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Poststroke depression
Poststroke Depression Satoru Shima, M.D., Yasuhisa Kitagawa, M.D., Toshinori Kitamura, M.D., Akira Fujinawa, M.D., and Yoshiyuki Watanabe
Abstract: Sixty-eight patients with stroke were investigated to assess their mood state. Nearly half of them were found to be depressed; according to DSM-III-R, 6 of these were diagnosed as suffering from major depression and the rest from adjustment disorder with depressive mood. A significant relationship was found between mood state on the one hand, and daily living activities and Type A behavior pattern on the other.
pression should be given sufficient attention by clinicians. The aim of this study was to determine the frequency of poststroke depression and to identify the factors associated with it.
Subjects and Methods Introduction Poststroke depression has received increasing attention during the past decade; several researchers have reported that while not uncommon, it is usually untreated, as physicians generally overlook depressed mood [1,2]. Knowledge of the etiology, pathophysiology, clinical course, and appropriate therapeutic strategies for this disorder remains limited. Because stroke may have an impact on patients not only as a stressful life event, but also as an alteration in their biochemical and neural balance, poststroke depression needs comprehensive consideration both as a biological and a psychosocial disorder. When depressed patients with stroke are neither properly assessed nor sufficiently treated, their functional level may be at risk of remaining unchanged or even of deteriorating because of lack of motivation for rehabilitation that may be due to their depression [3,4]. Therefore, poststroke de-
DeDartment of Mental Science, Tokyo Keizai University (SS); Depirtment of Neurology, Tokai eniversity Oiso H&$&l (YK1: National Institute of Mental Health CTK, AF); and DepartHei; of Psychology, Higashinippon Gak;en University (PW), Tokyo, Japan Address reprint requests to: Satoru Shima, 1-7 Minamicho, Kokubunji, Tokyo 185, Japan.
286 ISSN 0163-8343/94/$7.00
All inpatients in a rehabilitation hospital were asked to participate in the study. Although no exclusion criteria were employed, two severely demented patients and three aphasic patients who had great difficulty in communicating were excluded. The subjects comprised 68 inpatients (40 males and 28 females) suffering from stroke; their demographic characteristics are shown in Table 1. Forty-eight (71%) were diagnosed as suffering from brain infarction, and 20 (29%) from brain hemorrhage. The length of time poststroke ranged from 3 months to 10 years (mean = 5.2 f 3.4 months). The localization of the lesions as determined by computed tomography (CT) scan was right hemisphere, 25 cases (37%); left hemisphere, 27 cases (40%); both hemispheres, 16 cases (24%). Two psychologists and one psychiatrist (SS) interviewed the subjects, employing several measuring instruments. To assess mood state, the Center for Epidemiology Study of Depression Scale (CES-D Scale), the reliability and validity of which in its Japanese version was established in our previous study [5], was used. The Crichton Geriatric Behavior Rating Scale [6] was used to assess activities of daily living (ADL), and the Type A Behavior Pattern Rating Scale [7] was also administered. The subjects’ cognitive ability was assessed by the Hasegawa Dementia Scale [8]. The psychiatrist General Hospital Psychiatry 16, 286-289, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Poststroke Depression Table 1. Demographic Sex Age Marital status Education (years)
Occupation
data of the subjects
Male/Female 40128 38-94 (mean 69.3 years) 7 single, 26 married, 27 widowed, 4 separated 1 remarried 2 cases below 6 yr, 12 cases 6 yr, 21 cases 8 yr, 12 cases 9 yr, 15 cases 12 yr, 4 cases 16 yr 31 employed, 37 unemployed
clinically examined each subject and assigned a diagnosis according to DSM-III-R [9]. None of the subjects were receiving medication for depression at the time of the interview. The patient data were reviewed to establish the full medical history, including demographic information such as age, sex, and educational history, as well as CT scan data on the localization of the lesion. Informed consent was obtained after the nature of the study had been fully explained to each subject. Statistical analysis of the data was performed by the Chi-squared test, Student’s ,t test, and Pearson’s product-moment correlation using SPSS-X
POl* Results Psychiatric interview revealed that six (8.8%) of the patients fulfilled the criteria for major depression, and 35 (51.5%) had adjustment disorder with depressed mood according to DSM-III-R. The patients were then divided into two groups (depressed and nondepressive) and were compared in terms of demographic data and other variables. With regard to demographic data, no significant differences were found between the two groups, and the same was the case for the types of stroke (occlusion or hemorrhage), area of lesion localization, and the length of the time poststroke. Moreover, the relationships among these background variables and the total CES-D scores were tested, as shown in Table 2. Again, no significant relationship was found for each combination. A significant relationship was found between the total scores on the CES-D Scale and those on the Crichton Geriatric Rating Scale (Pearson’s correlation coefficient; 0.353, p < 0.01) as well as those on the Type A Behavior Rating Scales (0.256, p < 0.05), although the strength of effects explained by
these variables was low. There was no significant correlation between the depressive state and cognitive ability score.
