Post stroke depression underdiagnosed, undertreated, underestimated?

1. Post stroke depressionunderdiagnosed, undertreated, underestimated?

2. Definition • Better to speak of neuropsychiatric disorders with cerebrovascular disease • Includes depression, anxiety, apathy, cognitive impairment, mania, psychosis, pathological affective display, catastrophic reactions, anosognosia

3. DSM 5 criteria • Vascular depression (associated with microangiopathy) • PSD • Due to stroke with “depressive features, major depression-like episode or mixed mood features” • Depressed features or loss of interest or pleasure with four other symptoms of depression, lasting more than 2 weeks

4. Differing from geriatric depressionwithout vascular genesis • Greater cognitive impairment • Greater physical impairment • Poor response to treatment (?) • Less family and personal history • More cardiovascular risk factors (associated with severity of depression?)

5. Incidence and prevalence • Stroke risk between 10-20 in 10000 (55-64 yo) abd 200 in 10000 (>85 y olds) • Around 31% of stroke patients at any time within 5 y after stroke • Previous analysis up to 52% cumulative risk • Caution> meta analysis, not distinguishing between major depression and other forms, other formal weaknesses

6. Personal experiences?

7. Risk factors • Genetic factors: • 5-HTTLPR and STin2VTNR polymorphisms • DNA methylation status

8. Coincidence ?

9. Other factors: • Gender? • Age? • Cardiovascular risk factors surprisingly not • Depression in men underdiagnosed • Diabetes • Personal and possibly family history

10. Stroke characateristic and lesion • Mechanism apparently irrelevant • Localisation (left frontal, proximity to frontal pole) – better evidence shortly after stroke • Size of stroke, physical disability • Cognitive impairment more important than physical

11. Pathomechanisms

12. Candidates • Disruption of prefrontal-subcortical circuits • Increased activation of the default mode network, decreased activation of task related networks, dorsolateral prefrontal cortex • Transcortical magnet stimulation only effective if directed at this area

13. Reverse causality

14. Other biological factors:alterations in Ascending monoamine systems Hypothalamic-pituitary-adrenal axis Alterations in neuroplasticity Excess in proinflammatory cytokines, cortisol Altered glutamate levels in the cingulate cortex • Hypothesis for the efficacy of SSRI increased neuroplasticity, hippocampal neurogenesis (?) • BDNF, interleukin levels (serum) predictive

15. Detection • Patient Health Questionaire?

16. Geriatric depression scale (short)

17. Consequences • Depression severity predictive of impairment of ADLs • Increased mortality (even with mild PSD). One study reports odd-ratio of 1.41 at 5 Years

18. Therapy • Significant effect of SSRI and Tricyclics • No evidence for treatment of non-depressed patients

19. Complications • SSRI increased risk of haemorrhagic complications • Increased risk of falls • Increased risk for stroke, myocardial infarction and all-cause mortality • Relapse all depression if premature cessation of therapy 80%

20. Prevention • Psychotherapy better evidence than in treatment • Number of social ties inversely related to severity • Marital status, living situation not correlated • Lack of social support at admission increased risk • Citalopram vs problem solving therapy vs placebo 8.5% vs 11.9% vs 22.4% (n=58)

21. Future research