Decreased heart rate variability is associated with poststroke depression.

OBJECTIVE: Although decreased heart rate variability (HRV) has been well-documented in association with depression after myocardial infarction, this phenomenon has not been studied in patients with stroke. The present study was designed to prospectively assess heart rate in relationship to depression among patients with acute stroke. DESIGN: Using 24-hour Holter monitoring, HRV was assessed. SETTING: A large university rehabilitation hospital. PARTICIPANTS: Patients with first ever stroke and no other severe physical illness, cigarette smoking, or drug therapy that could affect HRV were evaluated over 24 hours for HRV. MEASUREMENTS: Patients were evaluated using the Structured Clinical Interview for depression diagnosis. Severity was assessed by the Hamilton Depression Rating Scale. Stroke severity was assessed by the National Institutes of Health Stroke Scale, the Barthel Index, and the Mini- Mental State Exam. The standard deviation (SD) of time in milliseconds of normal to normal beats (SDNN) was the primary measure of HRV. RESULTS: Among patients with poststroke major or minor depression (N = 33), the SDNN was 109 +/- 32.6 SD compared with nondepressed patients (N = 16) whose SDNN was 133.9 +/- 40.1 SD (Wilcoxon rank test S = 492, p = 0.048). The SDNN was significantly and independently related to the existence of depression, but no other intergroup differences. CONCLUSIONS: These findings, for the first time, have provided some evidence that both major and minor poststroke depression may lead to decreased HRV. Future research in larger groups of patients should determine whether other measures of HRV more specific to sympathetic-parasympathetic tone are decreased in patients with poststroke depression.

Unawareness of motor impairment and emotions in right hemispheric stroke: a preliminary investigation.

BACKGROUND: Awareness may lack in some stroke patients who are not capable of evaluating the nature and severity of illness. Thus, unawareness may have different forms such as anosognosia, neglect, and alexithymia or unawareness of emotions. In this study we investigated the relationship among anosognosia, neglect, alexithymia, and cognition. METHODS: Fifty consecutive right stroke inpatients were approached within the first 3 months from the acute event. Anosognosia was measured with the Bisiach scale, alexithymia with the TAS-20 scale and neglect with line crossing, letter cancellation, figure and shape copying, and line bisection tests. A neuropsychological test battery was used to measure different areas of cognition. RESULTS: despite the strong comorbidity rate among the different forms of unawareness, there are patients who suffer from pure forms of these types of lack of awareness. A multivariate logistic regression model evidenced that presence of neglect (OR = 10.3; 95% CI = 1.4-76.3; p = 0.023) and more difficulty in describing feelings (TAS-20 F2 subscore; OR = 1.3; 95% CI = 1.1-1.7; p = 0.014) were the only predictors of anosognosia. In addition, anosognosics with alexithymia performed worst in a frontal task such as the verbal fluency task (p = 0.042) and in the verbal span forward task (p = 0.026) than pure anosognosics. CONCLUSIONS: Anosognosia for motor impairment is strictly associated with a specific form of unawareness of emotions. Future studies have to clarify if frontal cognitive impairment previously described in anosognosics is a manifestation of unawareness of emotions or anosognosia for motor impairment.

Response of emotional unawareness after stroke to antidepressant treatment.

OBJECTIVE: Unawareness of impairment (anosognosia) is a phenomenon associated with right hemisphere lesions. Unawareness of emotion has rarely been studied. METHODS: Patients (N = 50) with poststroke major depression were administered the Toronto, Ontario, Canada, Alexithymia Scale to assess impairment in identifying feelings (F1), describing feelings (F2), and externally oriented thinking (F3). After eight weeks of treatment with sertraline or fluoxetine, patients were reassessed. RESULTS: Alexithymia was significantly associated with right hemisphere lesions. Patients with alexithymia had a significant improvement in identifying and describing feelings, but not in externally oriented thinking. In addition, cognitive functions improved after antidepressant treatment in patients without alexithymia with left lesions only. On the contrary, functional activities of daily living and depressive symptoms improved both in patients with alexithymia and those without alexithymia. CONCLUSIONS: The unawareness of emotions is a common impairment after right hemisphere stroke. This disorder may be significantly improved by antidepressant treatment.

Symptom profile of DSM-IV major and minor depressive disorders in first-ever stroke patients.

OBJECTIVE: Depressive disorders are very common in stroke patients. However, vegetative and cognitive symptoms primarily derived from brain damage could hypothetically be indistinguishable from those directly derived from neuropsychiatric disorders, and this could invalidate the diagnostic assessment. Thus, authors aimed to detect the frequency of clinically-rated DSM-IV depressive symptoms and the diagnostic validity of depressive disorders in stroke patients suffering from major depressive disorder (MDD), minor depressive disorder (MIND), and those free of any neuropsychiatric disorders (NODEP). METHODS: First-ever stroke patients (N=200) were approached within 3 months of the acute stroke and were interviewed with the SCID-P and administered the Hamilton Rating Scale for Depression (Ham-D), the Beck Depression Inventory (BDI), the Barthel Index, and the Mini-Mental State Exam. RESULTS: Fifty patients (25%) had MDD, 62 (31%) had MIND, and 88 (44%) had NODEP. Global cognitive level, functional impairment, total scores, and psychic and somatic subscores of the Ham-D and the BDI were different among the three groups. The only symptom that did not differ among patients with MDD, MIND, and NODEP was Feelings of Guilt; all the other eight DSM-IV symptoms were significantly different. In particular, the frequency of Depressed Mood, Diminished Interest or Pleasure, Fatigue or Loss of Energy, Insomnia, and Psychomotor Agitation/Retardation was higher in MIND patients than in NODEP patients. CONCLUSIONS: During the diagnostic procedure for depressive disorders in stroke patients, clinicians should consider equally important vegetative, cognitive, and psychological depressive symptoms, despite their nature.