From the Departments of Psychiatry (N.H.); Medicine (Neurology), Research
Program in Aging (S.E.B., J.L.); and Research Design and Biostatistics (C.S.,
J.P.S.), Sunnybrook Health Science Centre and University of Toronto, North
York, Ontario, Canada.
Correspondence to Nathan Herrmann, MD, Division of Geriatric Psychiatry, Sunnybrook Health Science Centre, 2075 Bayview Ave, Room FG20, North York, ON M4N 3M5, Canada. E-mail n.herrmann{at}utoronto.ca
Methods—Consecutive admissions to a regional stroke center who
met World Health Organization and National Institute of Neurological
Disorders and Stroke criteria for stroke were eligible.
Subarachnoid hemorrhage and brain stem strokes were
excluded. Patients underwent CT, single-photon emission CT, and
standardized neurological and cognitive examinations at entry. At 3
months and 1 year after stroke, depressive symptoms were assessed with
the Montgomery Asberg Depression Rating Scale (MADRS) and the Zung
Self-Rating Depression Scale (SDS). Functional outcome was measured
with the Functional Independence Measure, and handicap was assessed by
the Oxford Handicap Scale.
Results—We assessed 436 patients at entry (mean±SD age,
74.9±11.6 years). There were 150 patients available for assessment at
3 months and 136 at 1 year. Marked depressive symptoms were noted in
22% (SDS) to 27% (MADRS) at 3 months and 21% (SDS) to 22% (MADRS)
at 1 year. Patents with marked depressive symptoms had more
neurological impairment (P<.008), were more likely to
be female (P<.05), and were more likely to have
previous histories of depression (P<.03). There was no
relationship between depressive symptoms and age, lesion volume, or
side of lesion. Depressive symptoms were correlated with functional
outcome (r=-.31, P<.0001) and handicap
(r=.41, P<.0001) at 3 months and 1 year
(r=-.28, P<.001; r=.35,
P<.0001).
Conclusions—Depressive symptoms and functional outcome are
correlated. In view of the prevalence of depressive symptoms in this
population, diagnosis and treatment of depression are important in
optimizing recovery.
Despite 20 years of intensive research, there is still significant
controversy about the relationship between cerebrovascular accidents
and depression. Questions regarding the true prevalence and severity of
poststroke depressive symptoms, the relationship with clinical
correlates such as lesion laterality, and their effect on outcome await
more definitive answers. For example, the prevalence of poststroke
depression has varied from 18% to 61%.4 Some
studies have suggested that depressive symptoms largely remit over
time,5 while others have suggested a remarkably
chronic course.6 A recent review of 25 studies
that examined the relationship between depression and lesion laterality
noted 14 studies that showed no differences between right- and
left-sided lesions, 8 studies that showed that depression was more
common with left-sided lesions, and 3 studies that demonstrated that
depression was more common with right-sided
lesions.7
Numerous methodological problems in poststroke depression research have
been suggested to account for the differences in these findings. These
include the definition and classification of
stroke,8 the phenomenology and nosology of
depressive symptoms,9 the validity of the rating
methodology employed,4 and differences in the
selected cohorts (acute inpatients versus admitted rehabilitation
samples versus community samples).7 In an attempt
to address some of these concerns, the present study was designed
to prospectively follow a large, relatively unselected sample of
carefully diagnosed acute stroke patients and determine the frequency,
severity, and course of depressive symptoms, their clinical correlates,
and their effects on functional outcome.
Measures
At 3 months and 12 months after stroke, the following assessment
battery was administered:
Neurological Assessment
Depressive Symptom Assessment
Functional Outcome
Lesion Localization
During the follow-up period, patient and family were questioned, and
medical records were examined to document any psychiatric contact
or the prescription of psychotropic medication. Any patients suspected
by the stroke care team to be clinically depressed were assessed and,
if necessary, were treated by a geriatric psychiatrist (N.H.).
Data Analysis
Of the initial sample meeting inclusion criteria on entry, 109 patients
had died before the 3-month assessment of stroke or its medical
complications, and 140 had died before the 1-year assessment.
Assessments were completed in 150 patients (46% of survivors) at 3
months and 133 (45% of survivors) at 1 year. The reasons for missing
data at 3 months and 1 year (noted as percentage of survivors) included
the following: patients too ill/disabled (14%, 15%), patients too
cognitively impaired (8%, 7%), patients too aphasic (6%, 5%),
patients refused (12%, 14%), and other (eg, moved away) (13%, 12%).
