Depression and Stroke: Cause or Consequence?

ABSTRACT

Depression after stroke is common. Although different opinions exist about the definition, diagnosis, and measurement of outcomes related to depression after stroke, there is little debate about the prevalence of depression symptoms and their impact on stroke survivors and their families. Depression after stroke has long been recognized as a common condition with many negative effects in the poststroke period, but more recently depression has also been identified as an independent stroke risk factor. Given that there are at least 500,000 new ischemic strokes yearly in the United States, a conservative estimate is that 150,000 U.S. stroke survivors develop poststroke depression each year. Because effective treatments exist but are likely underutilized for depression, this is an important example of an evidence-practice gap to which increased efforts to improve care should be made. Such efforts would likely improve not only patient symptoms but may also decrease stroke risk, influence stroke functional recovery, decrease mortality, and reduce poststroke health care utilization. This article provides an overview of depression diagnosis in stroke, reviews the epidemiology of poststroke depression and its associated morbidity and mortality, and reviews existing evidence on the treatment and prevention of poststroke depression.

KEYWORDS

Stroke - depression - recovery - risk factors

REFERENCES

• 1 Gordon W A, Hibbard M R. Poststroke depression: an examination of the literature.  Arch Phys Med Rehabil. 1997;  78 658-663
• 2 Gordon W A, Hibbard M R, Egelko S et al.. Issues in the diagnosis of post-stroke depression.  Rehabil Psychol. 1991;  36 71-87
• 3 Starkstein S E, Robinson R G. Affective disorders and cerebral vascular disease.  Br J Psychiatry. 1989;  154 170-182
• 4 Black K J. Diagnosing depression after stroke.  South Med J. 1995;  88 699-708
• 5 Paradiso S, Ohkubo T, Robinson R G. Vegetative and psychological symptoms associated with depressed mood over the first two years after stroke.  Int J Psychiatry Med. 1997;  27 137-157
• 6 Mosnik D, Williams L S, Kroenke K, Callahan C. Symptoms of post-stroke depression: a distinct syndrome compared to geriatric depression [abstract].  Neurology. 2000;  54(suppl 3) A378-A379
• 7 Williams L S, Brizendine E J, Plue L et al.. Performance of the PHQ-9 as a screening tool for post-stroke depression.  Stroke. 2005;  36 635-638
• 8 Morris P L, Robinson R G, Raphael B. Emotional lability after stroke.  Aust N Z J Psychiatry. 1993;  27 601-605
• 9 Calvert T, Knapp P, House A. Psychological associations with emotionalism after stroke.  J Neurol Neurosurg Psychiatry. 1998;  65 928-929
• 10 Bogousslavsky J. William Feinberg lecture 2002: emotions, mood, and behavior after stroke.  Stroke. 2003;  34 1046-1050
• 11 Johnson G, Burvill P W, Anderson C S, Jamrozik K, Stewart-Wynne E G, Chakera T M. Screening instruments for depression and anxiety following stroke: experience in the Perth Community Stroke Study.  Acta Psychiatr Scand. 1995;  91 252-257
• 12 Gainotti G, Azzoni A, Razzano C, Lanzillotta M, Marra C, Gasparini F. The Post-Stroke Depression Rating Scale: a test specifically devised to investigate affective disorders of stroke patients.  J Clin Exp Neuropsychol. 1997;  19 340-356
• 13 O'Rourke S, MacHale S, Signorini D, Dennis M. Detecting psychiatric morbidity after stroke: comparison of the GHQ and the HAD Scale.  Stroke. 1998;  29 980-985
• 14 Aben I, Verhey F, Lousberg R, Lodder J, Honig A. Validity of the Beck depression inventory, hospital anxiety and depression scale, SCL-90, and Hamilton depression rating scale as screening instruments for depression in stroke patients.  Psychosomatics. 2002;  43 386-393
• 15 Lincoln N B, Nicholl C R, Flannaghan T, Leonard M, Van der Gucht E. The validity of questionnaire measures for assessing depression after stroke.  Clin Rehabil. 2003;  17 840-846
