Behavioral disinhibition in stroke.

Background: Post-stroke behavioral disinhibition (PSBD) is common in stroke survivors and often presents as impulsive, tactless or vulgar behavior. However, it often remains undiagnosed and thus untreated, even though it can lead to a longer length of stay in a rehabilitation facility. The proposed study will aim to evaluate the clinical, neuropsychological and magnetic resonance imaging (MRI) correlates of PSBD in a cohort of stroke survivors and describe its 12-month course. Methods: This prospective cohort study will recruit 237 patients and will be conducted at the Neurology Unit of the Prince of Wales Hospital. The project duration will be 24 months. The patients will be examined by multiple MRI methods, including diffusion-weighted imaging, within 1 week after stroke onset. The patients and their caregivers will receive a detailed assessment at a research clinic at 3, 9 and 15 months after stroke onset (T1, T2 and T3, respectively). The disinhibition subscale of the Frontal Systems Behavior Scale (FrSBe) will be completed by each subject and caregiver, and scores ≥65 will be considered to indicate PSBD.A stepwise logistic regression will be performed to assess the importance of lesions in the regions of interest (ROIs), together with other significant variables identified in the univariate analyses. For patients with PSBD at T1, the FrSBe disinhibition scores will be compared between the groups of patients with and without ROI infarcts, using covariance analysis. The demographic, clinical and MRI variables of remitters and non-remitters will be examined again at T2 and T3 by logistic regression. Discussion: This project will be the first MRI study on PSBD in stroke survivors. The results will shed light on the associations of lesions in the orbitofrontal cortex, anterior temporal lobe and subcortical brain structures with the risk of PSBD. The obtained data will advance our understanding of the pathogenesis and clinical course of PSBD in stroke, as well as other neurological conditions. The findings are thus likely to be applicable to the large population of patients with neurological disorders at risk of PSBD and are expected to stimulate further research in this field.

The impact of depressive symptoms on cognitive impairments in chronic ketamine users.

BACKGROUND: Chronic ketamine use has been associated with cognitive impairments, while depressive symptoms are commonly observed in individuals using ketamine. However, the influence of depressive symptoms on cognitive impairments in chronic ketamine users remains unclear. This study aimed to examine the impact of depressive symptoms on cognitive function in this population. METHODS: A cross-sectional study was conducted with a sample of chronic ketamine users. Participants underwent comprehensive cognitive assessments, including measures of attention, executive function, working memory, verbal and visual memory. Depressive symptoms were assessed using Beck Depression Inventory (BDI) scores. Multivariate analyses were utilized to compare the cognitive performance of individuals who use ketamine, both with and without depressive symptoms, as well as a control group, while controlling for relevant covariates. RESULTS: The results revealed a significant negative impact of depressive symptoms on cognitive impairments, particularly in the domains of memory and executive function, among chronic ketamine users. The analysis of partial correlations revealed that among individuals who use ketamine and have depressive symptoms, those with higher levels of depressive symptoms demonstrated poorer cognitive performance compared to individuals with lower levels of depressive symptoms, controlling for potential confounding factors. CONCLUSIONS: The findings suggest that depressive symptoms contribute to cognitive impairments, specifically in memory and executive function, in chronic ketamine users. Therefore, it is crucial to evaluate depressive symptoms when considering cognitive enhancement treatment for this population.

The association of disease activity with depression and sleep quality in patients with rheumatoid arthritis in Hong Kong.

Patients with rheumatoid arthritis (RA) often experience depression and poor sleep. Depression and poor sleep may, in turn, worsen RA disease activity. This cross-sectional study aimed to investigate the relationship between RA disease activity as measured using the Disease Activity Score-28 (DAS28-ESR), depression measured using the Beck's Depression Inventory-II (BDI-II), and sleep quality measured using the Pittsburgh Sleep Quality Index (PSQI). Anxiety was measured using the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). A total of 164 consecutive patients with RA were recruited from the Rheumatology Specialist Clinic of a regional hospital in Hong Kong. They were asked to complete questionnaires that included demographic information, the Health Assessment Questionnaire (HAQ), BDI-II, HADS-A, and PSQI. The DAS28-ESR was assessed by the attending rheumatologists. Clinical information was retrieved from the electronic medical records. The mean DAS28-ESR score was 3.35 ± 1.24 (SD). The mean BDI-II was 10.97 ± 9.15 (SD). The mean HADS-A score was 5.57 ± 3.77 (SD). The mean PSQI score was 7.55 ± 4.16 (SD). The BDI-II score was statistically correlated with the DAS28-ESR and PSQI scores. Multiple regression analysis revealed that the association of BDI-II with DAS28-ESR and PSQI was confounded by the HAQ. The association of DAS28-ESR with BDI-II but not with PSQI is in accordance with the results of previous studies. The association between the HAQ and BDI-II has also been demonstrated in previous studies. Clinicians should be aware of mood and sleep problems in patients with RA and adopt a multidisciplinary approach to their management. Future studies should provide information on causality in a more representative sample of patients with RA.

