Diagnostik und Therapie der Depression nach Schlaganfall

Zusammenfassung

Eine Depression tritt nach Schlaganfall häufig, bei 30 - 40 % der Patienten zumindest vorübergehend auf. In der Literatur hat sich bereits der Begriff einer „Poststroke Depression” (PSD) etabliert. Zur Diagnosestellung bestehen keine einheitliche Kriterien, zumeist erfolgt eine Anlehnung an die Klassifikationsschlüssel des DSM beziehungsweise der ICD. In anderen Fällen wird die Diagnose nur anhand von Depressionsskalen gestellt. Obwohl bekanntermaßen hohe Prävalenzraten bestehen, wird die Depression in der Schlaganfallbehandlung in den meisten Fällen nicht diagnostiziert und verbleibt auch nach Feststellung zumeist unbehandelt. Dabei kann es nach den bisherigen Untersuchungen als gesichert gelten, dass Schlaganfallpatienten, die depressive Symptome entwickeln, einen schlechteren Verlauf, besonders ein schlechteres funktionelles Behandlungsergebnis (motorische Fähigkeiten, selbständige Teilnahmen an den Aktivitäten des täglichen Lebens) zeigen. Dieser Unterschied in der Beeinträchtigung zu einem vergleichbaren nicht-depressiven Schlaganfallpatienten lässt sich auch nach mehreren Jahren noch nachweisen. Für eine sich daraus ergebende Behandlungsnotwendigkeit ist nach dem aktuellen Stand der Literatur sowohl der günstigste Zeitpunkt einer therapeutischen Intervention sowie deren Art und Umfang jedoch noch unklar. Einzelnen Untersuchungen zufolge, die selten unter den Bedingungen einer randomisierten kontrollierten Studie erfolgten, zeigen sich positive Effekte einer frühzeitigen medikamentösen Behandlung. Hier können neben den Psychostimulanzien, die vorwiegend im US-amerikanischen Raum eingesetzt werden, und den konventionellen trizyklischen Antidepressiva besonders die Gruppe der „ Selektiven Serotonin-Wiederaufnahmehemmer” (Selective Serotonin Reuptake Inhibitor, SSRI) mit einem breiten Einsatzspektrum bei älteren Patienten gute klinische Erfolge vorweisen.

Abstract

Depression occurs at least temporarily in up to 30 - 40 % of all patients that have experienced a stroke. In the literature the term of a “Poststroke Depression” (PSD) has already been established. However standardised criteria for this diagnoses do not exist to this day. In most cases the DSM or ICD classification system is applied. Other investigators used various psychiatric rating scales. Even though it is generally acknowledged that there is a high prevalence, the occurrence of depression in combination with a stroke fails in most cases to be diagnosed or is left untreated. The need for treatment is even more pronounced by studies showing that a combination of stroke and depression will result in a less favourable outcome, particularly pertaining to that of functional treatment (motor skills, independent participation in activities of daily life). This difference in impairment between a depressed stroke patient and a not depressed stroke patient could be proven in studies that have been conducted over years. Despite the necessity of treatment that can be concluded from such a finding, the recent literature does not offer consistent information as to the ideal point of time for intervention nor the kind and intensity necessitated. According to singular studies, that have rarely been conducted under controlled conditions, there have been positive outcomes after early treatment. Along with psychostimulants that were most predominantly applied in the USA, as well as conventional tricyclic antidepressants, the group of the “Selective Serotonin Reuptake Inhibitors, SSRIs” have resulted in particularly favourable clinical outcomes.

