Two-Year Longitudinal Study of Poststroke
Mood Disorders: Diagnosis and Outcome at One
and Two Years
Robert G. Robinson, MD, Paula L. Bolduc, MS, and Thomas R. Price, MD
As part of a prospective study of mood disorders in stroke patients, interviews were obtained from 37 patients at 1 year and 48 patients at 2 years follow-up. In-hospital evaluations for these 65 follow-up patients found that 9 patients (14%) had symptom clusters of major depression, 12 patients (18%) had symptom clusters of dysthymic or minor depression, and 44 patients (68%) did not meet the DSM i n diagnostic criteria for depression. Although overall prevalence of depression did not change signifi-cantly over time, the prognosis for individual patients, depending on diagnostic group, was different. All of the follow-up patients with major depression in-hospital were improved by 2 years, with a significant reduction in their mean depression scores and improvement in their activities of daily living, whereas only 30% of follow-up patients with dysthymic depression improved by this time. There was no significant improvement in their mean depression scores or mean activities of daily living score. Of the patients followed up who were not depressed in-hospital, 34% had developed major or minor depression by 2 years, and their mean depression scores were significantly increased. These data suggest that the prevalence of depression among the follow-up patients remains high (between 30 and 40%) for the first 2 years after stroke, but that untreated poststroke major depression has a natural course of about 1-2 years, with associated improvement in activity of dairy living scores, whereas the prognosis for poststroke dysthymic depression is frequently unfavorable and often persists for > 2 years. (Stroke 1987; 18:837-843)
D
uring the past few years, we have reported our I findings from a group of 103 patients who were examined during their acute hospitaliza-tion for stroke and followed for 2 years. '~3 At 6 months follow-up, 10 of 13 patients with symptoms of major depression in-hospital continued to have these symp-toms, whereas 5 of 9 patients with minor (dysthymic) depression in-hospital continued to have these symp-toms; the remaining 4 patients with dysthymic depres-sion had developed symptoms of major depresdepres-sion.2 Of the 28 patients who were not depressed at the time of the initial in-hospital evaluation, 9 had developed either major or minor depressive symptoms by 6 months follow-up.2 Thus, based on our initial follow-up, 19 of 22 patients who were depressed in-hospital snowed no significant improvement 6 months later, and another 32% of the follow-up patients developed depression after hospital discharge.Although the Diagnostic and Statistical Manual HI (DSM ED)4 does not recognize more than 1 category of depression in patients with brain injury (i.e., organic affective disorder), our previous investigations have From the Departments of Psychiatry (R.G.R., P.L.B.) and Neur-oscience (R.G.R), Johns Hopkins University School of Medicine, and the Departments of Psychiatry (R.G.R.) and Neurology (T.R.P.), University of Maryland School of Medicine, Baltimore, Md.
Supported in part by National Institute of Mental Health Re-search Scientist Development Award (to R.G.R.) MH00163, NS15178, MH40355, NS15O8O, NS16332, and NS9-2302.
Address for reprints: Robert G. Robinson, MD, Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Meyer 4-119, Baltimore, MD 21205.
Received December 8, 1986; accepted May 21, 1987.
demonstrated that the diagnostic differentiation into major and dysthymic depression appears to be impor-tant. Major depression was strongly associated with left anterior lesion location, whereas dysthymic de-pression occurred primarily with posterior brain in-jury.5 The severity of depression, as measured by ei-ther the Zung or Hamilton Depression Rating Scales, was significantly different for patients with major compared with dysthymic depression.2 A positive dex-amethasone suppression test (i.e., failure to suppress serum cortisol below 5 /ug/ml following 1 mg of dexa-methasone) was significantly associated with major but not dysthymic depression.6 Cognitive impairment associated with depression was also found only in stroke patients with major depression, whereas dysthy-mic depression did not appear to significantly affect cognitive impairment.7 Thus, there are several lines of evidence that suggest that the differentiation of major and dysthymic depression may be an important ele-ment in the evaluation of mood disorder associated with brain injury. In the present study, we examined whether in-hospital diagnosis of major depression, dysthymic depression, or no depression was signifi-cantly related to diagnostic status or physical or intel-lectual impairment at 1 and 2 years follow-up.
