Background

The relationship between depression and increased mortality due to physical illness has been a focus of interest among psychiatrists for many years. Maltzberg (1937) reported that the cardiac death rate among melancholic patients was eight times the rate found in the general population. Avery and Winokur (1976) reported that among 519 depressed patients treated with antidepressants or electroconvulsive therapy, there was a significantly increased death rate among patients who had been...

Mechanism of cognitive impairment

The finding that patients with major depression had significantly lower MMSE scores than non-depressed patients only during the first 6-12 months following stroke and that cognitive impairment occurred primarily in patients with major depression associated with left hemisphere lesions suggested that depression itself may not have played a major role in producing cognitive impairment. If depression produced cognitive impairment, all patients with major depression regardless of whether they had a...

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Depressed (n 79) 1 Non-depressed (n 316) Figure 7.2 The percent of patients hospitalized with acute stroke who acknowledge autonomic (vegetative) symptoms (top panel) depression (see Table 7.1 for list of symptoms). Patients without depressed mood do acknowledge some vegetative and psychological symptoms of depression but significantly fewer than the depressed mood patients (3.6 2.1 SD versus 1.0 1.1, p 0.001 for autonomic symptoms and 4.1 2.8 SD versus 0.9 1.2, p 0.001 for psychological...

Mortality and poststroke depression

Increased mortality is perhaps the ultimate validation of the importance of depression in the prognosis of physical illness. Several studies have been conducted among patients with stroke which have documented increased mortality rates among those with depression or depressive symptoms. Our first study was a 10-year follow-up of survival obtained for 91 of original series of 103 acute stroke patients (Morris et al. 1993a). Data was obtained by contacting patients' living relatives or searching...

Longitudinal course

The long-term outcome of anxiety disorders following stroke has been examined by several investigators (Burvill et al. 1995 Castillo et al. 1995 Astrom 1996 Schultz et al. 1997). The first of our two studies compared patients who developed generalized anxiety disorder (GAD) at the time of the acute stroke with patients who developed GAD 3 or more months after their stroke (Castillo et al. 1995). In this study we wanted to determine first whether there were significant differences in the...

Cognitive impairment and depression

The nature of the relationship between cognitive impairment and depression appears to involve a complex interaction between depression, the stroke lesion and cognitive impairment. Although one might understandably view cognitive impairment as a cause of depression, their relationship is clearly a more complex one. In 1989, we hypothesized that major depression following left hemisphere lesions produces through some physiological process a greater degree of cognitive impairment than can be...

References

Tofranil treatment of endogenous depressions. Acta Psychiatr Scand (1959) 34 387-397. Frank, E., Kupfer, D. J., Perel, J. M., et al. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatr (1990) 47(12) 1093-1099. Glassman, A. H., O'Connor, C. M., Califf, R. M., et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. J Am Med Assoc (2002) 288(6) 701-709. Narushima, K., Kosier, J. T., and...

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Figure 35.9 Relationship between denial of illness (anosognosia) and diagnosis of major or minor depression, or GAD using DSM-IV diagnostic criteria. Note that depression and GAD were just as common in the denial compared with the non-denial stroke patients (reprinted from Robinson 2004 with permission). From Self-Awareness Deficits in Psychiatric Patients, edited by Bernard D. Beitman and Jyotsna Nair, Copyright 2004 by Bernard D. Beitman and Jyotsna Nair. Used by permission of W.W. Norton...

Table 391 Background characteristics

Age (mean SD in years) Race ( African-American) Gender ( female) Education (mean number of ( Hollingshead IV, V) Martial status ( married) Family psychiatric history ( positive) Personal psychiatric history ( positive) Alcohol abuse ( positive) Time since stroke (mean SD days) History of CVA ( positive) Reprinted with permission, from Paradiso et al. (1996). *Compared to overall group p 0.008. alcohol or to have significantly less education. Since medication is a common cause of behavioral...