Clinical use of mood stabilizers beyond treatment for bipolar disorder: The REAP-MS study.

OBJECTIVE: Mood stabilizers are psychotropic drugs mainly used to treat bipolar disorder in the acute phase or for maintenance therapy to prevent relapse. In clinical practice, mood stabilizers are commonly prescribed for conditions other than bipolar disorder. This study investigated the distribution of mood stabilizer prescriptions for different psychiatric diagnoses and studied differences in the drugs, dosage, and plasma concentration in 10 Asian countries including Taiwan, South Korea, Malaysia, China, Thailand, India, Pakistan, Singapore, Indonesia, and Myanmar. METHODS: Patients prescribed mood stabilizers (lithium, carbamazepine, valproic acid, or lamotrigine) for a psychiatric condition other than bipolar disorder (codes F31.0-F31.9 in the International Classification of Diseases, 10th Edition, Clinical Modification) were recruited through convenience sampling. A website-based data entry system was used for data collection. RESULTS: In total, 1557 psychiatric patients were enrolled. Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (F20-F29, 55.8 %) was the most common diagnosis, followed by non-bipolar mood disorders (F30, F31- F39, 25.3 %), organic mental disorder (F00-F09, 8.8 %), mental retardation (F70-F79, 5.8 %) and anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders (F40-F48, 4.4 %). The most frequently targeted symptoms (>20 %) were irritability (48 %), impulsivity (32.4 %), aggression (29.2 %), anger (20.8 %), and psychosis (24.1 %). Valproic acid was the most frequently used medication. CONCLUSIONS: Clinicians typically prescribe mood stabilizers as empirically supported treatment to manage mood symptoms in patients with diagnoses other than bipolar disorders, though there is on official indication for these disorders. The costs and benefits of this add-on symptomatic treatment warrant further investigation.

Study protocol of a double-blind randomized control trial of transcranial direct current stimulation in post-stroke fatigue.

Rationale: Post-stroke fatigue (PSF) is a frequent problem in stroke survivors and often hinders their rehabilitation. PSF is difficult to treat, and pharmacological therapy is often ineffective. Transcranial direct current stimulation (tDCS) can modulate motor, sensory, cognitive and behavioral responses, as it alters neuronal activity by delivering a small amount of current via the scalp to the cortex, resulting in prolonged alterations to brain function. tDCS has been studied for the treatment of fatigue associated with other neurological diseases, namely, multiple sclerosis, Parkinson's disease and post-polio syndrome. Aims: This proposed project will examine the effect of tDCS on PSF. Sample size estimates: We will recruit 156 participants aged 18 to 80 with chronic stroke and allocate them equally to two groups (i.e., n = 78 per group). Methods and design: This proposed project will be a double-blind randomized control trial. The participants will be randomly divided into two groups. The control group will receive sham tDCS, and the treatment group will receive active tDCS. The latter treatment will involve application of a constant 2-mA current via one 5 × 5-cm anodal electrode positioned on the scalp over the C3 or C4 positions (motor cortex) of the lesioned hemisphere and one cathodal electrode positioned at the ipsilateral shoulder in two 20-min sessions per day for 5 days. The period of follow-up will be 4 weeks. Study outcomes: The primary outcome measure will be a change in fatigue severity, as measured using the modified fatigue impact scale (MFIS). The participants' scores on the MFIS (total score and physical, cognitive and psychosocial subscores) will be collected before treatment (T0), after 10 treatment sessions, i.e., 1 day after the fifth treatment day (T1), and 1 week (T2), 2 weeks (T3) and 4 weeks (T4) thereafter. Both per-protocol analysis and intention-to-treat analysis will be performed. Discussion: This proposed project will provide proof-of-concept, i.e., demonstrate the benefits of tDCS for the treatment of PSF. The beneficiaries are the subjects participated in the study. This will stimulate further research to optimize tDCS parameters for the treatment of PSF. Clinical trial registration: www.Chictr.org.cn, identifier: ChiCTR2100052515.