Subjects and Methods Study Population
The sample population consisted of patients who were admitted to the University of Maryland Hospital for acute treatment of thromboembolic, atherosclerot-ic, or hemorrhagic stroke and gave informed consent
for participation in this study. They were also included in the National Institute of Neurological and Commu-nicative Diseases and Stroke (NINCDS) Pilot Stroke Data Bank.8 A total of 154 consecutive admissions were evaluated; of these, 43 patients with severe com-prehension deficits were excluded, as were 7 patients who were discharged before an interview could be done and 1 patient who refused examination. Thus, 103 patients were included in the prospective longitu-dinal study. During the 24-months follow-up, 8 pa-tients died and 9 papa-tients were lost completely, not having received any follow-up, while 86 patients were reexamined at either 3, 6, 12, or 24 months after stroke. The present study involves 65 patients, 37 seen at 12 months and 48 seen at 24 months follow-up (20 patients were seen at both times).
Evaluations
In-hospital and follow-up neurologic examinations were done by the attending neurologist using the stan-dardized examination and rating criteria established by the NINCDS Pilot Stroke Data Bank.8 Neurologic di-agnoses were made using the Stroke Data Bank crite-ria, which are based on both computed tomography (CT) scan and other laboratory tests as well as on clinical examination.
Psychiatric examination was done in the hospital by a psychiatrist or a social worker trained in the adminis-tration of these scales in the late morning so that any possible effect of diurnal mood variation on the inter-view outcome would be standardized. The psychiatric examination included 3 quantitative measures of men-tal state, the Present State Examination (PSE),9 the Hamilton Depression Scale,10 and the Zung Depres-sion Scale." The reliability and validity of these mea-sures in this brain-injured population has been demon-strated in previous publications.11213
In addition to these quantitative measures of depres-sion, overall cognitive impairment was assessed using the Mini-Mental State Examination (MMSE).14 Scores range from 0 to 30, with scores < 23 indicating signifi-cant impairment. Functional physical impairment (i.e., activities of daily living, ADL) was quantified using the Johns Hopkins Functioning Inventory (JHFI).13 Scores range from 0 to 27, with higher scores indicating greater impairment. The quality of social functioning was determined using the Social Function-ing Exam (SFE).16 This is a 28-item semistructured interview assessment of social functioning, with total scores reported as a fraction of the maximum possible score. We have demonstrated the reliability and valid-ity of these instruments in this brain-injured population in previous publications.1121316
At the follow-up evaluation, a detailed longitudinal medical and psychiatric history was taken. Any record of treatment for depression or intervening medical ill-ness was carefully noted.
Diagnosis
Using the symptoms elicited from the PSE, DSM HI diagnoses were generated. Although there is not an
exact correspondence between PSE items and DSM i n symptom criteria, we have shown in previous publica-tions that there is a close correspondence between DSM HI, Research Diagnostic Criteria, and PSE diag-noses.1 The conversion criteria for making DSM i n diagnoses from PSE criteria is available upon request.
Statistical Analysis
Means and SDs were calculated for all quantitative measurement scales. Groups were compared using analysis of variance (ANOVA); a group was compared over time using repeated-measures ANOVA. If the ANOVA was significant, cells were compared using post-hoc planned orthogonal t tests. Nonparametric data were analyzed using %2 statistics with Yates' modification for expected cell sizes of < 5.
Results
Study Population and Neurologic Findings
Demographic characteristics for the 37 patients seen at 12 months and the 48 patients seen at 24 months are shown in Table 1. To determine whether the follow-up groups were in some way "aberrant samples" from our original group of 103, the no-follow-up group demo-graphics were compared with the 2 follow-up groups (Table 1). There were no significant intergroup differ-ences in any of the demographic data except age. The no-follow-up group was slightly younger (p < 0.05) than the follow-up groups.
Neurologic findings for patients evaluated at either 12 or 24 months as well as in-hospital findings in the no-follow-up group are shown in Table 2. There were no significant differences in neurologic findings be-tween these groups. Almost all of the patients had a hemiparesis or monoparesis with or without sensory deficit.
Ten of the 65 patients seen at either 12 or 24 months had suffered subsequent strokes by the follow-up
inter-Table 1. In-Hospltal Demographic Characteristics of 12- and 24-Months Follow-Up and No-Follow-Up Groups
Age (mean±SD) Race (% black) Sex (% male) Marital status % married % widowed % other Socioeconomic status Class I-m Class IV-V History of CVA History of depression 12-Months follow-up (" = 37) 63±11 76% 57% 32% 35% 33% Hollingshead 24% 76% 19% 0% 24-Months follow-up (#i = 48) 63+12 60% 63% 42% 23% 35% 30% 70% 27% 4% No-follow-up (#i = 38) 56±13* 63% 58% 45% 21% 34% 29% 71% 21% 5% CVA, cardiovascular accident.