• 16 Spitzer R L, Kroenke K, Williams J BW. Patient Health Questionnaire Study Group. Validity and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study.  JAMA. 1999;  282 1737-1744
• 17 Kroenke K, Spitzer R L, Williams J BW. The PHQ-9: validity of a brief depression severity measure.  J Gen Intern Med. 2001;  16 606-613
• 18 Davies S JC, Jackson P R, Potokar J, Nutt D J. Treatment of anxiety and depressive disorders in patients with cardiovascular disease.  BMJ. 2004;  328 939-943
• 19 Whyte E M, Mulsant B H, Vanderbilt J, Dodge H H, Ganguli M. Depression after stroke: a prospective epidemiological study.  J Am Geriatr Soc. 2004;  52 774-778
• 20 Ostir G V, Markides K S, Peek M K, Goodwin J S. The association between emotional well-being and the incidence of stroke in older adults.  Psychosom Med. 2001;  63 210-215
• 21 Ostir G V, Goodwin J S, Markides K S, Ottenbacher K J, Balfour J, Guralnik J M. Differential effects of premorbid physical and emotional health on recovery from acute events.  J Am Geriatr Soc. 2002;  50 713-718
• 22 Jonas B S, Mussolino M E. Symptoms of depression as a prospective risk factor for stroke.  Psychosom Med. 2000;  62 463-471
• 23 Ohira T, Iso H, Satoh S et al.. Prospective study of depressive symptoms and risk of stroke among Japanese.  Stroke. 2001;  32 903-908
• 24 Nilsson F M, Kessing L V. Increased risk of developing stroke for patients with major affective disorder: a registry study.  Eur Arch Psychiatry Clin Neurosci. 2004;  254 387-391
• 25 Lyness J M. The cerebrovascular model of depression in late life.  CNS Spectr. 2002;  7 712-715
• 26 Mast B T, MacNeill S E, Lichtenberg P A. Post-stroke and clinically-defined vascular depression in geriatric rehabilitation patients.  Am J Geriatr Psychiatry. 2004;  12 84-92
• 27 Thomas A J, Kalaria R N, O'Brien J T. Depression and vascular disease: what is the relationship?.  J Affect Disord. 2004;  79 81-95
• 28 Gump B B, Matthews K A, Eberly L E, Chang Y F. Depressive symptoms and mortality in men: results from the Multiple Risk Factor Intervention Trial.  Stroke. 2005;  36 98-102
• 29 Everson S A, Roberts R E, Goldberg D E, Kaplan G A. Depressive symptoms and increased risk of stroke mortality over a 29-year period.  Arch Intern Med. 1998;  158 1133-1138
• 30 Cassidy E M, Walsh M T, O'Connor R et al.. Platelet surface glycoprotein expression in post-stroke depression: a preliminary study.  Psychiatry Res. 2003;  118 175-181
• 31 Rasmussen A, Christensen J, Clemmensen P M et al.. Platelet serotonin transporter in stroke patients.  Acta Neurol Scand. 2003;  107 150-153
• 32 Ramasubbu R. Serotonin transporter gene functional polymorphism: a plausible candidate gene for increased vascular risk in depression.  Med Hypotheses. 2003;  61 36-44
• 33 Serebruany V L, Glassman A H, Malinin A I et al.. Platelet/endothelial biomarkers in depressed patients treated with the selective serotonin reuptake inhibitor sertraline after acute coronary events: the Sertraline AntiDepressant Heart Attach Randomized Trial (SADHART) Platelet Substudy.  Circulation. 2003;  108 939-944
• 34 Berkman L F, Blumenthal J, Burg M et al.. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial.  JAMA. 2003;  289 3106-3116
• 35 Black S A, Markides K S, Ray L A. Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes.  Diabetes Care. 2003;  26 2822-2828
• 36 Kiecolt-Glaser J K, McGuire L, Robles T F, Glaser R. Emotions, morbidity, and mortality: new perspectives from psychoneuroimmunology.  Annu Rev Psychol. 2002;  53 83-107
• 37 Penninx B W, van Tilburg T, Kriegsman D M, Deeg D J, Boeke A J, van Eijk J T. Effects of social support and personal coping resources on mortality in older age: the Longitudinal Aging Study Amsterdam.  Am J Epidemiol. 1997;  146 510-519