Discussion A number of studies have reported that a substantial portion of poststroke patients suffer from depression. Feibel et al. [ll] reported a prevalence of 26% at 6 months after stroke. Robinson and Price [l] investigated the mood state of 103 poststroke patients, and almost one-third were found to be depressed at the initial assessment. Using the Zung Depression Scale, Sinyor et al. [12] found that nearly half of 35 patients examined were depressed. Ebrahim et al. [13] studied 149 poststroke patients and found that 23% showed high scores. A community study [14] revealed that 25%30% of 976 stroke patients were depressed at some point, 3, 6, or 12 months after stroke. Sharpe et al. [15] demonstrated that the prevalence of depressive disorders (DSM-III-R) among 60 stroke patients from a community-based register was 8.3% for major depression and 18.3% for all depressive disorders. A study of 20 poststroke patients by Malec et al. [16] showed that 30% of the subjects fulfilled the criteria for depressive disorder according to the Research Diagnostic Criteria. Eastwood et al. 1171 studied 87 patients and found that 54% of them suffered from depression. In a study by Dam et al. [18], 28 of 64 (43.8%) stroke patients were depressed. House et al. [19] studied 73 patients with stroke and found that the prevalence of major depression (DSM-III-R) was 11% at 1 month and 5% at 12 months. Table 2. Demographic Sex
43 Education (years) Occupation Type of stroke Lesion Length of time after stroke
data and CES-D scale
Male (40) Female (28) Under 70 yr (32) Over 71 yr (36) Under 9 yr (46) Over 10 yr (20) Employed (31) Unemployed (35) Occlusion (47) Bleeding (19) Right (24) Left (26) Under 5 months (46) Over 6 months (20)
11.6 14.2 13.2 12.2 11.9 14.5 13.0 12.4 13.1 11.7 13.5 13.4 13.5 10.8
+ k k -c * + + k k + + f 2 k
9.4 10.5 9.3 10.4 7.9 13.5 10.9 9.0 9.3 11.5 10.1 11.0 10.8 7.1
“( ): number of cases.
287
S. Shima et al.
Among the 99 stroke patients examined by Morris et al. [20], 35 affective disorders were identified, including 18 minor depression, 14 major depression, and 3 dysthymic disorder (DSM-III-R). Furthermore, Schwartz et al. 1211 reported that 40% of 91 men undergoing stroke rehabilitation met the DSM-III criteria for major depressive disorder. Thus, the prevalence of poststroke depression appears to range from 20% to 50%. The characteristics of the samples as well as the interview methods and diagnostic criteria have differed among the studies. In the present study, nearly half of a group of stroke patients were found to be depressed, though many of these failed to meet the diagnostic criteria for major depression. This result is in line with the previous studies. Several factors are claimed to be associated with poststroke depression, including lesion location disorder [17], [1,12,19,221, p revious psychiatric family history of affective or anxiety disorder [20], functional physical impairment [13,14,23], and intellectual impairment [14,23]. In the present study, a significant relationship was also found between the depressive state and both daily living activities and the Type A behavior pattern. To our knowledge, this is the first report indicating a possible relationship between poststroke depression and Type A behavior pattern. The present study is cross-sectional, and the results obtained have several clinical implications. First, the prevalence of poststroke depression has been confirmed to be relatively high in Japan, where stroke is much more common than in western societies. Secondly, some factors associated with poststroke depression have been identified, although this result remains tentative because of the cross-sectional nature of the study as well as the relatively small sample. The Type A behavior pattern was originally proposed as indicating a coronary-prone personality [24]. One plausible explanation for the relationship we found between poststroke depression and the Type A pattern is that depressed patients may show more Type A characteristics based on their mental state at the time of interview. Another possibility is that this behavior pattern may have some effect on depression. In other words, patients with this pattern have a vulnerability to depression in the face of any life-threatening, stressful events. In a previous study, we found the same correlation between depression and Type A behavior pattern among employees 171, a finding that would support the vulnerability hypothesis. Therefore, mod-
288
ification of behavior away from Type A, which has been demonstrated to be effective for reducing the incidence of recurrence of coronary attack [25], may also be effective for depression following stroke. Further studies, in particular a prospective cohort study, are needed in order to test this correlation of Type A behavior with poststroke depression.