*Significantly different from follow-up groups (p<0.05); all other demographic variables not different by x2
Table 2. Neurologic Findings and Diagnoses in 12- and 24-Months Follow-Up and No-Follow-Up Groups
Stroke type Thromboembolic, atherosclerotic, or unknown cause Hemorrhage Lesion location Left hemisphere Right hemisphere Bilateral or brains tem Neurologic deficits Monoparesis or hemiparesis Monosensory or hemi sensory deficit Visual field deficit Aphasia Broca's Wemicke Other 12 Months follow-up (i = 37) 35 2 17 13 7 29 13 2 3 1 1
Computed tomography findings
Lesion visualized Mean lesion
vol-ume ±SD Mean distance of lesion from frontal pole (% of A-P dis-tance ± SD) 12 4.7 + 6.1 41.5±21.8 24 Months follow-up (n = 48) 42 6 22 14 12 33 15 5 5 1 3 19 5.6±4.8 40.0+17.2 No-follow-up (« = 38) 31 7 19 12 7 29 11 3 0 1 3 9 8.3+10 34.1 + 14.6 A-P, anterior-posterior distance.
views. Of these 10 patients, 6 were not depressed in-hospital or at follow-up. Two patients had symptoms of depression subsequent to a recurrent stroke; 1 had major depression, the other had dysthymic depression. One patient, who had an in-hospital diagnosis of major depression, had a 24-month follow-up diagnosis of dysthymic depression. One patient with dysthymic de-pression in-hospital had dysthymic dede-pression subse-quent to recurrent stroke.
In-Hospital Evaluation
In-hospital evaluations of the 37 patients seen at 12 months found 5 (14%) with symptom clusters of major depression and 7 (19%) with symptom clusters of dysthymic depression. Of the 48 patients seen at 24 months, in-hospital evaluations found 6 (13%) with symptom clusters of major depression and 10 (21%) with symptom clusters of dysthymic depression. In-hospital evaluations of the 38 no-follow-up patients revealed 11 (29%) with major depression and 9 (24%) with dysthymic depression. The frequency of
depres-sion in the no-follow-up group was not significantly different from either follow-up group (x2 = 3.62,
df= 2, not significant [NS] for 12-months follow-up; f = 4.34, df= 2, NS for 24-months follow-up).
Mean in-hospital depression scores on the Hamilton (F243 = 68.6, p < 0 . 0 0 1 ) , Zung (F2>4S = 33.1, p<
0.001), and PSE (F2,« = 69.2, p < 0.001) for both the
12- and 24-months groups were significantly higher for patients with major compared with dysthymic de-pression or nondepressed patients (Table 3). Similarly, mean depression scores for patients with dysthymic depression were significantly higher than the nonde-pressed group (Table 3). The different depression groups, however, did not differ significantly in either MMSE (F2>43 = 1.6, NS) or SFE scores (F2i4J = 1.7,
NS). Patients with major depression, however, had higher JHFI scores (F2>43 = 3.5, p < 0.05) than the
non-depressed patients but were not significantly different from patients with dysthymic depression.
Patients with major, dysthymic, or no depression seen only in-hospital, at 12 months, or at 24 months did not differ in their mean in-hospital depression scores. In addition, in-hospital scores of physical (JHFI) and intellectual (MMSE) impairment or social functioning (SFE) did not differ significantly among the 12-months, 24-months, or no-follow-up groups. Thus, the no-follow-up group did not differ signifi-cantly from the follow-up groups in frequency or se-verity of depression or sese-verity of impairment.
Follow-up Evaluation at 12 Months
Of the 37 patients interviewed at 12 months, 5 (14%) had major depressive symptoms, 7 (19%) had dysthymic symptoms, and 25 (67%) were not de-pressed. Although these were the same overall per-cents found in-hospital (i.e., 14, 19, and 67%, respec-tively), the composition of the diagnostic groups had changed (Figure 1). Of the 5 patients with major de-pression in-hospital, only 1 continued to have major depression at 12 months, 2 had dysthymic depression symptoms, and 2 were not depressed (Figure 1). Of the 7 patients with dysthymic depression in-hospital, 2 had developed major depressive symptoms, 2 continued to have dysthymic symptoms, and 3 had no depression. Among the 25 patients who were not depressed in-hospital, 2 had developed major depression, 3 had developed dysthymic depression, and 20 patients re-mained not depressed.
