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Journal Article•DOI•

Prevalence and predictors of post-stroke mood disorders: A meta-analysis and meta-regression of depression, anxiety and adjustment disorder

Alex J. Mitchell1, Bhavisha Sheth, John Gill, Motahare Yadegarfar, Brendon Stubbs2, Mohammad E Yadegarfar3, Nicholas Meader4 •
Leicester Royal Infirmary1, South London and Maudsley NHS Foundation Trust2, Anglia Ruskin University3, King's College London4
01 Jul 2017-General Hospital Psychiatry (Elsevier)-Vol. 47, pp 48-60
TL;DR: Depression, adjustment disorder and anxiety are common after stroke and the relative risk of any depressive disorder was higher following left (dominant) hemisphere stroke, aphasia, and among people with a family history and past history of mood disorders.
About: This article is published in General Hospital Psychiatry.The article was published on 2017-07-01 and is currently open access. It has received 232 citations till now. The article focuses on the topics: Major depressive disorder & Adjustment disorders.

Summary (3 min read)

Jump to: [Introduction] – [A C C E P T E D M A N U S C R I P T A C C E P T E D M A N U S C R I P T] – [Literature search] – [Quality assessment and Risk of bias assessment] – [Statistical Analysis] – [A C C E P T E D M A N U S C R I P T] – [Predictors of Post-Stroke Depression 1. The Effect of Hemispheric Laterality] – [2. The Effect of Aphasia] and [Discussion]

Introduction

  • The global burden of stroke (including years lived with disability) are substantial and continuing to increase.
  • 2 Depression is particularly problematic and persistent after stroke, with high risk of relapse, even after a long period of remission.
  • 14 Beyond depression, other mood disorders have been much less extensively investigated.
  • Four previous systematic reviews or meta-analyses have examined the importance of lesion location with varying results.
  • An unresolved question is whether mood disorders remain elevated during rehabilitation and discharge back to the community.

A C C E P T E D M A N U S C R I P T A C C E P T E D M A N U S C R I P T

  • Anxiety disorder was examined by all such studies but a minority also considered agoraphobia, panic disorder, agoraphobia, OCD and social phobia) by DSM (III,IIIR,IV) criteria.
  • Studies were excluded that a) relied upon self-report or observer scales to quantify depression including those using a two-step procedure of an initial scale and then interview in those who screen positive in step 1. b).
  • The authors also excluded duplicate publications; that is two or more studies on the same sample collected at the same time point.
  • The authors did not place any language restriction upon eligible studies.
  • The authors refer to the period prevalence (for example the last two weeks) hereafter simply as "prevalence".

Literature search

  • Two independent authors (AJM, NM) conducted searches of Medline , PsycINFO and Web of Knowledge from inception to June 2015.
  • The authors used the key words (stroke or cerebrovascular or hemorrhage or cerebral infarctions) and (depression, major depression, major depressive disorder, minor depressive disorder, dysthymia, adjustment disorder, anxiety, panic, generalized anxiety, social anxiety, phobia, mood and emotion$).
  • In addition, the authors conducted hand searches of the references lists of included articles and contacted numerous International experts to ensure completeness of data acquisition.
  • Where possible the authors reviewed the full text version.
  • For qualifying studies wherever possible the authors attempted to acquire the required data directly from the primary authors of included studies.

Quality assessment and Risk of bias assessment

  • Two authors (JSG, AJM) conducted the risk of bias assessment using a four point quality rating and a five point bias risk was applied to each study as used in a recent similar prevalence study.
  • The quality rating score was based on study sample size, study design, study attrition, follow-up (if any) and method of dealing with possible confounders with the following scale: 1 = low quality 2 = lowmedium quality 3 = mediumhigh quality 4 = high quality.
  • The bias rating score evaluated possible bias in assessments of results as influenced by consideration of setting, aphasia, interview method and sampling method.
  • Any area of disagreement was resolved by two supervisors (AJM, NM).
  • Type and hemispheric laterality) the prevalence of aphasia and family and personal history of mood disorders studies.

Statistical Analysis

  • Prevalence and relative risk meta-analyses were calculated.
  • Which describes the percentage of variation across studies that is due to heterogeneity rather than chance and does not inherently depend upon the number of studies considered (Higgins et al., 2003).
  • 28 Due to the moderate and high inconsistency/ heterogeneity (I 2 of ≥80% = moderate ≥90% = high respectively) data was pooled using DerSimonian-Laird random effects meta-analysis with StatsDirect (version 2.7.7).
  • 29 Harbord test maintains the power of the Egger test whilst reducing the false positive rate.
  • The authors examined the effect of age, gender, setting, stroke type and time since stroke.

