This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kotila, M. Articles by Kaste, M. Search for Related Content PubMed PubMed Citation Articles by Kotila, M. Articles by Kaste, M. Pubmed/NCBI databases Medline Plus Health Information Caregivers Depression

(Stroke. 1998;29:368-372.)
© 1998 American Heart Association, Inc.

Original Contributions

Depression After Stroke

Results of the FINNSTROKE Study

Mervi Kotila, MD; Heikki Numminen, MD; Olli Waltimo, MD; Markku Kaste, MD

From the Department of Clinical Neurosciences, Helsinki (Finland) University Central Hospital (M.Ko., O.W., M.Ka.), and the Department of Neurology, Central Hospital of South Karelia (H.N.).

Correspondence to Dr Mervi Kotila, Department of Clinical Neurosciences, Helsinki University Central Hospital, Haartmanninkatu 4, 00290 Helsinki, Finland.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose—We compared the incidence and severity of depression at 3 and 12 months after stroke in patients and their chief caregivers (spouses, 63%; children, 37%) in four districts of Finland, two with and two without after-hospital-discharge interventional programs (outpatient rehabilitation and activities of the local divisions of the Finnish Heart Association [FHA]). A population-based stroke register was used, and factors influencing depression were analyzed.

Methods—A stroke register of patients recruited over 2 years in four different districts (total population, 134 804) in Finland; 594 first-ever strokes were registered. Beck's Depression Inventory (BDI), with 10 as the cutoff point for depression, was applied to 321 of 423 survivors and 195 caregivers at 3 months and to 311 of 390 survivors and 184 caregivers at 12 months in the districts with and without interventional programs.

Results—At 3 months, fewer patients in the districts with active programs (41%) were depressed than in the control districts (54%) (odds ratio, 0.59; 95% confidence interval, 0.37 to 0.94), and the difference was maintained at 12 months (42% versus 55%) (odds ratio, 0.55; 95% confidence interval, 0.34 to 0.88). Univariate risk factors for depression at 3 months were female sex and severe prognostic score at the onset of stroke (14 points) on the Scandinavian Stroke Scale (SSS). Only SSS prognostic score and age emerged as significant independent contributors to depression on both linear and logistic multivariate analyses. There was no significant difference in the depression rate of caregivers between districts with active programs (42%) and those without such programs (41%) at 3 months; at 12 months the results were the same (39% in districts with active programs versus 42% in those without such programs). However, at 12 months there were significantly more severely depressed caregivers in districts without active programs than in districts with such programs (P.036). Poor Rankin scale score (grades III through V) and severe SSS long-term score (42 points) at 3 months among the patients were associated with depression of the caregivers at 3 months in the univariate analysis. Poor Rankin Scale score of the patients was independently associated with the depression of their caregivers at 3 months on multivariate logistic regression analysis.

Conclusions—Depression was common among stroke survivors and among their caregivers at 3 months, and its rate did not decrease at 1-year follow-up. The lower depression rate in districts with active programs compared to those without supports the idea that outpatient rehabilitation and support provided by local divisions of the FHA may be an effective way of decreasing the rate of depression after stroke.

Key Words: caregivers • depression • incidence • rehabilitation • stroke

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
As the third leading cause of death and the most common disabling disease, stroke has an enormous emotional impact on both patients and their family members.¹ This is especially true for Western societies with aging populations. Depression is an important consequence of stroke, and it influences stroke recovery.^{2 3 4 5 6 7 8 9 10 11 12 13 14} In spite of this, there are only a few population-based studies of the incidence and severity of depression after stroke in patients^{6 13} and among their caregivers.^{15 16 17 18}

The aim of this study was to determine in a population-based stroke register (1) the incidence and severity of depression at 3 and 12 months after stroke among patients and their chief caregivers; (2) possible differences in frequency of depression between districts with enhanced after-discharge rehabilitation programs provided by the local divisions of the FHA and those without such facilities; and (3) analysis of factors influencing the occurrence of depression and its severity.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
A stroke register was kept in four different districts in Finland from August 15, 1989 through August 14, 1991 (FHA 89–91). The study population consisted of 134 804 inhabitants. The four districts studied consisted of 21 rural municipalities, whose populations ranged from 31 975 to 35 142 inhabitants. In two of these districts there were active rehabilitation programs after discharge, together with support and social activities provided by the local divisions of the FHA; the two other districts without such programs served as comparison districts. In the latter, the stroke care was carried out according to the usual practice in Finland, which includes mainly physiotherapy and speech therapy provided at the respective health center responsible. Each health center has a chief physician in charge and a variable number of family doctors. In interventional districts, the backbone of extra rehabilitation was physiotherapy organized for a group of stroke patients. Stroke patients and their family members were actively encouraged to participate in the social activities of the local divisions of the FHA. The patients were also provided any help they needed for adapting to life after stroke. A total of 594 patients with first-ever stroke aged 15 and older were registered. The details of the register have been published previously.¹⁹ The total 3- and 12-month mortality rates were 28.5% and 34.1% in districts with and without programs, respectively.