The percentage of overlap between patients assessed at 3 months and 1
year was 80% for both depression rating scales. There were no suicides
documented in the sample. There was no significant difference between
those patients with completed measures and those without with respect
to marital status, history of stroke or depression, and lesion volume.
Patients without completed measures were more likely to be female
(P<.03), older (P<.001), and have higher HSS
scores (P<.001).
Depressive Symptoms
There were no differences in age, marital status, or lesion volume
between subjects with depressive symptoms and those without. In
contrast, depressed patients had higher HSS scores
[t(32)=-2.85, P<.008], were more likely to be
female [
Relationship Between Depressive Symptoms and Functional
Outcome
A series of multiple regression analyses were performed to
determine the predictors of depression. When we used 3-month scores on
the MADRS as the dependent measure and 3-month HSS, MMSE, lesion
volume, and 3-month OHS as the predictors, the model was significant
[F(4,92)=5.06, P<.01;
R2=.18], with 3-month OHS and 3-month HSS
being the significant predictors. When we used 1-year scores on the
MADRS as the dependent measure and 3-month MADRS, 1-year HSS, MMSE,
lesion volume, and 1-year OHS as the predictors, the model was
significant [F(5,69)=8.70, P<.0001;
R2=.39], with 3-month MADRS, 1-year OHS,
and 1-year HSS as the significant predictors. FIM scores could not be
included in this analysis because of a high degree of
collinearity. Two repeated-measures ANOVAs comparing patients with
marked depressive symptoms and those without on the OHS at 3 months and
1 year revealed significant main effects of depression [F(1,141)=8.55,
P<.004 with the MADRS and F(1,140)=19.54,
P<.0001 with the SDS] but no effects of time or a
groupxtime interaction with either the MADRS or SDS. Similar
repeated-measures ANOVAs on the FIM revealed a significant main effect
of depression as measured by the SDS [F(1,133)=17.92,
P<.0001] but no effect of depression as measured by the
MADRS [F(1,134)=1.0, P>.05]. There were no effects of
time or groupxtime interaction.
The correlations between depression scale scores and the FIM subscales
are shown in Table 3
Another strength of the present study is the use of
well-recognized, valid, and reliable measures of depression and
outcome. The subjective, self-rated SDS and objective, observer-rated
MADRS have been examined previously in poststroke populations and have
demonstrated acceptable sensitivity, specificity, and predictive
value.33 A potential weakness of the present
study is the lack of a structured diagnostic interview for
depression. There has been significant interest in classification of
poststroke depressive syndromes into "major" and "minor"
subtypes. According to studies by Robinson et
al,34 35 it is only the patients with major
depression who demonstrated characteristic localization findings and
abnormal dexamethasone suppression test results. The
validity of this classification, however, has been challenged by others
who have argued that diagnosable depression is mainly a function of
symptom severity and frequency rather than a qualitative difference in
symptom characteristics.5 While studies have
suggested that certain rating scales may overestimate the rates of
depressive disorders,36 we chose to measure the
severity of depressive symptoms with reliable, valid, and easily
administered rating scales. From a clinical standpoint, these results
may be more meaningful since stroke services would be able to screen
their patients with similar rating scales, but it might not be feasible
to provide a diagnostic psychiatric assessment for every
patient. The rates of marked depressive symptoms in the present
study (21% to 27%) are almost identical to the frequency of
depressive disorders in a recent community study in Perth, Australia
(23%).31 These rates are slightly lower than
those quoted by two other community samples by House et
al5 (32%) and Wade et al37
(32%) and much lower than rates from inpatient or rehabilitation units
(eg, Robinson et al38 [47%] and Sinyor et
al39 [49%]). While the nature of the different
samples and the instruments used to detect/assess depression likely
account for some of the variation in the studies, another potential
confounder is the time (after stroke) of the assessment, since some
studies have noted a decline in the incidence and prevalence of
depressive symptoms over time.5 14 The prevalence
of depressive symptoms in the present study may also be an
underestimatation for two additional reasons. At both 3 months and 12
months, approximately 10% of the sample of patients scoring in the
nondepressed ranges were being treated with antidepressants, many of
whom might have otherwise scored higher on the rating scales.
Furthermore, it is also possible that a number of patients who refused
to be assessed (12% to 14% of total survivors) may have been
depressed and/or refused assessment because of significant depressive
symptoms. Support for this possibility can be demonstrated in the fact
that this group of patients with missing data was more likely to be
female and to have higher scores on the HSS characteristics noted to be
correlated with depressive symptoms in the rest of the sample.