• 38 Licinio J, Wong M L. The role of inflammatory mediators in the biology of major depression: central nervous system cytokines modulate the biological substrate of depressive symptoms, regulate stress-responsive systems, and contribute to neurotoxicity and neuroprotection.  Mol Psychiatry. 1999;  4 317-327
• 39 Morey M C, Pieper C F, Crowley G M, Sullivan R J, Publisi C M. Exercise adherence and 10-year mortality in chronically ill older adults.  J Am Geriatr Soc. 2002;  50 1929-1933
• 40 Jonas B S, Lando J F. Negative affect as a prospective risk factor for hypertension.  Psychosom Med. 2000;  62 188-196
• 41 Davidson K, Jonas B S, Dixon K E, Markovitz J H. Do depression symptoms predict early hypertension incidence in young adults in the CARDIA study? Coronary Artery Risk Development in Young Adults.  Arch Intern Med. 2000;  160 1495-1500
• 42 Andersen G, Vestergaard K, Riis J O, Lauritzen L. Incidence of poststroke depression during the first year in a large unselected stroke population determined using a valid standardized rating scale.  Acta Psychiatr Scand. 1994;  90 190-195
• 43 Astrom M, Adolfsson R, Asplund K. Major depression in stroke patients: a 3-year longitudinal study.  Stroke. 1993;  24 976-982
• 44 Burvill P W, Johnson G A, Jamrozik K D, Anderson C S, Stewart-Wynne E G, Chakera T M. Prevalence of depression after stroke: the Perth Community Stroke Study.  Br J Psychiatry. 1995;  166 320-327
• 45 Fuh J L, Liu H C, Wang S J, Liu C Y, Wang P N. Poststroke depression among the Chinese elderly in a rural community.  Stroke. 1997;  28 1126-1129
• 46 Ghika-Schmid F, Bogousslavsky J. Affective disorders following stroke.  Eur Neurol. 1997;  38 75-81
• 47 Herrmann N, Black S E, Lawrence J, Szekely C, Szalai J P. The Sunnybrook Stroke Study: a prospective study of depressive symptoms and functional outcomes.  Stroke. 1998;  29 618-624
• 48 House A, Dennis M, Warlow C, Hawton K, Molyneux A. Mood disorders after stroke and their relation to lesion location: a CT scan study.  Brain. 1990;  113 1113-1129
• 49 Kotila M, Numminen H, Waltimo O, Kaste M. Depression after stroke: results of the FINNSTROKE study.  Stroke. 1998;  29 368-372
• 50 Robinson R G, Price T R. Post-stroke depressive disorders: a follow-up study of 103 patients.  Stroke. 1982;  13 635-641
• 51 Robinson R G, Starr L B, Price T R. A two year longitudinal study of mood disorders following stroke: prevalence and duration at six months follow-up.  Br J Psychiatry. 1984;  144 256-262
• 52 Pohjasvaara T, Leppavuori A, Siira I, Vataja R, Kaste M, Erkinjuntti T. Frequency and clinical determinants of poststroke depression.  Stroke. 1998;  29 2311-2317
• 53 Robinson R G, Starr L B, Kubos K L, Price T R. A 2-year longitudinal study of post-stroke mood disorders: findings during the initial evaluation.  Stroke. 1983;  14 736-741
• 54 Toso V, Gandolfo C, Paolucci S, Provinciali L, Torta R, Grassivaro N. DESTRO Study Group . Post-stroke depression: research methodology of a large multicentre observational study (DESTRO).  Neurol Sci. 2004;  25 138-144
• 55 Spitzer R L, Kroenke K, Linzer M et al.. Health-related quality of life in primary care patients with mental disorders: results from the PRIME-MD 1000 study.  JAMA. 1995;  274 1511-1517
• 56 Hays R D, Wells K B, Sherbourne C D, Rogers W, Spritzer K. Functioning and well-being outcomes of patients with depression compared with chronic general medical illness.  Arch Gen Psychiatry. 1995;  52 11-19
• 57 Wells K B, Stewart A, Hays R D et al.. The functioning and well-being of depressed patients: results from the Medical Outcomes Study.  JAMA. 1989;  262 914-919
• 58 Sinyor D, Amato P, Kaloupek D G, Becker R, Goldenberg M, Coopersmith H. Post-stroke depression: relationships to functional impairment, coping strategies and rehabilitation outcome.  Stroke. 1986;  17 1102-1107
• 59 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