The evaluation of the patients took place upon their admission to the hospital after the onset and at 3- and 12-month follow-ups. The same trained study coordinator in each district interviewed both the patient and the chief caregiver and applied the SSS, Speech scale, BI, and RS at onset and at 3 and 12 months; the Mini-Mental State Exam, Albert's test, and BDI at 3 and 12 months; and quality of life assessment at onset and at 12 months.^{20 21 22 23 24 25 26 27 28} The closest relative (spouse, 63%; children, 37%) attending to the patient's daily care (chief caregiver) was also evaluated with use of the BDI at 3 and 12 months.²¹

Three months after the stroke, 423 patients were still alive, and a BDI was performed for 321 (75.9%) of these survivors. At 12 months, the BDI was repeated for 311 of 390 (79.7%) of the survivors unless the patient was in such poor condition medically that she or he was not able to answer the questions of the study coordinator or had severe aphasia;, the patient had left more than one third of 21 items blank in the BDI instrument; or the time limit for evaluation was exceeded (6 weeks at 3 months and 2 months at 1 year). The BDI was assessed at 3 and 12 months in 195 chief caregivers (of whom 178 lived with stroke victim, 7 did not, and 10 had unknown living arrangements) and 184 chief caregivers (of whom 160 lived with stroke victim, 13 did not. and 11 had unknown living arrangements), respectively. At 3 and 12 months 64 and 67 patients, respectively, were living alone. At 3 and 12 months in all districts, 17% and 25% of the caregivers, respectively, refused to participate in the evaluation. At 3 months, there were 125 assessed caregivers in active districts and 70 in control districts; at 12 months there were 115 and 69, respectively.

Of the 321 patients for whom reliable BDI data was available, 181 were in districts with active programs and the remaining 140 in districts without such programs. The patients included in the analysis did not differ according to age, sex, or type of stroke in the active programs versus no active programs. Patients with a BDI assessment included 83 females and 98 males in the active programs and 73 females and 67 males in the comparison group. The mean age in the active districts was 72.3±10.5 years for females and 66.6±13.0 years for males; that in the control districts was 70.2±11.5 years for females and 66.5±12.1 years for males. The proportions of stroke types in active and control districts were: infarct (85.1%, 79.3%), intracerebral hemorrhage (8.8%, 15.0%), subarachnoid hemorrhage (4.4%, 5.0%) and nonspecified stroke (1.7%, 0.7%). At hospital admission, the patients did not differ according to the SSS score, BI score, or side of hemiparesis.

In analyzing the effects of risk factors, we took into consideration whether cardiovascular disease was present, whether the patients had received a diagnosis of coronary artery disease or heart failure from a physician, and whether the patients had received drug treatment for those disorders. Patients considered hypertensive were medically treated.

The categorical variables were compared with use of the ² test, and ORs were calculated for risk factors of depression. Both multivariate linear and logistic regression were used for analyzing the independence of these risk factors.^{29 30} For linear regression analyses a logarithmic transformation of the dependent variable was used, whereas for logistic regression the continuous variables were dichotomized as follows. A cutoff point of 70 was used for age. Scandinavian prognostic score (maximum of 22) was dichotomized into patients with severe symptoms (14 points) and those with mild-to-moderate symptoms (>14 points). In the SSS long-term score (maximum, 48), a cutoff point of >42 was used on the above basis. The RS was dichotomized into patients with a good outcome and independent activities of daily living (grades I and II) and those with a less favorable outcome and dependent activities of daily living (grades III through V [poor RS]). A cutoff point of 17 was used in the BI for independent patients. The subtype of stroke was dichotomized into brain infarcts and other strokes. Data from active and control districts were pooled in analyzing both the variables associated with depression in patients and the patients' variables associated with caregivers' depression.