Literatur

• 1 Morris P L, Robinson R G, Samuels J. Depression, introversion and mortality following stroke.  Aust N Z J Psychiatry. 1993;  27 443-449
• 2 Kraepelin E. Psychiatrie. Ein Lehrbuch für Studierende und Ärzte II und III. Leipzig 1910
• 3 Bleuler E P. Textbook of psychiatry. New York: Macmillan 1951
• 4 Post F. The significance of affective symptoms in old age. London: Oxford University Press 1962
• 5 Robinson R G. The clinical neuropsychiatry of stroke. New York: Cambridge University Press 1998
• 6 Hosking S G, Marsh N V, Friedman P J. Poststroke depression: Prevalence, course and associated factors.  Neuropsychol Rev. 1996;  6 107-133
• 7 Gordon W A, Hibbard M R. Poststroke depression: an examination of the literature.  Arch Phys Med Rehabil. 1997;  78 658-663
• 8 Starkstein S E, Robinson R G. Affective disorders and cerebral vascular disease.  Brit J Psychiatry. 1989;  154 170-182
• 9 Bryer J P, Starkstein S E, Votypka V, Parikh R M, Price T R, Robinson R G. Reduction of CSF monoamine metabolites in poststroke depression: a preliminary report.  J Neuropsychiatry Clin Neurosci. 1992;  4 440-442
• 10 Herrmann M, Wallesch C W. Depressive changes in stroke patients.  Disabil Rehabil. 1993;  15 55-66
• 11 Gainotti G, Azzoni A, Razzano C, Lanzilotta M, Marra C, Gasparini F. The Post-Stroke Depression Rating Scale: a test specifically devised to investigate affective orders of stroke patients.  J Clin Exp Neuropsychol. 1997;  19 340-356
• 12 Hüwel J, Weisner B, Kemmer H, Heyder J. Depressive Verstimmung im Akutstadium nach erstmaligem ischämischen Hirninfarkt.  Nervenarzt. 1998;  69 330-334
• 13 Ramasubbu R. Relationship between depression and cerebrovascular disease: conceptual issues.  J Aff Dis. 2000;  57 1-11
• 14 Finkelstein S P, Weintraub R J, Karmouz N, Davar G, Baldessarini R J. Antidepressants drug treatment for post-stroke depression: retrospective study.  Arch Phys Med Rehabil. 1987;  68 276-278
• 15 Parikh R M, Robinson R G, Lipsey J R, Starkstein S E, Fedoroff J P, Price T R. The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up.  Arch Neurol. 1990;  47 785-789
• 16 Price T R. Affective disorders after stroke.  Stroke. 1990;  21 12-13
• 17 Astrom M, Adolfsson R, Asplund K. Major depression in stroke patients: a 3-year longitudinal study.  Stroke. 1993;  24 976-982
• 18 Sharpe M, Hawton K, Seagroatt V, Bamford J, House A, Molyneux A, Sandercock P, Warlow C. Depressive disorders in long-term survivors of stroke: Associations with demographic and social factors, functional status, and brain lesion volume.  Brit J Psychiatry. 1994;  164 380-386
• 19 Kelly-Hayes M, Paige C. Assessment and psychologic factors in stroke rehabilitation.  Neurology. 1995;  45 (suppl 1) S29-S32
• 20 Polnitzky-Meißner P, Helbig P, Krause M, Ackl N, Ringleb P, Obhof W, Reichert K, Hacke W. Rehabilitation nach Schlaganfall - Kognitive Defizite, Depressivität und Lebenszufriedenheit nach Schlaganfall.  Neurol Rehabil. 1997;  3 223-227
• 21 Shimoda K, Robinson R G. The relationship between social impairment and recovery from stroke.  Psychiatry. 1998;  61 101-111
• 22 Chemerinski E, Robinson R G, Kosier T J. Improved recovery in activities of daily living associated with remission of poststroke depression.  Stroke. 2001;  32 113-117
• 23 Eastwood M R, Rifat S L, Nobbs H, Ruderman J. Mood disorder following CVA.  Br J Psychiatry. 1989;  154 195-200
• 24 Schubert D SP, Burns R, Paras W, Sioson E. Increase of medical hospital length of stay by depression in stroke and amputation patients: a pilot study.  Psychother Psychosom. 1992;  57 61-66
• 25 Jonkman E J, de Weerd A W, Vrijens N L. Quality of life after a first ischemic stroke. Long term developments and correlations with changes in neurological deficit, mood and cognitive impairment.  Acta Neurol Scand. 1998;  98 169-175
