POST STROKE DEPRESSION AND ANXIETY: PREVALANCE AND CORRELATES

Objectives: The objective of the study is to evaluate the prevalence of depression and anxiety in post-stroke patients and identify its predictors. Materials and Methods: This study was conducted for a period of 6 months among 81 patients admitted with stroke in SSIMS and RC, Davangere. The information compiled from patient data collection form was assessed for comorbid conditions and type of stroke. Assessment for depression and anxiety was conducted using Hamilton D (HAM-D) and HAM-A scale and information of location of lesion was obtained from patient’s neuroimaging results. Quality of life (QOL) of post-stroke was assessed using stroke and aphasia QOL (SAQOL) questionnaire. Follow-up was conducted for patients who were diagnosed with depression and anxiety within 1 to 3 months. Results: Depression was more prevalent as compared to anxiety in post-stroke patients and was predominant in males and between the ages 61 and 70 years. Hypertension and diabetes were found to be a major comorbid conditions in such patients. Factors contributing to increased risk of depression and anxiety after stroke include age, sex, comorbidities, lesion location, and type of stroke. Post-stroke depression (PSD) and anxiety showed statistically significant association with left-sided lesion. Conclusion: PSD and anxiety are a relatively common complications and can result in poor QOL in stroke patients. Early detection of depression and anxiety symptoms may assist functional recovery and improve QOL in stroke patients. Careful evaluation of PSD and post-stroke anxiety should be integrated into clinical care of stroke patients. depression, Hamilton rating scale for anxiety, Stroke and aphasia quality of life scale.


INTRODUCTION
Post-stroke depression (PSD) and post-stroke anxiety (PSA) are common neuropsychiatric symptoms after stroke, with estimated prevalence rates between 40% and 30%, respectively. "Depression is a common mental disorder characterized by sadness, loss of interest in activities and by decreased energy" whereas "Anxiety is characterized by feelings of distress or worry, maladaptive thinking, perceived threat, and physiological arousal". The association of neuropsychiatric disorders with cerebrovascular disease includes depression, anxiety disorder, apathy, cognitive disorder, mania, psychosis, pathological affective display, catastrophic reactions, fatigue, and anosognosia. PSD occurs in a significant number of patients and constitutes an important complication of stroke, leading to greater disability as well as increased mortality Robert G Robinson et al [1].
Due to similarity in symptoms of depression and anxiety, anxiety is often misdiagnosed as depression itself Monica Vermani et al [2]. However, now there exists specific screening test for both anxiety and depression which can also be supported by various constructs from anatomical and neurobiological areas. Both PSD and PSA can significantly affect the recovery of the neurological function in patients with stroke, significantly reduce the quality of life (QOL) and increase the mortality EM Khedr et al [3].
Since the identification of PSD and PSA is a significant clinical problem, we evaluated the predictors that indicate patients at risk of developing PSD and PSA which include type of stroke, gender, QOL, etc. Early identification of PSD may improve the stroke outcomes and prevent psychiatric consequences Yihong Fang et al [4].