We used the original version of the BDI,²¹ which has been validated in stroke patients.³¹ The cutoff point for depression was 10 points, which has been used in the evaluation of patients with somatic illnesses.^{32 33 34 35} The depression was categorized as follows: 0 to 9 points, null to minimal; 10 to 18, mild to moderate; 19 to 29, moderate to severe; and 30 to 63, severe.^{32 33 34 35} The latter three categories (from 10 through 63 points) were used in assessing the severity of depression.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The frequency and severity of depression of the patients and their caregivers at 3 and 12 months in districts with active after-hospital-discharge programs and in those without such programs is shown in Table 1. At 3 months, fewer patients with active programs (41%) were depressed than without such programs (54%) (OR, 0.59; 95% CI, 0.37 to 0.94, after adjustment for age, sex, and SSS score). This difference was maintained at 12 months (42% versus 55%) (OR, 0.55; 95% CI, 0.34 to 0.88, after adjustment for age, sex , and SSS score), whereas no difference was found in regard to severity of depression between districts with active programs versus without such programs.

View this table: [in this window] [in a new window]   Table 1. The Frequency and Severity of Depression of Patients and Caregivers at 3 and 12 Months After Stroke in Districts With and Without Active After-Hospital Discharge Programs

Depressed caregivers were equally common in the districts with active programs (42%) and in those without (41%) at 3 months, and the results were the same at 12 months (39% in active versus 42% in control districts) (Table 1). When depressed caregivers (BDI score of 10 to 63) were compared between districts with active and no active programs, there were significantly more severely depressed caregivers in the latter group than in the former at 12 months (Table 1) (P=.036). There was no difference in frequency and severity of depression between patients and caregivers.

Factors at stroke onset associated with depression at 3 months are shown in Table 2. Of these, ORs for females and those with a severe prognostic score on the SSS were significant. Other tested variables (age, diagnosis, side of hemiparesis, living alone, RS score, cardiovascular disease, diabetes, and musculoskeletal disease) did not reach significance, as can be seen in Table 2. Only age and the SSS prognostic score emerged as significant contributors to depression on both linear and logistic multivariate analyses (Table 2).

View this table: [in this window] [in a new window]   Table 2. Univariate and Multivariate ORs and 95% CIs of Variables Associated With Patients' Depression 3 Months After Stroke

Patient characteristics at 3 months associated with depression of the caregivers at the same point are shown in Table 3. Poor RS score and severe SSS long-term score of the patients at 3 months were associated with depression of the caregivers at 3 months after stroke onset. Other tested variables (BDI and BI scores of the patients at 3 months) did not reach significance as can be seen in Table 3. However, the severity of patients' depression at 3 months (BDI score of 19 to 63) was positively associated with the severity of depression among caregivers at 3 months (BDI score of 10 to 63) (OR, 2.57; 95% CI, 1.29 to 5.11). On multivariate logistic regression analysis poor RS score (III to V) of the patients was independently associated with depression of the caregivers at 3 months (Table 3). However, on multivariate linear regression the significance of patients' depression as the most important risk factor could be seen (P=.028), whereas the other factors were no more significant.

View this table: [in this window] [in a new window]   Table 3. Univariate and Multivariate ORs and 95% CIs of Patients' Variables Associated With Depression of Caregivers 3 Months After Stroke

Only 25 of 143 depressed patients (17.4%) were undergoing antidepressant drug treatment at 12 months after stroke onset. In terms of frequency of antidepressant therapy, there was no difference between districts with active programs and those without.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The population in this study is the largest unselected stroke population in which the occurrence of depression has systematically been examined. The first major result was the high rate of depression among patients and their caregivers and its persistence. Almost half of the patients and their caregivers were depressed at 3 months after the stroke; although this number had not decreased at 12 months, depression was diagnosed and treated in only a minority.

In an earlier Finnish population–based stroke register,³⁶ the frequency of depressive patients at 3 months from stroke onset was almost the same as in the present study but decreased from 44% to 29% in 1 year. Both studies used the BDI to measure depression, but in the earlier study the cutoff point for depression was higher (14 points). Furthermore, the patients were, on average, younger and also had access to a more extensive systematic rehabilitation program than was possible in the present study. In a community-based study by Wade et al,⁶ 41% of stroke survivors were classified as depressed during the 1-year follow-up. In a recent study among an unselected stroke population, the incidence of poststroke depression at 1 year was 41% for all strokes and 33% for first-ever strokes,¹³ which is less than in the present study. Most of our patients were classified as having mild-to-moderate depression. Only 9% had severe depression, which decreased only slightly during follow-up.