Other types of cerebrovascular disease

One of the other causes of cerebrovascular disease is fibromuscular dysplasia, which leads to narrowed arterial segments caused by degeneration of elastic tissue, disruption and loss of the arterial muscular coat, and an increase in fibrous tissue. Inflammatory diseases of the arterial system can also lead to stroke these include meningovascular syphilis, pyogenic or tuberculous meningitis, temporal arteritis, and systemic lupus erythematosus. There are many other less common causes of...

Vascular disease and age of onset

Another risk factor for late-onset mania was identified by Cassidy and Carroll (2002). The records of 366 bipolar patients were reviewed and divided at age 47 based on the bimodal distribution of age at first psychiatric hospitalization. Using that threshold, 23 (6.3 ) were classified as late onset and 343 (93.7 ) as early onset. The vascular risk factors included hypertension, hyperlipidemia, and history of smoking, atrial fibrillation, coronary artery disease, and cerebrovascular accident. In...

Relationship of depression to social functioning

Social functioning has been recognized for many years to play an important role in development of depression associated with stress or negative life events (Brown et al. 1986 Henderson 1990). Furthermore, the effect of social support on psychological distress depends upon the nature of the supportive attachment. Among women in a community sample, for example, inadequate social support from a spouse was found to have a greater emotional impact than lack of support from a non-spousal relationship...

Specificity of anxiety symptoms

In order to examine the frequency of anxiety symptoms and their specificity for anxiety disorder, patients with acute stroke were grouped according to whether they did or did not express anxiety or worry. As I discussed in Chapter 7 entitled, Phenomenology and the specificity of depressive symptoms, among patients with acute stroke, it is not obvious how one should assess the specificity of symptoms used for the diagnosis of anxiety disorder. If one uses the diagnostic criteria to define the...

Diagnosis of anxiety disorders

As with depressive disorders, the gold standard for the diagnosis of anxiety disorders is a structured or semistructured mental status examination which is applied to the diagnostic criteria of DSM-IV or ICD-10. Although cases of phobic disorder, panic disorder, and obsessive compulsive disorder, have been reported following stroke or brain injury (House 1987 Burvill et al. 1995 Max et al. 2002). The majority of investigators have focused on the more chronic disorder of GAD associated with...

Relationship of anxiety to outcome

For many years clinicians have recognized the importance of anxiety disorder as well as depression in patients following stroke (Schwartzman 1976). The spectrum of anxiety disorders includes panic disorder, generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD) and phobic disorders. There have been anecdotal reports of panic disorder (Maricle et al. 1991) and OCD occurring in patients with stroke. These are relatively rare conditions arising from ischemic brain injury. Our...

Aggressive patients had more anterior hemisphere lesions greater depressive and anxiety symptoms but less cognitive

In addition to confirming many of the findings from our first study of aggression in patients with stroke, in our second study, the patients were participating in our treatment study of poststroke depression (see Chapter 23). Response to antide-pressant medication was therefore evaluated in the 23 initially aggressive patients who entered this 12-week treatment trial. Among the active treatment patients, six were treated with fluoxetine titrated from 10 mg day up to 40 mg day. Four were treated...

Applicable diagnostic categories

In Chapter 7, I will discuss the controversy over the specificity of symptoms in patients with medical illness and alternative suggestions for diagnosis. This chapter, however, will be devoted to the methodology and criteria used for diagnosis of poststroke depression or poststroke mania. The diagnostic category mood disorder due to stroke has four subtypes the first is mood disorder due to stroke with depressive features the second is with major depressive-like episode the third is with manic...

Other diagnostic categories

Besides major and minor depression, the other diagnostic category, which may sometimes be applicable to patients with poststroke depression, is adjustment disorder with depressed mood or adjustment disorder with mixed anxiety and depressed mood. These diagnoses using DSM-IV criteria are based on the existence of depressed mood, tearfulness, or feelings of hopelessness with or without nervousness, worry, or jitteriness occurring within 3 months of the onset of an identified source of social...

Prevalence of depressive disorders

The prevalence of poststroke depression has been assessed in a large number of patients who have been examined in various settings throughout the world. Since the first edition of this text, large numbers of patient populations have been added to the literature and pooling of the data has provided prevalence rates based on more than 6000 patients. There are at least three factors which have complicated the determination of prevalence rates. The first is the setting in which patients were...