• 26 Bosworth H B, Horner R D, Edwards L J, Matchar D B. Depression and other determinants of values placed on current health state by stroke patients.  Stroke. 2000;  31 2603-2609
• 27 Morris P L, Robinson R G, Andrezejewski P, Samuels J, Price T R. Association of depression with 10-year post-stroke-mortality.  Am J Psychiatry. 1993 (a);  150 124-129
• 28 Burvill P W, Johnson G A, Jamrozik K D, Anderson C S, Stewart-Wynne E G, Chakera T MH. Prevalence of depression after stroke: the Perth Community Stroke Study.  Br J Psychiatry. 1995;  166 320-327
• 29 Feibel J H, Berk S, Joynt R J. The unmet needs of stroke survivors (abstract).  Neurology. 1979;  29 592
• 30 Labi M LC, Phillips T F, Gresham G E. Psychosozial disability in physically restored long-term stroke survivors.  Arch Phys Med Rehabil. 1980;  61 561-565
• 31 Andersen G. Post-stroke depression and pathological crying: clinical aspects and new pharmacological approaches.  Aphasiology. 1997;  11 651-664
• 32 Ramasubbu R, Robinson R G, Flint A J, Kosier T, Price T R. Functional impairment associated with acute poststroke depression: The stroke data bank study.  J Neuropsychiatry Clin Neurosci. 1998;  10 26-33
• 33 World Health Organization .Tenth Revision of the International Classification of Disease, Chapter V (F): Mental and Behavioural Disorders. Geneva: WHO 1992
• 34 American Psychiatric Association .Diagnostical and Statistical Manual of Mental Disorders, Fourth Edition. Washington D.C.: American Psychiatric Association 1994
• 35 Feighner J P, Robins E, Guze S B, Woodruff R A, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research.  Arch Gen Psychiatry. 1972;  26 57-63
• 36 Kishi J, Robinson R G, Kosier T J. The validity of observed depression as a criteria for mood disorders in patients with acute stroke.  J Affect Disord. 1996;  40 53-60
• 37 Harrington C, Salloway S. The diagnosis and treatment of post-stroke depression.  Med Health. 1997;  80 181-187
• 38 Radloff L S. The CES-D Scale: a self report depression scale for research in the general population.  App Psychol Mesas. 1977;  1 385-401
• 39 Zung W WK. A self-rating depression scale.  Arch Gen Psychiatry. 1965;  12 63-70
• 40 Brink T L, Yesavage J A, Lum O, Heersema P H, Adey M, Rose T L. Screening tests for geriatric depression.  Clin Gerontol. 1982;  1 37-43
• 41 Hamilton M A. A rating scale for depression.  J Neurol Neurosurg Psychiatry. 1960;  23 56-62
• 42 Alexopoulos G S, Abrams R C, Young R C, Shamoian C A. Use of the Cornell Scale in nondemented patients.  J Am Ger Soc. 1988;  36 230-236
• 43 Asberg M, Montgomery S A, Perris C, Schalling D, Sedvall G. A comprehensive psychopathological rating scale.  Acta Psychiatr Scand. 1978;  271 (Suppl) 5-27
• 44 Montgomery S A, Asberg M. A new depression scale designed to be sensitive to change.  Br J Psychiatry. 1979;  134 382-389
• 45 Robinson R G, Szetala B. Mood change following left hemispheric brain injury.  Ann Neurol. 1981;  9 447-453
• 46 Shinar D, Gross C R, Price T R, Banko M, Bolduc P L, Robinson R G. Screening for depression in stroke patients: the reliability and validity of the Center for Epidemiologic Studies Depression Scale.  Stroke. 1986;  17 241-245
• 47 Parikh R M, Eden D T, Price T R, Robinson R G. The sensitivity and specifity of the Center for Epidemiologic Studies in Depression Scale for post-stroke depression.  Int J Psych Med. 1988;  182 169-181
• 48 Agrell B, Dehlin O. Comparison of six depression rating scales in geriatric stroke patients.  Stroke. 1989;  20 1190-1194
• 49 Hermann C, Buss U, Snaith R P. HADS-D Hospital anxiety and depression scale - Deutsche Version. Bern: Huber Verlag 1995
