ABSTRACT

Depression is common after stroke. Post-stroke depression (PSD) is an independent predictor of poor long-term functional outcome following stroke. PSD has been associated with poor social and rehabilitation outcomes, cognitive impairment and increased mortality. Prevalence varies widely between studies because of differences in patient selection, time, evaluation methods and diagnostic criteria. Approximately a third of stroke survivors may suffer from PSD. The identification of risk factors is important to prevent and detect PSD early, and provide appropriate interventions. PSD may be associated with restriction in social activities and dependence in activities of daily living in the chronic phase of stroke. Pharmacologic and rehabilitation strategies are needed to treat PSD. More evidence is required before recommendations can be made about the routine use of antidepressants to prevent PSD. Keywords : stroke, depression, social activities

I. INTRODUCTION
I.1 Background Stroke is a leading cause of long-term disability in adults worldwide. Cognitive, emotional and behavioral symptoms can be observed frequently in people who have suffered a stroke. Mood depression is a common and serious complication after stroke. According to epidemiological studies, nearly 30% of stroke patients develop depression, either in the early or in the late stages after stroke. Although depression may affect functional recovery and quality of life after stroke, this such condition is often ignored. In fact, only a minority of patients is diagnosed and even fewer are treated in the common clinical practice.(1) Post-stroke depression (PSD) is probably the most common emotional disturbance, and the most important long-term psychosocial consequence following stroke. It is often unrecognised. The diagnosis can be difficult due to deficits of stroke such as impaired self reporting and cognition, poor insight and dysphasia.Untreated PSD can interfere with recovery and adversely affect functional and social outcomes. It is reported to have been missed in 50 80% of cases by nonpsychiatric physicians.(2) Therefore, I would like to review depression due after stroke or post-stroke depression from the aspect of definition, epidemiology, clinical features and treatment. I.2 Methods The creation of this paper is made possible with the aid of various sources such as textbook, medical website,article and medical journal.

II. DEPRESSION
II.1 Definition Major Depressive disorder (MDD) is one of the most common psychiatric illness in the general population across global cultures and is associated with a signficant degree of morbidity and mortality. (3) According to the text revision of the fourth edition of DSM (DSM-IV-TR), a major depressive disorder occurs without history of a manic, mixed, or hypomanic episode,must last at least 2 weeks and also experiences at least four symptoms from a list that includes changes in appetite and weight, change in sleep and activity, lack of energy, feelings of guilt, problem thinking and making decisions, and recurring thoughts of death or suicide.(4) II.2 Epidemiology Numerous studies have reported the lifetime prevalence of major depressive disorder in general adult population as 10% to 25% for women and 7% to 12% for men. More than 50% of people who experience a major depressive episode suffer a reccurence. (3) An almost universal observation, independent of country or culture, is the twofold greater prevalence of major edpressive disorder in women than in men. The reason have been hypothesized to involve hormonal differences, differing phychosocial stressor, the effects of childbirth, and behavioral of models of learned helplessness. Major depressive disorder can begin in childhood or in old age. 50% of all patients having an onset between the ages of 20 and 50. MDD occurs most of ten in persons without close interpersonal relationship or in those who are divorced or separated.(3,4)

II.3 Presenting Features The diagnostic criteria in DSM-IV-TR list the cardinal symtomps of MDD, requisite minimum duration of symtomps, features that preclude the diagnosis.(3)

DSM-IV-TR Ddiagnostic Criteria for Major Depressive Episode A. Five (or more) of the following symptoms have been preseent during the same 2 weeks period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note : Do not include symptoms that are clearly due to a general medical condition, or mood incongruent delusions or hallucinations.
(1) Depressed mood most of the day, nearly every day,as indicated by either subjective

report (e.g.,feels sad or empty) or obervation made by others (e.g.,appears tearful). Note: in children or adolescents, can be irritable mood. (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, neary everyday (as indicated by either subjective account or observation made by others).
(3) Significant weight loss when not dieting or wight gain )e.g., a change of more than

5% of body weight in a month), or decrease ir increase in appetite nearly everyday Note: in children, consider failure to make expected weight gains. (4) Insomnia or hypersomnia nearly everyday (5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). (6) Fatigue or loss of energy nearly everyday (7) Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly everyday (not merely self-reproach or guilt about being sick) (8) Diminished ability to think or concetrate, or indecisiveness, nearly everday (either subjective account or ass observed by others) (9) Reccureent thoughts of death (not just fear of dying), recurrent suicidal ideation without a spesific plan, or a suicide attempt or a specific plan or commiting suicide. B. The symptoms do noy meet criteria for a mixed episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a subtances (e.g., a drug of abuse, a medication), or a general medical condition (e.g.,hypothyroidism)
E. The symptoms are not better accounted for by bereavemet (i.e., after the loss of a loved

one); the symptoms persist for longer than 2 months or are characterized by marked 5 functional impairment, morbid preoccupation with worthlessness,suicidal ideation, psychotic sympstoms, or psychomotor retardation.

