Depressive

Symptoms

Robert

Ph.D.,

A. Stern,

and David

Objective: The primary to mood and vegetative

purpose of this study disturbance following

outpatients

single,

who

had

had

unilateral

Following

strokes

Stroke

L. Bachman,

M.D.

was to assess the relation of lesion location stroke. Method: Fifty-two inpatients and were

included.

Patients

with

past

CNS

or

psychiatric disorders were excluded. A modified Visual Analogue Dysphoria Scale was used to allow the inclusion of all but the most impaired aphasic patients. Sleep and eating disturbances were measured by using both self-report and nursing assessments. Location of lesions was determined by CT scan and classified according to three dimensions: right-left, dorsal-ventral, and frontal-nonfrontal. Results: On measures of dysphoric mood and sleep disturbance, results indicated significant three-way interactions among the three lesion dimensions. No differences were found with regard to eating disturbance. Greater dysphoria and sleep disturbance were found in subjects with left parietal/occipital, left inferior frontal, right superior frontal, and right temporal lesions than in subjects with lesions in other locations. Depressive symptoms were not associated with functional impairment as measured by activities of daily living, motor strength, or severity of aphasia. Conclusions: These results support the mixture of influences relation between the more complex than (AmJ Psychiatry

hypothesis that lesion location is a valid which may result in a dysphoric mood site ofthe lesion and subsequent depressive has been reported previously. 1991; 148:351-356)

M

ood disorders following stroke are common (1), can significantly reduce the speed and success of rehabilitation (2), and do not appear merely to mepresent an expected grief response to loss of function (3, 4). Robinson and colleagues (5, 6) suggested that patients with left anterior cerebral lesions have a higher incidence and severity of the psychiatric syndrome of major depression than do patients with lesions in other locations. A more recent report by Robinson’s group (7) and one by others (4), however, indicate that this finding may not be as definite as was first thought. A more precise assessment of intrahemisphenic lesion location may help to clarify the relation between lesion focus and depressive symptoms. On the basis of known neumoanatomical connections of cortical/sub-

Revised version of a paper presented at the I 7th annual meeting of the International Neuropsychological Society, Vancouver, B.C., Canada, Feb. 8-1 1, 1989. Received Sept. 15, 1989; revision received Aug. 16, 1990; accepted Sept. 25, 1990. From the Department of Neurology, Department of Veterans Affairs Medical Center, Boston, Mass. Address reprint requests to Dr. Stern, Department of Psychiatry, CB 7160, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7160. The authors thank Drs. Michael Alexander, Vikan Babikian, Dana Penny, Patricia Raymond, and Dominic Valentino, Ms. Carole Palumbo, and Ms. Denise Stiassny-Eder for their assistance in data collection and analysis.

Am

J

Psychiatry

148:3,

March

1991

cortical

limbic

and significant factor in the state following stroke. The symptoms, however, may be

system

pathways,

it would

that differences in mood and behavior within frontal or posterior regions, whether a lesion is in a more ventral or (e.g., orbital frontal versus domsolatemal temporal versus panietal lobe) (8-10).

be expected

would exist depending on dorsal location frontal lobe or Despite the ex-

istence of these dorsal-ventral neuroanatomical differences, no previous study of poststroke mood disordens has systematically evaluated this aspect of lesion

localization. A major limitation to previous investigations of depressive symptoms following stroke involves the selection of subjects. Many studies have included patients with prestroke histories of psychiatric illness or previous strokes (1, 11, 12). This has led to potentially confounding results, since these variables may increase the risk of depressive symptoms following stroke (12, 13). In addition, the majority of investigations have excluded many aphasic patients with impaired comprehension because of the inability of these patients to respond accurately to standardized depression scales and interviews (4, 14). Although some aspects of depressive bances,

symptoms, such as sleeping and can be readily observed, internal

eating mood

disturstate is

difficult to assess in aphasic patients (iS, 16). Finally, most previous studies have relied on multifactonial measures of the syndrome of depression or on psychi-

3S1

DEPRESSIVE

SYMPTOMS

FOLLOWING

atmic diagnostic criteria (e.g., measures of specific symptoms.