• 60 Morris P LP, Raphael B, Robinson R G. Clinical depression is associated with impaired recovery from stroke.  Med J Aust. 1992;  157 239-242
• 61 Schubert D SP, Taylor C, Lee S, Mentari A, Tamaklo W. Physical consequences of depression in the stroke patient.  Gen Hosp Psychiatry. 1992;  14 69-76
• 62 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
• 63 Kauhanen M, Korpelainen J T, Hiltunen P et al.. Poststroke depression correlates with cognitive impairment and neurological deficits.  Stroke. 1999;  30 1875-1880
• 64 Morris P LP, Robinson R G, Andrzejewski P, Samules J, Price T R. Association of depression with 10-year poststroke mortality.  Am J Psychiatry. 1993;  150 124-129
• 65 Williams L S, Ghose S, Swindle R W. The effect of depression and other mental health diagnoses on mortality after ischemic stroke.  Am J Psychiatry. 2004;  161 1090-1095
• 66 Unutzer J, Patrick D L, Simon G et al.. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study.  JAMA. 1997;  277 1618-1623
• 67 Druss B G, Rohrbaugh R M, Rosenheck R. Depressive symptoms and health costs in older medical patients.  Am J Psychiatry. 1999;  156 477-479
• 68 Simon G, VonKorff M, Barlow M. Health care costs of primary care patients with recognized depression.  Arch Gen Psychiatry. 1995;  52 850-856
• 69 Ghose S, Swindle R, Williams L S. Depression and other mental health diagnoses after stroke increase inpatient and outpatient medical utilization 3 years post-stroke.  Am J Psychiatry. 2004;  161 1090-1095
• 70 Carnwath T CM, Johnson D AW. Psychiatric morbidity among spouses of patients with stroke.  BMJ. 1987;  294 409-411
• 71 Tompkins C A, Schulz R, Rau M T. Post-stroke depression in primary support persons: predicting those at risk.  J Consult Clin Psychol. 1988;  56 502-508
• 72 Anderson C S, Linto J, Stewart-Wynne E G. A population-based assessment of the impact and burden of caregiving for long-term stroke survivors.  Stroke. 1995;  26 843-849
• 73 Dennis M, O'Rourke S, Lewis S, Sharpe M, Warlow C. A quantitative study of the emotional outcome of people caring for stroke survivors.  Stroke. 1998;  29 1867-1872
• 74 Greveson G C, Gray C S, French J M, James O FW. Long-term outcome for patients and carers following hospital admission for stroke.  Age Ageing. 1991;  20 337-344
• 75 Bugge C, Alexander H, Hagen S. Stroke patients' informal caregivers: patient, caregiver, and service factors that affect caregiver strain.  Stroke. 1999;  30 1517-1523
• 76 Bakas T, Austin J K, Jessup S L, Williams L S, Oberst M T. Time and difficulty of tasks provided by family caregivers of stroke survivors.  J Neurosci Nurs. 2004;  36 95-106
• 77 Bakas T, Kroenke K, Plue L D, Perkins S, Williams L S. Outcomes among family caregivers of aphasic versus non-aphasic stroke survivors.  Rehabil Nurs. 2005;  , In press
• 78 Carter J H, Nutt J G. Family caregiving: a neglected and hidden part of health care delivery.  Neurology. 1998;  51 1245-1246
• 79 Han B, Haley W E. Family caregiving for patients with stroke: review and analysis.  Stroke. 1999;  30 1478-1485
• 80 Robinson R G, Kubos K L, Starr L B, Rao K, Price T R. Mood changes in stroke patients: importance of lesion location.  Brain. 1984;  107 81-93
• 81 Robinson R G, Szetela B. Mood change following left hemispheric brain injury.  Ann Neurol. 1981;  9 447-453
• 82 Vataja R, Leppavuori A, Pohjasvaara T et al.. Poststroke depression and lesion location revisited.  J Neuropsychiatry Clin Neurosci. 2004;  16 156-162
• 83 Carson A J, MacHale S, Allen K et al.. Depression after stroke and lesion location: a systematic review.  Lancet. 2000;  356 122-126
• 84 Narushima K, Kosier J T, Robinson R G. A reappraisal of poststroke depression, intra- and inter-hemispheric lesion location using meta-analysis.  J Neuropsychiatry Clin Neurosci. 2003;  15 422-430
• 85 Cassidy E, O'Connor R, O'Keane V. Prevalence of post-stroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation.  Disabil Rehabil. 2004;  26 71-77
