Are Depressive in Patients
Symptoms With Acute
Nonspecific Stroke?
J. Paul Fedoroff, Rajesh
M. Parikh,
Objective: in stroke medical
M.D., Sergio E. Starkstein, M.D., Thomas R. Price, M.D., and Robert G. Robinson,
M.D.,
Some
investigators
have
suggested
patients because of changes illness; others have suggested
that
with
and
without
mood
to estimate
may be made. Method: They examined ofdepression in 205 patients who were
Eighty-five turbance.
(41 %) Forty-six
assigned
depressed
of these (54%)
the DSM-III
disturbance had a mean
ofmajor
had a mean ofone autonomic of almost four. Tightening
how
often
the rate consecutively
patients had depressed of the 85 patients with
diagnosis
might
be overdiagnosed caused by in stroke
ofanosognosia, neglect, or aprosody. depressive symptoms occur in acute
‘
or exclusion symptoms
depression
in appetite, sleep, or sexual interest that depression may be underdiagnosed
tients who deny symptoms of depression because authors goal was to determine how frequently patients
major
M.D.
mood, depressed
depression.
but
errors
The stroke
of inclusion
and psychological for acute stroke.
and 120 (59%) had no mood mood (22% ofall patients)
Results:
symptom, the diagnostic
diagnostic
ofautonomic hospitalized
The
120
their pa-
patients
without
diswere mood
the 85 patients with depressed mood criteria to account for one more non-
specific autonomic symptom decreased the number ofpatients with major depression by only three; adding two more criteria decreased the number by only five. Thus, the rate of DSM-III major depression was 1 % higher than the rate with one extra nonspecific autonomic symptom and
2 % higher
to account Conclusions: with
the syndrome
patients cortex
with or left
than
mood
J Psychiatry
publications of major
stroke basal
and ganglia
the
rate
with
two
denial ofdepressive Both autonomic and
depressed
(Am
I n previous
for
in acute
1991;
148:1
( I , 2), we have depression
that
lesions
are more
stroke
172-I
reported
is common
extra
loosening
diagnostic
criteria
depression by only 5%. are strongly associated
176)
that among
to be associ-
ated with major depression than lesions in any other brain areas. In addition, previous studies have found that patients with major depression following stroke
Received Aug. 1 1, 1989; revisions received Dec. 20, 1989, and April 17 and May 30, 1990; accepted March 29, 1991. From the Department of Psychiatry and Neuroscience, Johns Hopkins University School of Medicine, the Department of Neurology and Psychiatry, University of Maryland School of Medicine, Baltimore, and the Dcpartment of Psychiatry, University of Iowa College of Medicine. Address reprint requests to Dr. Robinson, Department of Psychiatry, University of Iowa College of Medicine, Psychiatric Hospital, Iowa City, IA 52242. Supported in part by Research Scientist Award MH-00I63 to Dr. Robinson and grant MH-40355 from NIMH, grants NS-15080, NS92302, and NS-16332 from the National Institute of Neurological and Communicative Disorders and Stroke, and a Young Investigator Award to Dr. Starkstein from the National Association for Research in Schizophrenia and Affective Disorders. Copyright © 1991 American Psychiatric Association.
I 172
Conversely,
patients.
in the left frontal likely
criteria.
illness increased the rate ofmajor psychological depressive symptoms
are similar to patients with functional depression (i.e., major depression with no known organic etiology) in phenomenology (3), response to dexamethasone (4, 5), cognitive impairment related to depression (6), natural course of untreated depressive disorder (7), and response to antidepressant medications (8-10). Q uestions remain, however, about whether the same diagnostic criteria that are used in patients with functional major depression should be used in stroke patients because symptoms used for the diagnosis of depression may occur in medically ill patients independent of depression. For this reason, some investigators have suggested that stroke patients with changes in appetite, sleep, or sexual interest as a result of their medical illness may be “overdiagnosed” as having major depression ( I 1 ). Conversely, some investigatoms have suggested that depression may be Undemdiagnosed in stroke patients who deny symptoms of depression because of anosognosia, neglect, or aprosody (12). Since, to our knowledge, no previous investigators have systematically examined this issue, this study was
Am]
Psychiatry
148:9,
September
1991
FEDOROFF,
designed to determine toms occur in acute mood compared mood disturbance roms of inclusion
how frequently stroke patients
with acute to estimate or exclusion
depressive sympwith depressed
stroke patients without how often diagnostic emmay be made.
METhOD
mood
was
turbance
pital with thromboembolic or hemorrhagic lesions. Patients were excluded if they had a low level of consciousness, moderate to severe comprehension deficit, or did
not
give
Interviews
informed
were
consent.
conducted
of admission. Neurological one of us (T.R.P.), who
findings, amination and
within
the first
2 weeks
evaluations were done was blind to the psychiatric
by
using the standardized Stroke Data Bank Exof the National Institute of Neurological
Communicative
Disorders
psychiatric examination ing Scale for Depression view using the Present
and
Stroke
(13).
The
included the Hamilton Rat(14) and a structured interState Examination (PSE) (15).
The PSE was modified to include primarily items melated to depression or anxiety and was used to make DSM-III-based diagnoses described in a previous
publication
(16).
Cognitive
of daily living were State Examination
impairment
assessed (17) and
and
activities
by using the Mini-Mental the Johns Hopkins Func-
tioning Inventory (18). Symptoms of depression were divided into autonomic and psychological as described by Davidson and Tunnbull (19). No attempt was made to determine whether
the symptoms
resulted
cal illness, medications, sion, or other possible by one of us (S.E.S.), cation (2). Intergroup
from
the patient’s
medi-
hospital environment, deprescauses. CT scans were evaluated as described in a previous publicomparisons of parametric data
were done with two-tailed t tests and appropriate analyses of variance (ANOVAs). Nonpamametnic data were compared by using chi-squame tests.
RESULTS
Background
Characteristics
The study group consisted mean±SD age of 58.7±13 years;
107 (52%) (66%)
were
were
men,
from
five (41 %) of the
96 (47%)
Hollingshead
patients
of 205 patients 13 1 (64%) were
with a black,
were
married,
class
IV and
V. Eighty-
having
depressed
reported
and
135
mood, There tween
and 120 (59%) reported no mood disturbance. were no statistically significant differences bethe patients with and without depressed mood in
terms
of sex, race,
socioeconomic
status,
marital
status,
personal or family history of psychiatric disorder, previous medical history, or medications taken at the time
of the
Am
]
interview.
Psychiatry
However,
I 48:9,
the
September
group
1991
with
depressed
than
(56.5±12
years
the
group
PARIKH,
without
compared
with
mood
60.4±14
ET AL.
dis-
years,
respectively) (t=-2.08, df=203, p=O.O4) and had lower scores on the Mini Mental State (22±5.6 versus 24±4.8) (t=-1.96, df=203, p=O.OS). The group with depressed mood also had higher Hamilton depression scores (13±6.5 versus 5.0±5.6) (t=9.37, df=203, p