The lation

present study was of specific lesion

STROKE

DSM-III)

rather

than

on

munication

was

Boston

undertaken locations

to

to assess internal

the memood

states and to two vegetative symptoms common in psychiatnic depressive disorders, i.e., sleeping and eating disturbances. In addition to night-left and frontal-non-

the

Dysphomic Visual

line with was left-side

METHOD

of dysphonic

Subjects

were

selected

from

among

consecutively

ad-

private

rehabilitation

the study subjects

and or

after

their

facility.

explanation representatives

Before

participation

of the procedures, gave

informed

in

sent. All subjects were might-handed men who had suffered a unilateral cemebrovasculam accident between 1 month and 4 years before participation (mean±SD time since stroke onset was 16.2±12.3 months). Only patients whose lesions could be documented by CT scan were included. All subjects had lesions involving the cerebral hemispheres; no subjects had isolated brainstem or cerebellan lesions. Patients who had had previous cemebrovasculam accidents or other disorders of the CNS were excluded, as were those with prestroke histories of psychiatric illness (including significant alcohol abuse). Aphasic patients were excluded only if their mean auditory comprehension scores on the Boston Diagnostic Aphasia Examination (17) were below the 10th percentile; only two aphasic patients were excluded by this criterion. Twenty-two aphasic patients participated. The total number of subjects was 52, and their mean±SD age was 65.8±7.9 years. Ninety percent (N=47) of the subjects were Caucasian; the remaining 10% were black. Thirty-three percent (N= 17) of the subjects had high school degrees, 38% 29%

(N=20) (N=1S)

had had

not had

completed high some education

school, beyond

and high

school. Each subject was assessed on one occasion. Self-report and interview ratings were conducted in the late morning or early afternoon to preclude effects of diurnal variation.

Functional impairment was measured with the Modified Bamthel Index of Mobility and Self Care (18) and a typical 6-point motor strength scale (19). The severity of the aphasic patients’ impairment in com-

352

severity

scone

of the

assessed by a modification Mood Scale (20) in which

a vertical

rather

used in order hemispatial

represented

by words

than

of a

a horizontal

to preclude bias due to neglect. The two poles

and

cartoon

faces

indicat-

mood,

such

as the MMPI

depression

scale

and the Profile of Mood States. A similar scale has been found useful in assessing mood in stroke patients because of its brevity and its limited linguistic requirements (21). Formal assessment of reliability and validity

for other

scales

has

The

vertically recently

Visual

presented been

for

Analogue

Depression

Checklist

All

battery the

and

of their aphasia, were to be reliable responses

Scale

mood

was

of mood Hamilton

the

subjects,

analogue

(22).

Dysphonia

(23)

(24).

visual

reported

tened as pant of a larger sion inventories, including

adminis-

and depresRating Scale

Depression

regardless

Adjective of the

able to provide what by using the Visual

severity

appeared Analogue

Dysphonia correlated measures

Scale. Furthermore, highly with scones of dysphonic mood

ratings on this scale on other standardized such as the Depression

Adjective

Checklist

in the

(n=0.81)

aphasic

patients

(25), thus providing additional evidence of concurrent validity for this new mood scale. The correlation between ratings on the Visual Analogue Dysphomia Scale and the Depression Adjective Checklist existed for the aphasic subjects with the most intact auditory cornprehension (r= 0.84; mean±SD Boston Diagnostic Aphasia Examination auditory comprehension percentile=75.3± 13.8) as well as for those with the most compromised auditory comprehension (r=0.64; auditory comprehension pencentile=29.7± 13.7). Ratings of vegetative symptoms were created by using a combination of interview response and observed

behavior. Sleep disturbance was assessed by a combination of the three insomnia items of the Hamilton depression

scale

and

a 5-point

rating

of early

morning

awakening completed by a nurse familiar with the patient. Eating disturbance was similarly assessed by a combination of the two eating-related items of the Hamilton scale and a nurse’s 5-point rating of diminished

Instruments

was

the

Examination.

ing “happy” and “sad.” The scone on this Visual Analogue Dysphonia Scale was the number of millimeters from the “happy” pole. We found this modified scale to be a valid measure of dysphonic mood in a series of 95 general neurology patients referred for neumopsychological assessment, with significant correlations between scones on it and on other standardized measures

all con-

mood Analogue

100-mm

were

by

Aphasia

presentation nightor

frontal dimensions, lesions were classified by using a ventral-dorsal dichotomy. Patients with previous neurological or psychiatric histories were excluded, and a modification of a self-report measure of dysphomic mood was used to allow the inclusion of all but the most severely impaired aphasic patients.

mitted inpatients and outpatients with neurology clinic appointments at the Boston Department of Veterans Affairs Medical Center and the Bnaintnee Hospital, a

assessed

Diagnostic

appetite.

meaningful

One

responses

patient

during

was

unable

the Hamilton

to

provide

depression

interview, and therefore the sleep and eating disturbance scales were composed solely of the nurse’s assessments. Ratings on each of these two scales were

transformed to standardized 50± 10) for the analyses.