Carotid system

A schematic coronal view of the brain taken through the temporal and parietal cortex and thalamus. The overlapping regions subserved by anterior and middle cerebral arteries (internal carotid circulation) and posterior cerebral arteries (posterior circulation) are demonstrated. Figure 4.4 The anterior and middle cerebral artery circulation demonstrating the medial course of the anterior cerebral artery along the interhemispheric separation and the lenticulostriate arteries which penetrate the...

Catastrophic reaction

The sudden onset of anxiety, tears, aggressive behavior, swearing, displacement, refusal, denouncement, and compensatory boasting constitute a syndrome referred to by Goldstein (1948) as a catastrophic reaction (CR). Goldstein believed that this syndrome represented a response to the inability of an organism to cope when faced with a serious defect in their physical or cognitive function. These emotional outbursts would generally last only a few seconds and were usually associated with a...

Mechanism of mortality following poststroke depression

Based on the fact that our studies found an association between both major and minor depression with mortality, it appears likely that severity of depression is not as important as the existence of some level of depression. Subsyndromal forms of major depression appear to place patients at risk for mortality just as much as major depression (House et al. 2001). The mechanism by which depression following stroke leads to increased mortality over many years remains a topic of debate. Although...

The relationship between severity of depression and severity of physical impairment

As indicated in Table 13.1, 83 of studies that have examined the relationship between poststroke depression and physical impairment have found that patients with depression are significantly more physically impaired than patients without depression, and furthermore that there is a direct correlation between severity of physical impairment and severity of depressive symptoms (Robinson et al. 1983 Eastwood et al. 1989 Astrom et al. 1993). We have examined our overall acute stroke patient database...

Relationship of aphasia to depression

Aphasia remains one of the most perplexing problems for investigators of neuropsychiatrie disorders following stroke. Since the diagnoses of all neuropsychiatrie disorders requires subjective responses by the patient to verbal or written questions, the existence of even a moderate degree of comprehension deficit may represent a severe obstacle to the diagnoses of numerous neuropsychiatric disorders. This conundrum has led almost all investigators of poststroke neuropsychi-atric disorders to...

Bipolar disorder following stroke

As indicated in the previous chapter, a significant number of patients with secondary mania were also found to have episodes of depression. In contrast, however, other patients with secondary mania did not have episodes of depression within the period of study or prior to the stroke. We examined patients with bipolar disorder and compared them to patients with secondary mania but no evidence of depressive episodes (Starkstein et al. 1991). The most obvious concern in patients with mania but...

Brain organization and cerebral basis of emotion

As described in Chapter 2, as early as the 19th century Hughlings-Jackson (1875) recognized that symptoms associated with brain lesions may produce both loss of normal function as well as emergence of new, sometimes abnormal symptoms. These new symptoms may arise from the effect of injury on distant uninjured brain areas leading to the release of normally inhibited functions or the loss of normally activated functions. Thus, this chapter will review brain anatomy, particularly the limbic...

Mechanism of mania following stroke

Injury to the inferior temporal cortex, orbital frontal cortex, caudate, and thalamus have all been demonstrated to lead to the development of mania in vulnerable patients. These constitute the major elements of the lateral orbital frontal circuit as described by Alexander et al. (1990) and the association of mania with injury to these structures suggests that these right hemisphere regions may play an important role in the mediation of mania following stroke. One of the main factors, however,...

Anosognosia and denial of illness

In 1914, Babinski (1914) reported that some patients with severe hemiplegia appeared to be unaware of their deficit. He called this absence of awareness anosognosia, a term derived from the Greek words gnosis (knowledge), a (without), and noso (disease). The medical literature of the late 19th and 20th centuries reported a variety of failures of awareness of one's own deficits or diseases including Anton's syndrome of cortical blindness (Anton 1896), unawareness of hemianopsia, amnesia,...