A C C E P T E D M A N U S C R I P T

  • The most common reasons for low quality were using an unstructured clinical interview, not fully reporting data and low sample size.
  • There were similar findings for any depressive disorder MnD and anxiety.
  • There were variations in the handling of aphasia, although the authors attempted to allow for this by clarifying if studies included or excluded patients with communication difficulties.
  • The key risk factors for post-stroke depression appear to be a past history of depression, a family history of depression, aphasia and left hemisphere lesions.

Predictors of Post-Stroke Depression 1. The Effect of Hemispheric Laterality

  • This effect was also significant using random effects meta-analysis (data not shown).
  • On fixed effects meta-analysis the risk of any depressive disorder.

2. The Effect of Aphasia

  • Only four analysis involving 113 patients examined MDD in stroke patients with clearly defined aphasia (all settings and all time periods) were available and the pooled prevalence of MDD in aphasic patients was 30.5% (95% CI = 10.1% to 56.1%).
  • There was insufficient data to perform a relative risk analysis because only two studies reported on the rate of depression in stroke patients with vs without aphasia in their sample.
  • Only five analysis involving 211 patients examined any depressive disorder in stroke patients with aphasia (all settings and all time periods).

Discussion

  • To their knowledge, this is the first study to examine the prevalence and predictors of post-stroke depression / anxiety / adjustment disorder using meta-analysis solely based upon interview defined clinical disorders.
  • Minor depression and other non-major depressions are associated with significant burden 32 and previous meta-analyses have failed to consider the range of mood disorders.
  • Overall the authors estimate that at least one in three have clinical depression (any depressive disorder) on any particular day after stroke.
  • 20 21 One recent meta-analysis examined anxiety disorders but included mixed scales and only 8 studies involved objective methods.
  • When examined cross-sectionally, at precisely 12 months, the authors found that 13.5% had MDD and 23.9% any depressive disorder using pooled data.

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Citations
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Journal Article•DOI•
Post-stroke depression: Mechanisms and pharmacological treatment.

[...]

Roberto Federico Villa1, Federica Ferrari1, Antonio Moretti1•
University of Pavia1
01 Apr 2018-Pharmacology & Therapeutics
TL;DR: This review will address the various areas of epidemiology, pathophysiology, preventive and therapeutic strategies for post‐stroke depression, as well as the effect of depression as risk factor for stroke.

278 citations

Cites background from "Prevalence and predictors of post-s..."

  • ...Adjustment disorder was present in 6.9% of patients and anxiety in 9.8% (Mitchell et al., 2017)....

    [...]

Journal Article•DOI•
Comorbid depression in medical diseases.

[...]

Stefan M. Gold1, Ole Köhler-Forsberg2, Rona Moss-Morris3, Anja Mehnert4, J. Jaime Miranda5, Monika Bullinger, Andrew Steptoe6, Mary A. Whooley7, Christian Otte1 •
Humboldt University of Berlin1, Aarhus University Hospital2, King's College London3, Leipzig University4, Cayetano Heredia University5, University College London6, University of California, San Francisco7
20 Aug 2020
TL;DR: The epidemiology, mechanisms, diagnosis and treatment of comorbid depression in patients with medical diseases, including major depressive disorder, are discussed.
Abstract: Depression is one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. Indeed, the prevalence of depression in these patient groups is often substantially higher than in the general population, and depression accounts for a substantial part of the psychosocial burden of these disorders. Many factors can contribute to the occurrence of comorbid depression, such as shared genetic factors, converging biological pathways, social factors, health behaviours and psychological factors. Diagnosis of depression in patients with a medical disorder can be particularly challenging owing to symptomatic overlap. Although pharmacological and psychological treatments can be effective, adjustments may need to be made for patients with a comorbid medical disorder. In addition, symptoms or treatments of medical disorders may interfere with the treatment of depression. Conversely, symptoms of depression may decrease adherence to treatment of both disorders. Thus, comprehensive treatment plans are necessary to optimize care.

191 citations

Journal Article•DOI•
Post-stroke depression: A 2020 updated review.

[...]

Gustavo C. Medeiros1, Gustavo C. Medeiros2, Durga Roy3, Nicholas Kontos4, Scott R. Beach4 •
University of Texas Southwestern Medical Center1, University of Maryland, Baltimore2, Johns Hopkins University School of Medicine3, Harvard University4
01 Sep 2020-General Hospital Psychiatry
TL;DR: PSD is a common, treatable condition that is associated with several negative outcomes, and early detection and proper management are critical to obtain better outcomes in individuals with PSD.

171 citations

Journal Article•DOI•
Electroconvulsive Therapy in Depression: Current Practice and Future Direction.

[...]