The majority of patients with depressive symptoms scored in the mild
range of symptom severity on both rating scales. A similar pattern of
generally mild depressive symptom severity has been noted in other
studies.5 31 With respect to the course of
depressive symptoms, the prevalence declined only slightly from 3
months to 12 months in the group as a whole, with 30% of those with
significant symptoms remitting over time. While differences between
studies may be the result of cohort differences and methodological
variations, these results appear intermediate between those of Robinson
et al,40 who noted that most depression was
chronic, and House et al,5 who found little
diagnosable depression persisting by 1 year. Our results are similar to
other community samples which demonstrated that approximately 33% of
patients recover37 and approximately 40% have
persistent symptoms.31
Significant correlates of depression in the present study
were female sex, HSS score, and history of depression, although only
the latter was a significant predictor of depression as measured by
both the MADRS and SDS when examined with multiple regression. The
importance of previous psychiatric history has been noted by other
investigators.31 41 42 43 44 The lack of a
relationship between significant depressive symptoms and lesion
laterality is not consistent with the studies of Robinson et
al,34 although this group has often noted that
the relationship with laterality is only evident in patients with
diagnosed major depressive disorder and may be specific to left frontal
lesions. As mentioned previously, however, most studies of depression
in stroke patients have found no differences in prevalence of
depression between right- and left-hemisphere lesions, regardless of
the nature of the sample or the assessment measures
utilized.7 Taken together, these results suggest
that depression after stroke may not be significantly different from
any other depressive illness in late life with respect to risk
factors.1 This lack of specific predictors for
poststroke depression has been used as the rationale for the need to
screen all stroke patients for depression.42
The most impressive finding in the present study relates to the
significant correlation between depressive symptoms and measures of
activities of daily living and social handicap. These results are all
the more significant when the mild nature of the depressive symptoms
mentioned earlier is considered. While the results do not allow for
speculation on the direction of causation, 3-month depression scores
were significantly correlated with functional outcome at 1 year,
suggesting a risk factor for poor prognosis after stroke. Several other
prospective studies have examined the relationship between depression
and functional outcome, although all these studies used extremely small
sample sizes.40 45 46 47 48 While the present
study confirms the negative correlation between depression and
functional outcome, several studies have also documented group
differences in changes over time that were not replicated in this
study. For example, Parikh et al46 demonstrated
that patients with either major or minor depression improved over 2
years, although at a slower rate and with poorer final scores than
nondepressed patients. Conversely, Loong et al48
in a small sample of rehabilitation unit patients found equal rates and
degrees of improvement in activities of daily living in depressed and
nondepressed patients, although initial and final functional status
were significantly negatively impacted by depression. These assessments
were conducted approximately 3 weeks after stroke for baseline and 7
weeks after stroke for follow-up. While sample differences might once
again account for the discrepancies, the sampling times of the
present study (3 months and 12 months) may represent a
period whereby little change in functional status actually occurs, thus
masking a time effect.
This study has highlighted the prevalence of significant depressive
symptoms after stroke and their negative impact on functional recovery
despite their relatively mild nature. These results should not be
surprising, especially in view of the findings of the Medical Outcomes
Study, which demonstrated that patients with depressive symptoms, even
in the absence of a depressive disorder, had poor functioning, ie,
functioning that was worse than or comparable to that of patients with
major chronic medical conditions.49 The
present study emphasizes the need for all practitioners
who manage stroke patients to screen for depressive symptoms in view of
their relationship with prognosis. Double-blind controlled trials have
documented the efficacy of tricyclic
antidepressants,50
trazodone,51 and selective serotonin
reuptake inhibitors52 53 in treating
poststroke depression. What is still unclear is whether improvements in
depressive symptoms will also improve functional status, or whether
this will require further individualized rehabilitation therapies.
Additional studies of poststroke outcome should attempt to address this
issue.
Received October 15, 1997;
revision received December 3, 1997;
accepted December 29, 1997.
© 1998 American Heart Association, Inc.
Original Contributions
The Sunnybrook Stroke Study
A Prospective Study of Depressive Symptoms and Functional Outcome
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background and Purpose—To assess the
prevalence of depressive symptoms, their clinical correlates, and the
effects of depressive symptoms on stroke recovery, a relatively
unselected, well-diagnosed cohort of consecutive stroke survivors was
followed prospectively.