Phenomenology and specificity of depressive symptoms

Phenomenology refers to the study of the structure of observable events. In the study of poststroke depression, phenomenology refers to the study of signs and symptoms which constitute the basis for the diagnosis of depression. Since depression occurs in the context of an acute medical illness, one might naturally wonder whether these depressions are like depressions in patients without acute illness or whether the acute medical illness interferes with our ability to diagnose depression using...

Figure 353 Impairment scores on the MMSE and the JHFI as well as severity of depression scores on the Hamilton

No significant differences between these lesion-matched patients in their total PSE score (14.8 16.5 anosognosia versus 8.1 10.4 control). In addition, three of the 6 patients with anosognosia were depressed (two with major depression and one with minor depression) compared with two of the 6 patients without anosognosia (one had major and one had minor depression). Thus, even after controlling for demographic and lesion location variables, depression was no less common in the anosognosic...

Treatment of poststroke anxiety disorder

The first treatment study of generalized anxiety disorder (GAD) following stroke was based on a merged analysis of results from previous treatment studies conducted by our research group (Kimura and Robinson 2003). These previous treatment studies included poststroke depression (Lipsey et al. 1984), pathological laughing and crying (Robinson et al. 1993) and a comparison of nortriptyline and fluoxetine for poststroke depression (Robinson et al. 2000). From the total of 106 patients in these...

Patients with typical and reversed brain asymmetries

The second study was undertaken to assess depression in patients with evidence on CT scan of reversed anatomical organization of the brain (Starkstein et al. 1991). LeMay and Kido (1978) first reported normal brain asymmetries on CT scans. They found that 78 of right-handed males had a greater occipital length in the left hemisphere compared with the right hemisphere and 67 had a greater left than right occipital width. On the other hand, the right frontal length was greater than the left in 70...

Biological markers

In spite of brief periods of enthusiasm about the potential diagnostic utility or etiological insights to be gained from neuroendocrine tests associated with depression, there has been an overall lack of success of neuroendocrine testing in primary depression. Similarly, among patients with poststroke depression, neuroendocrine tests have not been successful in establishing either an alternative method of diagnosing poststroke depression or illuminating neuroendocrine abnormalities which may...

Relationship of depression to bilateral hemisphere brain injury

The role of each cerebral hemisphere in emotion regulation has been a topic of speculation and experimental investigation for many years. Flor-Henry 1979 , for example, suggested a complex model for the organization of mood. He proposed that the neural substrate for both normal and abnormal mood was predominantly in the non-dominant hemisphere but with bilateral regulation. Thus, according to this hypothesis, euphoria results when the dominant hemisphere no longer receives transcallosal neural...

Irritability and aggression

Irritability and aggression are common disorders associated with neuropsychiatric conditions, such as stroke, dementia, traumatic brain injury, and Huntington's disease Burns et al. 1990 Paradiso et al. 1996 Chemerinski et al. 1998 Kim et al. 1999 . These symptoms create a major stress for the families of patients with stroke Brooks et al. 1986 Williams 1994 and lead to a poorer quality oflife for the patient Angeleri et al. 1993 . Aggressive behavior is a common reason for referral to...

Disturbance of prosody

Monrad-Krohn 1947 described prosody as the melodic line of speech produced by variations of pitch, rhythm, and stress of pronunciation. Heilman and Valenstein 1993 divided prosody into two types affective aprosody, described as the loss or defect in expression, repetition, or comprehension of emotionally intoned speech and prepositional aprosody, characterized by a loss of or defect in expression, repetition, or comprehension of sentences with prepositional content such as questions,...

Apathy

The definition of apathy in the dictionary is described as a lack of feeling or emotion or a lack of interest or concern. In a study of 124 poststroke patients who were examined at either 2, 6, or 12 months following stroke, apathy was reported in 27 of the patients while depression was reported in 61 and irritability in 33 Angelelli et al. 2004 . Apathy has been associated with bilateral paramedian, or interior thalamic infarctions Ghika-Schmid and Bogousslavsky 2000 Krolak-Salmon et al. 2000...