Adriana P. Hermida1, Oliver M. Glass1, Hadia Shafi1, William M. McDonald1•
Emory University1
15 Jun 2018-Psychiatric Clinics of North America
TL;DR: In this article, a balanced, in-depth look into the recent advances in electroconvulsive therapy (ECT) technique as well as the evidence of ECT for managing depression in special populations and patients with comorbid medical problems is presented.

71 citations

Journal Article•DOI•
Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study.

[...]

Jeffrey Rogers1, Jonathan Duckworth2, Sandy Middleton3, Bert Steenbergen4, Peter H. Wilson3 •
University of Sydney Faculty of Health Sciences1, RMIT University2, Australian Catholic University3, Radboud University Nijmegen4
15 May 2019-Journal of Neuroengineering and Rehabilitation
TL;DR: A course of Elements virtual rehabilitation using goal-directed and exploratory upper-limb movement tasks facilitates both motor and cognitive recovery after stroke, providing compelling preliminary evidence of the power of virtual rehabilitation when applied in a targeted and principled manner.
Abstract: Virtual reality technologies show potential as effective rehabilitation tools following neuro-trauma. In particular, the Elements system, involving customized surface computing and tangible interfaces, produces strong treatment effects for upper-limb and cognitive function following traumatic brain injury. The present study evaluated the efficacy of Elements as a virtual rehabilitation approach for stroke survivors. Twenty-one adults (42–94 years old) with sub-acute stroke were randomized to four weeks of Elements virtual rehabilitation (three weekly 30–40 min sessions) combined with treatment as usual (conventional occupational and physiotherapy) or to treatment as usual alone. Upper-limb skill (Box and Blocks Test), cognition (Montreal Cognitive Assessment and selected CogState subtests), and everyday participation (Neurobehavioral Functioning Inventory) were examined before and after inpatient training, and one-month later. Effect sizes for the experimental group (d = 1.05–2.51) were larger compared with controls (d = 0.11–0.86), with Elements training showing statistically greater improvements in motor function of the most affected hand (p = 0.008), and general intellectual status and executive function (p ≤ 0.001). Proportional recovery was two- to three-fold greater than control participants, with superior transfer to everyday motor, cognitive, and communication behaviors. All gains were maintained at follow-up. A course of Elements virtual rehabilitation using goal-directed and exploratory upper-limb movement tasks facilitates both motor and cognitive recovery after stroke. The magnitude of training effects, maintenance of gains at follow-up, and generalization to daily activities provide compelling preliminary evidence of the power of virtual rehabilitation when applied in a targeted and principled manner. this pilot study was not registered.

63 citations

References
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Journal Article•DOI•
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

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David Moher1, David Moher2, Alessandro Liberati3, Jennifer Tetzlaff2, Douglas G. Altman4 •
University of Ottawa1, Ottawa Hospital Research Institute2, Cochrane Collaboration3, University of Oxford4
21 Jul 2009-PLOS Medicine
TL;DR: Moher et al. as mentioned in this paper introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses, which is used in this paper.
Abstract: David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses

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Julian P T Higgins1, Simon G. Thompson1, Jonathan J Deeks, Douglas G. Altman•
University of Cambridge1
04 Sep 2003-BMJ
TL;DR: A new quantity is developed, I 2, which the authors believe gives a better measure of the consistency between trials in a meta-analysis, which is susceptible to the number of trials included in the meta- analysis.
Abstract: Cochrane Reviews have recently started including the quantity I 2 to help readers assess the consistency of the results of studies in meta-analyses. What does this new quantity mean, and why is assessment of heterogeneity so important to clinical practice? Systematic reviews and meta-analyses can provide convincing and reliable evidence relevant to many aspects of medicine and health care.1 Their value is especially clear when the results of the studies they include show clinically important effects of similar magnitude. However, the conclusions are less clear when the included studies have differing results. In an attempt to establish whether studies are consistent, reports of meta-analyses commonly present a statistical test of heterogeneity. The test seeks to determine whether there are genuine differences underlying the results of the studies (heterogeneity), or whether the variation in findings is compatible with chance alone (homogeneity). However, the test is susceptible to the number of trials included in the meta-analysis. We have developed a new quantity, I 2, which we believe gives a better measure of the consistency between trials in a meta-analysis. Assessment of the consistency of effects across studies is an essential part of meta-analysis. Unless we know how consistent the results of studies are, we cannot determine the generalisability of the findings of the meta-analysis. Indeed, several hierarchical systems for grading evidence state that the results of studies must be consistent or homogeneous to obtain the highest grading.2–4 Tests for heterogeneity are commonly used to decide on methods for combining studies and for concluding consistency or inconsistency of findings.5 6 But what does the test achieve in practice, and how should the resulting P values be interpreted? A test for heterogeneity examines the null hypothesis that all studies are evaluating the same effect. The usual test statistic …

45,105 citations

"Prevalence and predictors of post-s..." refers background in this paper

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Journal Article•DOI•
Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement

[...]