Only 1 depressed patient (in-hospital diagnosis ma-jor depression, patient taking medication at 12-months interview) had received treatment with antidepressant medication. This patient was not depressed at 12 months. A hypothesis of unequal frequency of diag-nostic change (i.e., 4 of 5 major depressions and 3 of 7 dysthymic depressions improved) based on in-hospital depression category was not substantiated (X2Y«CJ =
1.5, df = 1, NS). Similarly, there was no significant change (using repeated-measures ANOVA) in mean scores over time or the diagnosis X time interaction for the Zung (F234 = 0.57, NS), Hamilton (F234 =
0.54, NS), or PSE (F2t34 = 0.27, NS) scores
Table 3. Scores Obtained In-hospital and at 12- and 24-Months Follow-Up In-hospital diagnosis Major depression Zung Hamilton PSE MMSE JHFI SFE Dysthymic depression Zung Hamilton PSE MMSE JHFI SFE Nondepressed Zung Hamilton PSE MMSE JHFI SFE No-follow-up In-hospital ( i = H ) 60+14 14±7 25 ±10 16±5 8 + 7 0.25 + 0.07 (n = 9) 45 ±9 9 ± 6 13±5 2O±8 10±8 0.28±0.21 (n=18) 34±6 4 + 3 4 ± 3 22±5 4 ± 4 0.22±0.14 12-Months follow-up In-hospital d = 5) 53 ±13 15±3 22±5 22±7 9 ± 7 0.10±0.06 d = 7) 44±10 9 + 3 14±7 23 ±8 6 ± 6 0.24±0.1 (i = 25) 35±6 4 ± 3 4 + 3 23±7 5 ± 5 0.19±0.11 12 months (n = 5) 51 ± 15 15 + 3 23 ±4 23±6 6 ± 3 0.20 + 0.13* (i = 7) 45±11 12±8 (n = 6) 13±11 21±7 4 ± 4 0.31 ±0.13 d = 25) 40±ll 5 ± 5 6 ± 7 25±6 2±3* 0.21+0.14 24-Months In-hospital d = 6) 60±ll 18±5 23±4 16 + 5 13 + 9 0.26 ±0.11 (*=10) 46±10 8 ± 4 13±6 21 ±6 9 ± 7 0.23±0.16 d = 32) 35±6 4 + 4(n = 31) 6 + 4 22 + 6 6 ± 6 0.16±0.11 follow-up 24 months d = 6) 42 ±8* 8±7* 9±7* 23 ±7 5 + 6* 0.20±0.09 (n =10) 50±16t 13±9t 18±12t 22±8 7 ± 7 0.21 ±0.14 d = 32) 44+14* 8 ±7* 9±8* 24 + 6 3±4* 0.17±0.10 Depression scores in-hospital and at 12-months follow-up are significantly different between each diagnostic category. F values for statistical analyses are given in text. PSE, Present State Examination; MMSE, Mini-Mental State Examination; JHFI, Johns Hopkins Functional Inventory; SFE, Social Functioning Exam.
•Significantly different from in-hospital scores.
tSignificantly different from either major depression or nondepressed at 24-months follow-up.
tween the in-hospital and 12-months evaluation for patients with in-hospital diagnoses of major, dysthy-mic, or no depression.
Between the in-hospital and 12-months evaluations, there was significant improvement in mean JHFI scores over time but only in the nondepressed group (F, M = 6.21, p<0.05). The major and dysthymic
de-pression groups had not significantly changed from in-hospital scores. There were no significant diagnosis X time interactions (F2>34 = 0.36, NS). Thus, only
nonde-pressed patients showed a significant improvement in their ADL scores during the first year after stroke.
Scores on the MMSE were not significantly differ-ent between the in-hospital and 12-months evaluations for any of the depression groups (F,M = 0.27, NS),
and there was no significant diagnosis x time interac-tion (F2,34 = 0.68, NS). In contrast, however, SFE
scores were significantly worse at 12 months only for patients with major depression in-hospital
(FlM = 7.26, p < 0.01) while patients with dysthymic
or no depression did not deteriorate in social function-ing. There were no significant diagnosis x time inter-actions in SFE scores (F2i34 = 1.10, NS).
