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2-year follow-up

1-year follow-up

Figure 7.4

The frequency of psychological symptoms of depression in patients with depressed mood and without depressed mood following stroke. Symptom frequency is shown over the 2-year follow-up. Most symptoms (i.e., worrying, brooding, loss of interest, hopelessness, social withdrawal, lack of self-confidence, self-depreciation, ideas of reference, and irritability) were more frequent in depressed patients through the 2 years following stroke. Feelings of self-blame (self-depreciation and pathological guilt) were less common after the first year poststroke (Data taken from Paradiso etal. 1997).

diagnoses based on specific symptoms as the gold standard, unmodified DSM-IV criteria had 100% sensitivity and 97% specificity. Using the substitutive approach requiring depression plus four psychological symptoms, none of the 12 patients would have been excluded. There was one patient who had four or more specific symptoms of depression but denied the presence of a depressed mood.

At 6-month follow-up, the exclusive approach (i.e., weight loss and insomnia were excluded) resulted in 3 out of 15 patients no longer meeting the criteria for major depression. Using the specific symptoms as the gold standard, the unmodified DSM-IV criteria (i.e., using unmodified criteria and not differentiating between depression related to physical-illness-related symptoms) had 100% sensitivity and 95% specificity. Using the substitutive approach, none of the 15 patients with major depression would have been excluded. There were two patients who presented with four or more specific symptoms of major depression but denied the presence of depressed mood.

At 1-year follow-up, the exclusive approach (weight loss, difficulty concentrating, and suicidal ideation were excluded) resulted in three out of seven patients no longer meeting diagnostic criteria. Using specific symptom diagnosis as the gold standard, unmodified DSM-IV criteria had 100% sensitivity and 95% specificity. The substitutive approach resulted in none of the seven patients being excluded. There were two patients who presented with four or more specific symptoms of major depression but who denied the presence of a depressed mood.

At 2-year follow-up, the exclusive approach (i.e., weight loss was excluded) resulted in 2 out of 16 patients with major depression being excluded. Unmodified DSM-IV criteria had 100% sensitivity and 96% specificity. The substitutive approach excluded none of the 16 patients and one patient who presented with four or more symptoms of major depression denied the presence of depressed mood.

Kathol et al. (1990) concluded that the substitutive approach was the best approach given our current knowledge. However, the inclusive approach had a 100% sensitivity and 95 + % specificity compared with the exclusive (only specific symptoms) approach. Moreover, our 2-year study of the specificity of depressive symptoms found that three vegetative symptoms (autonomic anxiety, morning depression, and subjective anergia) were significantly more frequent in depressed than non-depressed patients at all time points throughout the 2-year period. The vegetative symptom of loss of libido was no longer significantly more common in depressed than non-depressed patients after 6 months and similarly, self-depreciation was no longer more common after 1 year. In contrast, early morning awakening was more frequent in the depressed group only at 2-year follow-up. Weight loss was the only symptom that was not significantly more frequent in depressed than non-depressed patients over the entire 2-year period. Autonomic symptoms of anxiety, anxious foreboding, and worrying were significantly associated with depression throughout the entire first 2 years following stroke. In the present study, the sensitivity of unmodified DSM-IV criteria consistently showed a sensitivity of 100% and a specificity that ranged from 95% to 98% compared to criteria only using specific symptoms. Thus, one could reasonably conclude that modifying DSM-IV criteria because of the existence of an acute medical illness is probably unnecessary.

These findings also suggest that the nature of poststroke depression may be changing over time. Since the symptoms that were specific to depression changed over time, this may reflect an alteration in the underlying etiology of poststroke depression associated with early onset depression compared to the late or chronic poststroke period. Early onset depression was found to be characterized by anxious foreboding, loss of libido, and feelings of guilt which may have been more biologically determined, while symptoms such as early morning awakening and social withdrawal, which were found to be significantly different in depressed compared with non-depressed patients only during the 1- or 2-year follow-up may characterize forms of depression that are related to psychosocial or other factors.

Another question we tried to address (Fedoroff et al. 1991) was whether major depression might be under diagnosed because some patients were unable or unwilling to acknowledge their depressed mood. To answer this question, we determined how many patients would have met diagnostic criteria for major depression except they had not denied having a depressed mood. In the initial study of 395 patients in-hospital, there were 19 such patients. The background characteristics of these patients, compared to those of the patients who met the standard DSM-IV criteria for major depression (i.e., they acknowledged a depressed mood) are shown in Table 7.2. There were no significant differences in background characteristics between the groups with major depression and major depression without depressed mood. The mean scores for the major depression and no depressed mood groups on the MMSE were 22 ± 6 (±SD) and 23 ± 7, respectively, and on the JHFI they were 8 ± 6 (±SD) and 8 ± 5, respectively. These scores were not significantly different. However, the 77 patients who met all of the criteria for major depression had more severe depressive symptoms as measured by the mean Ham-D score compared with patients without a depressed mood (18 ± 7 versus 15 ± 5) (NS). In addition, there was a significantly higher frequency of right hemisphere lesions in the patients with no depressed mood compared to those in the group with major depression (Table 7.2).

Although a number of explanations might be proposed to understand these findings, one explanation is that these19 patients had an inability to recognize their depressed mood as well as other symptoms of depression such as hopelessness or guilt. These patients, therefore, had less severe depressions. This failure to recognize depressive symptoms is associated with right hemisphere lesions. Future

Table 7.2. Characteristics of acute stroke patients who met all DSM-III criteria for major depression or all DSM-III criteria except depressed mood

Met all criteria except

Met all criteria

depressed mood

(n = 77)

(n = 19)

Characteristic

N

%

N

%

Male

40

52

8

42

Black

28

36

6

32

Married

37

48

10

53

Hollingshead social Class I—III

19

25

6

32

Lesion location

Left hemisphere

27

38

3

18

Right hemisphere*

30

42

13

76

Other (multiple, brain stem, or cerebellar)

15

21

1

6

*The difference between groups was significant (Fisher's exact p = 0.0142).

*The difference between groups was significant (Fisher's exact p = 0.0142).

studies may examine the longitudinal course of these patients or their response to treatment to determine whether they are truly masked depressions.

In summary, the phenomenology of major depressive disorder in patients with stroke appears to be similar to that found in patients with primary mood disorders. In addition, the presence of an acute cerebral infarction does not appear to lead to a significant number of incorrectly diagnosed cases of depression. Perhaps 1-2% of cases may be over diagnosed based on symptoms that result from physical illness. On the other hand, a small percentage of patients may be under diagnosed based on their failure to acknowledge having a depressed mood. Although these problems of evaluating depressive symptoms in acutely ill-stroke patients may lead to a small proportion of patients being over diagnosed or under diagnosed, the presence of an acute physical illness does not appear to necessitate the development of an entirely new method for diagnosing major depression in this population.

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