METHODS
A prospective observational study was conducted in SSIMS and RC (2019), a tertiary care teaching hospital, Davanagere, for a period of 6 months aiming to determine the incidence and correlates for PSD and PSA. Ethical approval for the study was obtained from the Institutional Ethics Committee of Bapuji Pharmacy College, Davanagere, Karnataka.A total of 81 patients were included in the study. Demographic details and Neuroimaging results were collected, and patients were evaluated at baseline and follow up for functional and cognitive deficits, PSD, PSA, and QOL after 3 months. Quantification of depression and anxiety was done by administration of Hamilton (HAM) A and HAM D scales. Patient's post-stroke QOL was quantified using stroke and aphasia QOL (SAQOL) questionnaire. Stroke severity was assessed using NIHSS scale and patient education was provided during the baseline. Collected data was then analyzed, significant variables associated within the data were identified by independent student t-test using SPSS 18.0 software. Descriptive characteristics among the groups were compared to check for deviations. Wilcoxon signed ranked test (2 independent samples) was employed to observe statistical significance between categories inaccuracy.A value of p<0.05 was considered significant. Descriptive analysis of baseline and follow-up data was conducted with the help of the Shapiro-Wilk test of normality. The summarized findings were rearranged and tabulated in a graphical and table form.
In view of lesion location, majority of the patients displayed a left hemispheric stroke followed by right and bilateral stroke Figure 2 and Table 4.
Among 81 patients-36 (44%) patients showed significant symptoms of depression and 11 (13%) showed significant symptoms of anxiety after stroke onset. Out of these 10 (12%), patients had both depression and anxiety Figure 3 and Table 5.
The number of male patients was found to be more in the case of both post-stroke depressed and anxiety patients Figure 4 and Table 8.
Among both post-stroke depressed and anxiety patients, the majority of them were found to have ischemic stroke Figure 5 and Table 9.
The effect of stroke type was assessed by comparison with respect to HAM D, HAM A, and SAQOL score. By conducting the Wilcoxon Signed rank test, it was known that there was significant positive effect of ischemic stroke type on the development of depression and anxiety and QOL of the patient (p≤0.05) Table 9b.
Among the post-stroke, depressed patients left-sided lesions were more predominant in all mild, moderate, and severe depression Figure  6 and Table 10.
Among the PSA patients left-sided lesions were more predominant in all mild, moderate, and severe anxiety Figure 7 and Table 11.
By comparison of scores within baseline of depression, anxiety, stroke severity, and aphasia; it was seen that aphasia has positive relation with the left location of lesion, but HAM D and HAM A scores did not show any significant relationship (p≤0.05) Table 11b.
Among the 81 stroke patients, the majority of them had moderate QOL followed by mild, normal, and severe based on the SAQOL scores Table 12.
Moderate QOL was predominant in post stroke depressed patients whereas severe SAQOL score is seen in PSA patients Figure 8 and Table 13. SAQOL scores of baseline patients were compared with HAM D and HAM A to assess if any decline in QOL patients showed significant relation with depression and anxiety. The results of the test showed a positive effect to moderate QOL (p≤0.05) Table 13b.
Out of the 31 patients who had PSD at baseline, 12 (39%) showed improvement in the HAM-D score and 19 (61%) showed no change Figure 9 and Table 15.
Out of the seven patients who had PSD at baseline, 4 (57%) showed improvement in the HAM-A score and 3 (43%) showed no change Table 17.
Among the post-stroke depressed and anxiety patients, most of them had mild QOL followed by moderate QOL according the SAQOL scores Figure 10 and Table 18.