Post-Traumatic Stress Disorder after Stroke: A Systematic Review.

Background: Post-traumatic stress disorder (PTSD) is a common and debilitating illness that accompanies many neurological disorders, including stroke. Objective: The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity, and time course of PTSD after stroke, the factors associated with its development, and its impact on patients' lives. Material and Methods: The PubMed EMBASE, PsycINFO, and Ovid Nursing databases were searched for studies published in English that had recruited at least 10 patients (>18 years old) after stroke and who were also diagnosed with PTSD. Results: Twenty studies covering a total of 1785 patients met the study inclusion criteria. The frequency of PTSD ranged from 3% to 31%, with a weighted proportion of 16.5%. PTSD runs a chronic course. PTSD after stroke was associated with premorbid neuroticism, negative affect, and maladaptive coping styles. Comorbid depression and anxiety also increased the risk of PTSD. Psychological factors such as negative appraisal and perceived high risk of recurrence and distress were associated with PTSD. Good social support reduced the risk of PTSD. PTSD reduced patients' quality of life, physical functioning, and medication compliance. Conclusions: PTSD is common after stroke. Further research is needed to clarify its time course and identify the neurochemical factors and brain circuits associated with the development of post-stroke PTSD. Randomized controlled treatment trials targeting PTSD in stroke are warranted.

Chronic Stroke Sensorimotor Impairment Is Related to Smaller Hippocampal Volumes: An ENIGMA Analysis.

Background Persistent sensorimotor impairments after stroke can negatively impact quality of life. The hippocampus is vulnerable to poststroke secondary degeneration and is involved in sensorimotor behavior but has not been widely studied within the context of poststroke upper-limb sensorimotor impairment. We investigated associations between non-lesioned hippocampal volume and upper limb sensorimotor impairment in people with chronic stroke, hypothesizing that smaller ipsilesional hippocampal volumes would be associated with greater sensorimotor impairment. Methods and Results Cross-sectional T1-weighted magnetic resonance images of the brain were pooled from 357 participants with chronic stroke from 18 research cohorts of the ENIGMA (Enhancing NeuoImaging Genetics through Meta-Analysis) Stroke Recovery Working Group. Sensorimotor impairment was estimated from the FMA-UE (Fugl-Meyer Assessment of Upper Extremity). Robust mixed-effects linear models were used to test associations between poststroke sensorimotor impairment and hippocampal volumes (ipsilesional and contralesional separately; Bonferroni-corrected, P<0.025), controlling for age, sex, lesion volume, and lesioned hemisphere. In exploratory analyses, we tested for a sensorimotor impairment and sex interaction and relationships between lesion volume, sensorimotor damage, and hippocampal volume. Greater sensorimotor impairment was significantly associated with ipsilesional (P=0.005; ß=0.16) but not contralesional (P=0.96; ß=0.003) hippocampal volume, independent of lesion volume and other covariates (P=0.001; ß=0.26). Women showed progressively worsening sensorimotor impairment with smaller ipsilesional (P=0.008; ß=-0.26) and contralesional (P=0.006; ß=-0.27) hippocampal volumes compared with men. Hippocampal volume was associated with lesion size (P<0.001; ß=-0.21) and extent of sensorimotor damage (P=0.003; ß=-0.15). Conclusions The present study identifies novel associations between chronic poststroke sensorimotor impairment and ipsilesional hippocampal volume that are not caused by lesion size and may be stronger in women.

Risk of self-harm in post TIA patients: A population-based cohort study.

