinal multicenter study (involved 15 facilities). The author studied the neuropsychiatric symptoms in elderly patients that were admitted to skilled nursing facilities (across the Netherlands). The author used a sample size of 145. Data was collected using the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) at admission, and compared with discharge. Data was analyzed using statistical methods. The findings of the survey revealed that the overall prevalence of Neuropsychiatric symptoms was lower than that reported by other studies. The findings of this study suggest that neuropsychiatric symptoms should be optimally managed so as to improve the rehabilitation outcome.

Mikami (2011) was a clinical drug trial involving comparison of a case with a control in an RCT setting. Treatment with antidepressant (escitalopram, an SSRI), psychotherapy (Problem-solving therapy/PST) and a placebo were studied. Data was collected using DSM-IV-TR and HRDS, and analysed using Kruskal-Wallis test (for continuous variables), along with Fisher’s extract test (for categorical variables). In the findings, Hamilton Depression scores and new onset major depression scores were increased 6 months after drug discontinuation, compared to the PST or placebo group. Therefore, antidepressants have an imperative role in decreasing post-stroke depressive symptoms.

Tsai (2011) was a double-blind randomized placebo-controlled trial, and like Mikami it was also relevant as it included studying a drug (milnacipran in patients with acute ischemic stroke) with placebo. Data was collected based on the DSM-IV-TR tool at frequent intervals (0, 1, 3, 6,9,12 months) (for identifying the signs of depression) and analysis done using appropriate statistical methods. DSM-IV-TR in both the drug trials was used as a tool to determine the presence of depression in post-stroke patients. Mikami and Tsai were both drug trials that compared an antidepressant to a placebo and other forms of treatment. The sample size of both the studies was similar (108 and 92 respectively). Tsai found out that Milnacipran had a significant role in preventing the development of Post-stroke depression. Therefore, the drug might prevent the development of depression within one year after stroke.

Schmid (2012) undertook a quantitative study to determine the role of social role functioning in the development of depression in post-stroke patients. This study was a cohort study, and data was collected using interventions such as phone calls for Patient Health Questionnaire Version 9 (PHQ9), which was ideal to complete information on the questionnaire. The social section of Stroke-Specific Quality of Life Scale tool was used to determine social role functioning. Schmid (2012) study had the highest sample size number with 372. Comorbidities and depression were found to have an independent association with a twelve week social role functioning. Therefore, improvement in social-role-functioning leads to depression improvement. It is important for rehabilitation providers to screen for and manage post-stroke depression.

All studies involved obtaining an appropriate sample, as the studies were conducted on patients with stroke and were undergoing or were supposed to be undergoing stroke rehabilitation. The duration of the studies were also appropriate as it would take PSD the same duration of time to develop as noted in the quantitative studies mentioned.

4.0 Themes in the Literature Review Articles

Several major themes were recurrent in these articles. These include: risk factors for depression and stress after stroke; symptoms and diagnosis of depression in cerebral vascular accidents (CVA); self-esteem and depression in CVA; therapeutic working alliance and antidepressant use in these patients; functional outcome and recovery; and lesion location after stroke in determining depression.

4.1 Risk factors for Post Stroke Depression

Previous history of depression is also noted as a strong precursor for the development of stroke by Miller and McCrone (2005). However, Burvill et al. (2005) study disputes some of these factors as being risk factors for depression development in these patients. These factors include sex, age and severity of stroke.

According to the findings of a study by Fatoye et al. (2009), the rates of post stroke depression are similar in African and western society. From this finding, it is possible to draw a conclusion that race or ethnicity may lack a significant role in influencing the development of depression following a stroke. However, it is imperative to note that cerebral vascular accidents are more common in African Americans than in Caucasians. Therefore, the overall ratio of patients with depression after a stroke may be higher in this group.

4.2 Self esteem and depression following acute stroke

According to Vickery et al (2008), self esteem is associated with individual functioning status following acute stroke. Following stroke, patients tend to have low self esteem because of their inability to perform various tasks. Anson and Ponsford (2006) suggest that self esteem acts as a mediator of improved psychosocial functioning and quality of life by allowing individual to adjust to stressful conditions. On the other hand, Schroevers et al. (2003), argues that self esteem is a personal attribute that buffers individuals against negative effects resulting from stressful events in life.

Vickery et al. (2008) also demonstrated a direct relationship between self esteem, depression and treatment outcome. According to the authors, self esteem acts as a modulator that moderates the effects of depression in patients undergoing intensive rehabilitation following stroke. The exploratory analysis conducted by the authors suggests that self esteem ratings facilitate the relationship between individual report on depression and functional outcome following discharge. On the other hand, Fatoye et al. (2009) relates depressive symptoms to lower education levels, age, motor and cognitive disabilities of the patient following acute stroke.