• 50 Herrmann M. Emotional-affektive Veränderungen nach cerebrovaskulären Insulten mit Aphasie. Freiburg: Dissertation 1991
• 51 Robinson R G, Benson F D. Depression in aphasic Patients: frequency, severity and clinical-pathological correlations.  Brain and Language. 1981;  14 282-291
• 52 Damecour C, Caplan D. The relationship of depression to symtomatology and lesion site in aphasic patients.  Cortex. 1991;  27 385-401
• 53 Herrmann M, Bartels C, Wallesch C W. Depression in acute and chronic aphasia: symptoms, pathoanatomical-clinical correlations and functional implications.  J Neurol Neurosurg Psychiatry. 1993;  56 672-678
• 54 Sutcliffe L M, Lincoln N B. The assessment of depression in aphasic stroke patients: the development of the Stroke Aphasic Depression Questionnaire.  Clin Rehabil. 1998;  12 506-513
• 55 Finklestein S P, Weintraub R J, Karmouz N, Askinazi C, Davar G, Baldessarini R J. Antidepressant drug treatment for poststroke depression: retrospective study.  Arch Phys Med Rehabil. 1987;  68 772-776
• 56 Lipsey J R, Robinson R G, Pearlson G D, Rao K, Price T R. Nortriptyline treatment of poststroke depression: a double-blind treatment trial.  Lancet. 1984;  1 297-300
• 57 Kimura M, Robinson R G, Kosier J T. Treatment of cognitive impairment after Poststroke depression.  Stroke. 2000;  31 1482-1486
• 58 Lauritzen L, Bendsen B B, Vilmar T, Bendsen E B, Lunde M, Bech P. Post-stroke depression: combined treatment with imipramine or desipramine and mianserin: a controlled study.  Psychopharmacology. 1994;  114 119-122
• 59 Andersen G, Vestergaard K, Lauritzen L. Effective treament of poststroke depression with the selective serotonin reuptake inhibitor citalopram.  Stroke. 1994;  25 1099-1104
• 60 Mok C K, Mak S K, Leung K S, Au S Y. Use of sertraline (an SSRI) in Chinese elderly stroke patients with depression.  Acta Pharmacologica Sinica. 1998;  19 (Suppl.) 47
• 61 Dahmen N, Marx J, Hopf H C, Röder R, Tettenborn B. Behandlung der frühen Post-Stroke-Depression mit Venlafaxin: Sicherheit, Verträglichkeit und Wirksamkeit in einer offenen klinischen Studie.  Neurol Rehabil. 1999;  5 84-88
• 62 Stahl S M. Essential Pharmacology. New York: Cambridge University Press 2nd ed 2000
• 63 Stamenkovic M, Schindler S, Kasper S. Poststroke depression and fluoxetine (letters to the editor).  Am J Psychiatry. 1996;  153 446-447
• 64 Weinman E, Ruskin P E. Anger attacks in Poststroke depression: response to fluoxetine.  Am J Psychiatry. 1994;  151 1839
• 65 Wiart L, Petit H, Joseph P A, Mazaux J M, Barat M. Fluoxetine in early poststroke depression.  Stroke. 2000;  31 1829-1832
• 66 Erfurth A, Loew M, Wendler G, Floreanu A. Depressive Störungen in der neurologischen Rehabilitation: Therapie mit Paroxetin.  Psychiat Prax. 2001;  28 43-44
• 67 De Leon O A, Furmaga K M, Kaltsounis J. Mirtazepine-induced mania in a case of poststroke depression.  J Neuropsychiatry Clin Neurosci. 1999;  11 115-116
• 68 Masand P, Murray G B, Pickett P. Psychostimulants in post-stroke depression.  J Neuropsychiatry. 1991;  3 23-27
• 69 Johnson M L, Roberts M D, Ross A R, Witten C M. Methylphenidate in stroke patients with depression.  Am J Phys Med Rehabil. 1992;  71 239-241
• 70 Lingam V R, Lazarus L W, Groves L, Oh S H. Methylphenidate in treating poststroke depression.  J Clin Psychiatry. 1988;  49 151-153
• 71 Lazarus L W, Winemiller D R, Lingam V R, Neyman I, Hartman C, Abassian M, Kartan U, Groves L, Fawcett J. Efficacy and side effects of methylphenidate for post-stroke depression.  J Clin Psychiatry. 1992;  53 447-449
• 72 Grade C, Redford B, Chrostowski J, Toussaint L, Blackwell B. Methylphenidate in early poststroke recovery: a double-blind, placebo-controlled study.  Arch Phys Med Rehabil. 1998;  79 1047-1050