Conclusion The present study confirmed that a high proportion of poststroke patients suffer from depression, and that low levels of daily living activities and a Type A behavior pattern are candidates as risk factors for poststroke depression. This work was supported in part by a grant for Research on Aging and Health, 2990.
References 1. Robinson RG, Price TR: Post-stroke depressive disorders: a follow-up study of 103 patients. Stroke 13: 635-641, 1982 after stroke: a 2. Lim ML, Ebrahim SBJ: Depression hospital treatment survey. Postgrad Med J 59:48% 491, 1983 3. Parikh RM, Robinson RG, Lipsey JR, et al: The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up. Arch Neurol47:785789, 1990 4. Morris PLP, Raphael B, Robinson RG: Clinical depression is associated with impaired recovery from stroke. Med J Aust 157~239-242, 1992 5. Shima S, Shikano T, Kitamura T, Asai M: New selfrating scales for depression. Seishinigaku (in Japanese) 27~717-723, 1985 6. Robinson R: Crichton Geriatric Behavior Rating Scale. Gerontol Clin 3:247-257, 1961 7. Shima S, Sato T: Depressive state in employees. Jpn J Social Psychiatry (in Japanese) 12:175-182, 1989 8. Hasegawa K, Inoue K, Moriya K: Dementia Rating Scale for the elderly. Seishinigaku (in Japanese) 16: 965-969, 1974 9. American Psychiatric Association: Diagnostic and Statistical Manual for Mental Disorders, 3rd ed, revised. Washington, DC, American Psychiatric Association, 1987 10. SPSS-X Users Guide, 3rd ed. Chicago, SPSS-X, 1988. 11. Feibel JH, Springer CJ: Depression and failure to resume social activities after stroke. Arch Phys Med Rehabil63:276-278, 1982 12. Sinyor D, Jacques I’, Kaloupek DG, et al: Poststroke depression and lesion location. Brain 109:537-546, 1986 13. Ebrahim S, Barer D, Nouri F: Affective illness after stroke. Br J Psychiatry 151:52-56, 1987
Poststroke Depression 14. Wade DT, Legh-Smith J, Hewer RA: Depressed mood after stroke: a community study of its frequency. Br J Psychiatry 151:20&205, 1987 15. Sharpe M, Hawton K, House A, et al: Mood disorders in long-term survivors of stroke: associations with brain lesion location and volume. Psycho1 Med 20:815-828, 1990 16. Malec JF, Richardson JW, Sinaki M, O’Brien MW: Types of affective response to stroke. Arch Phys Med Rehabil71:279-284, 1990 17. Eastwood MR, Rifat SL, Nobbs H, Ruderman J: Mood disorder following cerebrovascular accident. Br J Psychiatry 154:195-200, 1989 18. Dam H, Pedersen HE, Ahlgren P: Depression among patients with stroke. Acta Psychiatr Stand 80:1X3-124, 1989 19. House A, Dennis M, Warlow C, et al: Mood disorders after stroke and their relation to lesion location-a CT scan study. Brain 113:111~1129, 1990 20. Morris PLP, Robinson RG, Raphael B: Prevalence
21. 22.
23.
24. 25.
and course of depressive disorders in hospitalized stroke patients. Int J Psychiatr Med 20:349-364,199O Schwartz JA, Speed NM, Brunberg JA, et al: Depression in stroke rehabilitation. Biol Psychiatry 333694 699, 1993 Morris PLP, Robinson RG, Raphael B: Lesion location and depression in hospitalized stroke patients. Neuropsychiatry Neuropsychol Behav Neurol5:7582, 1992 Robinson RG, Starr LB, Kubos KL, et al: A two-year longitudinal study of post-stroke mood disorders: findings during the initial evaluation. Stroke 14:736741, 1983 Friedman M, Rosenman RH: Association of specific overt behavior pattern with blood and cardiovascular findings. JAMA 169:128&1296, 1959 Friedman M, Thoresen CE, Gill JJ, et al: Alteration of Type A behavior and reduction in cardiac recurrences in post-myocardial infarction patients. Am Heart J 108:237-248, 1984
289
Abstract: Sixty-eight patients with stroke were investigated to assess their mood state. Nearly half of them were found to be depressed; according to DSM-III-R, 6 of these were diagnosed as suffering from major depression and the rest from adjustment disorder with depressive mood. A significant relationship was found between mood state on the one hand, and daily living activities and Type A behavior pattern on the other.
pression should be given sufficient attention by clinicians. The aim of this study was to determine the frequency of poststroke depression and to identify the factors associated with it.