Follow-up Evaluation at 24 Months
Of the 48 patients seen at 24 months, 10 (21%) had major depression, 10 (21%) had dysthymic depression
symptoms, and 28 (58%) were not depressed. Al-though these percents were not significantly different from those found in-hospital (i.e., 14, 19, and 67%, respectively), the composition of the depression groups had changed (Figure 1). All patients with major depression at 24 months were different from patients with major depression in-hospital, and 7 of 10 patients with dysthymic depression were different from the pa-tients with dysthymic depression in-hospital.
Of the 6 patients with major depression in-hospital, 4 had no depression and 2 had symptoms of dysthymic depression (Figure 1). In contrast, however, among the 10 patients with dysthymic depression in-hospital, at 24 months 4 had developed symptoms of major depression, 3 continued to have symptoms of dysthy-mic depression, and only 3 had recovered. Of the 32 patients who were not depressed at the initial evalua-tion, 6 had developed symptoms of major and 5 symp-toms of dysthymic depression, whereas 21 remained nondepressed.
In this study, only 2 patients had a previous (i.e., prior to stroke) personal history of depression defined as seeing a health professional for evaluation or treat-ment of depression. These 2 patients were included in the 48 patients receiving 24-months follow-up. One patient had dysthymic depression in-hospital and re-mained depressed at 24 months, and the other had
in~hospltal
n.65 12 monthsn-37 24 monthsn.48
m»)of depression dysthymic depression no depression FIGURE 1. Diagnostic status in the hospital, 12 and 24 months
after stroke, for individual patients indicated by a numbered bar; subsequent follow-up diagnosis is horizontally displayed.
major depression in-hospital but was not depressed by 24 months. Neither patient received a 12-months eval-uation. Thus, a history of depression did not have a significant impact on the results of this study.
Remarkably, only 1 patient with dysthymic depres-sion (this patient was being treated at the 6-months interview but still had dysthymic symptoms at 24 months) and 1 patient who was not depressed in-hospi-tal but developed major depression by the 24-months follow-up (this patient was receiving treatment at 24 months) had received antidepressant medication.
In contrast to our findings at 12 months, at 24 months the hypothesis of unequal frequency of im-provement (i.e., imim-provement was defined as in-hos-pital major depression going to dysthymic or no de-pression at follow-up, while in-hospital dysthymic depression was improved if no depression was found at follow-up) for in-hospital major vs. dysthymic
depres-sion was statistically substantiated (X2YUM = 4 . 3 5 ,
df- \,p <0.025). Thus, patients with major depres-sion in-hospital were more likely to improve by 24 months than patients with dysthymic depression in-hospital.
The improvement in diagnostic status of patients with major depression between in-hospital and 24-months follow-up was also reflected by significant improvement in depression scores between in-hospi-tal and 24-months follow-up using repeated-mea-sures ANOVA of the diagnosis x time interaction for the Zung (F2 4 5=10.1, p<0.001), Hamilton (FM 5=12.6, p<6.001), and PSE (F245=12.6, p<0.001). Post-hoc comparisons revealed that de-pression scores between in-hospital and 24-months follow-up significantly improved for patients with in-hospital major depression but were not improved in patients with dysthymic depression (e.g., Hamilton in-hospital vs. 24 months for major depression t = 3.4, df = 5, p <0.05; Hamilton in-hospital vs. 24 months for dysthymic depression t - \.%,df=9, NS). On the other hand, by 24 months patients who were not de-pressed in the hospital had significantly worse scores on the Zung (r = 3.7, df= 31, p<0.05), Hamilton (r = 3.1,4f=31,p<0.05),andPSE(r= 1.9,rf/=31, p<0.05; one-tailed). At the 24-months follow-up, pa-tients with dysthymic depression in-hospital had sig-nificantly higher scores on the Zung (F24j = 4.6, p<0.01), Hamilton (F245 = 5.9, p<0.01), and PSE (F243 =7.0, /?<0.01) than patients with in-hospital diagnoses of either major or no depression, who were not significantly different from one another.
Patients showed significant improvements in their JHFI scores over 2 years (FM 3=17.4, p<0.05), whereas post-hoc comparisons indicated that this oc-curred only in patients with major or no depression in-hospital and that patients with dysthymic depression in-hospital were not significantly improved. The diag-nosis x time interaction was not significant (F2 43 = 2.7, p<0.08). MMSE scores (FM5 = 2.3, NS)'and SFE (FM3 = 0.82, NS) scores were not different be-tween the in-hospital and 24-months evaluations for any diagnostic category.