OBJECTIVE: The purpose of this study was to determine whether individuals who have experienced a transient ischemic attack (TIA) have an increased risk of self-harm behaviors. METHODS: In this matched cohort study, we reviewed the electronic health records of all patients admitted for any reason to Hong Kong public hospitals between January 1, 1993, and December 31, 2019. We selected a post-TIA cohort consisting of 37,356 patients and a comparison cohort comprising 37,352 subjects. All participants enrolled in this study were followed up until a diagnosis of self-harm, death from other causes, or the end of 2020, whichever occurred first. Univariate Cox proportional hazards regression models were used to calculate the risk of self-harm since the onset of TIA. RESULTS: Throughout the 27-year study period, the number of individuals exhibiting self-harm behavior in the TIA and comparison groups was 1031 (2.76%) and 512 (1.37%), respectively. The TIA group had a higher proportion of subjects with self-harm (χ2 = 178, p < .001). The incidence rates of self-harm were 33.94 and 19.27 per 10,000 person-years in TIA patients and comparators, respectively. Compared with the comparators, the adjusted hazard ratio for self-harm in TIA patients was 1.63 (95% confidence interval, 1.46-1.82). CONCLUSIONS: TIA is associated with an increased risk of self-harm. Healthcare professionals should help identify patients at heightened risk and provide efficient and targeted prevention strategies for this population.

Apathy after subarachnoid haemorrhage: A systematic review.

BACKGROUND: Apathy is a common and debilitating symptom accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH). OBJECTIVES: The aim of this systematic review was to identify and critically appraise all published studies that have reported the prevalence, severity, and time course of apathy after SAH, the factors associated with its development, and the impact of apathy on patients' quality of life after SAH. METHODS: The PubMed, EMBASE, PsycINFO, and Ovid Nursing databases were searched for studies published in English that recruited at least 10 patients (>18 years old) after SAH who were also diagnosed with apathy. RESULTS: Altogether 10 studies covering 595 patients met the study's inclusion criteria. The prevalence of apathy ranged from 15 to 68%, with a weighted proportion of 38%. The time course of apathy was unknown. Comorbid cognitive impairment increases the risk of apathy. Blood in lateral ventricles and hydrocephalus may also be related to apathy. Apathy reduces participation in leisure and sexual activities. There were several methodological shortcomings in the included studies, namely, heterogeneity in study design and timing of apathy assessment, hospitalized /clinic-based and biased sampling, small sample sizes and some had high attrition rates, and uncertain validity of the measures of apathy. CONCLUSIONS: Apathy is common after SAH. Further research is needed to clarify its time course and identify the neurochemical factors and brain circuits associated with the development of post-SAH apathy. Randomized controlled treatment trials targeting SAH-related apathy are warranted.

Changes in Mental Health among Psychiatric Patients during the COVID-19 Pandemic in Hong Kong-A Cross-Sectional Study.

BACKGROUND: The COVID-19 pandemic has had substantial impacts on citizens' daily living. Concerns over mental health issues are rising. Recent studies assessing the psychosocial impact of COVID-19 on the general public revealed alarming results. Meanwhile, the impact of the COVID-19 pandemic on mental health among patients with pre-existing psychiatric disorders remained unclear. METHODS: Patients diagnosed with anxiety disorders, depressive disorders, bipolar disorders, or schizophrenia were invited to complete a survey between July and October 2020. The survey collected information on subjects' demographics, accommodation status, changes in mental health status during the COVID-19 outbreak, and the factors that affect subjects' mental health during COVID-19. The primary outcome of this study was the change in mental health, defined by psychiatric symptom change and patient satisfaction on symptom control. The secondary outcomes were patients' emotional status-measured by the Depression, Anxiety and Stress Scale (DASS-21)-during the COVID-19 pandemic and factors that impacted patients' mental health during the COVID-19 pandemic. RESULTS: Out of the 294 patients recruited, 65.0% were living in hostel while 35.0% were living in the community. The proportion of patients with 'unsatisfied' or 'very unsatisfied' mental disease control increased from 10.2% to 17.1% after the COVID-19 outbreak (p < 0.001). Under the DASS-21 questionnaire, 24.2% subjects, 32.6% subjects, and 18.9% subjects were classified as severe or extremely severe in terms of the level of depression, anxiety, and stress they experienced, respectively. Patients living in the community, patients with mood disorders, and female patients reported significantly worse control over anxiety and mood symptoms. The three major factors that affected patients' mental health during COVID-19 were 'reduced social activities', 'worries over people around getting infected', and 'reduced exercise'. CONCLUSION: Psychiatric patients in general have poorer disease control after the COVID-19 outbreak. Patients in the community appeared to be more affected than patients residing in hostels. More efforts should be directed to screening patients with pre-existing mental health disorders to enable timely interventions.

