Post-stroke Depression: Can Prediction help Prevention?

Francisco Javier Carod-Artal


Future Neurology. 2010;5(4):569-580. 

In This Article


Definition & Clinical Symptoms

Neither biochemical nor functional neuroimaging-specific markers for PSD have been developed yet, so diagnosis is based on clinical symptoms. PSD has been defined as depression occurring in the context of a clinically apparent stroke, as opposed to silent vascular disease. This emphasizes the sequential nature of two temporally related events: stroke followed by depression.[23]

Diagnosis of PSD relies on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria.[32] Major depression requires the presence of at least one cardinal symptom (low mood) and at least three additional symptoms. Mood disorder is characterized by depressed mood or markedly diminished interest or pleasure in all, or almost all, activities and/or elevated, expansive or irritated mood. PSD is a direct physiological consequence of the stroke, and cannot be explained by another mental disorder. Symptoms result in significant distress or impairment in social, occupational or other important areas of function. Nevertheless, five of the nine criteria for depression included in the DSM-IV criteria reflect somatic symptoms that may be common in stroke survivors: significant weight loss, insomnia, psychomotor retardation, fatigue and reduced ability to concentrate.

Some authors have proposed that early-onset PSD could be characterized by anxiety, loss of libido and feelings of guilt, whereas late-onset PSD would be associated with diurnal variation of mood and social isolation.[33] Nevertheless, an ambiguity regarding the natural course of PSD and the type of symptoms at each stage remains.

The patterns of major and minor depression after stroke have also been studied. The feeling of guilt may not be a valid criterion in this context because its prevalence seems to be similar among patients with major/minor depressive disorder and those without PSD. The frequency of depressed mood, diminished interest or pleasure, fatigue or loss of energy, insomnia and psychomotor agitation/retardation was higher in major depressive disorder than in stroke survivors free of any neuropsychiatric disorder.[34]

Depression in the elderly may be marked by apathy or loss of interest in the activities of daily living, instead of sadness. According to the Italian Multicenter Observational Study on Post-Stroke Depression (DESTRO) study, PSD may present as minor depression with dysthymia, rather than major depression, in 80% of PSD patients.[31]

Scales to Assess PSD

Diagnosis of PSD can be made by means of a psychiatric interview, the DSM-IV criteria, the use of interviewer-administered scales, such as the Hamilton Depression Rating Scale (HDRS), and a wide variety of self-rating (screening) scales. A list of tools and scales[35–41] commonly used in the diagnosis of PSD are summarized in Table 1.

The Beck Depression Inventory, the Center for Epidemiological Studies Depression Scale and the Hospital Anxiety and Depression Scale are the most commonly used self-reported scales. They can be used easily in clinical practice and are not time-consuming; however, they are not specific enough to be used as a diagnostic tool. Many self-rating depression scales used for the diagnosis of PSD were originally designed to detect depressive symptoms in nonstroke people. In addition, many patients may have difficulties in answering the scales, owing to physical and cognitive impairments.

Many of the somatic symptoms of depression may arise from stroke itself; for example, fatigue, insomnia, sexual disturbances or psychomotor retardation. The HDRS includes several physical items that can overlap with physical symptoms following stroke (e.g., weight loss, lack of energy, insomnia, fatigue and psychomotor changes). The HDRS assesses neither anhedonia nor poor concentration.

Several reviews on the metric properties of self-reported scales used to diagnose PSD and quality of life following stroke have been published elsewhere.[42,43] Nevertheless, there is concern regarding the specificity and sensitivity of these tools in stroke patients, since both can vary during the follow-up of stroke survivors.[44] In addition, information regarding responsiveness of the scales, change over time and studies that assess the appropriateness of cut-off values are scarce.

Caregiver ratings have been found to be higher than the patient ratings because they often rate a patient's PSD as more severe than the patients themselves. Caregiver impressions should be confirmed later by means of a clinical diagnosis by a physician prior to starting any antidepressant treatment. Proxy ratings and visual analog mood scales among patients with aphasia and other cognitive impairments should be used with caution.[44]

There are few studies that have evaluated the psychometric properties of the scales specifically designed for PSD. The Post-Stroke Depression Rating Scale was specifically designed for the assessment of depression in stroke survivors. It is an observer-rating scale that requires training, and some level of expertise. Validity and reliability studies are still required, owing to the dearth of metric information in clinical settings.[40] The Stroke Aphasic Depression Questionnaire (SADQ) has a sensitivity of 70% and a specificity of 77%. It can be completed by healthcare professionals, and has a 14/15 cut-off value proposed for the 10-item version.[41] However, further assessment is still required among severe aphasic patients.


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