Discussion
This study demonstrated that the prevalence of de-pression remains high but relatively stable for the first 2 years after stroke. The composition of the depressed groups, however, changed over the 2 years. All of the patients with major depression improved by 2 years, and their depression scores were significantly lower compared with their in-hospital evaluation. In con-trast, however, only 30% of the patients with dysthy-mic depression improved in their diagnostic classifica-tion, and there was no significant improvement in their mean depression scores. As a group, patients who were not depressed in-hospital deteriorated in their mood state by 2 years, with more than a third of them developing clinically diagnosed depression and a sig-nificant increase in their mean depression scores.
The major uncertainties in this study are whether the
follow-up population is representative of the initial group and whether generalizations can be made to an overall stroke population based on the findings in this predominantly lower socioeconomic class population. Although these questions cannot be completely an-swered, we have shown that the follow-up patients did not differ in their diagnostic categories, severity of impairment, or demographic features from patients who were not followed up. Second, although the find-ings in these lower socioeconomic class patients may not always apply to the general stroke population, studies by other investigators have reported similar findings concerning the relation between severity of depression and lesion location,17 the association be-tween failure to suppress serum cortisol following dexamethasone administration and the existence of de-pression,18 the lack of statistical association between severity of impairment (cognitive or functional phys-ical) and severity of depression,17"19 and treatment re-sponse.20 Thus, although further studies will be needed to establish the general applicability and reproducibil-ity of these findings, there appears to be some indica-tion that this stroke populaindica-tion may provide some in-sights for the general stroke population.
The most important finding from this study was the poor prognosis of patients with an in-hospital diagno-sis of dysthymic depression. This is in contrast to the improvement in depression scores and ADL scores (JHFI) seen in patients with major depression over the 2 years follow-up. This finding is certainly consistent with our previous reports demonstrating the impor-tance of differentiating major from dysthymic post-stroke depression.5"7 It is also consistent with the find-ings of Jacoby et al21 and Post,22 who found that depression in the elderly is frequently associated with a poor prognosis, particularly when there was associated ventricular enlargement.
Although this kind of differential prognosis for ma-jor and dysthymic depression might be expected for patients without brain injury, to find this same clinical differentiation within the brain-injured population sur-prised us. Both major and dysthymic depression recog-nized in-hospital generally met the DSM HI diagnostic criteria of 2 weeks' duration of symptoms for major depression and 2 years' duration of symptoms for dysthymic disorder. It is possible, however, that some patients with dysthymic depression in-hospital im-proved and then relapsed by the 2-years follow-up.
Although we do not know why major depressive disorder remits between 1 and 2 years after stroke, this spontaneous remission is consistent with the untreated course of major depression in patients without brain injury.23 It is also consistent with our previous sugges-tion of neurochemical or neurophysiological contribu-tions to the development and remission of these de-pressive disorders.3i24M These major depressions may remit based on neural regeneration or biochemical compensatory mechanisms such as changes in receptor regulation or the rate of transmitter or enzyme synthesis.
The reason dysthymic depression disorders do not
significantly improve over 2 years is uncertain. In a previous study, we examined patients with dysthymic depression in-hospital and compared them with those who developed dysthymic depression several months after discharge.26 Although we hypothesized that these delayed-onset dysthymic depressions might be "reac-tive" to the severity of physical or intellectual impair-ment, we found no significant relation of depression to severity of impairment. Thus, dysthymic depressions do not appear to be psychological reactions to the im-pairment. These depressions, however, might be relat-ed to premorbid personality vulnerabilities, and this "depressive" personality trait may lead to prolonged "characterological depressions." This is only one pos-sibility, and others might be posed.
The other striking finding in this study was the asso-ciation between improvement in ADL (JHFI) and the existence of depression. At the 12-months follow-up, only nondepressed patients significantly improved in JHFI scores. We have suggested in a previous publica-tion26 that, although physical impairment does not cause depression, once depression occurs, there is an interaction that impacts significantly on the course of the recovery. It has been suggested by many clini-cians27 that depression adversely affects stroke reha-bilitation. These data provide some empirical support for this idea and also emphasize the need for ongoing clinical evaluation and treatment of depression in stroke patients. Although the demonstration of the effi-cacy of treatment of poststroke depressions by our-selves28 and others20 had not been published when this study was conducted (i.e., 1981), the lack of treatment of these disorders was striking.
Acknowledgments
The authors wish to thank Lynn Book Starr, MSW, who did some of the patient interviews and Sergio Starkstein, MD, for his assistance with the statistics.
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KEY WORDS • major depression • stroke • prognosis minor (dysthymic) depression • longitudinal study