The second main result of the present study was that depression among stroke patients was more common in districts without active after-discharge programs than in districts with such programs. This suggests that even a reasonably modest after-discharge rehabilitation program decreases the likelihood of poststroke depression. Processes facilitating the patient's return to society and new contacts with other people, whether professional (as in the case of group physiotherapy) or lay (as in the case of activities of local divisions of the FHA), seem to be an effective means of reducing the burden of depression in stroke victims and their caregivers.

The proportion of depressive caregivers did not differ between districts with active programs and those without such programs. The only difference verified between active and control districts was that there were more severely depressed caregivers in districts with no active programs at 12 months. Carnwath and Johnson¹⁵ studied the occurrence of depression among spouses of stroke patients 3 years after the event. Similar to our observations, they found that 39% of the spouses in the stroke group were depressed compared with 12% in the control group consisting of patients with diseases other than stroke. They also reported that depression increased with time during the 3 years. In a recent Australian study¹⁸ in which emotional distress was evaluated among the chief caregivers of 84 stroke patients who had survived 1 year with residual handicaps, half of the caregivers showed evidence of emotional distress.

An important question is which variables are associated with poststroke depression. In our series, female sex and severe SSS prognostic score at the onset of stroke were associated with depression at 3 months. On multivariate logistic regression analysis, severe SSS prognostic score and old age emerged as independent contributors to depression. In some earlier studies, female sex also correlated with depression,^{6 14} perhaps because many stroke patients are older women living alone. Severe SSS score reflects the severity of stroke, and both Wade et al⁶ and Sharpe et al¹⁴ have reported that physical disability and larger lesion volume are associated with depression. Contrary to some earlier reports which found that patients with left hemispheric lesions are more depressive than those with right hemispheric lesions,^{3 8} we did not find an association between depression and side of hemiparesis. This conclusion has been the subject of much controversy, and many researchers, including our team, have disagreed with it.^{4 37 38 39 40} In our series, the subtype of stroke (infarct/hemorrhage), living conditions at time of stroke (alone/with family), or preexisting diseases were not associated with depression. Living alone did not predict depression in some studies^{3 38} but did in another.¹²

In the present study, poor RS score and severe SSS long-term score of the patient at 3 months from onset of stroke were associated with depression of the caregiver at 3 months by univariate analysis. With multivariate logistic regression analysis, only poor RS score of the patient was independently associated with caregivers depression at 3 months. Anderson et al¹⁸ did not find a relation between the degree of the patients' physical disabilities and emotional stress among caregivers, a discrepancy that is hard to understand. In our study, the more severe depression of the patients at 3 months was associated with depression in the caregivers at the same point. It would seem that in paying more attention to stroke caregivers to prevent their depression, we might thereby also achieve better emotional adjustment of the patients. Evans et al⁴¹ have reported reduced depression in patients after counseling of stroke caregivers.

In the present study, in districts with active intervention programs, depression occurred significantly less often than in districts without such programs. This supports the idea that encouraging re-establishment of social ties may reduce the risk of depression.

	Selected Abbreviations and Acronyms

 

BDI = Beck's Depression Inventory BI = Barthel Index CI = confidence interval FHA = Finnish Heart Association OR = odds ratio RS = Rankin scale SSS = Scandinavian Stroke Scale

	Acknowledgments

 
This study was supported by the Finnish Heart Association. We would like to thank Associate Professor Seppo Sarna for statistical assistance and Jaana Immonen, Seija Keskiväli, Eeva Kröger, Pirjo Lyytikäinen, Oona Tuomi-Nikula, and Markku Karjalainen for registering patients.

Received December 2, 1996; revision received November 6, 1997; accepted November 6, 1997.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 
1. Weinfeld DF. The National Survey of Stroke. Stroke. 1981;12(suppl 1):1–91.

2. Folstein MF, Maiberger R, McHugh PR. Mood disorder as a specific complication of stroke. J Neurol Neurosurg Psychiatry.. 1977;40:1018–1020.[Abstract/Free Full Text]

3. Robinson RG, Price TR. Post-stroke depressive disorders: a follow-up study of 103 patients. Stroke.. 1982;13:635–641.[Abstract/Free Full Text]

4. Sinyor D, Amato P, Kaloupek DG, Becker R, Goldenberg M, Coopersmith H. Poststroke depression: relationships to functional impairment, coping strategities, and rehabilitation outcome. Stroke.. 1986;17:1102–1107.[Abstract/Free Full Text]

5. House A. Depression after stroke. BMJ. 1987;294:76–78.

6. Wade DT, Leigh-Smith J, Hewer RA. Depressed mood after stroke: a community study of its frequency. Br J Psychiatry.. 1987;151:200–205.[Abstract/Free Full Text]

