There is a large variation in the prevalence of depression after stroke due to the patient selection and diagnostic methods used by clinicians and researchers.
Wade, Legh-Smith and Langton-Hewer (1987) concluded that depressed mood was present in about one-quarter of survivors up to one year after stroke. Later studies have identified two types of depressive disorders associated with stroke: major depression, which occurs in up to 25 per cent of survivors; and minor depression, which occurs in 10 to 30 per cent of survivors (Eastwood et al 1989).
In a study by Kauhanen (1999), depression was diagnosed in 53 per cent of survivors at three months and in 42 per cent at 12 months following stroke, but the frequency of major depression increased from 9 per cent to 16 per cent during the first year. Similar prevalence rates for major depression among long-term stroke survivors have been found in several other studies (Åström, Adolfsson and Asplund 1993, Parikh et al 1990, Sharpe et al 1994; Wade, Legh-Smith and Langton-Hewer 1987).
More than half the patients who are depressed in the acute phase of stroke are at risk of developing chronic depression (Wade, Legh-Smith and Langton-Hewer 1987). Other factors reported as associated with post-stroke depression include functional dependence, age, gender and social impairment (RG Robinson et al 1997; Sharpe et al 1994). The aetiology of post-stroke depression is multifactorial and includes both personal and social pre stroke factors (G Andersen et al 1995; Herrmann, Bartles and Wallesch 1993; Lyketsos et al 1998).
The association between the location of specific cerebral lesions and post-stroke depression has been the subject of debate in recent decades. Several reports suggest a higher rate of depressed mood in those with a lesion in the left frontal region of the brain (Herrmann, Bartles and Wallesch 1993; Morris, Robinson and Raphael 1992), although Wade, Legh-Smith and Langton-Hewer (1987) failed to confirm any association between right-side weakness and depression. Higher rates of post-stroke depression was also found in survivors with left hemisphere lesions (Kauhanen 1999). Kauhanen's study demonstrated a higher frequency of depression amongst aphasic (with a diminished ability to use and understand language) survivors compared with non-aphasic survivors following stroke. (Aphasic strokes are usually associated with left hemispheric lesions.)
The need for early detection and treatment of depression has been underlined by many investigators (MS Clark and Smith 1998b; Reding et al 1986; van de Weg, Kuik and Langhorst 1999) and the possible beneficial effect of antidepressant medication on recovery after stroke has been suggested (Ebrahim and Harwood 1999).
One of the main cognitive deficits following stroke is hemianopia, or blindness in one half of the visual field (Pedersen et al 1997). This loss can be caused by a variety of medical conditions, of which stroke is among the most commonly experienced (Kalra et al 1997). ‘Neglect' refers to a tendency to ignore stimuli in one half of space and is another cognitive deficit found in 43 per cent stroke survivors affected by right hemisphere lesions (Pedersen et al 1997). It can involve all modalities (vision, hearing and touch) and usually results from right hemisphere lesions, most commonly in the parietal lobe of the brain. Kalra et al (1997) found that patients with visual neglect required longer hospitalisation and more therapy compared to patients with no visual neglect and that visual neglect may affect the ability of stroke survivors to live independently.
Memory disorders have been reported in 10 to 55 per cent of stroke survivors (Kotila et al 1985; Tatemichi et al 1994). However, estimates of the prevalence of memory disorders among stroke survivors is questionable since survivors with aphasia are often excluded. General intellectual decline characterised by impairment in several cognitive domains is not uncommon after stroke. Kase et al (1998) studied a cohort of older stroke survivors and found a correlation between large, left-side stroke damage and cognitive decline.
Emotional and behavioural disturbances:
A wide range of emotional and behavioural disturbances occur following stroke (RG Robinson 1997). Some of these neuropsychiatric disorders, such as depression and lack of interest, have a potential impact on rehabilitation and recovery from stroke. Other disturbances, such as post-stroke anxiety and crying, may affect social functioning. According to MS Clark and Smith (1997), similar disturbances were apparent in nearly 30 per cent of the patients in their study at discharge, and the disturbance persisted for 12 months.
By Saleh ALoraibi
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