• 86 Andersen G, Vestergaard K, Ingemann-Nielsen M, Lauritzen L. Risk factors for post-stroke depression.  Acta Psychiatr Scand. 1995;  92 193-198
• 87 Naess H, Nyland H I, Thomassen L, Aarseth J, Myhr K M. Mild depression in young adults with cerebral infarction at long-term follow-up: a population-based study.  Eur J Neurol. 2005;  12 194-198
• 88 Burvill P, Johnson G, Jamrozik K, Anderson C, Stewart-Wynne E. Risk factors for post-stroke depression.  Int J Geriatr Psychiatry. 1997;  12 219-226
• 89 Sharpe M, Hawton K, Seagroatt V et al.. Depressive disorders in long-term survivors of stroke: associates with demographic and social factors, functional status, and brain lesion volume.  Br J Psychiatry. 1994;  164 380-386
• 90 Robinson R G, Starr L B, Lipsey J R, Rao K, Price T R. A two-year longitudinal study of post-stroke mood disorders: dynamic changes in associated variables over the first six months of follow-up.  Stroke. 1984;  15 510-517
• 91 Robinson R G. Relationship of depression to physical impairment. In: Robinson RG The Clinical Neuropsychiatry of Stroke. Cambridge, UK; Cambridge University Press 1998: 141-149
• 92 Ouimet M A, Primeau F, Cole M G. Psychosocial risk factors in poststroke depression: a systematic review.  Can J Psychiatry. 2001;  46 819-828
• 93 Teasdale T W, Engberg A W. Suicide after a stroke: a population study.  J Epidemiol Community Health. 2001;  55 863-866
• 94 Bronnum-Hansen H, Davidsen M, Thorvaldsen P. for the Danish MONICA Study Group . Long-term survival and causes of death after stroke.  Stroke. 2001;  32 2131-2136
• 95 Pohjasvaara T, Vataja R, Leppavuori A, Kaste M, Erkinjuntti T. Suicidal ideas in stroke patients 3 and 15 months after stroke.  Cerebrovasc Dis. 2001;  12 21-26
• 96 Kishi Y, Robinson R G, Kosier J T. Suicidal ideation among patients with acute life-threatening physical illness: patients with stroke, traumatic brain injury, myocardial infarction, and spinal cord injury.  Psychosomatics. 2001;  42 382-390
• 97 Anderson C S, Hackett M L, House A O. Interventions for preventing depression after stroke (Cochrane review). In: The Cochrane Library; Issue 2. Oxford; Update Software 2004
• 98 Hackett M L, Anderson C S, House A O. Interventions for treating depression after stroke (Cochrane review). In: The Cochrane Library; Issue 3. Oxford; Update Software 2004
• 99 Lipsey J R, Robinson R G, Pearlson G D, Rao K. Nortriptyline treatment of post-stroke depression: a double-blind study.  Lancet. 1984;  1 297-300
• 100 Reding M J, Orto L A, Winter S W, Fortuna I M, Di Ponte P, McDowell F H. Antidepressant therapy after stroke: a double-blind trial.  Arch Neurol. 1986;  43 763-765
• 101 Ohtomo E, Hirai S, Terashi A et al.. Clinical evaluation of aniracetam on psychiatric symptoms related to cerebrovascular disease.  J Clinical Experimental Medicine. 1991;  156 143-187
• 102 Andersen G, Vestergaard K, Lauritzen L. Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram.  Stroke. 1994;  25 1099-1104
• 103 Robinson R G, Schultz S K, Castillo C et al.. 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
• 104 Wiart L, Petit H, Joseph P A, Mazaux J M, Barat M. Fluoxetine in early poststroke depression: a double-blind placebo-controlled study.  Stroke. 2000;  31 1829-1832
• 105 Murray V, von Arbin M, Bartfai A et al.. Double-blind comparison of sertraline and placebo in stroke patients with minor depression and less severe major depression.  J Clin Psychiatry. 2005;  66 708-716
• 106 Fruehwald S, Gatterbauer E, Rehak P, Baumhackl U. Early fluoxetine treatment of post-stroke depression: a three-month double-blind placebo-controlled study with an open-label long-term follow up.  J Neurol. 2003;  250 347-351
• 107 Rampello L, Chiechio S, Nicoletti G et al.. Prediction of the response to citalopram and reboxetine in post-stroke depressed patients.  Psychopharmacology (Berl). 2004;  173 73-78