Both phychiatrics and medical comobidities are exceedingly common in individuals with major depressive disorder. There are some medical illnesses that frequently co-occur with MDD such as HIV/AIDS (5% to 20%), parkison disease (app 50%), post cerebrovascular accident (CVA) (19% to 23%), diabetes mellitus (9%-26%).(3) II.4 Diagnosis Diagnosis of major depression is made in accordance with DSM-IV-TR criteria. The DSM-IV-TR differentiatees between major depressive episode (MDE) and major depressive disorder (MDD). An MDE characterizes the first clinical syndrome that fulfills the time and symptom criteria for major depression. MDD is diagnosed in patients who present with at least a second episode that fulfills criteria for major depression.(3,4) The DSM-IV-TR describes subtypes and specifiers for the current MDE. The specifies are divided into severity (mild, moderate, severe). Association withh psychotic features (mood congruent or incongruent), and state of remission (partial or full, if appropriate).While the subtype include catatonic features, melanchoic features, atypical features, seasonal onset, and postpartum onset (within 4 weeks postpartum).(3)
III.

STROKE

III.1 Definition A stroke or cerebrovascular disease, is defined by this abrupt onset of neurologic deficit that is attributable to a focal vascular cause.(5) The term cerebrovascular disease designates any abnormality of the brain resulting from a pathologic process of the blood vessels e.g. occlusion of the lumen by a thrombus or

embolus, rupture of the vessel, any lesion or altered permeability of the vessel wall and increased viscosity or other change in quality of blood.(6) III.2 Ethiology Strokes are classified as either hemorrhagic or ischemic. Acute ischemic stroke refers to stroke caused by thrombosis or embolism and is more common than hemorrhagic stroke. The ischemic stroke occurs 80-85% of the time.(7) Ischemic strokes occur when a blood vessel gets so narrow or clogged that not enough blood can get through to keep the brain cells alive. The clot may from plaques from atherosclerosis in the blood vessel walls can narrow the blood vessels that supply the brain. Ischemic strokes may also be caused by small blood clots or emboli that go through the bloodstream and then get clogged in an artery when the artery narrows. These clots can come from pieces of plaques in the bigger arteries that break off or from the heart. (8) Hemorrhagic strokes occur when the wall of a blood vessel becomes weak and blood leaks out into the brain. Hemorrhagic strokes tend to be more serious than ischemic strokes. Death occurs in 30-50% of people with this type of stroke.(8) III.3 Epidemiology Stroke is the leading cause of disability and the third leading cause of death in the United States. More than 700,000 persons per year suffer a first-time stroke in the United States, with 20% of these individuals dying within the first year after the stroke.The global incidence of stroke is unknown.

Men are at higher risk for stroke than women. White males have a stroke incidence of 62.8 per 100,000, with death being the final outcome in 26.3% of cases, while women have a stroke incidence of 59 per 100,000 and a death rate of 39.2%. Although stroke often is considered a disease of elderly persons, one third of strokes occur in persons younger than 65 years. Risk of stroke increases with age, especially in patients older than 64 years, in whom 75% of all strokes occur.(7) III.4 Presenting Features The symptoms of a stroke depend on what part of the brain and how much of the brain tissue is affected. The most common symptoms of stroke are abrupt onset of hemiparesis, monoparesis, or quadriparesis,hemisensory deficits,monocular or binocular visual loss,visual field deficits,diplopia, dysarthria, ataxia, vertigo, aphasia, sudden decrease in the level of consciousness.(7) III.5 Diagnosis Diagnosis concerning the specific type of stroke, its location, and how severe the damage is, can be determined by using a number of advanced imaging tests including Computerized Tomography (CT) Scans and Magnetic Resonance Imaging (MRI). In CT Scan, areas where there is an ischemic stroke, the brain may appear abnormal. Signs of swelling may also be present. Most strokes, even big ones, do not show up on the CT scan until 12-24 hours after the onset of symptoms. A CT scan can help rule out a hemorrhagic stroke. While MRI may be performed later in the course of patient care if finer details are required for further medical decision making because it may take more than an hour to complete.(7,8)

IV.

DEPRESSION DUE AFTER STROKE

Stroke is a common neurological problem and the third leading cause of death in developed countries in the world. One of the commonest pshychiatric complication of stroke is depression and National Institute of mental Health (NIMH) estimated that 10% to 27% of stroke survivors will experience major depression while additional 15% to 40% will have symptoms of depression within two months following stroke.(9)
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Depression due after stroke or Post-stroke depression (PSD) is an independent predictor of poor long-term functional outcome following stroke. Up to 6% of stroke patients may develop severe depressive symptoms in the acute stroke phase.The prevalence peak of major depression may occur between 3 and 6 months after stroke. However, the risk of PSD appears to remain high, even 13 years after stroke. Data from a prospective community study showed that patients who suffered a stroke had six-times higher probability of developing clinically significant depressive symptoms in the following 2 years.(10) The DSM-IV categorizes post-stroke depression as a mood disorder due to general medical conditions with the specifiers of: (a) depressive features; (b) major depressive-like episodes; (c) manic features; or (d) mixed features. The two types of depressive disorders most associated with stroke are major depression and minor depression, the latter of which has been defined for research purposes by the DSM-IV criteria as a depressed mood or loss of interest and at least 2 but fewer than 4 symptoms of major depression. Minor depression occurs in up to 30% of patients following stroke, while major depression occurs in 25% of patients who have stroke.(11) The identification of PSD risk factors is also important to improve the early detection of PSD and provide appropriate interventions to improve rehabilitation outcomes.The risks factor of this disease are age (elderly), gender (female), social ( living alone, social distress), education level, medical history (previous depressive disorder, past history of stroke, cognivite dysfunction, dementia),stroke characteristic (location e.g., anterior lesion, left hemisphere location), psycosocial factor (absence of coping,poor family function,social isolation and poor social support following stroke,personalities straits).(10) The underlying mechanisms of post-stroke depression are not completely understood, two pathogenic theories have arisen: biological and psychosocial.(10,12)