Personality changes after subarachnoid hemorrhage: A systematic review and meta-analysis.

OBJECTIVE: Personality changes (PC) comprise a common and debilitating illness that accompanies many neurological disorders, including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity, and time course of PC after SAH, the factors associated with the development of PC and the effects of PC on patients' lives after SAH. METHODS: We searched the PubMed, EMBASE, PsycINFO, and Ovid Nursing databases for studies published in English that recruited at least 10 patients (>18 years old) after SAH who were also diagnosed with PC. RESULTS: We found eight studies involving 1227 patients met the study entry criteria. The frequency of PC ranged from 32% to 59%, with a pooled frequency of 44%. The clinical course of PC after SAH was unclear. PC after SAH may be associated with the clinical features and treatment factors related to SAH and comorbid conditions. Neurological signs, disability and surgical treatment increased the risk of PC. PC reduced the study participants' chance of employment. CONCLUSION: In summary, PC commonly occurs after SAH. Further research is needed to clarify the time course of PC and identify the risk factors, neurochemical factors, and brain circuits associated with the development of post-SAH PC. Randomized controlled treatment trials targeting SAH-related PC are warranted.

Clinical and behavior characteristics of individuals who used ketamine.

This study aims to depict and compare clinical characteristics and risk behavior among groups of individuals using ketamine, polydrugs or smoking cigarette. A total of 185 drug-using participants and 49 smokers participated in this study. A cross-sectional interview was used to collect information on demographics, drug- and sex-related behaviors, HIV serostatus, lower urinary tract symptoms (LUTS), behavioral dispositions. N-back memory test was used to measure short-term memory. Result shows that 10 participants (5.41%) were HIV positive and 14 (7.57%) having LUTS. Individuals with ketamine and polydrugs use have significantly worse drug-related problem than cigarette smokers. Compared to cigarette smokers and ketamine users, individuals with polydrug users scored significantly higher on impulsivity measures. Cigarette smokers performed significantly better than the other two groups on the memory tests. A few patients had been infected with HIV and diagnosed with LUTS. Findings support that memory on short term recalls of patients with ketamine use might be impaired. Study findings warrants the necessarily of further study on influences of using ketamine.

Prescription Patterns for Bipolar Disorder in Asian Countries: Findings from Research on Asian Prescription Pattern-Bipolar Disorder.

OBJECTIVE: Pharmacotherapy including mood stabilizers and antipsychotics are frequently used in bipolar disorder (BD); however, the lack of consensus regarding the definition of polypharmacy hinders conducting comparative studies across different settings and countries. Research on Asian Prescription Pattern (REAP) is the largest and the longest lasting international collaborative research in psychiatry in Asia. The objective of REAP BD was to investigate the prescription patterns of psychotropic medications across Asian countries. The rates of polypharmacy and psychotropic drug load were also analyzed. METHODS: The data collection was web-based. Prescription patterns were categorized as (1) mood stabilizer monotherapy: one mood stabilizer; (2) antipsychotic monotherapy: one antipsychotic; (3) simple polypharmacy: one mood stabilizer and one antipsychotic; and (4) complex polypharmacy: ≥ 2 mood stabilizers or/and antipsychotics. The psychotropic drug load in each patient was calculated using the defined daily dose method. RESULTS: Among 2003 patients with BD (52.1% female, 42.4 years) from 12 countries, 1,619 (80.8%) patients received mood stabilizers, 1,644 (82.14%) received antipsychotics, and 424 (21.2%) received antidepressants, with 14.7% mood stabilizer monotherapy, 13.4% antipsychotic monotherapy, 48.9% simple polypharmacy, 20.3% complex polypharmacy, and 2.6% other therapy. The average psychotropic drug load was 2.05 ± 1.40. Results varied widely between countries. CONCLUSION: Over 70% of psychotropic regimens involved polypharmacy, which accords with the high prevalence of polypharmacy in BD under a permissive criterion (2 or more core psychotropic drugs) worldwide. Notably, ≥ 80% of our sample received antipsychotics, which may indicate an increasing trend in antipsychotic use for BD treatment.