7. Robinson RG, Bolduc PL, Price TR. Two-year longitudinal study of poststroke mood disorders: diagnosis and outcome at one and two years. Stroke.. 1987;18:837–834.[Abstract/Free Full Text]

8. Parikh RJ, Lipsey JR, Robinson RG, Price TR. Two-year longitudinal study of poststroke mood disorders: dynamic changes in correlates of depression at one and two years. Stroke.. 1987;18:579–584.[Abstract/Free Full Text]

9. Starkstein SE, Robinson RG. Affective disorders and cerebral vascular disease. Br J Psychiatry.. 1989;154:170–182.[Abstract/Free Full Text]

10. Robinson RG, Starkstein SE. Current research in affective disorders following stroke. J Neuropsychiatry Clin Neurosci.. 1990;2:1–14.[Abstract/Free Full Text]

11. Robinson RG, Morris PL, Fedoroff JP. Depression and cerebrovascular disease. J Clin Psychiatry.. 1990;51:26–31.

12. Åström M, Adolfsson R, Asplund K. Major depression in stroke patients: a 3-year longitudinal study. Stroke.. 1993;24:976–982.[Abstract/Free Full Text]

13. Andersen G, Vestergaard K, Riis JO, Lauritzen L. Incidence of post-stroke 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.[Medline] [Order article via Infotrieve]

14. Sharpe M, Hawton K, Seagroatt V, Bamford J, House A, Molyneux A, Sandercock P, Warlow C. Depressive disorders in long-term survivors of stroke: association with demographic and social factors, functional status and brain lesion volume. Br J Psychiatry. 1994;164:380–386.[Abstract/Free Full Text]

15. Carnwath TCM, Johnson DAW. Psychiatric morbidity among spouses of patients with stroke. Br J Med.. 1987;294:409–411.

16. Evans RL, Bishop DS, Haselkorn JK. Factors predicting satisfactory home care after stroke. Arch Phys Med Rehabil.. 1991;72:144–147.[Medline] [Order article via Infotrieve]

17. Grevenson GC, Gray CS, French JM, James OFW. Long-term outcome for patients and carers following hospital admission for stroke. Age Ageing.. 1991;20:337–344.[Abstract/Free Full Text]

18. Anderson CS, Linto J, Stewart-Wynne EG. A population-based assessment of the impact and burden of caregiving for long- term stroke survivors. Stroke.. 1995;26:843–849.[Abstract/Free Full Text]

19. Numminen H, Kotila M, Waltimo O, Aho K, Kaste M. Declining incidence and mortality rates of stroke in Finland from 1972 to 1991: results of three population-based stroke registers. Stroke.. 1996;27:1487–1491.[Abstract/Free Full Text]

20. Rankin J. Cerebral vascular accidents in patients over age 60, II: prognosis. Scott Med J.. 1957;2:200–215.[Medline] [Order article via Infotrieve]

21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry.. 1961;4:53–63.

22. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md Med J.. 1965;14:61–65.

23. Albert M. A simple test of visual neglect. Neurology.. 1973;23:658–664.[Free Full Text]

24. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res.. 1975;12:189–198.[Medline] [Order article via Infotrieve]

25. Scandinavian Stroke Study Group. Multicenter trial of hemodilution in ischemic stroke: background and study protocol. Stroke. 1985;16:885–890.[Free Full Text]

26. Cote R, Hachinski VC, Shurvell BL, Norris JW, Wolfson C. The Canadian Neurological Scale: a preliminary study in acute stroke. Stroke.. 1986;17:731–737.[Abstract/Free Full Text]

27. Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry.. 1987;50:177–182.[Abstract/Free Full Text]

28. Sintonen H, Pekurinen M. A fifteen-dimensional measure of health-related quality of life (15 D) and its applications. In: Walker SR, Rosser RM, eds. Quality of Life Assessement: Key Issues in the 1990s. Dordrecht, Netherlands: Kluver Academic Publishers; 1993:185–195.

29. Abacus Concepts. Statview II. Berkeley, Calif: 1987.

30. Dixon WJ, Brown MB, Engelman L, Jennrich RI, eds. BMDP Statistical Softwear. Los Angeles, Calif: University of California Press; 1990.