Vickery et al (2008) clearly elaborated on the effect of low self esteem on the functional recovery of the patient. Fatoye (2009) argues that decreased functioning of the stroke survivors is negatively influenced by the cognitive and motor deficits of the patient following rehabilitation. Both articles agree that depression in the post-stroke patient negatively influences the overall functioning status of the patient.

4.3 Symptoms and Diagnosis of Post-Stroke Depression by the Therapist

There are various studies, which show that primary care givers in the health sector under-diagnose depression, in up to 50% of patients (Kim et al., 2012). This is supported by a randomized controlled trial carried out by Williamson et al. (2011). According to Kim (2011), problems in the diagnosis of depression in the primary care setup arise because not many patients present with clearly identifiable symptoms and signs of depression. This means that some of these patients fail to reach the diagnostic criteria threshold for major depressive disorder. Problems may also arise because the patients fail to accept the diagnosis or when the patient has much mental comorbidity that competes for the attention of the clinician (Klinksman, 2005).

Tools such as Centre for Epidemiology Studies – Depression (CESD) are imperative in the assessment of Post-Stroke Depression (Kim et al., 2011). This will enable early initiation of appropriate management (Schmid et al., 2012). Depression symptoms according to Miller and McCrone (2005), with decreasing order of frequency, include: depressed mood; fatigue or loss of energy; insomnia or hypersomnia; alteration in appetite; diminished interest in activities; suicidal ideations; and decreased concentration. This is relevant to the scope of this paper in that it helps the primary care giver, including the nurse, in identifying patients with depression. Other symptoms that have been noted include feeling guilty, worthless or hopeless.

4.4 Lesion location and depression after stroke

According to Schonberger et al (2006) study, patients with right hemispheric lesions were more predisposed to developing depressive symptoms after six months. There was no notable discrepancy in the severity of depression in relation to anterior and posterior lesions. However, right hemispheric lesions were associated with major depressive syndromes. Unlike depth of the lesion, the size of the lesion directly correlated with the severity of depression. Patients with right anterior lesions reported a higher incidence of emotionalism than patients with lesions at other regions. Vickery et al (2008) and Fatoye et al (2009), relates low self esteem to emotionalism that is characteristic in patients with depression following acute stroke. Tang (2011) related geriatric cerebral microbleed resulting in stroke to depression. The MRI changes following cerebral microbleeds resulted in focal lesions that affected the functional outcome and neurological functioning of the patient.

4.5 Therapeutic Working Alliances

In providing treatment for those with depression after cerebral vascular accidents, it is imperative for the health providers to work in synchrony in affording the patient with the best care possible. In their retrospective case control study, Miller and McCrone (2005) note that mental health clinicians agree with primary care givers in the diagnosis of depression in 66-76% of the time. This shows that primary care givers have the skills needed in identifying depressed patients. Hackett (2010) noted that significant negative cognitions may be missed when post-stroke patients are screened for depression. It is thus imperative to include a sensitive exploration technique on the psychological effects of stroke in the patients so as to determine whether they are at risk of developing depression. Williamson (2011) recommended the application of Apple’s Test in predicting the functional outcome of the patient. The functional outcome of the patient plays a significant role in determining the development of depression following CVA.

Shmid et al., (2012) noted that of the best care that a patient with depression can be afforded with. Patients who were treated for depression in primary care setting with the collaboration of the psychiatric unit experienced better outcomes. In order to increase the therapeutic efficacy in treatment of depression, it is imperative for physicians to be alert to the most essential aspects of post stroke depression. Therapeutic collaboration is imperative in proper management of these patients (Schmid et al., 2012). In a randomized control study by Fatoye et al. (2009), physicians who were aware of depressive symptoms and associated factors of post stroke depression had better outcomes in affording a cure for their patients. Treatment of this condition leads to quality of life improvement among this group of patients.

4.6 Antidepressant treatment of patients with CVA

Post-stroke depression significantly affects the cognitive functions and motivation of the patient to engage in the treatment process. Vickery et al (2008) acknowledged that depression in stroke patients interferes with the patient’s ability to improve and maintain improvement following intensive rehabilitation. Tsai (2011) attributes poor functioning recovery to inability to cope with rehabilitation challenges in post-stroke depressed patients.