Key Words: depression • outcome
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
The co-occurrence of
depressive symptoms and physical illness is one of the hallmarks of
affective disorders in late life.1 The exact
nature of this relationship, however, is still unclear. Neurological
diseases are among the physical illnesses best studied with respect to
their relationship with depression. Because the neuroanatomic and
physiological features of these disorders are well
documented, their study has heuristic value and may shed light on the
etiology of depression in the absence of these conditions. It is
therefore not surprising that the relationship between depression and
cerebrovascular disease has received considerable attention in view of
the discrete nature of the lesions and
epidemiology of stroke. While stroke remains
the third most common cause of death with annual incidence rates of 5
to 8 per 1000, there has been a gradual, continuous decline in
mortality.2 This has resulted in increasing
numbers of survivors left with physical and mental impairments as well
as disabilities in activities of daily
living.3
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Site and Subjects
The site of the Sunnybrook Stroke Study was a
university-affiliated health science center located in a largely
middle-class, residential neighborhood in northern Toronto with
a regional catchment area population of approximately 250 000. The
500-bed, acute care portion of the hospital serves as a regional stroke
center. All consecutive stroke admissions between August 1990 and May
1993 were eligible for inclusion. During this time, it was the standard
practice for all patients with a diagnosis of stroke to be admitted for
investigation and treatment. Emergency records were also reviewed
during this time to ensure that all possible subjects were available
for inclusion. The diagnosis of stroke was made clinically according to
World Health Organization MONICA Project10
and National Institute of Neurological Disorders and Stroke
criteria.11 For the purposes of this study,
patients with a diagnosis of subarachnoid hemorrhage
and vertebrobasilar strokes were excluded. Subarachnoid
hemorrhage is managed differently, has a different prognosis,
and is often excluded from medical studies of
stroke.12 Similarly, vertebrobasilar strokes have
different mortality rates and prognosis compared with hemispheric
stroke.13 The methodology of limiting study to
hemispheric cerebral infarctions is similar to other
studies.14 15 Patients with aphasia were not
excluded; assessments were always attempted unless patients were
globally aphasic or had severe comprehension deficits. Written informed
consent was obtained from all subjects or their substitute
consent-givers after a detailed description of the study.
After admission, data on demographics, other medical illness,
past psychiatric and medical history, and medications were collected
with a standardized questionnaire. As part of the standard clinical
stroke protocol, patients received a CT scan and an HMPAO-SPECT scan as
well as carotid Doppler and cardiac investigations when indicated.
A standardized neuropsychological battery that included an
MMSE16 was also performed as part of the clinical
routine. A multidisciplinary stroke care team was involved as part of
the care protocol, including occupational therapy, physiotherapy, and
speech therapy. All patients were assessed by a rehabilitation medicine
specialist and offered rehabilitation services as appropriate.
Neurological status was assessed by a stroke neurologist
(S.E.B.) using the standardized HSS of Adams et
al.17 The scale measures impairment in
consciousness, vision, language, and motor and sensory function. The
scale ranges from 0 (no impairment) to 100 (severely impaired in all
domains).
Depressive symptoms were assessed with subjective and objective
measures. The objective, observer-rated MADRS18
is a 20-item scale that measures the severity of depressive symptoms.
While the scale has been shown to correlate well with the Hamilton
Depression Rating Scale,19 its lack of emphasis
on physical symptoms has led some investigators to suggest that it is a
more valid measure of depression in depressed, elderly patients
compared with the Hamilton Depression Rating
Scale.20 Cutoff scores for the MADRS were as
follows: 0 to 6 (normal), 7 to 19 (mild), 20 to 34 (moderate), and >34
(severe).21 The SDS22 is a
20-item, self-reported index of the frequency of experienced depressive
symptoms. This scale has recently been shown to have a sensitivity of
97% and specificity of 63% for depressive disorder in a general
medical clinic according to the Diagnostic and
Statistical Manual of Mental Disorders, edition
3.23 Cutoff scores for the SDS were as follows:
<50 (normal), 50 to 59 (mild), 60 to 69 (moderate), and >69
(severe).23 All depression scales were
administered by a research nurse trained by a psychiatrist specialized
in the assessment and management of poststroke mood disorders.
Functional outcome was measured with the
FIM24 and the OHS.25 The
FIM is an 18-item scale measuring levels of dependence and is scored
from 18 (total assistance in all areas) to 126 (complete independence
in all areas). Subscales assess function in self-care, sphincter
control, mobility, locomotion, communication, and social cognition.