31. House A, Dennis M, Hawton K, Warlow C. Methods of identifying mood disorders in stroke patients: experience in the Oxfordshire Community Stroke Project. Age Ageing. 1989;18:371–379.[Abstract/Free Full Text]

32. Beck AT. Depression: Causes and Treatment. Philadelphia, Pa: University of Pennsylvania Press; 1967:29.

33. Beck AT, Beamesderfer A. Assessment of depression: the depression inventory. In: Pichot P, ed. Modern Problems in Pharmcopsychiatry. Basel, Switzerland: Karger; 1974:151–169.

34. Kendall PC, Hollon SD, Beck AT, Hammen CL, Ingram RE. Issues and recommendations regarding use of the Beck Depression Inventory. Cognitive Ther Res.. 1987;11:289–299.

35. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinl Psychol Rev.. 1988;8:77–100.

36. Kotila M, Waltimo O, Niemi ML, Laaksonen R, Lempinen M. The profile of recovery from stroke and factors influencing outcome. Stroke.. 1984;15:1039–1044.[Abstract/Free Full Text]

37. House A, Dennis M, Warlow C, Hawton K, Molyneux A. Mood disorders after stroke and their relation to lesion location. Brain.. 1990;113:1113–1129.[Abstract/Free Full Text]

38. Feibel JH, Springer CJ. Depression and failure to resume social activities after stroke. Arch Phys Med Rehabil.. 1982;63:276–278.[Medline] [Order article via Infotrieve]

39. Collin SJ, Tinson D, Lincoln NB. Depression after stroke. Clin Rehabil. 1987;1:27–32.

40. Burvill PW, Johnson GA, Chakera TMH, Stewart-Wynne EG, Anderson CS, Jamrozik KD. The place of site of lesion in the aetiology of post-stroke depression. Cerebrovasc Dis.. 1996;6:208–215.

41. Evans RL, Matlock AL, Bishop DS, Stranahan S, Pederson C. Family intervention after stroke: Does counseling or education help? Stroke. 1988;19:1243–1249.[Abstract/Free Full Text]

This article has been cited by other articles:

				A. Visser-Meily, M. Post, I. van de Port, C. Maas, G. Forstberg-Warleby, and E. Lindeman Psychosocial Functioning of Spouses of Patients With Stroke From Initial Inpatient Rehabilitation to 3 Years Poststroke: Course and Relations With Coping Strategies Stroke, April 1, 2009; 40(4): 1399 - 1404. [Abstract] [Full Text] [PDF]

				S. A. Thomas and N. B. Lincoln Predictors of Emotional Distress After Stroke Stroke, April 1, 2008; 39(4): 1240 - 1245. [Abstract] [Full Text] [PDF]

				E. Townend, M. Brady, and K. McLaughlan A Systematic Evaluation of the Adaptation of Depression Diagnostic Methods for Stroke Survivors Who Have Aphasia Stroke, November 1, 2007; 38(11): 3076 - 3083. [Abstract] [Full Text] [PDF]

				L. Brereton, C. Carroll, and S. Barnston Interventions for adult family carers of people who have had a stroke: a systematic review Clinical Rehabilitation, October 1, 2007; 21(10): 867 - 884. [Abstract] [PDF]

				L. S. Williams, K. Kroenke, T. Bakas, L. D. Plue, E. Brizendine, W. Tu, and H. Hendrie Care Management of Poststroke Depression: A Randomized, Controlled Trial Stroke, March 1, 2007; 38(3): 998 - 1003. [Abstract] [Full Text] [PDF]

				K. J. Salaycik, M. Kelly-Hayes, A. Beiser, A.-H. Nguyen, S. M. Brady, C. S. Kase, and P. A. Wolf Depressive Symptoms and Risk of Stroke: The Framingham Study Stroke, January 1, 2007; 38(1): 16 - 21. [Abstract] [Full Text] [PDF]

				H. Jia, T. M. Damush, H. Qin, L. D. Ried, X. Wang, L. J. Young, and L. S. Williams The Impact of Poststroke Depression on Healthcare Use by Veterans With Acute Stroke Stroke, November 1, 2006; 37(11): 2796 - 2801. [Abstract] [Full Text] [PDF]

				M. L. Hackett, C. S. Anderson, and on behalf of the Auckland Regional Community Strok Frequency, Management, and Predictors of Abnormal Mood After Stroke: The Auckland Regional Community Stroke (ARCOS) Study, 2002 to 2003 Stroke, August 1, 2006; 37(8): 2123 - 2128. [Abstract] [Full Text] [PDF]

				I. G.L. van de Port, G. Kwakkel, I. van Wijk, and E. Lindeman Susceptibility to Deterioration of Mobility Long-Term After Stroke: A Prospective Cohort Study Stroke, January 1, 2006; 37(1): 167 - 171. [Abstract] [Full Text] [PDF]