Am

J

T scores

Psychiatry

148:3,

(mean

March

±

SD

1991

ROBERT

Lesion

MANOVA. formed by

Classification

All subjects independently

received

CT

by

members

two

scans,

which of

the

were CT

judged research

than this

least sample

A. STERN

AND

The MANOVAs using unweighted squares were

DAViD

L. BACHMAN

and ANOVAs were permeans analyses rather

analyses, since most likely due

unequal cell sizes in to chance sampling

group of the Boston Department of Veterans Affairs Medical Center Aphasia Research Center. Location of the lesions was assessed with a modification of the technique of Naeser and Hayward (26). Since all lesions were unilateral, the side of the lesion was easily

error

determined.

appropriate simple effects tests to assess the underlying two-way interactions or main effects. On the basis of previous research and theoretical arguments, an a priori decision was made to assess

Analysis

of intrahemisphenic

lesion

tion was performed on a region-by-region of the following six regions was rated scale

with

respect

the inferior and 43-47),

to the

frontal lobe the superior

percentage

on

loca-

basis. Each a 4-point

of infarcted

tissue:

(Brodmann’s areas 10-15, 25, frontal lobe (areas 4, 6, 8, 9,

24, 32, and 33), the temporal lobe (areas 20-22, 2630, 34-38, and 41-43), the inferior occipital lobe (ameas 17-19), the inferior panietal lobe (areas 23, 31, 39, and 40), and the superior pamietal and occipital lobes

(areas 1-3, 5, and 7). In order to provide intmahemispheric classifications, these ratings were then transformed using two dimensions: 1) dorsal (including the superior frontal and entire pamietal and occipital lobes) versus

ventral

(including

the inferior

frontal

and

entire

temporal lobes) and 2) frontal versus nonfrontal. A lesion was considered to be frontal if the mean rating for the two frontal regions was greaten than the mean rating for the remaining four regions. Similarly, a Icsion

was

considered

to

be

ventral

if the

mean

in

one

area

or

another,

rather

than

solely in that area. The inclusion of inferior occipital regions in the dorsal classification was based on known corticolimbic connections rather than on actual anatomical location. On the basis of these lesion classifications, 37% (N=19)

of the

subjects

had

night

hemisphere

lesions

(63%, N=33, left hemisphere), 65% (N=34) had predominantly dorsal lesions (35%, N 18, ventral), and 44% (N=23) had predominantly frontal lesions (56%, N=29, nonfrontal). In this classification scheme no distinction was made between involvement of cortical and subcortical lesions. Statistical

Analyses

The relation between lesion classifications and each of the three dependent variables (i.e., ratings of dysphomia, sleep disturbance, and eating disturbance) were first assessed with a multivamiate analysis of vanance (MANOVA) to protect against type I error and because of interconnelations among the dependent variables. A 2 x 2 x 2 design was used, with each of the three dichotomous lesion dimensions used as a grouping variable. Individual univamiate analyses of variance (ANOVAs) were performed subsequent to a significant

Am

J

Psychiatry

148:3,

March

1991

than

an expected

ity

of dispersion

Significant

the

matrices,

three-way

inequality

in the popu-

assumptions analyses (e.g.,

underlying homogene-

homogeneity

ANOVAs

of variance).

were

followed

up

by

might-left by fmontal-nonfrontal interactions at each of the two dorsal-ventral levels. For example, following a significant three-way interaction, two separate twoway ANOVAs were performed as simple effects tests (using appropriate error terms), one assessing the me-

lation

between

patients

with

side of the lesion predominantly

and

caudality

dorsal

among

lesions

and

the

other assessing this relation among patients with predominantly ventral lesions. These tests, if significant, were followed up by further simple main effects tests. The relations between the dysphomia ratings and the measures

of functional

impairment

were

assessed

with

two-tailed Pearson correlations, as were the relations among the three dependent variables. An alpha level of

0.05 was

used

throughout.

com-

bined rating for the inferior frontal and temporal lobe regions was greater than the mean combined rating for the superior frontal, inferior pamietal, inferior occipital, and superior panietal and occipital regions. The classifications, therefore, indicated whether the lesion was predominantly

rather

lation. All analyses met univaniate and multivaniate

RESULTS

There were no significant relations between dysphonic mood and measures of functional impairment. Specifically, rating on the Visual Analogue Dysphonia Scale was not significantly correlated with the Barthel index (n= -0.02, dfSO, p>O.OS), with the measure of motor strength (r0.01, df=S0, p>O.OS), or with the aphasia

severity

score

(m=-0.19,

df=18,

p>O.OS).

The MANOVA assessing the relation between lesion location and depressive symptoms yielded a significant three-way interaction (Wilks’ lambda=0.69; approximately

distributed

as

F=6.16,

df=3,

42,

p

Depressive symptoms following stroke.

The primary purpose of this study was to assess the relation of lesion location to mood and vegetative disturbance following stroke...
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