Elsevier

Revue Neurologique

Volume 164, Issue 10, October 2008, Pages 837-840
Revue Neurologique

Réunion commune de la SFN et de la SFNV, 8–10 octobre 2008
Post-stroke depressionDépression postaccident vasculaire cérébral

https://doi.org/10.1016/j.neurol.2008.07.010Get rights and content

Abstract

Post-stroke depression (PSD) is the most frequent psychiatric complication of stroke. Its prevalence has been estimated to be around 30–35%, ranging from 20 to 60%. Despite the extensive literature on this topic, there is no agreement on causal mechanisms, risk factors and consequences of PSD. Stroke patients with PSD suffer higher mortality rates and show a minor improvement in rehabilitation programs in comparison to non depressed stroke patients. Consequently, they have worse functional outcomes and quality of life. The available evidence supports PSD as being multifactorial in origin, and consistent with the biopsychosocial model of mental illness. Nonetheless, the stroke itself poses the risk of depression. Stroke survivors are more predisposed to PSD compared to physically ill patients with similar levels of disability, even quite a long time after the stroke, regardless of other risk factors. Early effective treatment of depression may have a positive effect not only on depressive symptoms but also on the rehabilitation outcome of stroke patients. On the other hand, there is no definitive evidence that antidepressants or psychotherapy are useful to prevent depression. Implementing preventive and therapeutic strategies to reduce the risk of mood alteration and thus improve rehabilitation outcomes would appear important in the organization of stroke services.

Résumé

La dépression postaccident vasculaire cérébral (DpAVC) est la manifestation psychiatrique la plus fréquente après un accident vasculaire cérébral (AVC). Sa prévalence est de 30 à 35 %, avec des extrêmes allant de 20 à 60 %. Malgré une abondante littérature sur le sujet, il n’y a pas de consensus sur les mécanismes causaux, les facteurs de prédisposition et les conséquences des DpAVC. Les patients qui développent une DpAVC ont une mortalité plus élevée et une moins bonne récupération dans les programmes de rééducation, comparés aux non-déprimés. Leur devenir fonctionnel et leur qualité de vie sont moins bons. Les DpAVC sont multifactorielles et sont compatibles avec le model biopsychosocial de maladie psychiatrique. Les survivants d’AVC ont un risque de dépression plus important que des témoins ayant le même niveau de handicap physique pour des pathologies non neurologiques, même des années après l’AVC, suggérant un rôle de la lésion cérébrale. Les traitements précoces de la dépression améliorent non seulement les symptômes dépressifs, mais aussi les résultats de la rééducation. Il n’y a toutefois pas d’argument clair dans la littérature pour un effet préventif de la dépression par antidépresseurs ou psychothérapie. Il semble que des programmes de prévention et de stratégies de prise en charge réduisent les DpAVC et leurs conséquences sur la rééducation. Cette prise en charge est importante dans les suites d’un AVC.

Introduction

Over the last 50 years, there has been a steady decline in stroke incidence and mortality. The improved acute management of stroke patients is the most important factor contributing to this decline. Nevertheless, about two-thirds of stroke patients remain with some degree of permanent disability that requires rehabilitation care (Chemerinski and Robinson, 2000).

Stroke survivors may present neuropsychiatric (NP) disorders resulting in a negative effect not only on social interactions and on the overall quality of life, but also on the recovery of their motor function. Depression, anxiety disorder, catastrophic reaction or psychosis are frequently observed after stroke (Chemerinski and Robinson, 2000). Because of their impact on quality of life, NP disorders should be promptly recognized and treated.

Post-stroke depression (PSD) could be defined as depression occurring in the context of a clinically apparent stroke and is the most frequent psychiatric complication of cerebrovascular lesions (Chemerinski and Robinson, 2000).

Section snippets

Epidemiology

The mean prevalence of PSD has been estimated to be around 30–35%, ranging from 20 to 60% (Paolucci et al., 2005). This high variability of the prevalence rate is essentially due to methodological problems: different diagnostic criteria applied, use of various depression rating scales, different timing of evaluation, different criteria for patients’ enrolment (Paolucci et al., 2005). Verdelho et al. (2004) in their prospective study have preferred to evaluate depressive symptoms as a

Diagnosis

The diagnosis of PSD is challenging in the acute and chronic aftermath. Therefore, it often remains unrecognized and undertreated.

Despite adopting a non etiological view, the DSM-IV criteria for PSD are: a diagnosis of “depression due to stroke with major depressive-like episode or depressive features”. One of the major problems with the DSM-IV criteria for PSD is related to the fact that the diagnosis also requires the presence of some somatic symptoms (weariness, energy loss, weight loss,

Premorbid risk factors

Risk factors related to PSD are constitutional (female gender), clinical (previous stroke, previous depressive or psychiatric episode, cognitive impairment or aphasia), functional (severity of disability); environmental (premorbid neurotic personality and social isolation), biological (family history of depression [both genetic and environmental – “double biological hit”]). Other risk factors such as education level, previous stroke, stroke severity, apathy, denial reaction at the acute stage,

Etiology

PSD pathophysiology is still debated. Either a biological hypothesis (ischemic insults affecting neural circuits involved in mood regulation) or a psychosocial hypothesis (social and psychosocial stressors associated with stroke are in fact a primary cause of depression) has been taken into consideration, but there is no definitive evidence to support or refute one of these hypothesis (Whyte and Mulsant, 2002).

With regard to biological mechanism, there are the following statements: on the one

Prognosis

The clinical relevance of depression following stroke is related to the increased risk of death, exalted caregiver burden, worsening of the cognitive impairment, and negative influence on functional recovery. PSD is an independent predictor of poor short-term and long-term (12–24 months) post-stroke functional outcome. Remission of PSD over the first few months after stroke is associated with greater recovery in activities of daily living functions (Chemerinski et al., 2001).

It seems that the

Treatment

Early effective treatment of depression may have a positive effect not only on depressive symptoms but also on the rehabilitation outcome of stroke patients.

Treated patients with PSD showed significantly better functional improvement than untreated ones (mainly fluoxetine and nortriptyline within one month after stroke).

In clinical practice, only a minority of the patients with PSD are diagnosed, and even fewer are treated, mainly because of the high frequency of contraindications, adverse

Conclusion

Depression is a frequent and serious complication after stroke for the possible negative repercussions on patients’ recovery.

The evidence available on the therapeutic indications and especially on the possibility of preventive interventions is still limited, although promising.

Large trials are needed to limit the impact of this complication. Implementing preventive and therapeutic strategies to reduce the risk of abnormal mood and thus improve rehabilitation outcomes would appear important in

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