Subjects and Methods Introduction Poststroke depression has received increasing attention during the past decade; several researchers have reported that while not uncommon, it is usually untreated, as physicians generally overlook depressed mood [1,2]. Knowledge of the etiology, pathophysiology, clinical course, and appropriate therapeutic strategies for this disorder remains limited. Because stroke may have an impact on patients not only as a stressful life event, but also as an alteration in their biochemical and neural balance, poststroke depression needs comprehensive consideration both as a biological and a psychosocial disorder. When depressed patients with stroke are neither properly assessed nor sufficiently treated, their functional level may be at risk of remaining unchanged or even of deteriorating because of lack of motivation for rehabilitation that may be due to their depression [3,4]. Therefore, poststroke de-
DeDartment of Mental Science, Tokyo Keizai University (SS); Depirtment of Neurology, Tokai eniversity Oiso H&$&l (YK1: National Institute of Mental Health CTK, AF); and DepartHei; of Psychology, Higashinippon Gak;en University (PW), Tokyo, Japan Address reprint requests to: Satoru Shima, 1-7 Minamicho, Kokubunji, Tokyo 185, Japan.
286 ISSN 0163-8343/94/$7.00
All inpatients in a rehabilitation hospital were asked to participate in the study. Although no exclusion criteria were employed, two severely demented patients and three aphasic patients who had great difficulty in communicating were excluded. The subjects comprised 68 inpatients (40 males and 28 females) suffering from stroke; their demographic characteristics are shown in Table 1. Forty-eight (71%) were diagnosed as suffering from brain infarction, and 20 (29%) from brain hemorrhage. The length of time poststroke ranged from 3 months to 10 years (mean = 5.2 f 3.4 months). The localization of the lesions as determined by computed tomography (CT) scan was right hemisphere, 25 cases (37%); left hemisphere, 27 cases (40%); both hemispheres, 16 cases (24%). Two psychologists and one psychiatrist (SS) interviewed the subjects, employing several measuring instruments. To assess mood state, the Center for Epidemiology Study of Depression Scale (CES-D Scale), the reliability and validity of which in its Japanese version was established in our previous study [5], was used. The Crichton Geriatric Behavior Rating Scale [6] was used to assess activities of daily living (ADL), and the Type A Behavior Pattern Rating Scale [7] was also administered. The subjects’ cognitive ability was assessed by the Hasegawa Dementia Scale [8]. The psychiatrist General Hospital Psychiatry 16, 286-289, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Poststroke Depression Table 1. Demographic Sex Age Marital status Education (years)
Occupation
data of the subjects
Male/Female 40128 38-94 (mean 69.3 years) 7 single, 26 married, 27 widowed, 4 separated 1 remarried 2 cases below 6 yr, 12 cases 6 yr, 21 cases 8 yr, 12 cases 9 yr, 15 cases 12 yr, 4 cases 16 yr 31 employed, 37 unemployed
clinically examined each subject and assigned a diagnosis according to DSM-III-R [9]. None of the subjects were receiving medication for depression at the time of the interview. The patient data were reviewed to establish the full medical history, including demographic information such as age, sex, and educational history, as well as CT scan data on the localization of the lesion. Informed consent was obtained after the nature of the study had been fully explained to each subject. Statistical analysis of the data was performed by the Chi-squared test, Student’s ,t test, and Pearson’s product-moment correlation using SPSS-X
POl* Results Psychiatric interview revealed that six (8.8%) of the patients fulfilled the criteria for major depression, and 35 (51.5%) had adjustment disorder with depressed mood according to DSM-III-R. The patients were then divided into two groups (depressed and nondepressive) and were compared in terms of demographic data and other variables. With regard to demographic data, no significant differences were found between the two groups, and the same was the case for the types of stroke (occlusion or hemorrhage), area of lesion localization, and the length of the time poststroke. Moreover, the relationships among these background variables and the total CES-D scores were tested, as shown in Table 2. Again, no significant relationship was found for each combination. A significant relationship was found between the total scores on the CES-D Scale and those on the Crichton Geriatric Rating Scale (Pearson’s correlation coefficient; 0.353, p < 0.01) as well as those on the Type A Behavior Rating Scales (0.256, p < 0.05), although the strength of effects explained by
these variables was low. There was no significant correlation between the depressive state and cognitive ability score.
