Clinical depression was associated with impaired recovery from stroke
ACP J Club. 1993 May-June;118:90. doi:10.7326/ACPJC-1993-118-3-090
Morris PL, Raphael B, Robinson RG. Clinical depression is associated with impaired recovery from stroke. Med J Aust. 1992 Aug 17;157:239-42.
To study the association between clinical depression after a stroke and cognitive and functional recovery at 1 year.
1-year cohort study of patients who had survived a stroke.
Rehabilitation units of 2 Australian university hospitals.
Out of 61 consecutive patients with stroke (World Health Organization clinical definition), 49 patients (mean age 68 y, 33 men), who consented, could understand and respond to interviews, and survived for 1 year without a subsequent stroke or other major illness, formed the cohort.
Assessment of risk factors
Neurologic assessment and computed tomography scans verified stroke type and location. 4 to 8 weeks after the stroke, psychiatric assessment was done to diagnose depression using a semistructured interview (Composite International Diagnostic Interview) and the Diagnostic and Statistical Manual of Mental Disorders III. Both major and minor depression were included. The General Health Questionnaire measured the severity of the psychiatric symptoms.
Main outcome measures
1 year after study entry, interviewers blinded to depression status used the Karnofsky index to measure functional status, the abbreviated Barthel Index to asure physical disability, and the Mental Status Questionnaire (MSQ) to measure cognitive performance (mainly orientation and memory functions). Mean changes from baseline values were compared between depressed and nondepressed patient groups.
At baseline 20 patients were depressed and 29 were not depressed. Depression developed a mean of 2.7 weeks after the stroke and lasted for a mean of 20 weeks. At the end of the study the patients who had not been depressed compared with those who had been depressed had better functional status (mean Karnofsky score changes from baseline, 48% vs. 23%; P = 0.001) and showed a trend toward improved mean MSQ scores (11% vs. -1%; P = 0.1). The groups did not differ for changes in Barthel scores (activities of daily living) or number of patients who improved their Barthel or MSQ scores. All patients who had not been depressed improved or stayed the same for the 3 measures. 4 patients (20%) who had been depressed had worse Barthel scores, and 3 (15%) had worse MSQ scores at the end of the study.
Clinical depression after a stroke was associated with decreased improvement in functional status after 1 year.
Sources of funding: New South Wales Institute of Psychiatry and the Australian Institute of Health.
For article reprint: Not available.
The study by Morris and colleagues showed an association between depression and impaired functional recovery from stroke. The strengths of the study are its prospective design, good follow-up, blinded outcome evaluation, and validated assessment instruments.
Potential weaknesses include the method of blinding, the use of different outcome measures compared with the study by Parikh and colleagues (1), and group differences. Details about the method of blinding were not provided; for example, did the same clinicians do the initial and 1-ye_ar assessments?
The instruments chosen for outcome assessment were appropriate for identifying differences between the depressed and nondepressed individuals. Further, this study complements the study by Parikh and colleagues (1) and supports their conclusions. Morris and colleagues compared the depressed and nondepressed groups for several variables that could influence stroke recovery and found no important differences. Some important variables, however, were not measured, including the type and duration of rehabilitation. If rehabilitation programs differed in patients who were depressed and not depressed, this may have influenced the results, particularly because the nondepressed group had somewhat greater baseline physical independence than the depressed group.
Two studies have shown that depression is associated with impaired functional recovery from stroke. Although the optimal timing or type of therapy for depression was not determined in this study, clinicians are urged to recognize and consider treating poststroke depression.
John R. Absher, MD
Bowman Gray School of MedicineWinston-Salem, North Carolina, USA