1. Post stroke depression underdiagnosed, undertreated, underestimated?

2. Definition
Better to speak of neuropsychiatric disorders with cerebrovascular disease
Includes depression, anxiety, apathy, cognitive impairment, mania, psychosis, pathological affective display, catastrophic reactions, anosognosia

3. DSM 5 criteria Vascular depression (associated with microangiopathy)
PSD
Due to stroke with “depressive features, major depression-like episode or mixed mood features”
Depressed features or loss of interest or pleasure with four other symptoms of depression, lasting more than 2 weeks

4. Differing from geriatric depression without vascular genesis
Greater cognitive impairment
Greater physical impairment
Poor response to treatment (?)
Less family and personal history
More cardiovascular risk factors (associated with severity of depression?)

5. Incidence and prevalence
Stroke risk between in (55-64 yo) abd 200 in (>85 y olds)
Around 31% of stroke patients at any time within 5 y after stroke
Previous analysis up to 52% cumulative risk
Caution> meta analysis, not distinguishing between major depression and other forms, other formal weaknesses

6. Personal experiences?

7. Risk factors Genetic factors: 5-HTTLPR and STin2VTNR polymorphisms
DNA methylation status

8. Coincidence ?

9. Other factors: Gender? Age?
Cardiovascular risk factors surprisingly not
Depression in men underdiagnosed
Diabetes
Personal and possibly family history

10. Stroke characateristic and lesion
Mechanism apparently irrelevant
Localisation (left frontal, proximity to frontal pole) – better evidence shortly after stroke
Size of stroke, physical disability
Cognitive impairment more important than physical

11. Pathomechanisms

12. Candidates Disruption of prefrontal-subcortical circuits
Increased activation of the default mode network, decreased activation of task related networks, dorsolateral prefrontal cortex
Transcortical magnet stimulation only effective if directed at this area

13. Reverse causality

14. Other biological factors: alterations in
Ascending monoamine systems Hypothalamic-pituitary-adrenal axis Alterations in neuroplasticity Excess in proinflammatory cytokines, cortisol Altered glutamate levels in the cingulate cortex
Hypothesis for the efficacy of SSRI increased neuroplasticity, hippocampal neurogenesis (?)
BDNF, interleukin levels (serum) predictive

15. Detection
Patient Health Questionaire?

16. Geriatric depression scale (short)

17. Consequences Depression severity predictive of impairment of ADLs
Increased mortality (even with mild PSD). One study reports odd-ratio of 1.41 at 5 Years

18. Therapy Significant effect of SSRI and Tricyclics
No evidence for treatment of non-depressed patients

19. Complications SSRI increased risk of haemorrhagic complications
Increased risk of falls
Increased risk for stroke, myocardial infarction and all-cause mortality
Relapse all depression if premature cessation of therapy 80%

20. Prevention
Psychotherapy better evidence than in treatment
Number of social ties inversely related to severity
Marital status, living situation not correlated
Lack of social support at admission increased risk
Citalopram vs problem solving therapy vs placebo 8.5% vs 11.9% vs 22.4% (n=58)

21. Future research