Stroke Care during the COVID-19 Pandemic: International Expert Panel Review.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. SUMMARY: The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.

Association Between Behavioral Dysexecutive Syndrome and the Health-Related Quality of Life Among Stroke Survivors.

AIM: Behavioral dysexecutive syndrome (BDES) is one common neuropsychiatric comorbidity after stroke. Despite evidences suggesting the adverse effect of BDES on the survivors' outcome, little is known about the association between BDES and the health-related quality of life (HRQoL) among stroke survivors and how BDES impacts the HRQoL. This study aimed to address these questions. METHODS: This study included 219 patients with acute ischemic stroke consecutively admitted to a regional hospital in Hong Kong. BDES was defined as a Chinese version of the Dysexecutive Questionnaire (DEX) score of ≥20 assessed at three months after stroke. The HRQoL was assessed with the Chinese version of the Stroke-Specific Quality of Life (SSQoL) questionnaire encompassing 12 domains. Multivariate linear regression models were employed to examine the association between BDES symptoms and the SSQoL total and domain scores. Structural equation model (SEM) was further constructed to delineate the linking pathways linking BDES and the HRQoL. RESULTS: The study sample compromised mainly older patients with mild to moderate ischemic stroke. Compared with patients without BDES, those with BDES exhibited poorer performances regarding with the summarized SSQoL (226.2 ± 18.8 vs. 200.3 ± 29.8, p < 0.001) and almost all domains. The BDES symptoms were independently contributed to the whole HRQoL (SSQoL total score) (ß = -0.20, p = 0.002), specifically to the domains in personality (ß = -0.34, p < 0.001), language (ß = -0.22, p = 0.01), and work/productivity (ß = -0.32, p < 0.001), after adjusting demographic and clinical characteristics in linear models. The impacts of the BDES symptoms on the HRQoL were mainly explained by the indirect path mediated by depression and anxiety (path coefficient = -0.27, p < 0.05) rather than physical disability, while the resting was elucidated by the path directly linking BDES to the HRQoL (path coefficient = -0.17, p < 0.05). CONCLUSION: The present study preliminarily demonstrated a potential association between BDES and a lower level of the HRQoL, predominantly in domains of personality, language, and work/productivityafter acute ischemic stroke. This study also offered insights into the underlying mechanisms linking BDES and the HRQoL, implicating that integrative psychological therapies were urged to achieve better HRQoL after stroke.

Cognitive impairment in chronic ketamine abusers.

BACKGROUND: The treatment of ketamine users is substantially challenged by high dropout rates, raising questions regarding contributing factors. A number of studies have highlighted the potential of greater focus on the clinical significance of cognitive impairments in ketamine users. The present study hypothesized that cognitive deficits would play a role in greater risk for treatment dropout in chronic ketamine users. METHODS: Our study examined cognitive performance in the form of working memory, verbal memory, visual memory and executive function among chronic ketamine users who completed three-month treatment in residential detoxification centres (N = 165), those who dropped out prematurely (N = 121) and drug-free healthy controls (N = 111). The data collection was completed in Hong Kong among the East Asia population. RESULTS: Compared to healthy controls, cognitive impairments were found in ketamine users, including in verbal/visual memory and executive function. Executive dysfunction was significantly associated with dropout in ketamine users within three months. CONCLUSION: Our findings suggest that executive dysfunction may have clinical benefits in ketamine users admitted to residential treatment programmes.

Striatal and white matter volumes in chronic ketamine users with or without recent regular stimulant use.