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Biological Hypothesis of PSD Biological hypothesis include four mechanisms: lesion location, neurotransmitters, and inflammatory cytokines. According to the 'vascular hypothesis of depression', the existence of vascular lesions affecting brain circuits responsible for mood control could lead to PSD. Disruption of prefrontal systems and lesions damaging the striatopallidothalamocortical pathways could provoke vascular depression. Stroke lesions affecting left-side frontal pole and basal ganglia could disrupt biogenic amine neurotransmission and, thus, provoke PSD. This theory could explain the presence of depressive symptoms observed in the acute stage of stroke. Vascular burden due to chronic accumulation of small macrovascular and microvascular lesions might also be a determinant for the development and evolution of PSD. During the acute brain infarction there is decreased monoamine synthesis (enzyme inhibition during ischaemia) resulting in decreased 5-HT levels. These have been implicated in altered mood, sleep, and appetite.The use of serotonergic agents has therefore been suggested to augment stroke recovery. Early studies proposed that patients with a left-hemisphere lesion were more likely to be depressed. Stroke lesions observed on brain MRI involving left-side prefrontosubcortical circuits have been associated with PSD, and for a brain infarct that affected pallidum, there was a strong independent MRI correlate for PSD.Nevertheless a review and meta-analysis of 35 studies of PSD found no consistent evidence that left intrahemispheric location was associated with depression.The authors concluded that the cumulative vascular burden resulting from chronic accumulation of lacunar infarcts within the thalamus, basal ganglia and deep white matter, may be more important than single infarcts in the prediction of PSD.

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Recently, the proinflammatory cytokine hypothesis, as a response to brain ischemia, has been proposed. The release of proinflammatory cytokines (e.g., TNF-, IL-1, IL-6 and IL-18) may be involved in the initiation and amplification of the inflammatory response following cerebral ischemia. Proinflammatory cytokines may have depressiogenic properties and, thus, deplete serotonin in limbic and paralimbic areas, leading to PSD. Early PSD might represent a transient reaction to stroke, mediated by cytokines and changes in receptor regulation, whereas late PSD may reflect neuropathological changes secondary to stroke. Psychosocial hypothesis: Psychosocial Determinants of PSD In the long term, following stroke, psychosocial and sociodemographic factors (disability and social support) may explain the observed variability in PSD. Disability, cognitive functioning and a previous depression history may significantly increase the risk of PSD. Coping strategies and psychosocial vulnerability may also influence chronic mild depressive symptoms (dysthymia) after stroke. Difficulty completing instrumental activities of daily living and fatigue have been found to be predictors of PSD 3 years after stroke. Loss of employment, financial difficulties, social isolation, poor self esteem and sexual difficulties are increasingly recognized psychosocial difficulties in stroke survivors. Reduced social activity, failure to return to work, work status (e.g., housewife) and poor participation in rehabilitation are associated with PSD.. Cognitive impairment and depressive symptoms commonly occur after stroke, and have a negative effect on functional recovery, and depressed stroke patients may be more cognitively impaired. Severity of depressive symptoms may be related to degree of overall cognitive impairment. In addition, in the early stages following stroke, severity of symptoms of PSD may be associated with a specific pattern of cognitive impairment, affecting primarily memory, visual perception and language.
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Aphasia is common after stroke, and results in a sudden inability to function in many activities of daily life, such as leisure, occupational and social activities, and may be an important risk factor for depression.Depression diagnosis can be made in the acute phase in at least two-thirds of aphasic patients. 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).The Hospital Anxiety and Depression Scale (HADS) and the General Health Questionnaire (GHQ) are the best validated scales in patients without communication problems and are probably the most useful for screening stroke patients without communication difficulties in the rehabilitation or community setting. 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.(2,10) Early initiation of antidepressant therapy in non-depressed individuals is effective in preventing post-stroke depression.(11)

V. CONCLUSION

Depression due after stroke also known as post-stroke depression is commonly happens in patient who just had stroke, it occurs 2 to 3 month after the stroke. This condition is commonly underdiagnosed. There are some theories that have revealed the mechanism of this condition, biological and psychological hypotesis. Post-stroke condition sometimes difficult to diagnose, but there are some scales that can we use to define whether the patient suffer this condition or not. Early initation of antidepressant therapy is effective in preventing PSD.

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