Compared with the more commonly used Barthel
Index,26 it is found to be more sensitive and
also includes measures of communication and cognition, important
components of poststroke functioning.27 28 The
OHS, also known as the modified Rankin Disability Scale, is an
observer-rated, global measure of handicap assessing any limitation in
the patient's social role. It is rated from 0 (no symptoms) to 5
(severe handicap, totally dependent, requiring constant attention night
and day) and has been shown to have good interrater
reliability.25
Lesion localization from CT was determined for each patient and
will be the subject of a future analysis. Lesion volume
estimates were obtained by tracing the CT lesion on each slice in which
it appeared with digitizing software, multiplying each area by the 1-cm
slice thickness, and summing the volume of each slice.
Descriptive statistics were used to summarize data.
Between-group comparisons were made with the Student's t
test or ANOVA for continuous variables and
2 test of independence for dichotomous
variables. Multiple regression was used to test the strength of the
association between depression and psychiatric risk factors. Tests were
two-tailed, with results considered significant at P<.05.
Univariate correlates were assessed with the Pearson
correlation coefficient adjusted for multiple correlations with a
Bonferroni correction.
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Between August 1990 and May 1993, there were 436 patients with 450
hemispheric strokes that met inclusion criteria for this study.
Mean±SD age of this group was 74.9±11.6 years (median age, 77 years).
Fifty-one percent were men, 93% were white, and 51% were married.
Only 4% of the sample resided in a long-term care facility before
admission. We found that 38.5% had a high school education and 23.6%
had attended college or university. There were 388 infarcts (86.2%)
and 62 hemorrhages (13.8%). Lesion location was left-sided in
219 (48.7%), right-sided in 221 (49.1%), and bilateral in 10 (2.2%)
(Table 1
).
View this table:
[in a new window]
Table 1. Description of Subjects (n=436)
The prevalence of symptoms of depression is shown in the
Figure. When standardized cutoff
scores21 23 were used at 3 months, 27% of
patients were rated as having marked depressive symptoms on the MADRS
(scores 
7) and 22% on the SDS (scores 50). At 1 year, 22% of
patients were rated as depressed on the MADRS and 21% on the SDS. Only
a small number of patients at either 3 months or 1 year scored in the
moderate or severe ranges of either rating scale. Of the 120 patients
scoring in the nondepressed range, 12 (10%) were taking
antidepressants at the 3-month assessment. Similarly, 13 of 133
patients (10%) scoring in the nondepressed range were taking
antidepressants at the 1-year assessment. In contrast, 19% and 24% of
patients scoring in the depressed ranges at 3 months and 1 year,
respectively, were on antidepressants. When we examined the changes in
marked depressive symptoms over time, 30% of those with marked
symptoms at 3 months remitted by 1 year, 45% were markedly
symptomatic at both assessments, and 25% developed
symptoms only after the 3-month assessment. There were no cases of
mania detected in the sample.
View larger version (40K):
[in a new window]
Figure 1. Prevalence of poststroke depressive symptoms
presented as the percentage of patients with marked depressive
symptoms (Total), with subsequent breakdown by symptom severity (Mild,
Moderate, Severe) using cutoff scores noted in "Subjects and
Methods." 2(1)=3.84, P<.05], and
were more likely to have histories of previous depressive episodes
[2(1)=4.97, P<.03]. There were
no significant differences between patients with left-sided versus
right-sided lesions on either the 3-month or 12-month depression
scales, although there was a trend for higher depression scores on the
SDS after a right-sided lesion compared with left-sided lesion
[t(144)=1.87, P<.06]. ANOVAs on each
depression scale at 3 months and 1 year revealed no significant effects
of sex, side of lesion, or history of depression. A stepwise multiple
regression with the 3-month MADRS as the dependent measure and age,
sex, side of lesion, MMSE, lesion volume, and history of depression as
potential predictors produced a significant model [F(1,116)=5.79,
P<.02], although this could only account for 5% of the
variance. The only variable that contributed significantly to the
model was a history of depression. A stepwise multiple regression with
the 3-month SDS as the dependent measure and age, sex, side, MMSE,
lesion volume, and history of depression as potential predictors
produced a significant model [F(3,112)=4.63, P<.005],
which accounted for 11% of the variance. In addition to history of
depression, age and lesion volume also contributed significantly to the
model. Similar models with 1-year depression scores were not
significant.
Correlations between depression rating scale scores and outcome
measured by the FIM and the OHS are shown in Table 2. For comparison, correlation scores of
the HSS were calculated as well. In an attempt to determine whether
depressive symptoms at 3 months predict functional outcome at 1 year,
the scores on the SDS and MADRS at 3 months were correlated with 1-year
scores on the FIM and OHS. As noted in Table 2, most of these
correlations were significant even after adjustment for multiple
correlations.