• 108 Rasmussen A, Lunde M, Poulsen D L, Sorensen K, Ovitazau S, Bech P. A double-blind, placebo-controlled study of sertraline in the prevention of depression in stroke patients.  Psychosomatics. 2003;  44 216-221
• 109 Palomaki H, Kaste M, Berg A et al.. Prevention of poststroke depression: 1 year randomized placebo controlled double blind trial of mianserin with 6 month follow up after therapy.  J Neurol Neurosurg Psychiatry. 1999;  66 490-494
• 110 Niedermaier N, Bohrer E, Schulte K, Sclattmann P, Heuser I. Prevention and treatment of poststroke depression with mirtazapine in patients with acute stroke.  J Clin Psychiatry. 2004;  65 1619-1623
• 111 Fruehwald S, Gatterbauer E, Rehak P, Baumhackl U. Early fluoxetine treatment of post-stroke depression: a three-month double-blind placebo-controlled study with an open-label long-term follow up.  J Neurol. 2003;  250 347-351
• 112 Masand P, Murray G B, Pickett P. Psychostimulants in post-stroke depression.  J Neuropsychiatry Clin Neurosci. 1991;  3 23-27
• 113 Lazarus L W, Winemiller D R, Lingam V R et al.. Efficacy and side effects of methylphenidate for poststroke depression.  J Clin Psychiatry. 1992;  53 447-449
• 114 Shima S. The efficacy of antidepressants in post-stroke depression.  Keio J Med. 1997;  46 25-26
• 115 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
• 116 Martensson B, Murray V, von Arbin M, Asberg M, Bartfai A, Malm K. Alternative treatment of poststroke depression [letter].  Am J Psychiatry. 1997;  154 583-584
• 117 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 clinical study.  Psychopharmacology (Berl). 1994;  114 119-122
• 118 Gonzalez-Torrecillas J L, Mendlewicz J, Lobo A. Effects of early treatment of poststroke depression on neuropsychological rehabilitation.  Int Psychogeriatr. 1995;  7 547-560
• 119 Spalletta G, Caltagirone C. Sertraline treatment of post-stroke major depression: an open study in patients with moderate to severe symptoms.  Funct Neurol. 2003;  18 227-232
• 120 Lincoln N B, Flannaghan T, Sutcliffe L, Rother L. Evaluation of cognitive behavioural treatment for depression after stroke: a pilot study.  Clin Rehabil. 1997;  11 114-122
• 121 Currier M B, Murray G B, Welch C C. Electroconvulsive therapy for post-stroke depressed geriatric patients.  J Neuropsychiatry Clin Neurosci. 1992;  4 140-144
• 122 Boter H. HESTIA Study Group . Multicenter randomized controlled trial of an outreach nursing support program for recently discharged stroke patients.  Stroke. 2004;  35 2867-2872
• 123 Smith J, Forster A, Young J. A randomized trial to evaluate an education programme for patients and carers after stroke.  Clin Rehabil. 2004;  18 726-736
• 124 Simon G E, Ludman E J, Tutty S, Operskalski B, Von Korff M. Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial.  JAMA. 2004;  292 935-942
• 125 Eriksson M, Asplund K, Glader E L et al.. Riks-Stroke Collaboration. Self-reported depression and use of antidepressants after stroke: a national survey.  Stroke. 2004;  35 936-941
• 126 Jorge R E, Robinson R G, Arndt S, Starkstein S. Mortality and poststroke depression: a placebo-controlled trial of antidepressants.  Am J Psychiatry. 2003;  160 1823-1829
• 127 Narushima K, Robinson R G. The effect of early versus late antidepressant treatment on physical impairment associated with poststroke depression: is there a time-related therapeutic window?.  J Nerv Ment Dis. 2003;  191 645-652
• 128 Williams L S, Jones W J, Shen J, Robinson R L, Kroenke K. Outcomes of newly referred neurology outpatients with depression and pain.  Neurology. 2004;  63 674-677
• 129 Neumeyer-Gromen A, Lampert T, Stark K, Kallischnigg G. Disease management programs for depression: a systematic review and meta-analysis of randomized controlled trials.  Med Care. 2004;  42 1211-1221