DISCUSSION
The present study was conducted among the students and faculties of Bapuji Pharmacy College, Davanagere for a period of 6 months. The aim of this study was to investigate the prevalence of depression and anxiety in post-stroke patients, the relationship between lesion location and type of stroke with the occurrence of depression or anxiety, assess the comorbidity and provide patient counselling. During the study period, a total of 81 cases of stroke were monitored prospectively.                [7].
Out of 81 subjects enrolled in the study, 54 patients were males and 27 were females. The gender distribution shows predominant male involvement. This observation was similar to the study conducted by Schöttke and Giabbiconi [8] and Habibi-Koolaee et al. [9]. The present study revealed that the patients belonging to the age group 61-70 years were more predominant which is in compliance with the outcomes of the study conducted by Schöttke and Giabbiconi [8].
In our study, hypertension (85%), diabetes mellitus (50.6%), and IHD (22%) were the major comorbidities among the post-stroke patients. This was in accordance with the findings of the study conducted by Habibi-Koolaee et al. [10]. In our study, the prevalence of depression and anxiety were mostly observed in post-ischemic stroke patient (79%), similar results were observed in the study conducted by Karmachandini et al. [6] and De Wit et al. [7].
Out of 36 post-stroke patients with depression and 11 with anxiety, 80.55% and 82% of patients had left side lesions, respectively. This observation was similar to a study conducted by Rajashekar et al. [11] and Barker-Collo [12].
Out of 36 patients with symptoms of depression, 23% of patients showed mild depression, moderate depression was seen in 12% and 9% of severe depression. Moreover, among 11 patients showing the symptoms of anxiety, 6% patients showed mild anxiety, 3% showed moderate anxiety, and 3% patients' severe anxiety which is similar to the study conducted by Fang et al. [3].
The number of PSD and anxiety were found to be more common in male patients, in contrast with the study conducted by Paradiso and Robinson [13].
In terms of stroke-related factors, ischemic stroke type was found statistically associated with depression and anxiety, and also significant relation was observed between lesion location of stroke (left side) and depression or anxiety corresponding to the study conducted by Tsehayneh and Tafesse [14] and Leppävuori et al. [15].
By comparison of scores within baseline of depression, anxiety, stroke severity, and aphasia; aphasia is related to the left side location of lesion, contrasting to the study conducted by Pedersen et al. [16] but HAM D and HAM A scores did not show any significant relationship (p≤0.05).
Among the 81 stroke patients, the majority of them had moderate QOL followed by mild, normal, and severe based on the SAQOL scores corresponding to the study conducted by Ramos-Lima et al. [17].
Moderate QOL was predominant in post-stroke depressed patients, whereas severe SAQOL score is seen in PSA patients, consistent to the study conducted by Khedr et al. [4] and Tang et al. [18], respectively. SAQOL scores of baseline patients were compared with HAM D and HAM A to assess if the degree of decline in QOL patients with depression Sudden occurrence of neurological deficits might cause depression and anxiety in stroke patients. Assessment of PSD and PSA was done by conducting HAM A, HAM D interview, and SAQOL questionnaire, along with the deliverance of bedside patient education. The study represents        Out of 31 post-stroke depressed patients who was followed up, 25% patients were found to be normal, 45% with mild depression, 19% with moderate, and 9% with severe depression. Moreover, among seven PSA patients followed up, 42% patients were found to be normal, 14% with mild anxiety, 42% with moderate anxiety corresponding to the study conducted by Fang et al. [3].
Out of the 31 patients who had PSD at baseline, 39% showed improvement in the HAM-D score and 61% showed no change and out of the seven patients who had PSA at baseline, 57% showed improvement in the HAM-A score and 43% showed no change. In PSD and anxiety patients, most of them had mild QOL followed by moderate QOL according to the SAQOL scores. Out of 32 patients followed up, SAQOL scores compared to the baseline 37% showed improved QOL, 47% had no change and in 16% patients, the QOL decreased.
Out of 36 patients showing depressive symptoms, 31 patients were followed up. (68%) of the population showed significant symptoms of depression at follow-up. Out of 11 patients showing anxiety symptoms, seven patients were followed up. (57%) of the population showed significant symptoms of anxiety at follow-up. On the other hand, 38.7% of the participants who showed depressive symptoms at baseline and 57% of the participants had improved scores during the follow-up.
To sum up, factors contributing to increased risk of depression and anxiety after stroke include age, sex, co-morbidities, location of lesion, and type of stroke. Early detection of depression and anxiety symptoms may facilitate functional recovery and improve QOL in stroke patients if careful evaluation of PSD and PSA is integrated into clinical care of stroke patients.

CONCLUSION
The results of our study show the prevalence of PSD and Anxiety and its correlation with left-sided lesions and ischemic type of stroke. Common comorbidities associated with PSD and PSA were found to be hypertension and diabetes mellitus. Though the scores for both HAM-D and HAM-A had improved during follow-up, the patients were still found to have depression and/or anxiety.
A clear understanding of the relationship between depression and anxiety with the mentioned correlates post-stroke will assist clinicians in early identification of patients at the highest risk for mood disturbance and those likely to benefit from treatment interventions.