Miller (2005) argues that antidepressants are effective in countering the depressive symptoms associated with negative effects on the rehabilitation process. According to Mikami (2011) early detection and treatment of depression significantly contributes to the patient’s ability of full recovery. Drugs such as escitopram are imperative in decreasing the symptoms of post-stroke depression (Mikami, 2011). Yi (2010) highlighted that flouxetine is effective in preventing post-stroke depression in patients who are at risk. However, Fatoye (2009) urged that improvement of the cognitive and motor functioning of the patient influenced the functioning recovery of the patient. According to Fatoye (2009), antidepressant drugs were not necessary in the rehabilitation process of post-stroke depressive patients.

5. Discussion

The incidence of depression following stroke is clearly higher especially between 6 months and 24 months following the stroke episode. The exact cause for the development of depression following stroke may be difficult to determine, though in general, it may be multi-factorial in origin. Some of the factors that are responsible for the condition include biological factors, familial factors, social factors among others. Biologically, depression may be associated with biochemical changes in the brain. During stroke, certain focal areas of the brain are involved, and this may also be responsible for the development of depression. Tang (2011) demonstrated that the cerebral micro vascular bleeds noted through MRI scans, was closely associated with the development of depression. MRI Scans are also useful in a variety of neurological disorders to identify the presence of lesions in the CNS (Hamdy, 2011). In the developing world, some of the associated factors of depression in post-stroke patients include cognitive problems, low education levels and paresis (Fatoye, 2009).

Anderson et al. (2004) reported from 12 trials involving 1200 subjects that antidepressants did not have a prophylactic effect compared to a placebo. However, PST was found to have a positive impact and needs to be pursued by long-term and large studies. The finding of the inefficiency of antidepressants also needs to be substantiated from long-term and larger studies. Tsai et al (2011) noted that antidepressant therapy administered prophylactically at an earlier date (one month compared to the third month), had a better functional outcome in post-stroke patients. This drug employed as a prophylaxis in this study was milnacipram. The effect of the antidepressant drug lasted for about 2 years. Supported by Reid et al (2011), Narushima et al (2003) also notes that the effect of antidepressants such as SSRIs and others is much more superior to a placebo.

Miller et al (2005) noted that in primary care settings, the referrals for patients with depression with mental health specialty clinics were high when a diagnosis of CVA or CVD was being made. The referrals and the problems were especially high when a large number of medications were taken.

Vataja (2004) noted that a brain lesion in the pallidum strongly predicted for depression following stroke. Earlier, several studies were disproved as they could not precisely suggest the location of the brain infarct that could result in depression (Rickards, 2005). When the brain rehabilitation programme enabled greater rapport between the client and the therapist, the outcomes were better (Schonberger, 2006). Neglect in post-stroke patients increased risk of depression (Williamson, 2011).

6. Conclusion

Incidences of cerebral vascular accidents are on the rise. This is attributed to lifestyle changes and increased longevity. A significant proportion of the stroke patients will develop depression. Depression in stroke patients is associated with poor outcomes. It is futile if we as the health care providers fail to address the CVA and its risk factors. With good dietary habits and exercise, most of the CVAs can be prevented. Though screening for depression in post stroke patient has been shown to be effective, minimal research has been done in assessing the best screening tools (Miller and McCrone, 2005). This is a potential area for further research. It will enable disease prevention, rather than cure, which will decrease the disease burden. Henceforth, a research question that comes up is “what are the best practices in screening for depression in stroke patients?”

COMMENTS:

I would be better to critically appraise the arictle together with the themes.

Reference List

Anderson CS & House AO (2004) Interventions for Preventing Depression afterStroke: The Cochrane Library Issue 3

Buijck B Zuidema SU Geurts AC Spurit-van EM Koopmans RT (2012) Neuropsychiatric symptoms in geriatric patients admitted to skilled nursing facilities in nursing homes for rehabilitation after stroke: a longitudinal multicenter study. Int J Geriatric Psych 27(7) p734-74 online at: HYPERLINK “http://www.ncbi.nlm.nih.gov/pubmed/21932248″http://www.ncbi.nlm.nih.gov/pubmed/21932248 [ Accessed on : 01 December 2012]

Burvill P W Johnson G A Jamrozik KD Anderson CS Stewart-Wynne EG Chakera T (2005) Prevalence of depression after stroke: The Perth Community Stroke Study. British Journal of Psychiatry 166 pp. 320 – 327

Calpadi VF & Wynn G (2010) Post stroke depression: treatments and complications in a young adult Psychiatr Q 81(1) p73-79 oneline at: HYPERLINK “http://www.ncbi.nlm.nih.gov/pubmed/20033774″http://www.ncbi.nlm.nih.gov/pubmed/20033774 [ Accessed on : 10 December 2012 ]

Chau JP Thompson DR Chang AM Woo J Twinn S Cheung SK Kwok T (2010) Depression among Chinese stroke survivors six months after discharge from a rehabilitation hospital J Clin Nursing 19 [21-22]