Affective disorders in poststroke patients: A review
KOUTSOURAKI E.
Lecturer of 1st Department of Neurology, Aristotelian University, Thessaloniki, Greece
Chairman: Prof. S.J. Baloyannis

Poststroke depression (PSD) has been linked to negative outcomes, including mortality and decreased functioning. Mental health diagnosis after stroke increases inpatient and outpatient healthcare utilization in the first 3 years poststroke. The natural history of PSD suggests that most PSD is not immediate but develops over months with peak prevalence between 6 and 24 months, and in some cases persists up to 3 years following stroke. Progressive or focal brain damage, cognitive impairment, depressive symptoms, dementia and cardiovascular diseases, all seem to be liable to lead to one or another. Stroke may lead to depression and the inverse may also be true. Depression may lead to cognitive impairment and cardiovascular diseases, which in turn may lead to subtle brain impairment, thereby causing more depression and cognitive impairment.

Studies have found an association between lesion location, physical impairment, cognitive impairment, aphasia and post-stroke depression. The location of the lesion in terms of proximity to the left frontal pole of the brain has a profound impact on the frequency and severity of post-stroke depression. Some authors showed that the severity of neurological deficit, female gender, history of previous psychiatric disorders and a bad social living conditions increase the risk of PSD but increasing age is not associated with a higher PSD incidence. Other than showing that depression is associated with more severe strokes, current evidence does not allow for ready identification of patients most at risk of developing this important complication of stroke.

Identifying children at risk for problems one year after parental stroke requires assessment of children's functioning and the perception of the marital relationship at the start of rehabilitation. This demonstrates the need for a family-centered approach in stroke rehabilitation. Children's functioning after parental stroke improved during the first year after stroke.

Baune et al. in 4.181 participants of the general population, examined lifetime prevalences for affective disorders through the Composite International Diagnostic Interview and cardiovascular diseases by self-report and subsequent physician-verified diagnosis. Dysthymia had a stronger association with coronary heart disease than unipolar depression or any depression. In contrast, unipolar depression showed a significant relation with stroke compared to dysthymia that reached no statistical significance.

Selective serotonin re-uptake inhibitors (SSRI) are effective and have a good profile of safety and tolerability in PSD. They are, therefore, used as first-line drugs in the treatment of PSD, although potential cardiovascular and cerebrovascular effects drug-drug interactions and intolerability in a minority of patients have to be considered. Available evidence suggests that SSRI treatment has a very low rate of cerebrovascular adverse reaction. More research iws warranted to examine the variability of pharmacologic and genetic factors, depressive illness and stroke on the antiplatelet and vasospastic effects of SSRIs and their significance to cerebrovascular protection or adverse reactions.

Evidence suggests that a high concentration of C-reactive protein (CRP) is a cardiovascular risk factor and an important correlate of cognitive disorders and depression. Meta-analysis of studies with long follow-up (>8 years) by Kuo HK. et al showed that the risk for stroke in healthy individuals with the highest CRP increased nearly 70% compared to those with the lowest. The relations of CRP to depression were all cross-sectional and were not consistent.

Spalletta et al. supported the hypothesis that proinfammatory cytokines are involved in the occurrence of stroke as well as mood disorders linked to the brain damage. The increased production of IL-1beta, TNF-alpha or IL-18 resulting from stroke may lead to an amplification of the inflammatory process, particularly in limbic areas, and widespread activation of indoleamine 2,3-dioxygenase and subsequently to depletion of serotonin in paralimbic regions such as the ventral lateral frontal cortex, polar temporal cortex and basal ganglia.

Depression is a frequent and important complication after stroke. The occurrence of a post-stroke-depression has a significant impact on the functional and cognitive deficit on mortality and on quality of life after stroke. In contrast to the clinical importance, PSD is often ignored in routine management of stroke patients and remains often untreated if diagnosed. The diagnostic uncertainty is aggravated by the lack of appropriate diagnostic criteria for PSD in the International Classification of Diseases (ICD-10).

Key words: Depression, affective disorders, stroke.