• 73 Masand P, Chaudhary P. Methylphenidate treatment of Poststroke depression in a patient with global aphasia.  Ann Clin Psychiatry. 1994;  6 271-274
• 74 Martensson B, Murray V, von Arbin M, Asberg M, Bartfai A, Malm K. Alternative treatment for poststroke depression (letters to the editor).  Am J Psychiatry. 1997;  154 583-584
• 75 Gonzales-Torrecillas J L, Hildebrand J, Mendlewicz J, Lobo A. Effects of early treatment of post-stroke depression on neuropsychological rehabilitation.  Int Psychogeriatr. 1995;  78 547-560
• 76 Lazarus L W, Moberg P J, Langsley P R, Lingam V R. Methylphenidate and nortriptyline in the treatment of poststroke depression: A retrospective comparison.  Arch Phys Med Rehabil. 1994;  75 403-406
• 77 Balunov O A, Sadov O G, Alemasov A Y. Therapy of depression in post-stroke patients.  Alaska Med. 1990;  32 20-29
• 78 Miyai I, Reding M J. Effects of antidepressants on functional recovery following stroke: a double-blind study.  J Neuro Rehab. 1998;  12 5-13
• 79 Grober S E, Hibbard M R, Gordon W A, Stein P N, Freeman A. The psychotherapeutic treatment of post-stroke depression with cognitive behavioral therapy.. In: Gordon WA (ed.). Advances in stroke rehabilitation. Andover: Andover Medical Publishers 1993: 217-241
• 80 Kneebone II . Psychological management of post-stroke depression.  Br J Clin Psychol. 2000;  39 53-65
• 81 Lincoln N B, Flannaghan T, Sutcliffe L, Rother L. Evaluation of cognitive behavioural treatment for depression after stroke: a pilot study.  Clin Rehabil. 1977;  11 114-122
• 82 Hibbard M R, Grober S E, Gordon W A, Aletta E G. Modification of cognitive psychotherapy for the treatment of post-stroke depression.  Behav Ther. 1990 (a);  13 15-17
• 83 Hibbard M R, Grober S E, Gordon W A, Aletta E G, Freeman A. Cognitive therapy and the treatment of poststroke depression.  Top Geriatr Rehabil. 1990 (b);  5 43-55
• 84 Watzlawick P, Coyne J C. Depression following stroke: brief, problem-focused family treatment.  Fam Process. 1980;  19 13-18
• 85 Hager K, Ziegler K. Stages in coping after stroke.  Z Gerontol Geriatr. 1998;  31 9-15
• 86 Murray G B, Shea V, Conn D K. Electroconvulsive therapy for poststroke depression.  J Clin Psychiatry. 1986;  47 258-260
• 87 Currier M B, Murray G B, Welch C C. Electroconvulsive therapy for post-stroke depressed. 
• 88 Martin M, Figiel G, Mattingly G, Zorumski C F, Jarvis M R. ECT-Induced interictal delirium in patients with a history of a CVA.  J Geriatr Psychiatry Neurol. 1992;  5 149-155
• 89 Palomäki H, Kaste M, Berg A, Lönnqvist R, Lönnqvist J, Lehtihalmes M, Hares J. Prevention of poststroke depression: 1 year randomised placebo controlled double blind trial of mianserin with 6 month follow up after therapy.  J Neurol Neurosurg Psychiatry. 1999;  66 490-494
• 90 Rasmussen A, Hindberg I, Mellerup E. Does Sertraline induced platelet dysfunction protect stroke patients against cardiovaskular comorbidity.  Int J Neuropsychopharmacol. 2000;  3 (Suppl 1) 372
• 91 Reding J J, Orto L A, Winter S W, Fortuna I M, DiPonte P, McDowell F H. Antidepressant therapy after stroke: a double-blind trial.  Arch Neurol. 1986;  43 763-765
• 92 Dam M, Tonin P, DeBoni A, Pizzolato G, Casson S, Ermani M, Freo U, Piron L, Battistin L. Effects of fluoxetin and maprotilin on functional recovery in poststroke hemiplegic patients undergoing rehabilitation therapy.  Stroke. 1996;  27 1211-1214
• 93 Robinson R G, Schultz S K, Castillo C, Kopel T, Kosier J T, Newman R M, Curdue K, Petracca G, Stakstein S E. Nortriptyline versus Fluoxetine in the treatment of depression and in short-term recovery after stroke: a placebo-controlled, double blind study.  Am J Psychiatry. 2000;  157 351-359