View this table:
[in a new window]
Table 2. Product-Moment Correlations Between Depression
Rating Scale Scores and Outcome . While most of the
subscales (except sphincter control and communication) were
significantly correlated with both depression scales at 3 months, the
social cognition subscale had the highest correlation coefficients. At
1 year there were almost no significant correlations, although social
cognition remained significantly correlated with the MADRS
(r=-.34, P<.0001), and there was a trend with
the SDS (r=-.25, P<.003).
View this table:
[in a new window]
Table 3. Product-Moment Correlations Between Depression
Rating Scale Scores and FIM Subscales
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
The major findings of the Sunnybrook Stroke Study relate to the
frequency of depressive symptoms after hemispheric stroke, their
correlation with some but not all of the previous predictors of
poststroke depression, and the significant relationship between
depressive symptoms and functional outcome. The major strength of this
study was the ability to follow one of the largest groups to date of
poststroke patients over the course of a year. The nature of the
inception cohort (consecutive admissions to a regional stroke center)
places the sample in the middle of a continuum of those studies that
have focused on rehabilitation units or inpatient medical wards and
those studies of community samples. Samples from rehabilitation units
tend to be preselected for positive rehabilitation
potential,7 while the published studies from
medical inpatient wards, largely American, have tended to be much
younger and may have been influenced by regional practice patterns in
terms of criteria for admission. These studies may include patients
with more severe and persistent disabilities.29
For example, in the influential follow-up studies of Robinson et
al,6 30 the average ages of the samples were
between 56 and 63, with a large percentage of black subjects (60% to
70%) of low socioeconomic status. Conversely, the community sampling
methods5 31 may include patients with extremely
mild deficits and/or no disabilities. The present study's sample,
however, more closely reflects the age and sex distribution of stroke
found in community samples31 32 and is
representative of other stroke registries.
Selected Abbreviations and Acronyms
FIM
=
Functional Independence Measure
HMPAO
=
hexamethylpropyleneamine oxime
HSS
=
Hemispheric Stroke Scale
MADRS
=
Montgomery Asberg Depression Rating Scale
MMSE
=
Mini-Mental State Examination
OHS
=
Oxford Handicap Scale
SDS
=
Zung Self-Rating Depression Scale
SPECT
=
single-photon emission computed tomography
Acknowledgments
This study was supported by grants from the Heart and Stroke
Foundation of Canada. The authors would also like to thank Dr P.
Fedoroff and Dr A. Feinstein for their helpful comments.
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
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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]
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C. Weimar, T. Kurth, K. Kraywinkel, M. Wagner, O. Busse, R. L. Haberl, and H.-C. Diener Assessment of Functioning and Disability After Ischemic Stroke Stroke, August 1, 2002; 33(8): 2053 - 2059. [Abstract] [Full Text] [PDF]
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 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]
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L. Jorgensen, T. Engstad, and B. K. Jacobsen Higher Incidence of Falls in Long-Term Stroke Survivors Than in Population Controls: Depressive Symptoms Predict Falls After Stroke Stroke, February 1, 2002; 33(2): 542 - 547. [Abstract] [Full Text] [PDF]
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 G Gainotti, G Antonucci, C Marra, and S Paolucci Relation between depression after stroke, antidepressant therapy, and functional recovery J. Neurol. Neurosurg. Psychiatry, August 1, 2001; 71(2): 258 - 261. [Abstract] [Full Text] [PDF]
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E. J. Lenze, J. C. Rogers, L. M. Martire, B. H. Mulsant, B. L. Rollman, M. A. Dew, R. Schulz, and C. F. Reynolds III The Association of Late-Life Depression and Anxiety With Physical Disability: A Review of the Literature and Prospectus for Future Research Am J Geriatr Psychiatry, May 1, 2001; 9(2): 113 - 135. [Abstract] [Full Text]
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D. Sulch, I. Perez, A. Melbourn, and L. Kalra Randomized Controlled Trial of Integrated (Managed) Care Pathway for Stroke Rehabilitation Stroke, August 1, 2000; 31(8): 1929 - 1934. [Abstract] [Full Text] [PDF]
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J. S. Kim and S. Choi-Kwon Poststroke depression and emotional incontinence: Correlation with lesion location Neurology, May 9, 2000; 54(9): 1805 - 1810. [Abstract] [Full Text] [PDF]
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