Discussion A number of studies have reported that a substantial portion of poststroke patients suffer from depression. Feibel et al. [ll] reported a prevalence of 26% at 6 months after stroke. Robinson and Price [l] investigated the mood state of 103 poststroke patients, and almost one-third were found to be depressed at the initial assessment. Using the Zung Depression Scale, Sinyor et al. [12] found that nearly half of 35 patients examined were depressed. Ebrahim et al. [13] studied 149 poststroke patients and found that 23% showed high scores. A community study [14] revealed that 25%30% of 976 stroke patients were depressed at some point, 3, 6, or 12 months after stroke. Sharpe et al. [15] demonstrated that the prevalence of depressive disorders (DSM-III-R) among 60 stroke patients from a community-based register was 8.3% for major depression and 18.3% for all depressive disorders. A study of 20 poststroke patients by Malec et al. [16] showed that 30% of the subjects fulfilled the criteria for depressive disorder according to the Research Diagnostic Criteria. Eastwood et al. 1171 studied 87 patients and found that 54% of them suffered from depression. In a study by Dam et al. [18], 28 of 64 (43.8%) stroke patients were depressed. House et al. [19] studied 73 patients with stroke and found that the prevalence of major depression (DSM-III-R) was 11% at 1 month and 5% at 12 months. Table 2. Demographic Sex
43 Education (years) Occupation Type of stroke Lesion Length of time after stroke
data and CES-D scale
Male (40) Female (28) Under 70 yr (32) Over 71 yr (36) Under 9 yr (46) Over 10 yr (20) Employed (31) Unemployed (35) Occlusion (47) Bleeding (19) Right (24) Left (26) Under 5 months (46) Over 6 months (20)
11.6 14.2 13.2 12.2 11.9 14.5 13.0 12.4 13.1 11.7 13.5 13.4 13.5 10.8
+ k k -c * + + k k + + f 2 k
9.4 10.5 9.3 10.4 7.9 13.5 10.9 9.0 9.3 11.5 10.1 11.0 10.8 7.1
“( ): number of cases.
287
S. Shima et al.
Among the 99 stroke patients examined by Morris et al. [20], 35 affective disorders were identified, including 18 minor depression, 14 major depression, and 3 dysthymic disorder (DSM-III-R). Furthermore, Schwartz et al. 1211 reported that 40% of 91 men undergoing stroke rehabilitation met the DSM-III criteria for major depressive disorder. Thus, the prevalence of poststroke depression appears to range from 20% to 50%. The characteristics of the samples as well as the interview methods and diagnostic criteria have differed among the studies. In the present study, nearly half of a group of stroke patients were found to be depressed, though many of these failed to meet the diagnostic criteria for major depression. This result is in line with the previous studies. Several factors are claimed to be associated with poststroke depression, including lesion location disorder [17], [1,12,19,221, p revious psychiatric family history of affective or anxiety disorder [20], functional physical impairment [13,14,23], and intellectual impairment [14,23]. In the present study, a significant relationship was also found between the depressive state and both daily living activities and the Type A behavior pattern. To our knowledge, this is the first report indicating a possible relationship between poststroke depression and Type A behavior pattern. The present study is cross-sectional, and the results obtained have several clinical implications. First, the prevalence of poststroke depression has been confirmed to be relatively high in Japan, where stroke is much more common than in western societies. Secondly, some factors associated with poststroke depression have been identified, although this result remains tentative because of the cross-sectional nature of the study as well as the relatively small sample. The Type A behavior pattern was originally proposed as indicating a coronary-prone personality [24]. One plausible explanation for the relationship we found between poststroke depression and the Type A pattern is that depressed patients may show more Type A characteristics based on their mental state at the time of interview. Another possibility is that this behavior pattern may have some effect on depression. In other words, patients with this pattern have a vulnerability to depression in the face of any life-threatening, stressful events. In a previous study, we found the same correlation between depression and Type A behavior pattern among employees 171, a finding that would support the vulnerability hypothesis. Therefore, mod-
288
ification of behavior away from Type A, which has been demonstrated to be effective for reducing the incidence of recurrence of coronary attack [25], may also be effective for depression following stroke. Further studies, in particular a prospective cohort study, are needed in order to test this correlation of Type A behavior with poststroke depression.