BACKGROUND: Previous studies found enlarged striatum and white matter in those with stimulants use disorders. Whether primarily ketamine users (Primarily-K) and ketamine users who co-used stimulants and other substances (K+PolyS) have abnormal brain volumes is unknown. This study aims to evaluate possible brain structural abnormalities, cognitive function and depressive symptoms, between Primarily-K and K+PolyS users. METHODS: Striatal and white matter volumes were automatically segmented in 39 Primarily-K users, 41 K+PolyS users and 46 non-drug users (ND). Cognitive performance in 7 neurocognitive domains and depressive symptoms were also evaluated. RESULTS: Ketamine users had larger caudates than ND-controls (Right: 1-way-ANCOVA-p=0.035; K+PolyS vs. ND, p=0.030; Linear trend for K+PolyS>Primarily-K>ND, p=0.011; Left: 1-way-ANCOVA-p=0.047, Primarily-K vs. ND p=0.051) and larger total white matter (1-way ANCOVA-p=0.009, Poly+K vs. Primarily-K, p=0.05; Poly+K vs. ND p=0.011; Linear trend for K+PolyS>Primarily-K >ND, p=0.004). Across all ketamine users, they performed poorer on Arithmetic, learning and memory tasks, and were more depressed than Non-users (p<0.001 to p=0.001). Greater lifetime ketamine usage correlated with more depressive symptoms (r=0.27, p=0.008). Larger white matter correlated with better learning across all participants (r=0.21, p=0.019), while larger right caudate correlated with lower depression scores in ketamine users (r=-0.28, p=0.013). CONCLUSION: Ketamine users had larger caudates and total white matter than ND-controls. The even larger white matter in K+PolyS users suggests additive effects from co-use of ketamine and stimulants. However, across the ketamine users, since greater volumes were associated with better learning and less depressive symptom, the enlarged caudates and white matter might represent a compensatory response.

Depression after Subarachnoid Hemorrhage: A Systematic Review.

BACKGROUND AND PURPOSE: Depression is common and debilitating illness accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH). The aim of this systematic review was to identify and critically appraise all published studies that have reported the frequency, severity and time course of depression after SAH, the factors associated with its development and the impact of depression on patients' quality of life after SAH. METHODS: The PubMed database was searched for studies published in English that recruited at least 40 patients (>18 years old) after SAH who were also diagnosed with depression. RESULTS: Altogether 55 studies covering 6,327 patients met study entry criteria. The frequency of depression ranged from 0% to 61.7%, with a weighted proportion of 28.1%. Depression remained common even several years after the index SAH. Depression after SAH was associated with female sex, premorbid depression, anxiety, substance use disorders or any psychiatric disorders, and coping styles. Comorbid cognitive impairment, fatigue, and physical disability also increased the risk of depression. Aneurysmal SAH and infarction may be related to depression as well. Depression reduces the quality of life and life satisfaction in patients after SAH. CONCLUSIONS: Depression is common after SAH and seems to persist. Further research is needed to clarify its time course and identify the neuroendocrine and neurochemical factors and brain circuits associated with the development of post-SAH depression. Randomized controlled treatment trials targeting SAH-related depression are warranted.

Topological reorganization of the default mode network in patients with poststroke depressive symptoms: A resting-state fMRI study.

OBJECTIVE: This study mapped the topological configuration of the default mode network (DMN) in patients with depressive symptoms after acute ischemic stroke. METHODS: The study sample comprised 63 patients: 36 with poststroke depressive symptoms (PSD) and 37 without PSD matched according to age, gender and the severity of stroke. PSD was defined by a cutoff of ≥ 7 on the 15-item Geriatric Depression Scale (GDS). Resting-state functional magnetic resonance imaging (fMRI) was used to examine functional connectivity (FC) to reconstruct the DMN. Network based statistics estimated the FC differences of the DMN between the PSD and non-PSD groups. Graph theoretical approaches were used to characterize the topological properties of this network. RESULTS: The study sample mainly comprised patients with mild to moderate stroke. A widespread hyper-connected configuration of the functional DMN was characterized in PSD group. The orbital frontal, dorsolateral prefrontal, dorsal medial prefrontal and, ventromedial prefrontal corticis, the middle temporal gyrus and the inferior parietal lobule were the functional hubs related to PSD. The nodal topology in inferior parietal lobule and superior frontal gyrus, overlapping with dorsal medial prefrontal and, ventromedial prefrontal cortices, tended to be functionally integrated in patients with PSD. After False Discovery Rate correction, no significant difference between the PSD and non-PSD groups was found with respect to the global and nodal metrics of the DMN. However, the correlations between these altered network metrics and severity of PSD were lacking. LIMITATIONS: The diagnosis of PSD was based on the GDS score rather than established with a structured clinical interview. CONCLUSIONS: The DMN in PSD was functionally integrated and more specialized in some core hubs such as the inferior parietal lobule and dorsal prefrontal cortex. The configuration of the subnetwork like DMN may be more essential in the pathogenesis of PSD than single stroke lesions.