David Moher1, David Moher2, Alessandro Liberati3, Jennifer Tetzlaff2, Douglas G. Altman4 •
University of Ottawa1, Ottawa Hospital Research Institute2, Cochrane Collaboration3, University of Oxford4
01 Jan 2010-International Journal of Surgery
TL;DR: A structured summary is provided including, as applicable, background, objectives, data sources, study eligibility criteria, participants, interventions, study appraisal and synthesis methods, results, limitations, conclusions and implications of key findings.

31,379 citations

Journal Article•
Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement [in Spanish]

[...]

David Moher, Alessandro Liberati, Jennifer Tetzlaff, Douglas G. Altman, Gerd Antes, David C. Atkins, Virginia Barbour, N Barrowman, Jesse A. Berlin, J Clark, Mike Clarke, Deborah J. Cook, Roberto D'Amico, Jonathan J Deeks, Philip J. Devereaux, Kay Dickersin, M Egger, E Ernst, P C Gøtzsche, Jeremy M. Grimshaw, G Guyatt, Julian P T Higgins, Ioannidis Jpa., Jos Kleijnen, Tom Lang, N Magrini, D McNamee, Lorenzo Moja, C Mulrow, M Napoli, Andrew D Oxman, B Pham, Drummond Rennie, Margaret Sampson, Kenneth F. Schulz, Paul G. Shekelle, David Tovey, Peter Tugwell 
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26,749 citations

Journal Article•DOI•
Meta-analysis of observational studies in epidemiology - A proposal for reporting

[...]

Donna F. Stroup1, Jesse A. Berlin2, Sally C. Morton3, Ingram Olkin4, G. D. Williamson1, Drummond Rennie5, Drummond Rennie6, David Moher, Betsy Jane Becker7, Theresa Ann Sipe8, Stephen B. Thacker1 •
Centers for Disease Control and Prevention1, University of Pennsylvania2, RAND Corporation3, Stanford University4, University of California, San Francisco5, American Medical Association6, Michigan State University7, Georgia State University8
19 Apr 2000-JAMA
TL;DR: A checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion should improve the usefulness ofMeta-an analyses for authors, reviewers, editors, readers, and decision makers.
Abstract: ObjectiveBecause of the pressure for timely, informed decisions in public health and clinical practice and the explosion of information in the scientific literature, research results must be synthesized. Meta-analyses are increasingly used to address this problem, and they often evaluate observational studies. A workshop was held in Atlanta, Ga, in April 1997, to examine the reporting of meta-analyses of observational studies and to make recommendations to aid authors, reviewers, editors, and readers.ParticipantsTwenty-seven participants were selected by a steering committee, based on expertise in clinical practice, trials, statistics, epidemiology, social sciences, and biomedical editing. Deliberations of the workshop were open to other interested scientists. Funding for this activity was provided by the Centers for Disease Control and Prevention.EvidenceWe conducted a systematic review of the published literature on the conduct and reporting of meta-analyses in observational studies using MEDLINE, Educational Research Information Center (ERIC), PsycLIT, and the Current Index to Statistics. We also examined reference lists of the 32 studies retrieved and contacted experts in the field. Participants were assigned to small-group discussions on the subjects of bias, searching and abstracting, heterogeneity, study categorization, and statistical methods.Consensus ProcessFrom the material presented at the workshop, the authors developed a checklist summarizing recommendations for reporting meta-analyses of observational studies. The checklist and supporting evidence were circulated to all conference attendees and additional experts. All suggestions for revisions were addressed.ConclusionsThe proposed checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion. Use of the checklist should improve the usefulness of meta-analyses for authors, reviewers, editors, readers, and decision makers. An evaluation plan is suggested and research areas are explored.

17,663 citations

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Frequently Asked Questions (3)
Q1. What have the authors contributed in "Prevalence and predictors of post-stroke mood disorders: a meta- analysis and meta-regression of depression, anxiety and adjustment disorder" ?

Citing this paper Please note that where the full-text provided on King 's Research Portal is the Author Accepted Manuscript or Post-Print version this may differ from the final Published version. And where the final published version is provided on the Research Portal, if citing you are again advised to check the publisher 's website for any subsequent corrections. 

Future research should investigate the long-term burden of depression on patients and families. Future research should investigate not just the prevalence but also the impact of anxiety on rehabilitation and mortality. There was also inadequate data to examine several potentially useful predictors of mood disorders such as disability, gender and quality of life and receipt of antidepressants ; these should ideally be addressed in future studies. Further almost all studies examined point prevalence, meaning that transitions in to and out of remission were poorly described as were the total number of cases developing over a period of time ( cumulative prevalence ). 

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