				M. H.L. Lui, F. M. Ross, and D. R. Thompson Supporting Family Caregivers in Stroke Care: A Review of the Evidence for Problem Solving Stroke, November 1, 2005; 36(11): 2514 - 2522. [Abstract] [Full Text] [PDF]

				M. L. Hackett and C. S. Anderson Predictors of Depression after Stroke: A Systematic Review of Observational Studies Stroke, October 1, 2005; 36(10): 2296 - 2301. [Abstract] [Full Text] [PDF]

				M. L. Hackett, C. Yapa, V. Parag, and C. S. Anderson Frequency of Depression After Stroke: A Systematic Review of Observational Studies Stroke, June 1, 2005; 36(6): 1330 - 1340. [Abstract] [Full Text] [PDF]

				W. K. Tang, S. S. M. Chan, H. F. K. Chiu, G. S. Ungvari, K. S. Wong, T. C. Y. Kwok, V. Mok, K. T. Wong, P. S. Richards, and A. T. Ahuja Poststroke Depression in Chinese Patients: Frequency, Psychosocial, Clinical, and Radiological Determinants J Geriatr Psychiatry Neurol, March 1, 2005; 18(1): 45 - 51. [Abstract] [PDF]

				A. Berg, H. Palomaki, J. Lonnqvist, M. Lehtihalmes, and M. Kaste Depression Among Caregivers of Stroke Survivors Stroke, March 1, 2005; 36(3): 639 - 643. [Abstract] [Full Text] [PDF]

				L. S. Williams, E. J. Brizendine, L. Plue, T. Bakas, W. Tu, H. Hendrie, and K. Kroenke Performance of the PHQ-9 as a Screening Tool for Depression After Stroke Stroke, March 1, 2005; 36(3): 635 - 638. [Abstract] [Full Text] [PDF]

				J Stone, E Townend, J Kwan, K Haga, M S Dennis, and M Sharpe Personality change after stroke: some preliminary observations J. Neurol. Neurosurg. Psychiatry, December 1, 2004; 75(12): 1708 - 1713. [Abstract] [Full Text] [PDF]

				J. Onishi, H. Umegaki, Y. Suzuki, K. Uemura, M. Kuzuya, and A. Iguchi The Relationship Between Functional Disability and Depressive Mood in Japanese Older Adult Inpatients J Geriatr Psychiatry Neurol, June 1, 2004; 17(2): 93 - 98. [Abstract] [PDF]

				J M A. Visser-Meily, M. W M Post, I. I Riphagen, and E. Lindeman Measures used to assess burden among caregivers of stroke patients: a review Clinical Rehabilitation, June 1, 2004; 18(6): 601 - 623. [Abstract] [PDF]

				G. Forsberg-Warleby, A. Moller, and C. Blomstrand Psychological well-being of spouses of stroke patients during the first year after stroke Clinical Rehabilitation, April 1, 2004; 18(4): 430 - 437. [Abstract] [PDF]

				M. Eriksson, K. Asplund, E.-L. Glader, B. Norrving, B. Stegmayr, A. Terent, K. H. Asberg, P.-O. Wester, and for The Riks-Stroke Collaboration Self-Reported Depression and Use of Antidepressants After Stroke: A National Survey Stroke, April 1, 2004; 35(4): 936 - 941. [Abstract] [Full Text] [PDF]

				A. Verdelho, H. Henon, F. Lebert, F. Pasquier, and D. Leys Depressive symptoms after stroke and relationship with dementia: A three-year follow-up study Neurology, March 23, 2004; 62(6): 905 - 911. [Abstract] [Full Text] [PDF]

				N B Lincoln, C R Nicholl, T Flannaghan, M Leonard, and E Van der Gucht The validity of questionnaire measures for assessing depression after stroke Clinical Rehabilitation, August 1, 2003; 17(8): 840 - 846. [Abstract] [PDF]

				J. Bogousslavsky William Feinberg Lecture 2002: Emotions, Mood, and Behavior After Stroke Stroke, April 1, 2003; 34(4): 1046 - 1050. [Abstract] [Full Text] [PDF]

				A. Berg, H. Palomaki, M. Lehtihalmes, J. Lonnqvist, and M. Kaste Poststroke Depression: An 18-Month Follow-Up Stroke, January 1, 2003; 34(1): 138 - 143. [Abstract] [Full Text] [PDF]