Conclusion The present study confirmed that a high proportion of poststroke patients suffer from depression, and that low levels of daily living activities and a Type A behavior pattern are candidates as risk factors for poststroke depression. This work was supported in part by a grant for Research on Aging and Health, 2990.
References 1. Robinson RG, Price TR: Post-stroke depressive disorders: a follow-up study of 103 patients. Stroke 13: 635-641, 1982 after stroke: a 2. Lim ML, Ebrahim SBJ: Depression hospital treatment survey. Postgrad Med J 59:48% 491, 1983 3. Parikh RM, Robinson RG, Lipsey JR, et al: The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up. Arch Neurol47:785789, 1990 4. Morris PLP, Raphael B, Robinson RG: Clinical depression is associated with impaired recovery from stroke. Med J Aust 157~239-242, 1992 5. Shima S, Shikano T, Kitamura T, Asai M: New selfrating scales for depression. Seishinigaku (in Japanese) 27~717-723, 1985 6. Robinson R: Crichton Geriatric Behavior Rating Scale. Gerontol Clin 3:247-257, 1961 7. Shima S, Sato T: Depressive state in employees. Jpn J Social Psychiatry (in Japanese) 12:175-182, 1989 8. Hasegawa K, Inoue K, Moriya K: Dementia Rating Scale for the elderly. Seishinigaku (in Japanese) 16: 965-969, 1974 9. American Psychiatric Association: Diagnostic and Statistical Manual for Mental Disorders, 3rd ed, revised. Washington, DC, American Psychiatric Association, 1987 10. SPSS-X Users Guide, 3rd ed. Chicago, SPSS-X, 1988. 11. Feibel JH, Springer CJ: Depression and failure to resume social activities after stroke. Arch Phys Med Rehabil63:276-278, 1982 12. Sinyor D, Jacques I’, Kaloupek DG, et al: Poststroke depression and lesion location. Brain 109:537-546, 1986 13. Ebrahim S, Barer D, Nouri F: Affective illness after stroke. Br J Psychiatry 151:52-56, 1987
Poststroke Depression 14. Wade DT, Legh-Smith J, Hewer RA: Depressed mood after stroke: a community study of its frequency. Br J Psychiatry 151:20&205, 1987 15. Sharpe M, Hawton K, House A, et al: Mood disorders in long-term survivors of stroke: associations with brain lesion location and volume. Psycho1 Med 20:815-828, 1990 16. Malec JF, Richardson JW, Sinaki M, O’Brien MW: Types of affective response to stroke. Arch Phys Med Rehabil71:279-284, 1990 17. Eastwood MR, Rifat SL, Nobbs H, Ruderman J: Mood disorder following cerebrovascular accident. Br J Psychiatry 154:195-200, 1989 18. Dam H, Pedersen HE, Ahlgren P: Depression among patients with stroke. Acta Psychiatr Stand 80:1X3-124, 1989 19. House A, Dennis M, Warlow C, et al: Mood disorders after stroke and their relation to lesion location-a CT scan study. Brain 113:111~1129, 1990 20. Morris PLP, Robinson RG, Raphael B: Prevalence
21. 22.
23.
24. 25.
and course of depressive disorders in hospitalized stroke patients. Int J Psychiatr Med 20:349-364,199O Schwartz JA, Speed NM, Brunberg JA, et al: Depression in stroke rehabilitation. Biol Psychiatry 333694 699, 1993 Morris PLP, Robinson RG, Raphael B: Lesion location and depression in hospitalized stroke patients. Neuropsychiatry Neuropsychol Behav Neurol5:7582, 1992 Robinson RG, Starr LB, Kubos KL, et al: A two-year longitudinal study of post-stroke mood disorders: findings during the initial evaluation. Stroke 14:736741, 1983 Friedman M, Rosenman RH: Association of specific overt behavior pattern with blood and cardiovascular findings. JAMA 169:128&1296, 1959 Friedman M, Thoresen CE, Gill JJ, et al: Alteration of Type A behavior and reduction in cardiac recurrences in post-myocardial infarction patients. Am Heart J 108:237-248, 1984
289