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

Are depressive symptoms nonspecific in patients with acute stroke?

Some investigators have suggested that major depression might be overdiagnosed in stroke patients because of changes in appetite, sleep, or sexual int...
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