				H. E. Andersen, K. Eriksen, A. Brown, K. Schultz-Larsen, and B. H. Forchhammer Follow-up services for stroke survivors after hospital discharge-a randomized control study Clinical Rehabilitation, June 1, 2002; 16(6): 593 - 603. [Abstract] [PDF]

				G. Forsberg-Warleby, A. Moller, and C. Blomstrand Spouses of first-ever stroke patients: their view of the future during the first phase after stroke Clinical Rehabilitation, May 1, 2002; 16(5): 506 - 514. [Abstract] [PDF]

				L. Turner-Stokes and N. Hassan Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 1: Diagnosis, frequency and impact Clinical Rehabilitation, March 1, 2002; 16(3): 231 - 247. [Abstract] [PDF]

				G. Forsberg-Warleby, A. Moller, and C. Blomstrand Spouses of First-Ever Stroke Patients : Psychological Well-Being in the First Phase After Stroke Stroke, July 1, 2001; 32(7): 1646 - 1651. [Abstract] [Full Text] [PDF]

				T. Ohira, H. Iso, S. Satoh, T. Sankai, T. Tanigawa, Y. Ogawa, H. Imano, S. Sato, A. Kitamura, T. Shimamoto, et al. Prospective Study of Depressive Symptoms and Risk of Stroke Among Japanese Editorial Comment : Is Depression a Risk Factor for Ischemic Stroke? Stroke, April 1, 2001; 32(4): 903 - 908. [Abstract] [Full Text] [PDF]

				H. E. Andersen, K. Schultz-Larsen, S. Kreiner, B. H. Forchhammer, K. Eriksen, and A. Brown Can Readmission After Stroke Be Prevented? : Results of a Randomized Clinical Study: A Postdischarge Follow-Up Service for Stroke Survivors Stroke, May 1, 2000; 31(5): 1038 - 1045. [Abstract] [Full Text] [PDF]

				M. L. Hackett, J. R. Duncan, C. S. Anderson, J. B. Broad, and R. Bonita Health-Related Quality of Life Among Long-Term Survivors of Stroke : Results From the Auckland Stroke Study, 1991-1992 Stroke, February 1, 2000; 31(2): 440 - 447. [Abstract] [Full Text] [PDF]

				M. Dennis, S. O'Rourke, S. Lewis, M. Sharpe, and C. Warlow Emotional outcomes after stroke: factors associated with poor outcome J. Neurol. Neurosurg. Psychiatry, January 1, 2000; 68(1): 47 - 52. [Abstract] [Full Text]

				R. Gesztelyi, I. Fekete, M. Kellermann, L. Csiba, and D. Bereczki Screening for Depressive Symptoms among Post-Stroke Outpatients in Eastern Hungary J Geriatr Psychiatry Neurol, December 1, 1999; 12(4): 194 - 199. [Abstract] [PDF]

				L. S. Williams, M. Weinberger, L. E. Harris, and J. Biller Measuring quality of life in a way that is meaningful to stroke patients Neurology, November 1, 1999; 53(8): 1839 - 1839. [Abstract] [Full Text]

				M.-L. Kauhanen, J. T. Korpelainen, P. Hiltunen, E. Brusin, H. Mononen, R. Maatta, P. Nieminen, K. A. Sotaniemi, and V. V. Myllyla Poststroke Depression Correlates With Cognitive Impairment and Neurological Deficits Stroke, September 1, 1999; 30(9): 1875 - 1880. [Abstract] [Full Text] [PDF]

				B. Han and W. E. Haley Family Caregiving for Patients With Stroke : Review and Analysis Stroke, July 1, 1999; 30(7): 1478 - 1485. [Abstract] [Full Text] [PDF]

				H. Palomäki, M. Kaste, A. Berg, R. Lönnqvist, J. Lönnqvist, M. Lehtihalmes, and J. Hares 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, April 1, 1999; 66(4): 490 - 494. [Abstract] [Full Text]

				M.-G. Bousser Stroke in Women : The 1997 Paul Dudley White International Lecture Circulation, February 2, 1999; 99(4): 463 - 467. [Full Text] [PDF]

				T. Pohjasvaara, A. Leppavuori, I. Siira, R. Vataja, M. Kaste, and T. Erkinjuntti Frequency and Clinical Determinants of Poststroke Depression Stroke, November 1, 1998; 29(11): 2311 - 2317. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kotila, M. Articles by Kaste, M. Search for Related Content PubMed PubMed Citation Articles by Kotila, M. Articles by Kaste, M. Pubmed/NCBI databases Medline Plus Health Information Caregivers Depression